In a latest Meet the Press look, Sen. James Lankford (R-Okla.) joined a rising variety of Republicans who’re talking out in opposition to Obamacare. One in all his traces of assault: that the Reasonably priced Care Act fueled well being care consolidation.
“What Democrats did 15 years in the past was they radically modified all well being care in America. They moved all physicians below hospitals. They modified all of the reimbursement packages. They shifted all the things in,” Lankford stated Nov. 9.
That is one among a set of Republican speaking factors associated to the ACA that’s been repeatedly reprisedand there’s a motive for it.
Democrats have been promised a Senate vote this month on whether or not to increase the ACA’s enhanced subsidies, set to run out at yr’s finish. The controversy, nevertheless, has given Republicans a possibility to resurface previous criticisms and reignite efforts to overtake and even undo the ACA. One GOP argument is that the sweeping well being regulation fueled business consolidation, which has led to larger costs and pushed extra docs to promote their practices to hospitals or insurers.
However business consultants disagree about how a lot this market pattern may be tied to the regulation often known as Obamacare.
Like all the things in well being coverage, it’s sophisticated.
“Most of us reside in a special actuality,” stated Chip Kahn, president and CEO of the Federation of American Hospitals, which helps extending the improved tax credit. “Our well being system has many challenges, and I can’t say the associated fee to people, to taxpayers, shouldn’t be a difficulty. However to say having higher protection for extra folks made all these issues worse is mostly a stretch.”
What’s Occurred to Medical doctors and Hospitals?
First, some context. The ACA was handed by Congress in 2010, and most of its main provisions turned efficient in 2014.
Many well being care mergers happened each earlier than and after Obamacare turned regulation, so it’s onerous to quantify its impact.
From 1998 to 2017 — an almost two-decade interval that included the primary three years of full ACA implementation — 1,573 hospital mergers happened. An extra 428 hospital and well being system mergers had been introduced from 2018 to 2023, in response to a 2024 temporary by KFF, a well being info nonprofit that features KFF Well being Information.
“The consolidation pattern was in place earlier than the ACA and simply continued” as hospitals and different entities sought to enhance their negotiating energy, stated Glenn Melnick, who research hospital economics and is a professor on the College of Southern California’s Value College of Public Coverage.
The KFF temporary didn’t instantly handle what function the ACA may need performed in such mergers, though others have instructed its deal with coordinating care might have led to among the exercise.
Hospital teams contend that mergers are wanted to bolster funds and counter growing insurer consolidation, and that they can lead to price financial savings. Others disagree, arguing that many research present value will increase following mergers.
Even with that pattern — and regardless of what Lankford stated — not all docs now work for hospitals.
The share of physicians who’ve offered their practices to hospitals or non-public fairness teams continues to rise, with solely 42% at the moment working in non-public practicesin response to the American Medical Affiliation. That’s down from about 60% in 2012, earlier than the ACA’s major provisions took impact.
Those that offered practices in the course of the previous 10 years, in response to the AMA, most frequently cited insufficient fee charges as the rationale.
Others word that many docs wish to be half of a bigger group, with extra scheduling flexibility and fewer paperwork hassles. Different adjustments, together with the 2009 regulation often known as the HITECH Actwhich required hospitals and docs to spice up their use of digital medical information, added to physicians’ need to promote, Kahn stated.
“Physicians at this time, with their heavy debt load, should not trying to enter the previous particular person apply anymore,” Kahn stated. “That didn’t occur due to the ACA.”
One other key dynamic driving this market pattern is market leverage, which was occurring anyway, say some coverage consultants.
Hospitals “received management of the doctor teams for contracting functions,” Melnick stated.
When hospitals meet to barter with insurers, “they’ll say, ‘We’ll drop out of your community, and we management 30% of the docs, so that they’ll drop out, too.’ It was a leverage play, and it labored,” Melnick stated.
How Do Insurers Match In?
Like hospitals, some insurers have been on a shopping for spree, snapping up physician practices, for instance. Optum, a division of UnitedHealth Group, owns or is affiliated with almost 10% of the nation’s physicians.
The well being regulation “triggered an arms race amongst insurers and hospitals to develop bigger and dearer, leaving sufferers and small companies with rising premiums and shrinking choices,” stated Joel White, president of the Council for Reasonably priced Well being Protectionin testimony earlier than a Senate subcommittee in November. The council touts amongst its priorities right-leaning points akin to opposing government-run well being care and supporting expanded market competitors and well being financial savings accounts.
Once more, the insurance coverage query is complicated.
The variety of insurers submitting annual experiences with the Nationwide Affiliation of Insurance coverage Commissioners has fluctuated: for instance, 949 in 2015 and 1,155 final yr.
However mixture numbers are just one measure. A number of large insurers management giant market shares. In a single latest evaluation that regarded throughout a wide range of sorts of insurance coverage — not simply ACA plans — the American Medical Affiliation concluded that the majority areas are extremely concentrated, with about 47% of these markets having one insurer with a industrial market share of fifty% or extra.
The AMA says such market energy results in larger premiums and ends in diminished funds to docs.
As for the marketplaces that provide ACA protection, the variety of insurers has additionally fluctuated over time, often due to variations in anticipated premiums and the regulatory panorama, with a nationwide common of almost eight on the regulation’s inception, falling to five.4 in 2018, however rising to just about 10 nationally in 2025, in response to KFF. As a result of that’s a mean, some states, akin to Texas, have 15 insurers, whereas seven states — Alaska, Arkansas, Connecticut, Hawaii, Rhode Island, Vermont, West Virginia — and the District of Columbia have solely two.
Premium will increase aren’t new both, nor are they hitting solely ACA plans.
In truth, premiums for folks shopping for their very own protection and people for staff who get insurance coverage by an employer have virtually at all times risen yearly — usually above inflation ranges —a pattern that predates the ACA.
Critics of the ACA word that premiums within the particular person market had been decrease earlier than the regulation kicked in. Nevertheless, critics usually don’t word how totally different pre-ACA protection was for folks within the particular person market, which may make it inexpensive. Earlier than the regulation, for instance, insurers may reject folks with preexisting well being situations, cost ladies greater than males, and set annual or lifetime greenback limits on protection. After 2014, that wasn’t allowed in ACA plans.
Common premiums for the benchmark “silver” ACA plans have gone from $481 nationally in 2018 to $497 in 2025, in response to KFF. The typical month-to-month premium jumps to $625 subsequent yr, partly due to insurers’ expectations of upper prices and a decline in enrollment if Congress doesn’t prolong the extra beneficiant tax subsidies. These are averages, and costs will fluctuate throughout the nation relying on things like age, location, and family earnings.
The conservative Paragon Well being Institute notes that rising premiums imply bigger taxpayer-supported subsidies. Deductibles, too, have gone up, with folks on “bronze” plans, which have the bottom premiums, going through a mean $7,476 deductible subsequent yr, in contrast with $5,113 in 2014.
The Value-Consolidation Hyperlink
A 2025 Well being and Human Providers reportissued over the last days of the Biden administration, discovered the pattern of extremely concentrated hospital providers in most metropolitan statistical areas had began earlier than and continued after the ACA. Costs additionally rose. The report, which famous the function of personal fairness companies in consolidation efforts, additionally cited research displaying physicians more and more merged — with each other, hospitals, or non-public equity-backed companies.
That’s vital as a result of the most important share of well being care spending within the U.S. goes to hospital care, with doctor providers not far behind.
For Kahn, on the hospital federation, the true motive behind the mergers is monetary: Many hospitals, he says, needed to increase their attain or danger going below.
“Many well being economists are my greatest buddies,” Kahn stated, “however they’ve tunnel imaginative and prescient once they have a look at the well being system.” Hospitals should have adequate income streams to cowl the price of affected person care, he stated, and consolidation is their approach to reply “to all the burdens and necessities and calls for” they face.
Whereas there is no such thing as a query that well being care consolidation has occurred, a lot of it predated the ACA, Melnick stated.
“On the finish of the day, the ACA market by no means turned that large to drive the general restructuring of the business,” he stated. “Lots of what they’re attributing to the ACA would have occurred anyway.”
