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. Certainly one of 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 underneath hospitals. They modified all of the reimbursement packages. They shifted all the things in,” Lankford stated Nov. 9.
That is considered one of a set of Republican speaking factors associated to the ACA that’s been recurrently reprised, and there’s a cause 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 increased costs and pushed extra docs to promote their practices to hospitals or insurers.
However business consultants disagree about how a lot this market development might be tied to the regulation generally known as Obamacare.
Like all the things in well being coverage, it’s sophisticated.
“Most of us stay in a distinct 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, just isn’t a problem. However to say having higher protection for extra folks made all these issues worse is known as 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 grew to become efficient in 2014.
Many well being care mergers came about each earlier than and after Obamacare grew to become regulation, so it’s laborious 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 came about. An extra 428 hospital and well being system mergers have been introduced from 2018 to 2023, in response to a 2024 transient by KFF, a well being data nonprofit that features KFF Well being Information.
“The consolidation development 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 transient didn’t instantly handle what function the ACA may need performed in such mergers, though others have advised its give attention to coordinating care might have led to a few of the exercise.
Hospital teams contend that mergers are wanted to bolster funds and counter growing insurer consolidation, and that they can lead to value financial savings. Others disagree, arguing that many research present worth will increase following mergers.
Even with that development — and regardless of what Lankford stated — not all docs now work for hospitals.
The share of physicians who’ve bought their practices to hospitals or non-public fairness teams continues to rise, with solely 42% presently working in non-public practices, in response to the American Medical Affiliation. That’s down from about 60% in 2012, earlier than the ACA’s essential provisions took impact.
Those that bought practices throughout the previous 10 years, in response to the AMA, most frequently cited insufficient fee charges as the rationale.
Others be aware that many docs wish to be half of a bigger group, with extra scheduling flexibility and fewer paperwork hassles. Different modifications, together with the 2009 regulation generally known as the HITECH Act, which required hospitals and docs to spice up their use of digital medical information, added to physicians’ want to promote, Kahn stated.
“Physicians at this time, with their heavy debt load, should not wanting 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 development is market leverage, which was occurring anyway, say some coverage consultants.
Hospitals “bought 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, in order 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 practically 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 Protection, in testimony earlier than a Senate subcommittee in November. The council touts amongst its priorities right-leaning points equivalent 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 advanced.
The variety of insurers submitting annual reviews with the Nationwide Affiliation of Insurance coverage Commissioners has fluctuated: for instance, 949 in 2015 and 1,155 final yr.
However combination numbers are just one measure. A number of massive insurers management giant market shares. In a single latest evaluation that regarded throughout quite a lot of varieties of insurance coverage — not simply ACA plans — the American Medical Affiliation concluded that almost all 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 increased premiums and ends in diminished funds to docs.
As for the marketplaces that supply ACA protection, the variety of insurers has additionally fluctuated over time, normally due to variations in anticipated premiums and the regulatory panorama, with a nationwide common of practically 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, equivalent 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 actual fact, premiums for folks shopping for their very own protection and people for employees who get insurance coverage by means of an employer have virtually at all times risen yearly — usually above inflation ranges —a development that predates the ACA.
Critics of the ACA be aware that premiums within the particular person market have been decrease earlier than the regulation kicked in. Nevertheless, critics usually don’t be aware how completely different pre-ACA protection was for folks within the particular person market, which might make it inexpensive. Earlier than the regulation, for instance, insurers might reject folks with preexisting well being situations, cost girls 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 range 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 Companies report, issued over the last days of the Biden administration, discovered the development 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 essential 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 actual cause behind the mergers is monetary: Many hospitals, he says, needed to develop their attain or danger going underneath.
“Many well being economists are my finest pals,” Kahn stated, “however they’ve tunnel imaginative and prescient once they take a look at the well being system.” Hospitals will need to have enough income streams to cowl the price of affected person care, he stated, and consolidation is their solution to reply “to all the burdens and necessities and calls for” they face.
Whereas there isn’t 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 grew to become that massive to drive the general restructuring of the business,” he stated. “Quite a lot of what they’re attributing to the ACA would have occurred anyway.”