OPINION:
Ask Americans what is breaking their budgets, and you will hear one answer over and over: healthcare.
I have heard it in living rooms and union halls from coast to coast. The data is brutal: Premiums are growing three times faster than paychecks, and coverage now costs some families as much as their mortgages.
Decades of policy decisions helped create the conditions for insurers to buy up pharmacy benefit managers, pharmacies, doctors, clinics, imaging centers, hospitals and even banks.
Insurers now own the three largest pharmacy benefit managers, which together control roughly 80% of drug prescriptions. Nearly 80% of physicians work for corporate-owned practices. UnitedHealth Group alone employs 1 in 10 doctors in the United States and controls more than 2,000 subsidiaries.
As a result, providers and pharmacies no longer compete on price and quality, as they would in a healthy market. Instead, insurers profit by steering patients toward their own subsidiaries and squeezing out independent competitors.
As smaller providers and pharmacies are forced out, large insurers gain even more leverage to raise costs and limit patient choice.
Just how concentrated have insurance markets become? About 73% of commercial markets are uncompetitive.
According to KFF, 165 U.S. counties had only a single insurer participating in the Affordable Care Act Marketplace in 2026. In Medicare, an overwhelming majority of Medicare Advantage enrollees (89%) live in highly concentrated markets.
Given this level of consolidation, it is not surprising that roughly 70% of voters support using antitrust enforcement to break up large health insurance companies.
These distortions stem directly from policies Democrats championed, most notably the ACA, which has subsidized dominant insurers and rewarded consolidation over competition.
The ACA restricted how insurers could design their plans, preventing smaller companies from differentiating themselves with low-cost options. It took choice away from consumers and forced all subsidies into narrowly designed, expensive options that are unaffordable without a subsidy.
The law also set insurer subsidies to rise along with premiums, allowing insurers to profit as premiums increase and incentivizing them to maximize government payouts rather than compete on price.
The ACA’s medical loss ratio rule compounded the problem. Intended to force insurers to spend more on care by capping their profits, it has instead reinforced consolidation. Insurers can shift revenue among subsidiaries to satisfy the rule on paper while preserving their market power.
Beyond the ACA, Democratic lawmakers have resisted efforts to rein in abuses of the 340B program, which allows safety-net, or charity-care, hospitals to purchase drugs at steep discounts.
Because of extremely lax oversight, many hospitals pocket those savings rather than passing them on to patients, creating a lucrative revenue stream for insurers integrated with corporate hospital chains.
Instead of confronting this consolidation, lawmakers on the left often double down. Just months ago, Democrats sought to extend hundreds of billions of dollars in additional insurer subsidies. This move would have further entrenched the monopolies, driving up costs.
Each of these policies has distorted the market in favor of dominant insurers, and each requires reform. Congress should curb wasteful ACA subsidies, revise the medical loss ratio rule and strengthen oversight of federal programs, such as 340B.
Yet those reforms alone will not be enough to lower costs for patients. For lasting change, policymakers must go further and dismantle the insurance monopolies that those Democratic-engineered policies created.
Fortunately, they already have antitrust tools at their disposal. Congress passed the Sherman and Clayton Antitrust Acts to address this kind of consolidation, prohibiting anticompetitive conduct and empowering the government to break up vertically integrated monopolies.
In 2021, Congress repealed insurers’ exemption from antitrust laws. The Justice Department has begun to exercise that authority. It is investigating UnitedHealth Group and recently filed a lawsuit against a major New York City hospital system for violating the Sherman Act.
Now is the time for the Justice Department to use its authority to break up mega-conglomerates to ensure consumers benefit from competition.
If Washington is serious about lowering healthcare costs, the path is clear. Reform the policies that enabled consolidation, enforce the laws that prohibit it, and stop sending taxpayer subsidies to the firms that profit from it.
Most Americans across party lines support exactly these kinds of structural reforms.
Until policymakers confront predatory insurers, competition will remain little more than a talking point, and patients, employers and taxpayers will continue to pay the price.
• Joel White is the president of the Council for Affordable Health Coverage, a nonprofit advocacy organization that seeks to lower the costs of healthcare for all Americans.
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