“The largest health care companies in the US are no longer just health insurers, pharmacy benefit managers (PBMs), physician practices, home health agencies, hospices, data warehouses, data analytics firms, or hospitals. They are increasingly all of the above. A small number of unavoidable health care intermediaries are incorporating these services into essential platforms that simultaneously serve as payers, providers, and everything in between. While these companies claim to rationalize health care and realize the promise of coordinated, integrated care, the reality may be quite different. The creation of “big health care” platforms risks worsening the already serious problem of monopoly power that plagues US health care.
Consolidated health markets have failed to deliver better care, lower prices, increased access, or improved population health. Evidence on the decades-long experiment with consolidation in health care in the US shows that concentrated markets have led to higher consumer prices and spending, without improvements in quality or gains in efficiency. (While some have advocated for payer/provider consolidation to improve patient care and lower costs, the evidence does not support this claim. Integrated health care firms perform no better than independents—thus payer/provider consolidation is neither necessary nor sufficient to achieve better care and lower costs.) [..]
Platforms provide different products or services to 2 or more groups or “sides” who benefit from each other’s participation. For example, a platform might connect a provider to a payer. To compete in health care today, it is nearly impossible to avoid doing business with the small number of major health care platforms that connect different sides of the market, but, increasingly, compete with independent participants via their own platform. In this respect, big health care resembles many of the characteristics of big tech. [..]
The dominance of these large systems not only prevents fair competition and stymies the entry of new competitors, it denies independent physicians, practitioners, and pharmacists the ability to compete fairly and build thriving small businesses that function as pillars of their communities. It also thwarts badly needed innovation in the organization and delivery of care—innovation that is technically and humanly feasible, but is not in the self-interest of these huge, profitable systems. (We note that understanding and addressing competition issues in these kinds of markets requires new thinking that goes beyond some traditional antitrust approaches. This is reflected in the newly revised 2023 Merger Guidelines adopted by the US Department of Justice’s Antitrust Division and the Federal Trade Commission).
We are at an inflection point. In technology markets, the world has coalesced around a few technology stacks. Incumbent technology firms seek to maintain their dominance in any number of ways across multiple markets. Once industries settle in such a place, it is hard to remedy the situation. [..]
The trends we are experiencing are undermining the ability of health care markets to function adequately, making the US health care system even more expensive, unresponsive, and inaccessible. We may be witnessing the march to single-payer health care, but a private, profit-seeking single payer without oversight or competition to constrain it is not the kind of single payer anyone imagines or wants.
If these platforms are violating the law, then it is both appropriate and critical to take action to stop those violations and open markets up to vigorous competition and prevent further consolidation and concentration. All appropriate remedies—including traditional structural remedies, such as breakup—should be on the table for consideration.
The US public deserves more from our health care system and competition policy. We need to take an aggressive, whole-of-government approach to health care markets and consider the nature of competition and the harms that can arise with the platformization of health care. We must address these problems before it is too late. The time is now.”
Full editorial, J Kanter and M Gaynor, JAMA, 2025.4.9