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 among his traces of assault: that the Inexpensive 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 mentioned Nov. 9.
That is one in every of a group of Republican speaking factors associated to the ACA that’s been commonly 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 12 months’s finish. The controversy, nonetheless, 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 trade consolidation, which has led to larger costs and pushed extra medical doctors to promote their practices to hospitals or insurers.
However trade consultants disagree about how a lot this market development might be tied to the regulation often known as Obamacare.
Like all the things in well being coverage, it’s sophisticated.
“Most of us stay in a unique actuality,” mentioned 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 fee to people, to taxpayers, will not be a difficulty. However to say having higher protection for extra folks made all these issues worse can be a stretch.”
What’s Occurred to Docs 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 came about each earlier than and after Obamacare turned regulation, so it’s onerous to quantify its impact.
From 1998 to 2017 — a virtually 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 had been introduced from 2018 to 2023, in keeping with a 2024 temporary by KFF, a well being info 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, mentioned Glenn Melnick, who research hospital economics and is a professor on the College of Southern California’s Worth College of Public Coverage.
The KFF temporary didn’t straight tackle what position the ACA may need performed in such mergers, though others have steered its give attention to coordinating care could have led to among the exercise.
Hospital teams contend that mergers are wanted to bolster funds and counter growing insurer consolidation, and that they may end up in value financial savings. Others disagree, arguing that many research present worth will increase following mergers.
Even with that development — and regardless of what Lankford mentioned — not all medical doctors now work for hospitals.
The proportion of physicians who’ve bought their practices to hospitals or non-public fairness teams continues to rise, with solely 42% at present working in non-public practicesin keeping with the American Medical Affiliation. That’s down from about 60% in 2012, earlier than the ACA’s predominant provisions took impact.
Those that bought practices through the previous 10 years, in keeping with the AMA, most frequently cited insufficient cost charges as the rationale.
Others be aware that many medical doctors 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 medical doctors to spice up their use of digital medical data, added to physicians’ want to promote, Kahn mentioned.
“Physicians as we speak, with their heavy debt load, should not wanting to enter the previous particular person follow anymore,” Kahn mentioned. “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 “obtained management of the doctor teams for contracting functions,” Melnick mentioned.
When hospitals meet to barter with insurers, “they’ll say, ‘We’ll drop out of your community, and we management 30% of the medical doctors, so that they’ll drop out, too.’ It was a leverage play, and it labored,” Melnick mentioned.
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 costlier, leaving sufferers and small companies with rising premiums and shrinking choices,” mentioned Joel White, president of the Council for Inexpensive Well being Protectionin testimony earlier than a Senate subcommittee in November. The council touts amongst its priorities right-leaning points corresponding 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 stories with the Nationwide Affiliation of Insurance coverage Commissioners has fluctuated: for instance, 949 in 2015 and 1,155 final 12 months.
However mixture numbers are just one measure. A number of massive insurers management massive market shares. In a single latest evaluation that regarded throughout a wide range of forms 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 larger premiums and ends in decreased funds to medical doctors.
As for the marketplaces that provide 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 almost eight on the regulation’s inception, falling to five.4 in 2018, however rising to just about 10 nationally in 2025, in keeping with KFF. As a result of that’s a mean, some states, corresponding 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 reality, premiums for folks shopping for their very own protection and people for employees who get insurance coverage by an employer have nearly 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 had been decrease earlier than the regulation kicked in. Nonetheless, critics usually don’t be aware how totally different pre-ACA protection was for folks within the particular person market, which might make it cheaper. Earlier than the regulation, for instance, insurers might 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 keeping with KFF. The common month-to-month premium jumps to $625 subsequent 12 months, 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 differ 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, dealing with a mean $7,476 deductible subsequent 12 months, 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 development of extremely concentrated hospital companies in most metropolitan statistical areas had began earlier than and continued after the ACA. Costs additionally rose. The report, which famous the position of personal fairness companies in consolidation efforts, additionally cited research exhibiting 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 companies not far behind.
For Kahn, on the hospital federation, the true motive behind the mergers is monetary: Many hospitals, he says, needed to broaden their attain or threat going underneath.
“Many well being economists are my greatest mates,” Kahn mentioned, “however they’ve tunnel imaginative and prescient once they take a look at the well being system.” Hospitals should have ample income streams to cowl the price of affected person care, he mentioned, and consolidation is their strategy 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 mentioned.
“On the finish of the day, the ACA market by no means turned that massive to drive the general restructuring of the trade,” he mentioned. “Lots of what they’re attributing to the ACA would have occurred anyway.”
