The solutions

Let's start by talking about the bucket of policies that Congress or the Biden administration are pursuing.

• Particularly in the House, there's been bipartisan interest in measures promoting hospital price transparency and aligning payment rates for different settings of care, known as site-neutral payments. There's also been chatter (mostly among Democrats) about increasing resources and authorities for the FTC to pursue antitrust cases.
• The FTC has been aggressive in challenging health care mergers under President Biden, and the administration this year put out a request for information about consolidation in health care markets.
• But "I do think there is a lot of consolidation in the rearview mirror, and unless the FTC is really talking about breaking up some of these big systems — which I'm not hearing — I do think it's mostly preventative," said Mark Miller, executive vice president at Arnold Ventures.
• Banning what experts say are anti-competitive practices among providers, or those that generally lead to higher health care costs, could both curb the downstream impact of consolidation and remove the incentive for future combinations, by making them less lucrative.
• "What you're trying to do is take the juice out of consolidation," Miller said.

Yes, but: At the think tank level, things get a little more interesting — there's way more talk about price regulations.

• Experts still have differences over the extent to which market competition is itself a solution. But there's pretty widespread buy-in to the idea that the government will have to do something to fix broken health care markets.
• Proposals by the Bipartisan Policy Center, the Hamilton Project (which Harvard's Dafny coauthored), the Foundation for Research on Equal Opportunity and the Progressive Policy Institute include some kind of price cap.

The intrigue: This section is light on payer-side solutions because most people don't seem to know what to do, or say that being big isn't the root cause of insurers' or PBM's anti-competitive practices.

• "It's not just United. United is just the best at all of this," Miller said. "If there are limitations on how much money they can make — if they get consolidated but they can't engage in the upcoding — maybe I'm less concerned about it."
• And some experts say payer consolidation is at least in part a response to provider consolidation.

Others are more concerned about the mere existence of such large companies. (One of the ironies about the way the Change Healthcare cyberattack put the spotlight on UnitedHealth Group's size is that the DOJ unsuccessfully challenged the acquisition in 2022.)

• An idea that's been floated by the American Economic Liberties Project — an anti-monopoly think tank — is for Congress to simply ban insurers and providers from being owned by the same company, which would effectively break up a behemoth like UnitedHealth.

The bottom line: "If we're getting serious about policy, this really isn't a question about government intervention or not," said Hayden Rooke-Ley, a senior fellow at AELP who recently wrote a white paper on Medicare Advantage and vertical consolidation.

• "I think we've had these fallacies about these markets being natural and having this bias against governing," he added. "It's left us with a system that's so irrational, so inefficient and so wasteful, and preserves this idea that the government isn't involved when the government is deeply involved in these dynamics."