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Expand chart
Data: Open Markets Institute; Chart: Axios Visuals

Even the behind-the-scenes parts of the health care industry are dominated by a small handful of companies — and critics say that drives up prices for everyone.

Why it matters: The U.S. spends more than any other industrialized country for health care, largely because our prices are higher. And the monopolies that support those high prices could undermine both liberal and conservative dreams of a more efficient system.

The big picture: This is a trend that's happening at every level.

  • Hospital systems continue to merge with each other and gobble up doctors’ practices, which lets them charge more for the care they provide.
  • Insurers and pharmacy benefit managers are also merging, and are now on track to bring in more revenue than the tech industry's biggest powerhouses.

Yes, and: That trend toward concentration extends throughout the system, even into sectors that most patients never directly interact with, according to new data from the Open Markets Institute, shared first with Axios.

  • As long as we’re talking about hospitals, for example, let’s look at their suppliers: One company controls 64% of the market for syringes, according to OMI’s data. Just 3 companies control 86% of the market for IV solution. Two companies make 47% of hospital beds.
  • None of those sectors is particularly huge — syringes are the biggest, with $3.8 billion in annual revenue. But in a system that’s already not very competitive, each step without competition feeds into the next one.

“America’s health care crisis is brought you by monopoly,” Open Markets policy director Phil Longman said.

Dialysis is a particularly stark example:

  • Dialysis clinics bring in about $25 billion per year in revenue. And 2 companies — Fresenius and DaVita — control 92% of that market.
  • Fresenius is the leader, with almost 50% market share.
  • The manufacture of dialysis supplies is also concentrated around 2 companies — one of which is Fresenius. It controls 33% of that market.

This level of concentration can pose a problem for both liberal and conservative policy proposals, Longman argues.

  • Conservatives, for example, wanted to shift dialysis away from VA facilities and let veterans use private care instead.
  • Especially in sparsely populated areas, there's an argument that such an arrangement would be more efficient, Longman said — but without actual competition in the private market, the VA just ends up paying more.
  • But by the same token, large hospital systems dominate some regions entirely. They’re not only the only source of care for miles, but also the largest employer and thus an important political constituency.
  • And that could make it hard for Democrats to follow through on big payment cuts in an expanded public program or "Medicare for All."
  • “What are the chances the taxpayers get a good price if we don’t fix the monopoly problem?"

Go deeper

2 hours ago - World

Special report: Trump's U.S.-China transformation

Illustration: Aïda Amer/Axios

President Trump began his term by launching the trade war with China he had promised on the campaign trail. By mid-2020, however, Trump was no longer the public face of China policy-making as he became increasingly consumed with domestic troubles, giving his top aides carte blanche to pursue a cascade of tough-on-China policies.

Why it matters: Trump alone did not reshape the China relationship. But his trade war shattered global norms, paving the way for administration officials to pursue policies that just a few years earlier would have been unthinkable.

McConnell: Trump "provoked" Capitol mob

Senate Majority Leader Mitch McConnell (R-Ky.) said on Tuesday that the pro-Trump mob that stormed the U.S. Capitol on Jan. 6 was "provoked by the president and other powerful people."

Why it matters: Trump was impeached by the House last week for "incitement of insurrection." McConnell has not said how he will vote in Trump's coming Senate impeachment trial, but sources told Axios' Mike Allen that the chances of him voting to convict are higher than 50%.

3 hours ago - Politics & Policy

GOP leaders skip Trump sendoff in favor of church with Biden

House Speaker Nancy Pelosi (D-Calif.), Senate Majority Leader Mitch McConnell (R-Ky.), Senate Minority Leader Chuck Schumer (D-N.Y.) and House Minority Leader Kevin McCarthy (R-Calif.) in July. Photo by Erin Scott-Pool/Getty Images

Congressional leaders, including House GOP leader Kevin McCarthy and Senate Majority Leader Mitch McConnell, will skip President Trump's departure ceremony in Maryland tomorrow morning in favor of attending mass with incoming President Joe Biden ahead of his inauguration, congressional sources familiar with their plans tell Axios.

Why it matters: Their decision is a clear sign of unity before Biden takes the oath of office.

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