National health spending totaled $5.3 trillion in 2024—18% of gross domestic product (GDP)—and is projected to grow faster than GDP through 2033, contributing to higher costs for families, employers, states, and the federal government. As policymakers consider a variety of strategies to make health care more affordable, they have been increasingly attentive to the effects of consolidation in health care markets and the potential implications for cost and quality of care. Hospital consolidation has been a subject of particular focus in part because spending on hospital care is the largest source of spending on health. Hospital care has also contributed more than other categories to the growth in national health spending over time, including from 2022 to 2024, when it accounted for 40% of spending growth. Consolidation may allow providers to operate more efficiently and help struggling providers keep their doors open in underserved areas, but it often reduces competition. A substantial body of evidence has found that consolidation can contribute to higher prices, with unclear effects on quality.

This analysis examines the competitiveness of markets for hospital care, based on RAND Hospital Data—a cleaned and processed version of cost reports from Medicare-certified hospitals—and American Hospital Association (AHA) survey data. The analysis examines competition among independent hospitals and health systems, referring to both as “health systems” throughout for brevity. Competition is measured in three ways: the share of metropolitan statistical areas (MSAs) controlled by a small number of health systems, the level of market concentration in MSAs based on the Herfindahl-Hirschman Index (HHI), and the share of hospitals affiliated with health systems over time. Using hospital data from 2024 (the most recent year available), this analysis focuses on general short-term or general medical and surgical hospitals depending on the dataset and excludes federal hospitals (see Methods for more details).

Key Takeaways

• One or two health systems controlled the entire market for inpatient hospital care in nearly half (47%) of metropolitan areas in 2024.
• In more than four of five metropolitan areas (83%), one or two health systems controlled more than 75 percent of the market.
• Nearly all (97% of) metropolitan areas had highly concentrated markets for inpatient hospital care when applying HHI thresholds from antitrust guidelines to MSAs.
• Most hospital markets in metropolitan areas (80%) became less competitive from 2015 to 2024 or were controlled by one health system over that entire period.

One or Two Health Systems Controlled the Entire Market for Inpatient Hospital Care in Nearly Half (47%) of Metropolitan Areas in 2024

Nearly one in five (19%) metropolitan statistical areas (MSAs) were controlled by a single health system, and more than one in four (27%) markets were controlled by two systems in 2024 (see Figure 1). In more than four of five metropolitan areas (83%), one or two health systems controlled more than 75 percent of the market. These markets all met the definition of highly concentrated markets based on thresholds in current antitrust guidelines (see below). One health system controlled at least half of the market in about three out of four MSAs (76%) and at least a quarter of the market in nearly every MSA (98%).

The number of health systems in a given MSA tends to increase with the population of the region. For example, in 79% of MSAs with a population of less than 200,000, one or two health systems controlled the entire market for inpatient hospital care in 2024, as in the Muncie, IN; Napa, CA; and Amherst Town-Northampton, MA MSAs (Figure 2). MSAs with one or two health systems account for nearly half (47%) of all MSAs but 12% of the U.S. population living in metropolitan areas.

Conversely, virtually all (54 of 55) MSAs with a population of at least one million people had at least four health systems, as in the MSAs encompassing Detroit, Miami, and Phoenix. MSAs with four or more health systems accounted for 35% of all MSAs but 79% of the U.S. population living in metropolitan areas.

However, in fourteen of these relatively large MSAs with four or more health systems, the two largest health systems controlled at least 75% of the market, and in 44 of these areas, they controlled at least 50% of the market. For example, in the MSA encompassing Austin, TX, with 2.6 million residents, two systems (HCA Healthcare and Ascension Healthcare) controlled 89% of the inpatient hospital care market, though Austin is home to more than four health systems. The metropolitan area encompassing Portland, OR, with 2.5 million residents and more than four health systems, is a less concentrated market than Austin’s, but the two largest systems (Legacy Health and Providence) still control a combined 62% of the market. (See Methods for discussion about MSAs as geographic hospital markets).

Nearly All (97% of) Metropolitan Areas Had Highly Concentrated Markets for Inpatient Hospital Care in 2024 Based on Thresholds Used in Current Antitrust Guidelines

Another way to assess market competitiveness is to evaluate a measure of concentration known as the Herfindahl-Hirschman Index (HHI), which is based on the number of participants in a market and their respective shares. The measure runs from 0 (perfectly competitive) to 10,000 (monopoly market). Based on current merger guidelines from the Federal Trade Commission (FTC) and Department of Justice (DOJ), markets can be grouped into three categories: not concentrated (HHI < 1,000), moderately concentrated (1,000 – 1,800), and highly concentrated (HHI > 1,800). This analysis calculates HHIs for MSAs and groups these regions accordingly, though there are other ways of defining the boundaries of hospital markets (see Methods).

Nearly all (97% of) MSAs had highly concentrated markets for inpatient hospital care in 2024 based on thresholds used in current merger guidelines (Figure 3). These guidelines reflect updates in 2023 that lowered the HHI thresholds for moderately concentrated and highly concentrated markets. Based on the thresholds used in prior guidelines, a large majority but somewhat smaller share (93%) of MSAs were highly concentrated markets for inpatient hospital care in 2024, closer to an estimate from an earlier study (90%) that used data from 2016.

As was the case when looking at counts of health systems in MSAs, larger metropolitan areas tended to be less concentrated and more competitive than less populated metropolitan areas, although this was not always the case. All 10 MSAs that were identified as either not concentrated or moderately concentrated had more than one million residents, such as the MSAs encompassing Cincinnati, Los Angeles, and Miami. However, 45 MSAs with more than one million residents—including the MSAs encompassing Houston, Denver, and Atlanta—had highly concentrated hospital markets. Overall, 72% of people living in metropolitan areas lived in highly concentrated hospital markets.

The Share of Hospitals Affiliated With Health Systems Increased From 56% in 2010 to 69% in 2024, With the Share Growing in Both Rural and Urban Areas

More than two thirds of hospitals (69%) are now part of a larger system, an increase from 56% in 2010 (Figure 4). A smaller share of rural than urban hospitals were part of a health system in 2024 (53% versus 80%), though shares have increased over time for both rural and urban regions: from 43% in 2010 to 53% in 2024 among rural hospitals and from 66% in 2010 to 80% in 2024 among urban hospitals.

Most system-affiliated hospitals in 2024 (52%) were part of a system with at least 15 hospitals, and 19% were in a system with at least 50 hospitals. Systems with at least 100 hospitals accounted for 10% of system-affiliated hospitals.

Hospitals joining larger systems may not always reduce local market competition, for example, if an independent hospital is acquired by a larger system that does not own facilities in the same market. However, mergers between hospitals that operate in different geographic markets for patient care—also known as “cross-market” mergers—may nonetheless lead to higher prices in some cases.

Most Hospital Markets in Metropolitan Areas (80%) Became More Concentrated From 2015 to 2024 or Were Controlled by One Health System Over That Entire Period

Four out of five metropolitan areas (80%) experienced an increase in hospital market concentration between 2015 and 2024 (Figure 5) or were controlled by a single hospital or health system for the duration. About two thirds of MSAs (65%) saw an increase in market concentration over this period, as measured by HHI, and the share of MSAs that were highly concentrated increased by two percentage points, from 95% to 97%. Fifteen percent of metropolitan areas were controlled by a single health system in both 2015 and 2024, meaning that concentration could not increase further in these markets. Concentration declined in only 20% of markets. In some cases, increases or decreases in concentration were very small.

The trend toward greater concentration was widespread across metropolitan areas of different sizes and regions. Among the 65% of MSAs that experienced increased concentration, the average HHI increased from 4,545 to 5,273, a 728 point increase. In markets that are not already controlled by one hospital or health system, market concentration may rise as a result of continued consolidation through mergers and acquisitions (Figure 4), shifts in hospital stays towards larger hospitals and health systems and away from smaller competitors, or hospital closures that reduce the number of competitors in a given market.

Methods

Analyses of market shares and HHI (e.g., every figure except for Figure 4) were based in part on RAND Hospital Data. RAND Hospital Data are a cleaned and processed version of annual cost reports that Medicare-certified hospitals are required to submit to the federal government. Although limited to Medicare-certified hospitals, in 2024, the analysis of RAND data included the vast majority (98%) of non-federal general medical and surgical hospitals in US metropolitan areas included in the analysis of system affiliation based on the AHA Annual Survey Database (see below). Cost reports were assigned to years based on the end of the reporting period and were scaled up or down to reflect a 365-day period, as necessary. In cases where a hospital had multiple cost reports assigned to the same analysis year, the cost report covering the longer reporting period was retained. When cost reports were longer than 365 days and fully spanned a calendar year (such as one beginning 1/1/2022 and ending 7/31/2023), the cost report was assigned to both the year spanned in full (2022) and the year in which it ended (2023).

Analyses of market shares and HHI were restricted to non-federal, general short-term hospitals as identified in the RAND Hospital Data. Some general short-term hospitals in the analysis were identified as other hospital types, such as surgical hospitals, in the AHA data (6% of those that could be matched), though these represented a small share of discharges (1%). Market shares were calculated as the share of inpatient discharges in an MSA that occurred within a given health system or independent hospital. One percent of hospitals that met the other sample restrictions had missing values for inpatient discharges and were excluded. Hospitals were grouped into health systems, as applicable, based primarily on the hospital’s system affiliation in the AHA Annual Survey Database. A previous version of this analysis relied on the AHRQ Compendium of US Health Systems, but that file has not been updated to include 2024 information.

For 2024 analyses, in the small number of cases where a cost report could not be matched to the AHA Annual Survey database (2% of observations), the 2023 AHRQ Compendium was used to identify the hospital’s corresponding AHA system identifier, where available. Twelve hospitals could not be matched to AHA or AHRQ records, of which 7 were manually assigned system affiliations based on internet searches. System affiliations for 40 hospitals (2% of the sample) were updated using the 2023 AHRQ Compendium when confirmed by internet searches in cases where: (1) the Compendium identified at least two hospitals in an MSA as being part of a Compendium health system that did not correspond to an AHA system and (2) at least one of those hospitals was identified as independent in the AHA data. In 3 instances (covering 11 hospitals), two AHA systems were combined into one when indicated by the AHRQ Compendium and confirmed through internet searches.

Analyses of changes in system affiliation and market structure over time (Figures 4 and 5) relied only on AHA system identifiers. When cost reports did not match to AHA data in the Figure 5 analysis, those hospitals were treated as independent.

MSAs reflect 2023 geographic definitions from the Census Bureau delineated based on data from the 2020 decennial census. HHIs were calculated as the sum of squared market shares for all health systems in a given MSA (e.g., an MSA divided evenly between two systems would have an HHI of 50² + 50² = 5,000). MSA population estimates for 2024 were obtained from the Census Bureau.

MSAs were used as a proxy for hospital markets, which is one approach used by other studies summarizing hospital market competition across the country. There are other ways of defining markets that would yield different results when calculating the level of competition. For example, one report also evaluated MSAs but focused on where residents received their care, including at hospitals outside of a given MSA. As another example, some have defined markets based on a radius around the hospital defined by distance or estimated travel time. More precise market definitions, such as those used to define competition in antitrust cases, were not feasible. This study did not exclude MSAs with populations of at least three million as some others have done, because the analysis sought to describe competition across all metropolitan areas.

The analysis of the share of hospitals affiliated with systems was based on the AHA Annual Survey Database alone. This analysis was restricted to nonfederal, general medical and surgical hospitals. Urban hospitals were defined as those operating in a metropolitan area, while rural hospitals were defined as those operating in nonmetropolitan areas. Metropolitan and nonmetropolitan designations were identified using Urban Influence Codes (UIC) data.

Introduction

Costs associated with health care and other household expenses weigh heavily on LGBT adults and health care affordability is poised to be a significant issue for all voters as we approach the 2026 midterm elections. This data note highlights the health care affordability challenges facing LGBT adults, a growing population that faces health related disparities, including related to both mental and physical health. At the same time, LGBT adults are a lower income group compared to non-LGBT adults. Findings from KFF Health Tracking Polls show that LGBT adults face more widespread concerns with affording basic necessities, including health care, compared to non-LGBT adults.

Findings

LGBT people, like the public overall, worry about the economy, with eight in ten (83%) LGBT adults saying their cost of living has increased in the past year, including more than half (58%) who say it has increased “a lot.” These are similar to the concerns among non-LGBT adults, 82% of whom say their cost of living has increased, including half who say it has increased “a lot”. Very small shares of both groups say their cost of living has “decreased” (4% of LGBT and 5% of non-LGBT adults). About one in ten LGBT and non-LGBT adults say their living expenses have remained stable over the past year (13% and 12%, respectively).

Large majorities of both LGBT adults and non-LGBT adults worry about being able to afford health care for themselves and their family, with health care topping the list of economic worries for non-LGBT adults. However, LGBT adults have broader and more pronounced concerns related to affording basic necessities across multiple categories. Three-quarters of LGBT adults (76%) say they worry about paying for health care, including the cost of health insurance and out-of-pocket costs for things like office visits and prescription drugs. This ranks similarly to their financial worries related to other household expenses like food and groceries (also 76%), rent or mortgage (74%), and monthly utilities (71%). In each case, these concerns are more widespread than those of non-LGBT adults, likely reflecting LGBT adults’ lower incomes. Cost-concerns related to gas and transportation were somewhat lower for LGBT adults (67%) compared to other household expenses but still outpaced worries among non-LGBT adults (51%). However, the survey was conducted prior to the recent rise in gas prices in the wake of the Iran war.

When asked specifically about prescription medication costs, nearly two-thirds of LGBT adults (64%) say that they are worried about being able to afford prescription drug costs for themselves and their family, similar to the share of non-LGBT adults (58%). However, LGBT adults are more likely to say they are “very worried” about these costs than non-LGBT adults (36% v. 20%).

In addition to reporting worries related to health care affordability, LGBT adults commonly report facing difficulty with these expenses in their day-to-day lives. Four in ten LGBT adults (43%) report problems paying for health care, and a similar share (39%) say they had problems affording prescription drugs in the past year. In both cases LGBT adults report experiencing these difficulties at higher rates than non-LGBT adults.

Introduction

As of March 18, 2026, Immigration and Customs Enforcement (ICE) reported that 46 people died while in their custody or detention facilities since the start of the second Trump administration in January 2025. The number of deaths of people in detention during 2025 exceeded the highest seen in over two decades, and deaths in 2026 are on track to meet or exceed that number. President Trump implemented immigration policy changes focused on increasing interior enforcement efforts to support mass deportation, which increased the number of immigrants detained by ICE to over 68,000 as of February 7, 2026, an increase of over 70% from the 39,000 immigrants held in detention at the end of the Biden administration in December 2024.

ICE is required to maintain certain basic health and safety standards in all detention facilities, which include an initial medical and mental health screening as well as comprehensive health services that include diagnoses and treatments, transfers to off-site medical care when necessary, and access to 24-hour emergency care. However, detention facilities have a history of inadequate compliance with health and safety standards, insufficient health care, shortages in health care staffing, and limited oversight, which may create health risks for those detained. The increased number of people in detention facilities and overcrowding of facilities may further increase health risks, particularly for communicable diseases like measles and people with complex medical conditions. This brief provides an overview of deaths in ICE custody and detention centers under the Trump administration based on KFF analysis of ICE detainee death reporting and news releases and reviews recent reports of health care issues in detention centers.

Deaths in ICE Custody and Detention

The number of deaths occurring among people in ICE custody or detention increased from 11 in 2024 and less than ten in earlier years to 33 in 2025 after the Trump administration took office (Figure 1). ICE is required to publish a news release with relevant details regarding custody deaths within two days, while full reports regarding custody deaths are published within 90 days of occurrence that may contain more details from investigations into the deaths. Six of the deaths that occurred between January 1, 2025 and March 18, 2026 were among people with no reported criminality or pending criminal charges. A total of 36 deaths occurred among people who spent three or fewer months in ICE detention, including those ICE transferred to a hospital for additional medical care. Thirty-eight (38) deaths occurred among people younger than age 65, and 21 were among those under age 45 (Figure 2). Twenty-two (22) deaths were among people from Mexico and Central America, while ten were among people from Asia.

A total of 32 deaths among people in ICE custody or detention between January 2025 and March 2026 were among people with existing medical conditions who appeared to experience worsening health complications contributing to their death, while the remaining share were reported as due to suicide or other causes (Figure 3). While ICE does not always report an official cause of death as determined by a medical examiner, they report the details of initial health screenings and medical history. The causes of death due to health complications and the initial severity of health conditions varied. For example, ICE detained a 68-year-old adult with reported mild blood pressure issues who experienced steadily worsening symptoms over the course of two months that led to his hospitalization and death. In contrast, a 55-year-old adult with severe physical and mental health issues was transferred one day after his arrest to a hospital, where he stayed until his death. ICE reported the remaining deaths as suicide (9) and other causes (5), such as a fatal traffic collision during arrest. ICE reporting may differ from independent assessments of deaths. For example, the El Paso County Medical Examiner’s Office in Texas ruled a death in January 2026 to be a homicide due to the actions of enforcement officers, while ICE reported it as a suicide.

Reported Health Care Issues

The Trump administration’s mass deportation efforts led to a significant increase in immigrants held in detention centers, which can lead to overcrowding if deportations do not keep up with the pace of arrests as well as challenges to accessing health care due to limited capacity and resources. Moreover, ICE payments to contractors providing medical care in detention facilities lapsed after the Department of Veterans Affairs terminated a longstanding agreement to process medical reimbursement claims in October 2025, which may impact certain health care services as the new claims system may not be active until April 2026. Overcrowding as well as limited capacity and resources may also increase the risk of the spread of communicable diseases, such as measles. For example, media reports indicate that recent measles outbreaks in Arizona and Texas detention facilities may have been the result of overcrowding and delays in providing vaccinations. ICE also terminated the contract with a private company that operated the Texas detention facility in March 2026 according to a media report indicating that, despite having no prior experience, the company was selected to build and operate the largest ICE facility and that there were reports of inadequate health care.

Reports since January 2025 suggest ICE may not be maintaining health and safety standards for immigrants held in detention centers. ICE is responsible for oversight and management of health care in detention facilities, but it has a history of inadequate compliance with detention standards and provides little to no publicly available data on health care use, quality, and outcomes. A 2025 report based on an investigation launched by Democratic Senator Jon Ossoff of Georgia documented instances of lack of access to prescribed medications, mistreatment of pregnant women, malnutrition and dehydration, unsanitary conditions, sleep deprivation, and abuse in detention facilities. A report based on interviews with people held at an Arizona detention facility between July 2024 to November 2025 conducted by a nonprofit organization serving detainees found instances of medical and mental health care lapses, such as several month delays in necessary specialty treatment and people with serious mental illnesses never seeing a mental health provider. Other media reports indicate instances of lost medical treatments and prescriptions during transfers between detention facilities.

There have also been recent reports of health care issues for children and pregnant people held in detention under the Trump administration. A media report on a Texas facility, where over half of detainees during the first nine months of the Trump administration were children, identified problematic health care issues, including inadequate staffing of pediatricians and child psychologists. Additionally, although ICE policy limits the detention of pregnant, postpartum, and nursing individuals to “very limited circumstances,” ICE data shared in response to an inquiry from Democratic Senator Patty Murray of Washington showing that 121 were detained as of February 16, 2026. This stands in contrast to when most of these groups were released on parole according to the most recent publicly available ICE report on these groups from the first half of fiscal year 2024. A media report and interviews conducted by legal organizations in 2025 with pregnant, postpartum, and nursing individuals in ICE detention identified gaps in prenatal and postnatal care. Another media report based on interviews with pregnant individuals held in ICE detention between 2025 and 2026 identified reports of excessive bodily restraints, inadequate nutrition and prenatal care, delayed emergency care, and an instance where ICE attempted to deport an individual in a late-term and high-risk pregnancy.

Several legal challenges related to poor health care conditions and limited oversight have been brought against ICE, some of which resulted in court rulings requiring ICE to implement changes. In February 2026, a judge ruled that ICE was required to improve conditions in California detention facilities due to poor conditions, including by ensuring adequate health care staffing, access to medical specialists, and providing timely care and medications. ICE faces pending lawsuits alleging that they delayed providing cancer care medication for an extended period of time during transit between facilities between August and October 2025 and that they provided inadequate medical care in Illinois in October 2025. In March 2026, local officials in California filed lawsuit to gain access to ICE facilities and conduct public health inspections after being denied access, and Maryland filed a lawsuit to obtain records detailing conditions at an immigration detention facility in Baltimore after investigations revealed multiple issues, including denial of medical care. These lawsuits to increase oversight followed a previous court order for ICE to restore unannounced congressional oversight visits to DHS facilities. A court order also required the Trump administration to restore DHS oversight offices that investigated issues of neglect and mistreatment in the ICE facilities. Despite reversing their decision to close the offices, the administration faces additional legal challenges due to low staffing in the offices that may reduce their ability to investigate ICE facility health care issues. The outcomes of court orders may change due to appeals by the Trump administration.

On September 18, 2025, the U.S. government (USG) released its new America First Global Health Strategy, which details how the U.S. will engage in global health efforts moving forward. As part of this new strategy, the U.S. has announced that it will be establishing bilateral health cooperation agreements with countries that receive U.S. global health assistance. These agreements, or Memorandums of Understanding (MOUs), between the U.S. and partner countries represent five-year plans (for the period 2026-2030) outlining U.S. engagement in each country’s health efforts with the goal of “helping countries move toward more resilient and durable health systems.” Central to these plans is transitioning country programs from U.S. assistance to long-term country ownership, with a pledge from each partner country to increase its domestic health spending, or co-investment in health, over the next five years as the U.S. decreases its health assistance. The U.S. began signing these agreements in late 2025 and this process is ongoing. Implementation is slated for later this year.

This tracker provides an overview of the MOUs signed to date. Data are based on press releases issued by the State Department, U.S. embassies, and partner country Ministries of Health, as well as MOU documents (if publicly available). See Methods for more information. This tracker will be updated as agreements are signed and more data become available.

Methods

This tracker provides information on U.S. MOU bilateral global health agreements to date. Information is sourced from publicly available U.S. Department of State, U.S. embassies, and partner country Ministries of Health press release statements and MOU texts, and will be updated as more information becomes available and when additional agreements are signed. Currently, MOU text, which contains the most detailed information of these sources, is publicly available for only a limited number of countries; for these countries, data were sourced directly from these MOU documents. For countries with available MOU documents, overall totals are based on the sum of annual amounts presented in the text. 

Program areas are captured using keyword searches; for global health security (GHS) specifically, country agreements were categorized as targeting GHS if they specifically mentioned GHS, or if they included descriptions of outbreak preparedness and response activities and containing health threats. Due to the limited nature of press release statements, this tracker may not comprehensively capture the global health program areas targeted in each country’s agreement.