Federal spending on bonus payments to insurance companies that offer Medicare Advantage plans will reach at least $12.8 billion in 2023, according to a new KFF analysis. That is a nearly 30% increase from 2022, and more than quadruple the spending in 2015.

These data come from one of three analyses released today by KFF that examine various facets of the Medicare Advantage program, which provides health insurance coverage to nearly 31 million Americans. KFF examined trends in enrollment, premiums, out-of-pocket limits, cost sharing, supplemental benefits, prior authorization, star ratings and bonus payments.

Bonus payments, which were established by the Affordable Care Act, are based on a five-star rating system and are intended to encourage Medicare Advantage plans to compete for enrollees based on quality. The payments vary substantially across firms, with UnitedHealthcare receiving the largest total payments ($3.9 billion) and Kaiser Permanente the highest payment per enrollee ($523).

Eighty-five percent of Medicare Advantage enrollees are in plans that are receiving bonus payments in 2023. The impact of star ratings on bonus payments lags a year, and several policies in place during the COVID-19 Public Health Emergency have expired, reducing 2023 star ratings relative to 2022, which will likely lead to a smaller share of enrollees in plans that receive bonuses in the 2024 plan year. 

Enrollment in Medicare Advantage in 2023 comprises more than 51% of the eligible Medicare population — more than twice the share enrolled in 2007 (19%), as noted in a companion analysis that provides the latest information about Medicare Advantage enrollment, by plan type and firm, and shows how enrollment varies by state and county.

Enrollment continues to be highly concentrated among a handful of firms, with UnitedHealthcare (29%) followed by Humana (18%), comprising nearly half of all Medicare Advantage enrollees nationwide, according to the analysis. Blue Cross Blue Shield (BCBS) affiliates (including Anthem BCBS plans) account for another 14%. And four other firms (CVS Health, Kaiser Permanente, Centene, and Cigna) account for another 23%.

Additional research released by KFF today shows that 73% of Medicare Advantage enrollees are in plans with prescription drug coverage (MA-PDs) that require no premium other than the Medicare Part B premium. KFF also documents that the vast majority of enrollees in Medicare Advantage plans have access to some benefits not covered by traditional Medicare, such as eye exams and/or glasses, hearing exams and/or aids, a fitness benefit, dental care, and reduced cost-sharing.

Plans are able to offer these extra benefits, often for no additional premium, largely due to the current Medicare payment system that provides an additional $2,350 per enrollee above plans’ estimated costs of providing Medicare-covered services, on average.

One tradeoff of enrolling in Medicare Advantage is that many plans routinely require patients to obtain prior authorization for services. Virtually all Medicare Advantage enrollees (99%) are in plans that require authorization for some services, according to the analysis.

For more information, please visit:

• Medicare Advantage in 2023: Enrollment Update and Key Trends
• Medicare Advantage in 2023: Premiums, Out-of-Pocket Limits, Cost Sharing, Supplemental Benefits, Prior Authorization, and Star Ratings
• Spending on Medicare Advantage Quality Bonus Payments Will Reach at Least $12.8 Billion in 2023

Policymakers and the media have been increasingly attentive to mergers and acquisitions and other potentially anticompetitive practices of hospitals, physicians, and other health care providers. Consolidation has the potential to increase efficiency and help some struggling providers to keep their doors open in relatively underserved areas, but it can also reduce market competition and ease pressure on providers to lower prices or invest in quality improvements. A substantial body of evidence shows that consolidation has led to higher prices without clear evidence of improvements in quality, which has implications for consumers and employers. As a result, some have proposed strengthening antitrust regulation—which aims to protect competitive markets—as a tool for tackling rising health care costs, increasing the affordability of care, and reducing the large number of adults with medical debt.

Federal and state antitrust agencies play a role in challenging anticompetitive practices of health care providers and other businesses. At the federal level, the Federal Trade Commission (FTC) and the Department of Justice (DOJ) share responsibility for enforcing federal antitrust laws, including the Sherman Act, the Clayton Act, and the FTC Act. State attorneys general (AG) offices also have the authority to bring action under federal antitrust law, as well as under state statutes, which sometimes expand upon federal law.

This issue brief explains the role of federal and state antitrust agencies in challenging anticompetitive practices among health care providers, including the legal authority of federal and state agencies, the role that they play in enforcing antitrust laws, and proposed options for strengthening their authority. The brief focuses on health care providers, though many of the principles discussed in this issue brief apply to the practices of other health care entities as well, such as health insurers and pharmacy benefit managers (PBMs) (which are currently being reviewed by the FTC).  While the focus of this brief is on the role of government agencies, antitrust law also authorizes private parties, such as employer health plans, to challenge anticompetitive practices in the courts.

What types of anticompetitive practices do governments challenge and why?

Governments challenge anticompetitive practices to promote competitive markets, often for the benefit of consumers (e.g., patients and health plan enrollees).¹  Governments seek to address a variety of anticompetitive practices that may lead to higher prices without commensurate improvements in quality of care. These include anticompetitive mergers and acquisitions (referred to as “mergers” in this brief), and other activities that hinder competition (referred to as “nonmerger anticompetitive practices” in this brief).

Provider consolidation can be beneficial to consumers in some instances and detrimental in others. On the one hand, consolidation has the potential to increase efficiency, such as by allowing providers to purchase supplies in bulk at a discount or by facilitating the coordination of care across different providers. On the other hand, consolidation has the potential to lead to worse outcomes for consumers by increasing providers’ market power and decreasing competition, which enhances the ability of providers to negotiate for higher prices (increasing costs for consumers and employers) and reduces the pressure on providers to invest in quality improvements. A substantial body of evidence shows that consolidation has led to higher prices without clear indications of quality improvements, though the strength of this evidence varies based on the type of consolidation and provider.

There are three main types of mergers:

• Horizontal mergers occur when there is consolidation between providers that offer the same or similar services, such as when a health system acquires a hospital or when two physician practices that provide overlapping services merge. Horizontal mergers can raise concerns about competition because they, by definition, reduce competitiveness when occurring between providers in the same market, and because consolidated entities can take actions to increase and protect their market power.
• Vertical mergers occur when there is consolidation between providers that offer different services along the same supply chain, such as when a hospital acquires a physician practice. Vertical mergers can raise anticompetitive concerns, for example, if physicians refer patients to hospitals within their health system rather than to competing hospitals. Some mergers may entail both vertical and horizontal consolidation (e.g., if a health system acquires a physician group that provides services offered by the system’s existing physician group).
• Cross-market mergers occur when there is consolidation between providers that operate in different geographic markets.²  Cross-market mergers may raise concerns about competition, for example, if a health system with providers in different areas of a state is able to use its dominant position in one market to negotiate higher prices in another when contracting with a given health plan (e.g., a state employee plan with enrollees that reside in several markets).

Governments also challenge other types of anticompetitive practices, such as the use of anticompetitive clauses in contracts between providers and insurers or providers and workers. Anticompetitive contract clauses give dominant parties an unfair advantage over potential competitors and can lead to higher prices. For example, some health systems have highly regarded hospitals (also known as “must have” hospitals) that insurers need to include in their provider networks in order to attract enrollees, which gives these systems substantial bargaining leverage over insurers. These health care systems can in turn use this bargaining leverage to pressure insurers to contract with all providers in the system (through “all-or-nothing clauses”), shielding expensive or low-quality members from competition with more desirable providers. The textbox below provides definitions of various anticompetitive contract clauses.

What federal antitrust laws govern anticompetitive practices?

There are three primary federal antitrust laws—the Sherman Act, the Clayton Act, and the FTC Act—that prohibit anticompetitive mergers and other anticompetitive practices.

• The Sherman Act (1890) broadly prohibits anticompetitive practices. It has been used to challenge various anticompetitive practices, such as mergers, wage suppression, agreements among competing businesses to fix prices, and anticompetitive contracting clauses.
• The Clayton Act (1914) builds on the Sherman Act by explicitly prohibiting anticompetitive mergers as well as other types of anticompetitive practices that are not clearly addressed by the Sherman Act (such as by barring the same individual from serving on the board of directors for two competing health systems, with some exceptions). Additionally, as amended under the Hart-Scott-Rodino Act in 1976, the law requires that merging entities report their plans in advance to federal regulators in certain cases where the transaction exceeds a specified value ($111.4 million in 2023), which gives regulators time to investigate and intervene if needed.
• The Federal Trade Commission (FTC) Act (1914) created the FTC and prohibits “unfair methods of competition” and “unfair or deceptive acts or practices.” The FTC Act encompasses the same types of violations that are covered by the Sherman Act and the Clayton Act, in addition to other anticompetitive practices, and grants the FTC regulatory authority. Unlike the Sherman Act and the Clayton Act, the Act generally cannot be applied to nonprofit entities.⁵ 

Some forms of business practices, such as almost all instances where competitors coordinate to raise prices, are inherently illegal under federal law. The legality of other types of business practices depends on the context. For instance, when government agencies challenge a merger, courts assess whether the merger would likely harm competition in a given market.

What is the FTC’s role in enforcing federal antitrust law?

Two federal agencies—the FTC and DOJ—have overlapping, as well as distinct, authority to challenge anticompetitive practices under federal law. The FTC is the only entity that can enforce the FTC Act. Although this Act generally cannot be applied to nonprofit entities, the FTC has the authority to enforce the Clayton Act against nonprofit entities (in addition to for-profit entities), such as by challenging anticompetitive mergers among nonprofits. The DOJ has the authority to enforce the Sherman and Clayton Acts. States can also bring lawsuits under federal antitrust law, as can some private parties, such as competing providers.

The FTC focuses on “protecting the public from deceptive or unfair business practices and from unfair methods of competition.” This includes challenging activities such as misleading advertisements, violations of consumers’ data privacy, and efforts to accumulate market power through mergers and other anticompetitive practices. For instance, the FTC sued Facebook in 2020, alleging, in part, that the company had sought to maintain its monopoly power by buying up competitors, such as Instagram and WhatsApp.

The FTC plays a larger role than the DOJ in enforcing federal antitrust law in health care provider markets, though there are gaps in its authority. The FTC and DOJ have each developed expertise in certain areas and have tended to divide merger oversight accordingly, with the FTC typically overseeing provider markets and the DOJ typically overseeing insurance markets (see more below). However, although the FTC has broad authority to challenge anticompetitive mergers, its authority to challenge other anticompetitive practices often excludes nonprofits. Nonprofit ownership is common in provider markets. For example, nonprofits account for about three-fifths (58%) of community hospitals in 2023. The DOJ may fill in for the FTC when the FTC does not have the authority to challenge nonprofit providers that are engaging in certain anticompetitive practices (see example of Atrium Health below).

The FTC has successfully challenged several hospital mergers over the past two decades. Beginning in the 1990s and for several years afterwards, the FTC had difficulty challenging hospital mergers in the courts, allowing rapid consolidation in the hospital sector to continue unabated.⁶  Since the late 2000s, the FTC has since been more successful in challenging hospital mergers, reflecting advances in both economics and the FTC’s new legal strategies.⁷  However, the FTC challenges only a fraction of hospital mergers, and it is difficult to know the extent to which mergers that go unchallenged have an adverse impact on consumers, in terms of costs and quality. For instance, in 2022, the FTC challenged 3 hospital mergers and, in each case, the hospitals abandoned their plans to merge, while one analysis documented 53 hospital merger announcements in that year. The same analysis identified more hospital merger announcements in the years prior to the start of the COVID-19 pandemic (e.g., 92 in 2019).

The FTC has played a smaller role in challenging physician mergers. A key challenge is that physician mergers tend to be smaller, and physician groups often grow slowly over time by acquiring small group practices and hiring new physicians. As a result, physician groups often do not need to report mergers to federal regulators as their transactions tend to fall below Hart-Scott-Rodino reporting thresholds (though regulators can still challenge mergers that they learn about in other ways). Additionally, because they tend to be small, any given merger may not have an appreciable effect on market power, even if the cumulative effect of these mergers leads to a large concentration of market power over time.

Vertical mergers in health care provider markets have largely escaped FTC enforcement and the FTC has never challenged a cross-market merger, though it has expressed interest in both practices. For instance, in 2021, the FTC announced that it would begin to study the effect of vertical mergers between health care facilities and physician groups. The FTC previously conducted studies of horizontal mergers in advance of successful litigation. The FTC has also investigated specific instances of cross-market mergers, although it has yet to bring a challenge.

The FTC has not played a large role in overseeing nonmerger anticompetitive practices in nonprofit health care provider markets, such as the use of anticompetitive contract clauses. This may reflect the fact that the FTC’s authority to challenge and regulate nonmerger anticompetitive practices generally excludes nonprofit entities. Nonetheless, the FTC has brought legal challenges in some instances, such as cases where separate physician groups have coordinated with each other to raise prices. Relatedly, the FTC drew on its regulatory authority when it proposed a rule in 2023 that would ban non-compete clauses between employers and workers.

What is the DOJ’s role in enforcing federal antitrust law?

The DOJ enforces a wide range of laws on behalf of the federal government, including—through its Antitrust Division—anticompetitive practices. For instance, in one landmark antitrust case in the 1990s, the DOJ sued Microsoft, alleging that the company had illegally sought to protect its monopoly power. The DOJ argued that the company had done so, in part, by requiring computer manufacturers that wanted to use Microsoft’s popular Windows operating system to also include Internet Explorer as a default.

Although the FTC typically oversees the conduct of health care providers, the DOJ has occasionally done so as well (see example below).

The DOJ typically takes the lead in promoting competition in health insurance markets. For instance, in 2017, the DOJ, along with some state governments, successfully prevented a proposed merger between Anthem and Cigna—which would have been the largest merger of health insurance companies on record—and a proposed merger between Aetna and Humana.

How do the FTC and DOJ work together on antitrust issues?

The FTC and DOJ have a clearance process to determine which agency will investigate and challenge a given merger. The FTC and DOJ have each developed expertise in different areas and have tended to divide merger oversight accordingly, with the FTC typically overseeing provider markets and the DOJ typically overseeing insurance markets. The division of labor is formalized through a clearance process that determines which agency will investigate a proposed transaction based on its expertise and other factors, such as its capacity and ties to a given case.

The FTC and DOJ collaborate on guidelines that establish how they determine whether to challenge a given merger. This includes the Horizontal Merger Guidelines, which, as the name suggests, outline the criteria that the FTC and DOJ consider when reviewing horizontal mergers. For instance, the guidelines indicate that the agencies evaluate the effects of a merger on market concentration based on a measure known as the “Herfindahl-Hirschman Index” (HHI) (see textbox below). The guidelines also indicate that the agencies consider the possible benefits of a given merger, such as whether a merger might allow research to be conducted more effectively.

Although markets for inpatient hospital services are now often highly concentrated, there is wide variation across the country. For instance, one study estimated that, in 2021, the New York City metro area had an HHI of 753 for inpatient hospital services, while the Wilmington, North Carolina metro area had an HHI of 7,600.

The FTC and DOJ have also released a set of Vertical Merger Guidelines, though the FTC withdrew from these guidelines in 2021. Some economists are more critical of the Vertical Merger Guidelines than the Horizontal Merger Guidelines, perhaps reflecting the fact that there is less consensus about the effects of vertical consolidation and the proper role of antitrust enforcement.

In July 2023, the FTC and DOJ released a draft version of their updated merger guidelines, which would apply to both horizontal and vertical mergers and which indicate that the agencies will be scrutinizing a broader range of mergers. Among other changes, the draft guidelines expand the definition of highly concentrated markets, rely on a lower threshold for identifying large changes in market concentration, consider the combined effect of a series of acquisitions (e.g., of a health system acquiring several small physician practices over time), and add an explicit discussion of the agencies’ views on how workers may be negatively impacted when their employers merge. These guidelines might also be used to challenge cross-market mergers, although this is not yet clear. The deadline for public comments on the draft guidelines is September 18, 2023.

In addition to working together on general merger guidelines, the DOJ and FTC have in the past collaborated on antitrust policy statements that are specific to health care, though both agencies withdrew from these statements in February 2023 and July 2023, respectively, arguing that the statements are outdated based on changes in health care markets.⁸ 

What is the role of states in enforcing antitrust law?

States can bring legal challenges under federal antitrust law. States may do so through their AG offices as either a purchaser of health care (for instance, through state employee health plans) or on behalf of their residents. States sometimes file lawsuits jointly with each other or with the federal government, which can help overcome resource constraints. States and the federal government may play complementary roles, with the federal government providing greater resources and general antitrust expertise and states providing more specialized knowledge of local market conditions.

Most states have passed laws that expand oversight of provider mergers, which may lead to additional legal challenges. Thirty-four states and DC require that at least some hospitals notify state AG offices of their plans to merge, expanding on federal reporting requirements. For instance, Rhode Island requires all hospitals to do so, regardless of the value of the transaction. Additionally, thirteen states and DC require that some or all types of providers receive approval from the government prior to merging, instead of requiring that the government file a lawsuit to challenge a merger. Eleven states require AG offices to consider relatively expansive criteria when reviewing health care mergers. For instance, California law requires the AG office to consider criteria such as the general public’s interest and the effect of a merger on access to care.

Some states have prohibited certain types of anticompetitive contract clauses. These laws either broadly prohibit a given type of clause or ban their use in only specific circumstances. Regarding contracts between insurers and dominant providers, two states (Massachusetts and Nevada) have laws restricting at least some all-or-nothing clauses and anti-tiering or anti-steering provisions, and five states (Massachusetts, Minnesota, Nevada, New Hampshire, and Wisconsin) have laws restricting exclusive contracting. Additionally, 22 states restrict non-compete provisions—which dominant providers sometimes use in contracts with their workers—and 20 states restrict most favored nation clauses, which dominant insurers sometimes use in their contracts with providers.

Some states have enacted laws that have the potential to shield health care providers from antitrust scrutiny in certain instances.  For example, 19 states have Certificate of Public Advantage (COPA) laws, which immunize a merger from antitrust challenges while directly regulating the merged entity for a period of time, such as by limiting price increases or prohibiting certain contracting practices. The intent of COPA laws is to facilitate mergers that are perceived as being beneficial overall while mitigating anticompetitive concerns through state oversight. However, the FTC and some researchers have been critical of these laws, arguing, for example, that states have not followed through in providing ongoing oversight following a given merger. Other state policies, such as Certificate of Need (CON) statutes—which attempt to reduce costs by restricting, for example, the construction of new facilities when they do not meet a community need—may also play a role in limiting competition or preventing antitrust scrutiny.

What are the potential remedies in antitrust enforcement?

Federal or state agencies challenging a merger can seek structural remedies or conduct remedies (also known as “behavioral remedies”).

• Structural remedies mitigate consolidation by preventing a merger from moving forward, breaking up mergers that have already taken place, or requiring a merged entity to sell off a portion of its business.
• Conduct remedies entail restrictions or requirements imposed on providers after a merger, such as by limiting the prices providers can charge, prohibiting providers from engaging in certain contracting practices, or requiring providers to spend a minimum amount on community benefits.

Conduct remedies may be less effective than structural remedies in certain circumstances, as they tend to be time-limited and government agencies may not have the resources to monitor and enforce them. However, where markets are already concentrated and regulators are reluctant to break up merged entities, conduct remedies may be the only option.

When the government challenges proposed mergers before they occur, the recourse is typically to prevent the merger from moving forward. Antitrust enforcers have only infrequently attempted to unwind mergers that have already taken place, which the FTC describes as a “difficult and potentially ineffective” process.

There are other ways in which the government can be successful in challenging anticompetitive mergers. For example, the government and merging providers may avoid trial through a settlement agreement or consent decree. In this scenario, the government drops its legal challenge in exchange for structural or conduct remedies. Additionally, providers may abandon a merger after a lawsuit is announced or a court makes a preliminary ruling against the merger or may decide not to attempt to merge in the first place in anticipation that doing so would be successfully challenged in court.

The outcomes of successful legal challenges to nonmerger anticompetitive practices are similar, though the remedy would involve abandoning the relevant business practice (e.g., no longer using anticompetitive contract clauses).

What are some practical challenges facing antitrust enforcement?

There are at least a few challenges that may limit the ability of the federal government and states to foster competitive provider markets through antitrust enforcement:

• It is difficult to break up mergers after they have already occurred, and many provider markets are already highly concentrated. For example, one study estimated that the vast majority (90%) of metropolitan statistical areas (MSAs) had highly concentrated hospital markets in 2016 (i.e., with an HHI above 2,500), most (65%) had highly concentrated specialist physician markets, and nearly two in five (39%) had highly concentrated markets for primary care physicians. Breaking up a merger after providers have already consolidated can be difficult. At the same time, regulating the behavior of merged providers—such as through restrictions on the prices they charge—may be difficult to do on an ongoing basis.
• Some regions cannot support competitive provider markets. For instance, rural communities may not have enough residents to support several providers that offer the same service.
• Antitrust litigation can be complex and expensive. Without adequate funding, it may be impractical to challenge a large number of provider business practices that raise anticompetitive concerns.
• Antitrust agencies may have difficulty staying ahead of market trends. For example, it could take time for the government to develop strong guidelines for challenging vertical or cross-market mergers and to accumulate enough evidence to convince courts that these practices harm competition. In the meantime, these mergers will likely continue.
• The benefits of competitive provider markets for individuals with health insurance will depend in part on the competitiveness of health insurance markets. The study referenced above also estimated that most MSAs (57%) had highly concentrated insurance markets in 2016. When insurance markets are not competitive, cost savings from competitive provider markets might not be fully passed along to consumers.

What policies have been proposed to strengthen antitrust law and enforcement?

Several federal and state policy proposals have been floated to help antitrust regulators more easily identify and challenge anticompetitive mergers and regulate markets that are already concentrated. One set of policies would make it easier for governments to enforce antitrust law, such as by requiring more providers to report any planned mergers, lowering the legal standards by which mergers are deemed anticompetitive, and mandating that providers receive approval from the government before merging. Another set of policies would increase the scope of antitrust law, such as by giving the FTC full authority to regulate nonprofit providers and outlawing certain anticompetitive contracting clauses. A third set of proposals would improve the infrastructure of antitrust enforcement, such as by increasing funding for antitrust agencies, creating agencies to monitor health care markets (as some states have done), and establishing specialized courts for antitrust cases.

Discussion

The FTC, DOJ, and states seek to promote competition in health care markets to encourage providers to lower costs for consumers and provide high quality medical care. Over the years, FTC, DOJ, and some states have challenged mergers as well as other anticompetitive practices. Nonetheless, there are inherent challenges to an approach that relies solely on efforts to foster competitive provider markets through antitrust regulation, particularly given the already high level of market concentration of providers across the country.

Several policy ideas have been floated at the federal and state level that are intended to strengthen antitrust regulation. However, given the challenges facing antitrust regulation and pro-competition policies, some policymakers have proposed a more direct regulatory approach, such as by capping prices or price growth or by establishing global budgets for hospitals. Some proponents of these approaches have highlighted that antitrust efforts and regulatory approaches could play complimentary roles. For instance, caps on health care prices could serve as a backstop in concentrated markets where at least some providers would not otherwise offer competitive rates or in small markets that are unable to support competition. Antitrust regulation may also play a useful role under price regulation, for example, by encouraging providers to compete for patients by offering higher quality care.

1. Among other objectives, there has also been increasing interest in promoting competition to protect workers from large, dominant employers. For example, SEIU Healthcare Pennsylvania recently filed a complaint with the DOJ that UPMC, a large health system in Pennsylvania, had used its market power to suppress the wages of nurses and other health care workers, increase workloads, and restrict the ability of health care workers to seek better employment elsewhere. ↩︎
2. For example, BJC Healthcare—which is based in St. Louis, Missouri—recently announced plans to merge with Saint Luke’s Health System, which is based across the state in Kansas City. ↩︎
3. Gag clauses, which prevent insurers and providers from disclosing negotiated rates, are an additional type of anticompetitive contracting clause. However, these have been prohibited by the Consolidated Appropriations Act of 2021. ↩︎
4. The benefits of these clauses to different parties may be more complicated in practice. For instance, while some dominant insurers may require most favored nation clauses in their contracts with providers, some dominant providers may offer these clauses to insurers to help facilitate increases in their prices. ↩︎
5. One exception is that the FTC Act can be applied to nonprofit health insurance companies (in addition to for-profit health insurance companies), as authorized by the Competitive Health Insurance Reform Act of 2020. ↩︎
6. The FTC and DOJ lost six consecutive cases against hospital mergers during this time and then refrained from bringing legal challenges for several years. Part of the reason for their limited success reflected the reliance of courts on an older economic framework that tended to suggest that geographic markets for hospital care were large, and therefore appeared to be more competitive than they were in reality. Courts at the time also questioned whether mergers between nonprofit hospitals would raise prices, though more recent research suggests that this may be the case. ↩︎
7. One turning point occurred when the agency successfully challenged a merger between Evanston Hospital and Highland Park Hospital (both nonprofits) in the Chicagoland area. The FTC first filed a complaint in 2004 after the merger had already taken place, which allowed the FTC to introduce direct evidence that the merger had led to increases in prices. The agency also provided evidence suggesting that previous methods for defining geographic markets resulted in boundaries that were too large, and it presented new models developed by economists that implied much narrower geographic markets, with greater market concentration. Relatedly, the agency’s evidence of actual price changes weakened arguments that hospitals would behave differently because of their nonprofit status. Courts have continued to rely on the new economic models used in this case, and the evidence that hospital mergers lead to price increases has grown over time. ↩︎
8. This included withdrawing from several statements that had discussed various scenarios involving providers, such as hospital mergers, certain joint ventures, information sharing arrangements, and joint purchasing agreements. These statements had described how the agencies would conduct antitrust analyses and identified scenarios, known as “safety zones,” that would have generally been exempt from antitrust scrutiny (e.g., hospital mergers involving small, low-volume hospitals). The FTC and DOJ also withdrew from a policy statement that had described the agencies’ approach to regulating accountable care organizations (and which had been timed with the release of the Centers for Medicare and Medicaid Services final rules for the Medicare Shared Savings Program). ↩︎

Note: This data note was updated on Aug. 4, 2023, to correct a data error in Figure 4.

From 2011 to 2022, over half a million lives (539,810) were lost to suicide, with 2022 showing the highest number of deaths on record. Within this period, the adjusted suicide rate increased by 16%. Recognizing the mounting mental health crisis and demand for accessible crisis care, the federal government introduced a new crisis number, 988, available nationwide in July 2022. This easy to remember three-digit number connects callers who are suicidal or experiencing a mental health emergency to a crisis counselor at one of 200+ local crisis call centers. There, they may access crisis counseling, resources, referrals, and connections to other crisis services. Though suicide deaths slowed in 2019 and 2020, they began to increase again in 2021 and 2022, but the cause of this recent rise in suicides is unclear.

Key takeaways from an analysis of aggregate provisional data from 2022 and CDC WONDER data from 2011 to 2021, which represents the most recent and comprehensive data available before the mid-2022 launch of 988, include the following:

• CDC’s provisional data for 2022 show a record high of 49,369 suicide deaths, coming after modest declines in 2019 and 2020.
• In 2022, provisional data indicates the highest number of gun-related suicides on record; increases in firearm suicides are driving the increases in overall suicide deaths in recent years.
• Suicide death rates in 2021 were highest among American Indian and Alaska Native people, males, and people who live in rural areas.
• Suicide deaths are increasing fastest among people of color, younger people, and those who live in rural areas with many groups seeing increases of 30% or more from 2011 to 2021.
• Suicide death rates varied considerably by state in 2021, as did the rate of change between 2011 and 2021.

Provisional CDC data show that the number of suicide deaths in 2022 is the highest recorded, exceeding the next closest year (2018) by over 1,000 deaths (Figure 1). When adjusted for population growth and age, the suicide rate has risen by 16% from 2011 to 2022, moving from 12.3 to 14.4 deaths per 100,000 individuals. Looking back further to 1999, there is a substantial 37% increase from a rate of 10.57 per 100,000. Notably, while 2022 had the highest recorded number of suicide deaths, its rate is similar to 2018 (14.5 in 2022 vs. 14.2 in 2018 per 100,000) but higher than the rate in 2020—the year before suicide deaths began to climb again. Increases in the number of suicide deaths follow high levels of mental health symptoms during COVID, rising financial stressors, and longstanding difficulty accessing needed mental health care—particularly for some populations. Total suicide numbers may be undercounted, as some research suggests that suicides may be misclassified as drug overdose deaths since it can be difficult to determine whether drug overdoses are intentional.

Provisional data from 2022 show the highest number of firearm-related suicides on record, driving the overall increases in suicide deaths to record levels. Firearm-related suicides have been increasing in recent years. In 2021, firearm-related suicides increased by 8% from 2020 and went up another 3% in 2022, while deaths from other suicide methods remained more stable (Figure 2). Firearm-related suicides are now the most common method of suicide, accounting for 55% of all suicide fatalities in both 2021 and 2022. The availability of guns (measured indirectly by the number of gun laws in a state) is linked to firearm suicide rates – with states with fewer gun laws having higher rates. Suicide deaths accounted for more than half (55%) of all deaths involving a firearm in 2021.

Suicide death rates in 2021 were highest among American Indian and Alaska Native (AIAN) people, males, and people who live in rural areas. As of 2021, AIAN people had the highest suicide death rate at 28.1 per 100,000 people, one and a half times higher than the rate for White people (17.4 per 100,000 people). Suicide death rates for Black, Hispanic, and Asian and Pacific Islander people were at least half the rate of White people. Females are more likely to report mental illness and are more likely to attempt suicide, but male suicide death rates are four times higher (22.8 versus 5.7 per 100,000). Non-metropolitan areas have a higher suicide rate (20.2 per 100,000) than metro areas (13.6 per 100,000). There are similar suicide rates across adult age groups in 2021 (Figure 3). Because younger people are less likely to die of other causes, suicides are the second leading cause of death in adults under the age of 45, accounting for 16% of deaths in people 18-25 and 9% of deaths in people 26-44 in 2020. 

Suicide deaths are increasing fastest among people of color, younger individuals, and people who live in rural areas. Between 2011 and 2021, suicide death rates increased substantially among people of color, with the highest increase among AIAN people (70% increase, from 16.5 to 28.1 per 100,000), followed by Black (58% increase, from 5.5 to 8.7 per 100,000), and Hispanic (39% increase, 5.7 to 7.9 per 100,000) people (Figure 3). Other studies show a particularly large increase in suicide deaths among Black youth and adolescents. Underdiagnosis of mental health conditions, structural barriers to care, stereotypes and discrimination associated with poor mental health, racism and discrimination, and disparities in the use of mental health services may all contribute to rising suicide rates among people of color. Among adolescents, emergency department visits for suicide attempts have increased in recent years, primarily driven by females. And a KFF/CNN survey found that roughly half of parents said the pandemic had a negative impact on their child’s mental health, including 17% who said it had a “major negative impact.” In rural areas, suicide death rates increased significantly, possibly due to acute shortages of mental health workers in these areas. The suicide death rate also increased in adolescents (48% increase, from 4.4 to 6.5 per 100,000) and young adults (39% increase, from 13.0 to 18.1 per 100,000) between 2011 and 2021 (Figure 3).

Suicide death rates varied substantially by state in 2021, as did the rate of change from 2011 to 2021. Suicide death rates by state range from a low of 6.21 per 100,000 population in Washington, D.C. to a high of 32.34 in Wyoming, with a median death rate of 15.3 per 100,000 in 2021 (Figure 4). The suicide rate may vary by state due to factors such as demographics, firearm availability (involved in over half of suicides), mental health status, and access to mental health services. Between 2011 and 2021, suicide death rates increased by 25% or more in 12 states, with the largest increases in Alaska (54% increase, from 20.0 to 30.8 per 100,000), South Dakota (48% increase, from 15.7 to 23.4 per 100,000), Nebraska (43% increase, from 10.5 to 15.0 per 100,000), and Montana (42% increase, from 22.5 to 32.0 per 100,000).

While the exact cause for the rise in suicides in recent years is unknown, it may reflect, in part, increasing stressors and longstanding unmet mental health needs—challenges that coincide with 988’s launch. In its first year, 988 improved answer rates and reduced wait times while handling nearly 5 million contacts due to surging demand; however, its influence on overall suicide rates, particularly among people of color or other vulnerable populations, is yet to be seen. Since its introduction in July 2022, 988 has received almost 5 million contacts, including almost 1 million from the Veteran’s Crisis Line. While early nationwide metrics look positive, disparities in state performance and questions about long-term funding for state call centers and crisis infrastructure persist. Current publicly available data on 988 gives only a partial view of its implementation and possible access challenges. Analysis of more comprehensive 988 metrics, coupled with future data on suicide attempts and deaths may help shed light on the impact of 988 and related crisis services in addressing escalating suicide deaths.

If you or someone you know is considering suicide, contact the 988 Suicide & Crisis Lifeline at 988.

More than 49,000 people died by suicide across the country in 2022, a record number driven largely by an increase in the number of firearm-related deaths, a new KFF analysis of provisional CDC data shows.

Firearm-related suicide deaths have been increasing in recent years and are now the most common method of suicide, accounting for 55% of all suicide deaths in both 2021 and 2022. Deaths from other suicide methods have remained relatively steady.

The recent increase in suicide deaths follows high levels of mental health symptoms during the COVID pandemic, financial stressors, and difficulty accessing needed mental health care—particularly for some populations.  

Suicide deaths are increasing fastest among people of color, younger individuals, and people who live in rural areas. Between 2011 and 2021, suicide death rates increased substantially among people of color, with the highest increase among American Indian or Alaska Native people (70%), followed by Black people (58%) and Hispanic people (39%). The suicide death rate also increased among adolescents (48%), young adults (39%), and people who live in rural areas (26%) during the same period.

In July 2022, a three-digit crisis number, 988, launched nationally to provide an easy-to-remember way for people who are suicidal or experiencing a mental health emergency to connect with a crisis counselor and other resources. In its first year, 988 improved answer rates and reduced wait times while handling nearly 5 million contacts because of surging demand; however, its influence on overall suicide rates, particularly among people of color or other vulnerable populations, remains to be seen.

From 2011 to 2022, over half a million people (539,810) died by suicide, with 2022 showing the highest number of deaths on record. Within this period, the adjusted suicide rate increased by 16%. The rate increased by 37% since 1999.

Read “A Look at the Latest Suicide Data and Change Over the Last Decade” for more information about suicide death rates between 2011 and 2022.

ACA Marketplace insurers are requesting a median premium increase of 6% for 2024, according to a new KFF analysis of the preliminary rate filings. Insurers’ proposed rate changes – most of which fall between 2% and 10% – may change during the review process.

Although most Marketplace enrollees receive subsidies and are not expected to face these added costs, premium increases could result in higher federal spending on subsidies.

Insurers cite price increases for medical care and prescription drugs as a key driver of premium growth in 2024, according to KFF’s examination of publicly-available documents from 58 insurers.

In addition to inflation’s impact on medical costs, insurers point to growth in the utilization of health care, which fell in 2020 but has since returned to more normal levels.

Meanwhile, the impact of COVID-19-related costs on premiums remains much more uncertain. While some of the 320 ACA Marketplace insurers expect vaccine commercialization to increase costs on a per-dose basis, drops in COVID treatments and new cost sharing for testing may lower insurer costs and offset some growth in premiums.

A small number of insurers cite other potential drivers of premium hikes, including the unwinding of the Medicaid continuous enrollment provision (which has already led to the disenrollment of at least 3.8 million people from Medicaid) and new high-cost weight loss drugs.

The full analysis and other data on health costs are available in the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Nearly half (45%) of the public are at least somewhat interested in taking a prescription weight-loss drug, including many who say they only want to lose a little weight, though many people lose interest when presented with potential financial and medical drawbacks, the latest KFF Health Tracking Poll reveals.The poll gauges the public’s interest in using prescription drugs to lose weight as a relatively new class of drugs, initially approved to treat diabetes, is garnering attention for their potential to aid weight loss. Among those trying to lose weight, six in 10 (59%) say they would be interested in a safe and effective weight-loss drug, including half (51%) of those who say they are trying to lose less than 10 pounds.People’s interest in trying such drugs drops significantly when asked about potential obstacles and drawbacks. For instance, about one in six say they would remain interested if it were not covered by their insurance (16%) or if the U.S. Food and Drug Administration had not approved the drug for weight loss but for a different condition (16%). A similar share (14%) say they would still be interested if they might gain back the weight they lost if they stopped taking the drug. 

A large majority (80%) of the public says insurers should cover the cost of weight-loss drugs for adults who have been diagnosed as overweight or obese while half of adults (53%) says insurers should cover the cost of these drugs for anyone who wants to lose weight. Half (50%) say that insurers should cover the drugs’ cost even if it could increase monthly insurance premiums for everyone. Few Aware of Medicare Drug-Price Provisions Included in Last Year’s Inflation Reduction ActNearly a year after President Biden signed the Inflation Reduction Act into law, relatively few people are aware of its provisions aimed at lowering prescription drug costs in Medicare.For example, a quarter of the public are aware that there’s a law requiring the federal government to negotiate some drug prices for people with Medicare (25%); capping insulin costs for people with Medicare (25%); and placing an annual limit on Medicare enrollees’ out-of-pocket drug costs (24%). Fewer know that there’s a law penalizing drug companies that raise Medicare drug prices faster than the rate of inflation (10%).People ages 65 and older, who are largely covered by Medicare, are more likely than younger adults to be aware of most of these provisions, but still the shares are modest. For instance, among people who are at least 65 years old, 44% know about the insulin price caps and 34% know about the annual limit on out-of-pocket drug spending.The poll also gauges the public’s views about drug manufacturers and drug prices.

Key findings include:

• About three in 10 (28%) adults, including 40% of those with annual household incomes under $40,000, say it’s difficult for them to afford prescription drugs. A similar share of adults (31%) say that they did not take their medicine as prescribed in the past year due to their costs.
• About eight in 10 (83%) adults say drug companies’ profits are a major factor contributing to the price of prescription drugs, including large majorities of Republicans (89%), Democrats (84%), and independents (78%). Fewer adults say that research and development costs (54%) or marketing and advertising (45%) are major factors affecting drug prices.
• Nearly three-quarters (73%) of the public say there is not enough regulation of prescription drug prices, up from 63% in May 2021. This includes two thirds of Republicans (68%), up from 57% in May 2021.

Designed and analyzed by public opinion researchers at KFF, the survey was conducted from July 11-19, 2023, online and by telephone among a nationally representative sample of 1,327 U.S. adults. Interviews were conducted in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

For updated data on child vaccination trends, including MMR vaccination coverage and vaccine exemption rates, read our latest analysis: Headed Back to School in 2024: An Update on Children’s Routine Vaccination Trends

This week the U.S. Food and Drug Administration (FDA) approved the first monoclonal antibody shot to protect young children against respiratory syncytial virus (RSV). While rates have now fallen, the three respiratory viruses (RSV, influenza, and COVID-19) surged among children last winter. Routine vaccinations, including the COVID-19 and flu shot, and the new RSV injection can provide important protection for children as they head back to school and into the winter season this year. This issue brief examines the most recent trends in children’s routine vaccinations, including COVID-19, and explores what to watch as children head back to school this year.

What are recent trends in children’s routine vaccination rates?

Since the beginning of the COVID-19 pandemic, the share of kindergarten children up to date on their vaccinations has ticked down. The CDC recommends children receive immunizations against 14 diseases by the age of two (or 24 months), with additional doses and immunizations through age 18. Data collected and aggregated annually by the CDC from state and local immunization programs, found that for the second year in a row, the national measles, mumps, and rubella (MMR) vaccination rate among kindergarten students fell below the Healthy People 2030 target of 95%, which is the level needed to prevent community transmission of measles. Specifically, the share of kindergarteners with all state-required vaccines, including MMR, DTaP (diphtheria, tetanus, and acellular pertussis), and varicella, has declined for the two school years following the onset of the pandemic, from approximately 95% in 2019-2020 to 94% in 2020-2021 and then declining again to 93% in 2021-2022. While this is a small decline, this is the lowest MMR rate reported in almost a decade and leaves approximately 250,000 school children unvaccinated and unprotected against measles, one of the world’s most contagious viruses.

While vaccination rates vary by state, the majority of states experienced declines in the share of kindergarteners up to date on their vaccines. There is substantial variation in vaccination coverage by state, with the latest available data for kindergarteners during the 2021-2022 school year showing MMR vaccine coverage rates ranged from 78% in Alaska to 98.6% in Mississippi (Figure 1). There is similar state variation in coverage for other state-required vaccines including DTaP, varicella, and polio. In addition, vaccine coverage rates for all vaccines among kindergarteners declined in a majority of states when comparing the 2021-2022 school year to the previous school year. Looking specifically at MMR coverage, 32 states saw declines, with the largest decline (over 5 percentage points) in Georgia.

There is evidence of declines in vaccination coverage rates for kindergarteners, but early data for children in other age groups is more mixed. A CDC survey (National Immunization Survey (NIS) – Child) of younger children found no decline in vaccination coverage overall for children aged 24 months associated with the pandemic. Another CDC survey of teens (NIS-Teen) ages 13-17 reported human papillomavirus (HPV) vaccine coverage remained stable but found potential decreases in meningococcal conjugate (MenACWY) and tetanus, diphtheria, and pertussis (Tdap) coverage associated with the pandemic. However, researchers noted they are unable to assess the full impact of the pandemic on adolescent routine vaccinations until more children age into the teen survey sample.

There is also evidence that disparities in vaccine coverage rates that pre-dated COVID, persisted during the pandemic and may have worsened for some groups. While the CDC survey of children aged 24 months mentioned above found no decline in vaccination coverage overall for children aged 24 months associated with the pandemic, it did find declines among specific groups of children, including low-income children and children living in rural areas. Even before the pandemic, the percent of children aged 24 months immunized was lower for children with Medicaid or uninsured children (compared with privately insured children), Black and Hispanic children (compared with White children), low-income children (compared with children in families with incomes greater than 133% of the federal poverty level), and children in rural areas (compared with children in more densely populated areas) (Figure 2). Research has shown that distrust, safety concerns, and experiences with discrimination and other factors can contribute to racial disparities in vaccination rates. Structural barriers such as distance to vaccine provider and other logistical challenges can also contribute to these differences across groups. KFF COVID-19 Vaccine Monitor data have shown Hispanic and Black parents are more likely than White parents and to cite concerns that reflect access barriers to vaccination, including not being able to get the vaccine from a trusted place, believing they may have to pay an out-of-pocket cost, having difficulty traveling to a vaccination site, or needing to take time off work to get their child vaccinated. Parents of children with household incomes under $50,000 were more likely than those with higher incomes to report similar concerns.

What are recent trends in children’s COVID-19 vaccination rates?

COVID-19 vaccination uptake has stalled, and vaccination rates remain low for young children. Last year, the CDC’s Advisory Committee on Immunization Practices (ACIP) voted to add COVID-19 vaccines to the recommended pediatric immunization schedule that includes the other routine vaccines for children discussed above. As of May 2023, 5.5% of children under age five, 32.9% of children ages 5-11, and 61.8% of children ages 12-17 had completed their COVID-19 primary series. Some of this variation in uptake may reflect parental views and concerns. KFF’s COVID-19 Vaccine Monitor from December 2022 reported that 45% of parents of children under five said they will “definitely not” get their child vaccinated, which is has increased from earlier surveys, when the vaccines were not yet available.

What to watch looking ahead?

It will take some time before we can understand the full impact of the pandemic on children’s routine vaccination rates and what is driving the recent changes. There is evidence of declines in vaccination coverage rates for kindergarteners, but early data for younger children (0-24 months) and adolescents (13-17) is more mixed. Even so, there have been recent reports that the CDC is expected to decrease federal funding for state vaccination programs due to budget cuts by Congress, a move that could impact data collection used to track vaccinations and prevent outbreaks. Some children missed or delayed preventive care early in the pandemic, and it is unclear the extent to which they will catch up and the magnitude of gaps that will remain. One study found weekly routine vaccination administration rates declined early in the pandemic, but then rebounded back to pre-pandemic levels by fall 2020. Despite the rebound in vaccine administration, the share of children up to date with all their vaccinations declined, likely due to some children still needing to make up for missed vaccinations early in the pandemic. Preliminary data for Medicaid/CHIP children through July 2022 show a similar trend.

There have been some recent shifts in public opinion as well as state vaccination policies that will be important to watch as they could have implications for children’s vaccination rates going forward. The KFF Vaccine Monitor in December 2022 found that about seven in ten adults (71%) say healthy children should be required to get vaccinated for MMR in order to attend public schools. This remains high but is down from 82% who said the same in an October 2019 Pew Research Center poll. Almost three in ten (28%) now say that parents should be able to decide not to vaccinate their school-age children, even if this creates health risks for others, up from 16% in 2019. All states allow a medical exemption from required vaccinations, and 46 states (including D.C.) allow for a religious or personal belief exemption (or both). The most recent CDC data showed the percentage of children claiming a vaccine exemption remained low at 2.6% for the 2021-2022 school year, but the percentage did increase in 38 states and D.C compared to the previous school year. While one state (D.C.) currently requires the COVID-19 vaccine for school children, 21 states have banned student COVID-19 vaccine mandates. Vaccine misinformation and disinformation may be contributing to vaccine hesitancy and the recent uptick in exemptions and slight declines in vaccination coverage.

With gains in enrollment during the pandemic, Medicaid now covers almost half of children in the U.S.; however, some children may lose coverage during the unwinding of the continuous enrollment provision which could impact vaccination rates. It is estimated that between 2 and 7 million children could lose Medicaid coverage during the unwinding of the Medicaid continuous enrollment provision that was in place during most of the pandemic, though the share of individuals disenrolled across states will vary due to differences in how states prioritize renewals. Significant declines in Medicaid enrollment are likely to increase the number of uninsured, which may have implications for children’s vaccination rates, as uninsured children typically have the lowest vaccination rates (Figure 3). Still, even with the COVID-19 public health emergency (PHE) having ended in May, all ACIP recommend vaccines (including the COVID-19 vaccine) are available with no cost sharing for all children, either through an insurer or the Vaccines for Children program (VFC). Various tools, including discussions with providers, incentives, outreach, and the media, can be used to increase children’s vaccination rates.

The Senate Committee on Appropriations approved the FY 2024 Labor, Health and Human Services, Education, and Related Agencies (Labor HHS) appropriations bill and accompanying report on July 27, 2023. The Labor HHS appropriations bill includes funding for U.S. global health programs provided to the Centers for Disease Control and Prevention (CDC) and funding for global health research activities provided to the National Institutes of Health (NIH). Total global health funding at CDC and NIH through the Labor HHS bill is not yet known, as funding for some programs at NIH is determined at the agency level rather than specified by Congress in annual appropriations bills. Funding for global health programs at CDC totals $693 million, flat compared to the FY 2023 enacted level, $72 million (9%) below the President’s FY24 request ($765 million), and $322 million (87%) above the House level ($371 million). See the table below (downloadable table here) for additional detail on global health funding. See other budget summaries and the KFF budget tracker for details on historical annual appropriations for global health programs.