In addition to having the highest obesity rates, the U.S is currently facing significantly higher prices for several major drugs used for weight loss and other health needs, according to a new KFF analysis of the list prices for semaglutide and tirzepatide drugs.

Ozempic, which has been approved in the U.S. for diabetes, is more than five times as expensive in the U.S. ($936) as in Japan ($169), which has the second highest list price. Similarly, Wegovy, which has the same active ingredient and was approved for weight loss, is nearly four times as expensive in the U.S. ($1,349) as in Germany ($328.)

The chart above shows list prices available through website searches for four weekly shots or a 30-day supply. List prices are not necessarily net prices paid as manufacturers provide insurer rebates and patient coupons. Private insurers and employers in the U.S. may also be able to negotiate lower prices with drug manufacturers or get larger rebates.

Even if prices lower some, higher drug prices and higher obesity rates in the U.S. could still lead to a larger impact on overall health spending in the U.S. than in peer countries.

One-third of U.S. adults (33.6%) have obesity compared to an average of 17.1% across peer nations. KFF polling also found that about half of adults in the U.S. would be interested in taking prescription weight-loss drugs, though interest drops if not covered by insurance or after hearing they might gain weight back after end the use.

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.

A class of drugs initially approved for diabetes treatment has captured the public’s and policymakers’ attention as interest in their off-label use for weight loss rises. The weight-loss benefits of these drugs have led to their prescribed use for obesity or overweight treatment.

A new analysis compares list prices for semaglutide—including Ozempic, which has been approved in the U.S. for diabetes, and Wegovy, which has the same active ingredient and has been approved for weight loss—and tirzepatide (Mounjaro) in the U.S. and other large, wealthy OECD nations.

Semaglutide prices are higher in the U.S. than in other countries. Ozempic is more than five times as expensive in the U.S. ($936) as in Japan ($169), which has the second highest list price. Similarly, Wegovy is nearly four times as expensive in the U.S. ($1,349) as in Germany ($328.)

The U.S. has by far the highest rates of adults with obesity. A third of adults (33.6%) have obesity in the U.S. compared to an average of 17.1% across peer nations

The analysis can be found on the Peterson-KFF Health System Tracker, an information hub dedicated to monitoring and assessing the performance of the U.S. health system.

A new KFF poll assessing the broad reach of the nation’s opioids crisis on families across the United States reveals that three-in-ten adults (29%) say they or someone in their family have ever been addicted to opioids, including prescription painkillers and illegal drugs like heroin. Rural residents (42%) and White adults (33%) are among the groups hardest hit.

The poll also showed that the opioid crisis is part of a much larger picture of addiction affecting American families: two-thirds (66%) of the public report that either they or a family member has been addicted to alcohol or drugs, experienced homelessness because of an addiction, or experienced a drug overdose leading to an emergency room visit, hospitalization, or death. This includes one-in-five adults (19%) who say they have personally been addicted to drugs or alcohol, had a drug overdose requiring an emergency room visit or hospitalization, or experienced homelessness because of an addiction.

Less than half (46%) of those who report addiction in their families say the person suffering from addiction got treatment. A larger share of White adults (51%) than Black adults (35%) and Hispanic adults (35%) report that they or their family member received treatment.

Large shares of those whose families have been impacted by addiction say it had at least a minor impact on their relationship with their family (76%), their mental health (70%), or their family’s financial situation (57%). On each of these questions, at least a quarter say it had a “major impact.”

Among the public overall, half (51%) worry that someone in their family will experience substance use disorder, and one-third (32%) are worried that someone in their family will overdose on opioids, such as prescription painkillers or illegal drugs like heroin. About four-in-ten adults are worried that someone in their family will unintentionally consume the opioid drug Fentanyl (39%). Respondents in rural areas expressed more concern about these issues overall. 

Most adults prescribed an opioid painkiller in the past five years say their doctor talked to them about the possible consequences of the drugs, including possible side-effects. Six in ten (60%) who say they were talked to about other ways to manage their pain also say their doctor has spoken to them about the possibility of addiction or dependence (57%). 

In addition to gauging the public’s experiences with addiction to drugs and alcohol, the poll examined public support for policies aimed at curbing drug overdoses. The public broadly supports two approaches aimed at reducing opioid overdoses, including majorities across partisans. Most people support addiction treatment centers in their community (90%) or making Narcan (naxolone), a medicine that can reverse an opioid overdose, freely available in places like bars, health clinics, and fire stations (82%). About half “strongly support” both policies, and they are also supported by at least three-quarters of Democrats, Republicans, and independents.

Fewer, but still nearly half (45%), support safe consumption sites where people can use illegal drugs monitored by trained personnel in an emergency. A majority of Democrats (61%), half of independents (49%), and fewer Republicans (23%) support safe consumption sites.

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 three percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

As states resumed disenrolling people from Medicaid earlier this year as part of the “unwinding” of the continuous enrollment provision, early data have shown wide variation in disenrollment rates across states, ranging from 82% of completed renewals in Texas to 10% in Michigan. Although there are a range of state policy choices and other factors contributing to this variation, this policy watch examines which states are prioritizing renewals for enrollees that were flagged as likely ineligible and what effect that may have on disenrollment rates early in the unwinding period.

Prior to the start of the unwinding, many states flagged enrollees they deemed as likely ineligible. Although states could not disenroll anyone while the continuous enrollment provision, many states identified people as likely ineligible if there was information available showing the enrollee had a change in circumstance (e.g., aged out of children’s coverage), a change in income that would make them ineligible, or if they did not respond to renewal requests.

Early data from three states (Arizona, Idaho, and Pennsylvania) show that disenrollment rates for flagged enrollees are higher than for other enrollees. While several states publish total disenrollments among flagged enrollees, only Arizona, Idaho, and Pennsylvania publish enough information to be able to compare disenrollment rates for flagged enrollees to overall disenrollment rates. Based on early unwinding data, the disenrollment rate for flagged enrollees in each of these states exceeded the overall disenrollment rate by about 20 percentage points (Figure 1).

Some states are prioritizing renewals for enrollees flagged as likely ineligible early in the unwinding period. States have taken different approaches to processing renewals during the unwinding period and some states have chosen to prioritize renewals for enrollees they identified as likely no longer eligible during the first six months. Based on unwinding plans submitted to the Centers for Medicare and Medicaid Services (CMS), a total of 17 states indicated that they would prioritize renewals for enrollees that the state flagged as likely ineligible at the start of their unwinding period (Figure 2). Of these, 11 states plan to work through renewals for flagged enrollees during the first two-to-six months of the unwinding, while the remaining six states will spread renewals for flagged enrollees over the first seven-to-nine months.

State approaches to renewing flagged enrollees may explain some – but not all – variation in disenrollment rates across states. Consistent with the data from Arizona, Idaho, and Pennsylvania showing higher disenrollment rates for flagged enrollees, states that prioritize renewals for flagged enrollees in the first two-to-six months have a higher median disenrollment rate (48%) compared to all other states with available data (33%). However, there is still considerable variation in disenrollment rates among these states, ranging from 82% in Texas to 27% in Maryland (Figure 3). Some variation may reflect how states identified likely ineligible enrollees and the share of flagged enrollees undergoing a renewal each month. Other state policies likely contribute to the variation as well, such as the approach states take to increase the number of automatic (or ex parte) renewals, how states use temporary flexibilities made available by the federal government during the unwinding, and the effectiveness of states’ outreach to enrollees.

For states prioritizing likely ineligible enrollees, additional data may be required to identify potential reasons for high Medicaid disenrollments. Generally, states that heavily frontload renewals with flagged enrollees can be expected to have higher early disenrollment rates relative to states that spread out renewals for flagged enrollees over a longer period. But, over time, as these states work through renewals for flagged enrollees, disenrollment rates should moderate. However, if these higher disenrollment rates are because of other issues with a state’s renewal process, waiting several months to see whether disenrollment rates decrease could mean many eligible enrollees may lose coverage. More complete information on the reasons why individuals were flagged as likely ineligible, the share of flagged enrollees being renewed each month, as well as disenrollment data broken out by flagged enrollees versus all other enrollees could help identify the factors that underpin disenrollment rates early in the unwinding period.

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.