Why healthcare should unite abundance and antitrust
Over the last few months, internecine battles between abundance and antitrust advocates have been fought across book reviews, podcasts, and social media. Yet if the two camps were to put together a list of proposed policies, there would be a surprising amount of mutual compatibility, certainly enough for both factions to camp under the same tent in American politics in 2025. This is most true when it comes to healthcare.
Both sides of the debate have multiple policy organizations, each with their own nuanced framing of the issues. Broadly, however, antitrust focuses on attacking concentrations of power that shut out competition, stifling innovation while burdening small business owners and individuals with higher costs and fewer choices. Abundance focuses on reducing supply-limiting regulations and developing state capacity to grow the overall pie of healthcare services.
In a broken healthcare status quo marked by increasing consolidation, these are two sides of the same coin. Both stricter antitrust enforcement and the removal of regulations that stymie independent and innovative market entrants will reduce costs and improve access to care.
American healthcare: Cramped and captured
No one disputes that American healthcare is suffering from serious problems. American life expectancy is falling, maternal mortality is high (even when accounting for changes in how the data is collected), and treating a serious illness like cancer demands that patients not only undergo painful medical treatments but also navigate a highly complex, bureaucratic insurance process.
Meanwhile, the percentage of physicians who practice primary care has fallen and emergency room visits have increased, even as recent studies have found that 40-50 percent of such visits are treatable with primary care. Access to rural healthcare continues to decline as outlying hospitals close. Fewer than 10 percent of Americans are uninsured, a historic low. But even those who are insured struggle to get care at reasonable costs, especially if they live in a rural area.
What’s causing these problems?
On one hand, corporate size and bureaucracy. Hospital mergers are associated with price increases that range between 3 and 65 percent, depending on the location of the merger and proximity of alternative options. Private equity firms frequently acquire hospitals just to strip them of assets. The tactics include making a hospital sell its land and lease it back at exorbitant rates and shuttering less profitable locations. This can leave whole towns stranded without easy access to care. Nearly 80 percent of all physicians in the U.S. are employed by a corporate entity — with approximately 10 percent employed by UnitedHealth Group alone — leaving many feeling powerless and burnt out.
In a broken healthcare status quo marked by increasing consolidation, antitrust and abundance approaches are two sides of the same coin.
At the same time, healthcare is suffering from a lack of supply. Nearly 200 rural hospitals have closed in the last 20 years, and an additional 700 are at risk of closure. The National Center for Healthcare Workforce Analysis estimates that there will be a shortage of over 87,000 primary care doctors by 2037 (for comparison, only 29,000 medical students graduate from American medical and osteopathic programs every year). Despite this shortage, the U.S. limits medical residency training slots, most acutely by capping the amount of Medicare funding available for graduate medical education at 1997 levels.
Health policy efforts since the 2010 Affordable Care Act have generally focused on subsidizing demand or indulging corporate power with only feeble oversight, creating perverse incentives that undermine cost control without producing benefits in quality. Prices have gone up, and despite a historically low rate of uninsured Americans, the U.S. continues to underperform other OECD countries. Large corporations have been encouraged, in the vain hope that they might lead to efficiencies. Medicare Advantage is one example. Created in 1997, this program appeared to be a win — letting private insurers manage Medicare for seniors in return for hefty government reimbursement. But the result has been a bureaucratic morass, with patients suffering from denials and limited care networks. Lawmakers of both parties have requested that the Government Accountability Office investigate the program, noting the potential for Medicare Advantage organizations to game the system and redirect taxpayer dollars back to their bottom lines rather than spending them on patient care.
More of the right things
Unwinding the tapestry of perverse incentives and regulation in healthcare will require an approach that combines antitrust and abundance tools, constraining market power and simultaneously eroding barriers to entry that stem from over-regulation of practices and underfunding of training.
For hospitals and practices
Hospital mergers reduce access while increasing costs — the research is indisputable and both sides agree that this is a central driver of the recent rise in healthcare costs. Both antitrust and abundance advocates have targeted Certificate of Need laws that restrict competition by making it more difficult to expand or build new facilities. Both also have been working to reduce the incentives hospital systems have to consolidate by stopping Medicare from paying more for the same service when it is performed at a facility that can claim “hospital” rather than outpatient status.
Antitrust proponents have tended to focus their policy prescriptions on preventing mergers through better and stronger enforcement — a policy that would benefit supply by arresting the hospital closures mentioned above. States that don’t require hospitals to report plans to merge should mandate such notice, and state attorneys general should have the authority to block mergers that might harm care. Corporate practice of medicine laws that require practices to be run by a physician are another option that make it more difficult for corporate consolidators to buy up the practices in an area — the law recently passed in Oregon is one example. Going a step further, Congress should allow physicians to own hospitals again. That ban on physician ownership, leveled in the 1990s and continued with the Affordable Care Act in 2010, was intended to prevent physician referrals to facilities in which they owned a stake. But when the alternative owner is a private equity firm, Congress should trust that physicians are more capable of running a patient-centered institution.
For doctors
The U.S. needs more doctors. Medicare funds approximately two-thirds of all graduate medical education and yet the residents flowing from these programs are mismatched with Americans’ needs. This program should be expanded to support more doctors and simultaneously reformed to provide a uniform payment per resident rather than privileging research hospitals in wealthy regions. The weight of this program should also be used to incentivize more trainees to become primary care physicians.
Other commonsense policies include allowing graduates of accredited foreign medical colleges to practice in the U.S. without entirely repeating residency and allowing physicians licensed in one state to practice across state lines.
Our container-ship fleet of health systems, insurers, and pharma certainly isn’t delivering the dramatic pivot America must make to keep pace with the rest of the developed world. An improved healthcare system would have more doctors and hospitals, with more readily available primary care appointments and rapid triage. It would also be more dynamic, with independent pharmacists able to stay open in suburban areas, physicians incentivized to set out a shingle in rural communities, and smaller biotech firms powering the engine of pharmaceutical innovation.
To achieve this vision, corporations must be held to account — and antitrust and abundance must find common ground.
Olivia Webb Kosloff writes about healthcare, policy, and state capacity, and is the creator of the newsletter Acute Condition.
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