In a recent “Meet the Press” appearance, Sen. James Lankford (R-Okla.) joined a growing number of Republicans who are speaking out against Obamacare. One of his lines of attack: that the Affordable Care Act fueled health care consolidation.
“What Democrats did 15 years ago was they radically changed all health care in America. They moved all physicians under hospitals. They changed all the reimbursement programs. They shifted everything in,” Lankford said Nov. 9.
This is one of a collection of Republican talking points related to the ACA that’s been regularly reprised, and there’s a reason for it.
Democrats have been promised a Senate vote this month on whether to extend the ACA’s enhanced subsidies, set to expire at year’s end. The debate, however, has given Republicans an opportunity to resurface old criticisms and reignite efforts to overhaul or even undo the ACA. One GOP argument is that the sweeping health law fueled industry consolidation, which has led to higher prices and pushed more doctors to sell their practices to hospitals or insurers.
But industry experts disagree about how much this market trend can be tied to the law known as Obamacare.
Like everything in health policy, it’s complicated.
“Most of us live in a different reality,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which supports extending the enhanced tax credits. “Our health system has many challenges, and I can’t say the cost to individuals, to taxpayers, is not an issue. But to say having better coverage for more people made all these problems worse is really a stretch.”
What’s happened to doctors and hospitals?
First, some context. The ACA was passed by Congress in 2010, and most of its major provisions became effective in 2014.
Many health care mergers took place both before and after Obamacare became law, so it’s hard to quantify its effect.
From 1998 to 2017 — a nearly two-decade period that included the first three years of full ACA implementation — 1,573 hospital mergers took place. An additional 428 hospital and health system mergers were announced from 2018 to 2023, according to a 2024 brief by KFF, a health information nonprofit that includes KFF Health News.
“The consolidation trend was in place before the ACA and just continued” as hospitals and other entities sought to improve their negotiating power, said Glenn Melnick, who studies hospital economics and is a professor at the University of Southern California’s Price School of Public Policy.
The KFF brief did not directly address what role the ACA might have played in such mergers, although others have suggested its focus on coordinating care may have led to some of the activity.
Hospital groups contend that mergers are needed to bolster finances and counter increasing insurer consolidation, and that they can result in cost savings. Others disagree, arguing that many studies show price increases following mergers.
Even with that trend — and despite what Lankford said — not all doctors now work for hospitals.
The percentage of physicians who have sold their practices to hospitals or private equity groups continues to rise, with only 42% currently working in private practices, according to the American Medical Association. That’s down from about 60% in 2012, before the ACA’s main provisions took effect.
Those who sold practices during the past 10 years, according to the AMA, most often cited inadequate payment rates as the reason.
Others note that many doctors want to be part of a larger group, with more scheduling flexibility and fewer paperwork hassles. Other changes, including the 2009 law known as the HITECH Act, which required hospitals and doctors to boost their use of electronic medical records, added to physicians’ desire to sell, Kahn said.
“Physicians today, with their heavy debt load, are not looking to go into the old individual practice anymore,” Kahn said. “That didn’t happen because of the ACA.”
Another key dynamic driving this market trend is market leverage, which was happening anyway, say some policy experts.
Hospitals “got control of the physician groups for contracting purposes,” Melnick said.
When hospitals meet to negotiate with insurers, “they’ll say, ‘We’ll drop out of your network, and we control 30% of the doctors, so they’ll drop out, too.’ It was a leverage play, and it worked,” Melnick said.
How do insurers fit in?
Like hospitals, some insurers have been on a buying spree, snapping up doctor practices, for example. Optum, a division of UnitedHealth Group, owns or is affiliated with nearly 10% of the nation’s physicians.
The health law “triggered an arms race among insurers and hospitals to grow larger and more expensive, leaving patients and small businesses with rising premiums and shrinking options,” said Joel White, president of the Council for Affordable Health Coverage, in testimony before a Senate subcommittee in November. The council touts among its priorities right-leaning issues such as opposing government-run health care and supporting expanded market competition and health savings accounts.
Again, the insurance question is complex.
The number of insurers filing annual reports with the National Association of Insurance Commissioners has fluctuated: for example, 949 in 2015 and 1,155 last year.
But aggregate numbers are only one measure. Several big insurers control large market shares. In one recent analysis that looked across a variety of types of insurance — not just ACA plans — the American Medical Association concluded that most areas are highly concentrated, with about 47% of those markets having one insurer with a commercial market share of 50% or more.
The AMA says such market power leads to higher premiums and results in reduced payments to doctors.
As for the marketplaces that offer ACA coverage, the number of insurers has also fluctuated over time, usually because of variations in anticipated premiums and the regulatory landscape, with a national average of nearly eight at the law’s inception, falling to 5.4 in 2018, but rising to nearly 10 nationally in 2025, according to KFF. Because that’s an average, some states, such as Texas, have 15 insurers, while seven states — Alaska, Arkansas, Connecticut, Hawaii, Rhode Island, Vermont, West Virginia — and the District of Columbia have only two.
Premium increases aren’t new either, nor are they hitting only ACA plans.
In fact, premiums for people buying their own coverage and those for workers who get insurance through an employer have almost always risen yearly — often above inflation levels —a trend that predates the ACA.
Critics of the ACA note that premiums in the individual market were lower before the law kicked in. However, critics often don’t note how different pre-ACA coverage was for people in the individual market, which could make it less expensive. Before the law, for example, insurers could reject people with preexisting health conditions, charge women more than men, and set annual or lifetime dollar limits on coverage. After 2014, that wasn’t allowed in ACA plans.
Average premiums for the benchmark “silver” ACA plans have gone from $481 nationally in 2018 to $497 in 2025, according to KFF. The average monthly premium jumps to $625 next year, partly because of insurers’ expectations of higher costs and a decline in enrollment if Congress does not extend the more generous tax subsidies. Those are averages, and prices will vary across the country depending on such things as age, location, and household income.
The conservative Paragon Health Institute notes that rising premiums mean larger taxpayer-supported subsidies. Deductibles, too, have gone up, with people on “bronze” plans, which have the lowest premiums, facing an average $7,476 deductible next year, compared with $5,113 in 2014.
The cost-consolidation link
A 2025 Health and Human Services report, issued during the last days of the Biden administration, found the trend of highly concentrated hospital services in most metropolitan statistical areas had started before and continued after the ACA. Prices also rose. The report, which noted the role of private equity firms in consolidation efforts, also cited studies showing physicians increasingly merged — with one another, hospitals, or private equity-backed firms.
That’s important because the largest share of health care spending in the U.S. goes to hospital care, with physician services not far behind.
For Kahn, at the hospital federation, the real reason behind the mergers is financial: Many hospitals, he says, had to expand their reach or risk going under.
“Many health economists are my best friends,” Kahn said, “but they have tunnel vision when they look at the health system.” Hospitals must have sufficient revenue streams to cover the cost of patient care, he said, and consolidation is their way to respond “to all of the burdens and requirements and demands” they face.
While there is no question that health care consolidation has happened, much of it predated the ACA, Melnick said.
“At the end of the day, the ACA market never became that big to drive the overall restructuring of the industry,” he said. “A lot of what they are attributing to the ACA would have happened anyway.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
