Federal Antitrust Retreat Threatens Patient Access
President Trump's August 13, 2025 revocation of Biden's Executive Order 14036 creates a federal healthcare competition enforcement vacuum that threatens to accelerate consolidation-driven cost increases and access barriers for people living with chronic conditions, even as bipartisan pharmacy benefit manager (PBM) reform momentum paradoxically continues and states scramble to fill regulatory gaps through expanded oversight programs.
The timing proved strategic, if not coordinated. UnitedHealth completed its $3.3 billion Amedisys acquisition one day after the revocation. The simple four-sentence order contained no specific rationale beyond dismantling "burdensome" Biden regulations, yet its implications reshape healthcare markets fundamentally. Industry analysts immediately anticipated a "more favorable consolidation landscape" following the revocation.
Biden's Competition Legacy
Executive Order 14036, signed July 9, 2021, directed 72 competition-promoting initiatives across federal agencies, explicitly targeting hospital mergers that left rural communities "without good options for convenient and affordable healthcare service." The Federal Trade Commission (FTC) challenged four hospital mergers during Biden's first two years compared to fewer than one per year under the previous administration.
The order catalyzed enforcement mechanisms beyond merger challenges. The FTC withdrew outdated healthcare policy statements, calling them "no longer reflective of market realities," while the DOJ established its Task Force on Health Care Monopolies and Collusion. Most significantly, the FTC's PBM investigation produced reports documenting how the Big Three PBMs extracted $7.3 billion in excess revenue from specialty drug markups between 2017-2022.
Sixty-three percent of specialty generic drugs dispensed by PBM-affiliated pharmacies were marked up more than 100% over acquisition costs. For people living with HIV, this meant $521 million in excess revenue extracted from essential medications alone.
The UnitedHealth Monopoly Machine
UnitedHealth's vertical integration exemplifies the consolidation risks that relaxed enforcement enables. The company now employs over 70,000 physicians through its Optum Health subsidiary, making it the largest physician employer in the United States. As Dr. Glaucomflecken's satirical healthcare commentary notes: "Why reimburse doctors when you can own them."
UnitedHealth operates across insurance (UnitedHealthcare), PBM services (OptumRx), and provider services (Optum), allowing the company to control every aspect of patient care while maximizing profit at each step. The Change Healthcare cyberattack demonstrated these consolidation vulnerabilities, affecting half of all U.S. medical claims processing and leaving people living with HIV facing $2,000 balance bills when Patient Assistance Programs couldn't be processed. Independent pharmacies faced severe financial strain as they couldn't process claims or receive reimbursements, forcing many to consider closing while UnitedHealth's own pharmacies remained operational.
The commentary's prediction proves prescient: "Just imagine every interaction you have with the U.S. healthcare system throughout your life all owned and operated by United Healthcare." From ambulance services to hospital stays to prescription fills, vertical integration eliminates market competition while creating systemic vulnerabilities that drive up cost, reduce quality, and limit patient access to essential care.
The PBM Paradox: Aggressive Reform Amid Broader Deregulation
Trump's healthcare policy creates unusual dynamics where consolidation enforcement broadly weakens while PBM scrutiny intensifies. His May 12, 2025 "Most Favored Nation" executive order declared "We're going to totally cut out the famous middleman," claiming potential savings of 30-80% on drug costs. This aggressive anti-PBM stance contrasts sharply with the permissive approach toward hospital consolidation.
The FTC's September 2024 lawsuit against CVS Caremark, Express Scripts, and OptumRx for artificially inflating insulin prices continues despite the executive order revocation. FTC Chair Andrew Ferguson reversed his initial recusal in April 2025 to maintain quorum, with evidentiary hearings scheduled for February 2026.
States are simultaneously pursuing PBM reforms, though facing industry pushback. Arkansas enacted the nation's first-in-the-nation law prohibiting companies that own PBMs from also operating pharmacies. However, CVS and Express Scripts successfully challenged the law in federal court, with Judge Brian Miller ruling it "appears to overtly discriminate against plaintiffs as out-of-state companies."
Meanwhile, congressional momentum for PBM reform has been building over several years across party lines. The House Energy and Commerce Committee previously held hearings titled "Reining in PBMs Will Drive Competition and Lower Costs," while the bipartisan Pharmacy Benefit Manager Reform Act has been reintroduced. Spring 2025 legislative updates show continued bipartisan interest in PBM transparency and reform measures, though comprehensive legislation faces the typical challenges of a closely divided Congress.
Filling the Federal Enforcement Gap
With federal antitrust enforcement retreating, some states are rapidly expanding healthcare oversight programs. These initiatives represent a fundamental shift in competition policy, moving from federal leadership to a patchwork of state-level enforcement.
California leads through its Office of Health Care Affordability, which can block healthcare transactions that threaten affordability or access. Since April 2024, the office reviewed 26 transactions, approving 96% with conditions that protect consumers. California's healthcare spending targets of 3.5% for 2025-2026, decreasing to 3% by 2029, create enforceable benchmarks. Starting in 2026, the state can impose financial penalties on health systems that exceed cost growth limits.
New York Governor Hochul's FY 2026 budget proposes strengthening the state's ability to scrutinize healthcare deals before they close. The 60-day pre-closing notification requirement with potential 180-day delays gives regulators time to assess whether mergers will harm patients.
Massachusetts demonstrates mature oversight through its Health Policy Commission, which completed substantial market impact findings for the Dana-Farber/Beth Israel merger and required Mass General Brigham's first-ever Performance Improvement Plan when the health system exceeded cost growth benchmarks.
The state-level enforcement patchwork creates geographic disparities in patient protection. People living with chronic conditions may find robust protections in California or New York while facing minimal oversight in states without comprehensive programs. This creates particular challenges for multistate health systems that can shift operations to less regulated jurisdictions or structure transactions to avoid state oversight entirely.
Merging Toward Disaster
Accelerated healthcare consolidation creates documented barriers to access and affordability for people living with HIV and chronic conditions. Hospital mergers historically increase prices 6-18% in consolidated markets while reducing specialized service lines. The Hartford HealthCare lawsuit revealed pricing disparities of $3,800 for colonoscopies compared to $1,400 at competing hospitals.
Private equity ownership compounds these risks through systematic cost-cutting that prioritizes profits over patient care. Sen. Chris Murphy's report on Prospect Medical Holdings documented how private equity-backed facilities experienced supply shortages so severe that patients were "sometimes left on the operating table while staff scrambled" for basic equipment. Nurses and technicians reported personally buying food for patients to prevent hunger after the company stopped paying vendors.
Healthcare consolidation also drives intentional understaffing crises that compromise patient safety. Hospital Corporation of America, despite $7 billion in profits, maintains staffing ratios 30% lower than national averages while allocating $8 billion to stock buybacks. This profit-over-patients approach contributed to preventable tragedies like Rep. Eddie Bernice Johnson's death from an infection caused by medical neglect at an understaffed facility.
The revocation of Executive Order 14036 marks a decisive federal retreat from aggressive healthcare competition enforcement while states emerge as primary competition enforcers through oversight programs that may prove more durable than federal initiatives. For people managing HIV and chronic conditions, this enforcement vacuum creates compounded access barriers. Accelerated provider consolidation, private equity exploitation, narrowed networks, and increased costs threaten the specialized care relationships that we depend on. Healthcare advocates must pivot to intensive state-level engagement while supporting targeted federal initiatives like PBM reform that maintain bipartisan support. The strategic timing of major transactions immediately following the revocation demonstrates industry confidence in this permissive environment. Sustained advocacy pressure remains essential to protect patient access and care quality as healthcare markets consolidate with minimal oversight.
