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 The FTC withdrew outdated healthcare policy statements, calling them "no longer reflective of market realities," while the DOJ established its Task Force on Health Care Monopolies and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.

Mapping Injustice: Redlining's Legacy in HIV Treatment Delays

A new study from Tulane University reveals how discriminatory housing policies from decades ago continue to shape HIV care outcomes today. Published in JAMA Internal Medicine, the research shows that people living with HIV (PLWH) in historically redlined neighborhoods face 15% longer delays in achieving viral suppression compared to counterparts in non-redlined areas—193 days versus 164 days. These delays impact both patient health outcomes and broader public health efforts to prevent HIV transmission.

The Lasting Legacy of Redlining

Redlining—the practice where mortgage lenders marked certain areas with red lines to deny loans based on race or ethnicity—was officially abolished in 1968. Yet its consequences persist in the built environment, healthcare infrastructure, and social conditions that determine health outcomes.

The Tulane study analyzed 1,132 newly diagnosed patients in New Orleans between 2011 and 2019. Of these patients, 62% resided in formerly redlined neighborhoods. Most were men between ages 25-44 years, and despite New Orleans having a majority Black population, the study found a higher concentration of Black residents in redlined areas than in non-redlined ones.

The findings validate what many healthcare advocates have long observed: geography profoundly influences health. As senior author Scott Batey noted, "The association between redlining and health outcomes is not a new concept, but applying this lens specifically to HIV was novel." Even where gentrification has occurred, treatment delays remain—indicating that historical marginalization creates barriers that investment alone cannot remove.

Interconnected Barriers to HIV Care

What explains these persistent treatment delays? The answer lies in multiple overlapping structural barriers that create a healthcare access quagmire for PLWH in redlined communities.

Pharmacy Deserts

One-third of neighborhoods in major U.S. cities qualify as pharmacy deserts, with predominantly Black and Latino neighborhoods disproportionately affected. In Los Angeles, for example, one-third of all Black and Latino neighborhoods were pharmacy deserts, particularly concentrated in South Central LA neighborhoods.

For PLWH, this means not just longer travel times for medication but reduced access to HIV prevention resources and testing services. Pharmacies serve as crucial health access points—they provide HIV prevention tools like PrEP, conduct HIV testing, and offer medication counseling essential for treatment adherence. When pharmacies close or never open in certain neighborhoods, these services disappear too.

Medicare Part D and Medicaid plans often exclude independent pharmacies serving these communities, forcing PLWH to travel even farther for care. These policies function as a form of structural racism that requires historically marginalized populations to overcome additional barriers to access life-saving medications.

Provider Network Inadequacy

Healthcare provider shortages plague formerly redlined areas. Current federal network adequacy standards fail to ensure sufficient HIV care providers in these communities. Provider directories frequently overstate physician availability, and narrow insurance networks often include less than one-fourth of available providers.

Studies show that adults with Medicaid or Marketplace coverage are more likely than those with Medicare or employer-sponsored insurance to report network problems. This is especially concerning as approximately 40% of people living with HIV (PLWH) rely on Medicaid for their healthcare coverage. For PLWH, this translates to longer wait times, fewer options for culturally competent care, and reduced provider continuity—all factors that influence treatment adherence and viral suppression rates.

Time/distance standards for network adequacy ignore the reality that residents often rely on limited public transportation, making even "acceptable" distances functionally unreachable. A mile can feel like thirty when bus service is limited, transfers are required, or service ends before evening clinic hours conclude.

Hospital Consolidation

The acceleration of hospital consolidation has further eroded healthcare infrastructure in vulnerable communities. When acquiring systems take over local hospitals, they frequently close specialized services, forcing patients to travel further for care.

"The unfortunate reality is that more than 25 years of market-driven health facility consolidation has really left too many communities across the U.S. without timely access to needed care," experts note. This especially impacts residents of redlined neighborhoods, who often must navigate complex transportation systems to reach consolidated healthcare facilities.

Research shows hospitals without nearby competitors charge prices 12.5% higher than those in competitive markets—a financial burden that falls heavily on communities already struggling with economic disadvantage. As of 2017, 19% of markets—representing 11.2 million U.S. residents—were served by only one hospital system, creating healthcare monopolies that exacerbate access disparities.

Political Context: New Threats to Health Equity Research

Political attacks on health equity initiatives now compound these structural barriers. Recent executive orders targeting Diversity, Equity, and Inclusion (DEI) programs across federal agencies threaten vital HIV research and services.

The U.S Department of Health and Human Services (HHS) faces proposed budget cuts from $121 billion to $80 billion in discretionary funding, cutting precisely the prevention-focused health initiatives designed to address disparities. Healthcare researchers report increasing censorship pressures around health disparity research, particularly when using terminology associated with equity.

One cancer researcher noted the chilling effect: "We aren't sure what we can say in our grants. I very freely — before — wrote about disparities and equity in my grants." This uncertainty threatens the very research needed to understand and address HIV treatment delays in historically redlined communities.

Federal agencies have removed HIV-related content from websites, especially materials serving transgender populations. Reports indicate hundreds of HIV-related web pages were removed following executive orders targeting "gender ideology" and "DEI." When pages were restored, they often lacked reference to transgender people, creating significant gaps in data and care recommendations for key populations.

The threat extends to global HIV prevention efforts, with pauses on foreign aid affecting PEPFAR implementation and leaving vital medication and services in limbo. These disruptions threaten to reverse hard-won progress in controlling the HIV epidemic both domestically and globally.

From Analysis to Action

Understanding redlining's impact on HIV treatment access demands more than recognition—it requires targeted policy responses:

1. Strengthen pharmacy access in underserved areas by incentivizing pharmacy establishment and requiring Medicaid and Medicare Part D plans to include independent pharmacies serving marginalized communities. State pharmacy boards should consider pharmacy access when reviewing new applications and closures.

2. Reform PBM practices to eliminate patient steering by prohibiting PBM-owned specialty pharmacies from exclusively dispensing HIV medications. Research shows that patient steering to mail-order or specific chain pharmacies disrupts established care relationships and reduces medication adherence, particularly affecting PLWH in historically redlined areas who rely on community pharmacies for wrap-around services.

3. Reform network adequacy standards to ensure sufficient culturally-competent providers in historically redlined neighborhoods. Standards must account for transportation realities and penalize narrow networks that exclude critical HIV care providers. Secret shopper surveys should validate actual appointment availability beyond paper compliance.

4. Mandate PBM transparency and fair reimbursement to prevent discriminatory practices forcing community pharmacies in redlined neighborhoods to close. State legislation should require PBMs to disclose all revenue streams, prohibit retroactive fee clawbacks, and establish minimum reimbursement rates based on acquisition cost plus a fair dispensing fee.

5. Enhance antitrust enforcement to prevent further hospital consolidation, reducing access points in vulnerable communities. When mergers occur, mandate maintenance of essential services in historically underserved areas and require community benefits agreements that address historical inequities.

6. Protect and expand community-based HIV programs that provide testing, prevention education, and linkage to care services directly within affected neighborhoods. This includes mobile testing units, community health worker programs, and faith-based outreach initiatives.

7. Prioritize long-acting injectable antiretrovirals as a solution for areas with limited pharmacy access, reducing adherence challenges for people facing transportation barriers. Delivery models should include provision through mobile clinics and community-based organizations.

8. Defend health equity research funding against political attacks that threaten to undermine our understanding of how structural racism impacts health outcomes. Ensure that Institutional Review Boards (IRBs) and research institutions protect researchers examining health disparities.

Moving Forward

The link between historical redlining and HIV treatment delays reveals how structural inequities become embodied in health outcomes. This connection demands that policymakers, healthcare systems, and advocates recognize that achieving HIV treatment equity requires addressing the legacy of discriminatory housing policies.

As Dr. Batey notes, "If we can make services more accessible and get people virally suppressed sooner, the impact on the HIV epidemic can be quite significant." This requires defending existing health equity initiatives and developing new approaches that confront the structural barriers in historically redlined communities.

The one-month treatment delay identified in the Tulane study translates to real health consequences for PLWH and increased transmission risk within communities. Moving from awareness to action means investing in healthcare infrastructure that overcomes geography as destiny, creating systems where treatment access doesn't depend on neighborhood history.

In an era of political attacks on health equity initiatives, this research underscores why structural analysis matters. Without understanding how policies like redlining continue to shape healthcare access, we risk addressing symptoms while ignoring causes. Achieving HIV treatment equity demands both acknowledging historical injustice and implementing structural change—starting with the communities where barriers remain highest.