Remarks as Prepared for Delivery
Thank you for that kind introduction. It is a pleasure to join you in the Crescent City and to meet many of the members of Transparency Rx and others attending this conference. As a law enforcer with responsibilities across the economy, it is an honor to be in the room with folks who have the depth of expertise that you have when it comes to the healthcare system and the issues related to prescription drug pricing and delivery, which you and your members think about every day. I look forward to learning more about your perspective. In turn, I will share how the Antitrust Division at the Department of Justice under President Trump views our enforcement role, especially in healthcare, along with some thoughts about how antitrust enforcement may relate to points that your organization has raised in the broader healthcare policy discussion.
Within the Antitrust Division, we are constantly required to make choices about how to allocate our law enforcement resources. We are ever mindful that we have limited, albeit significant, resources to tackle seemingly endless important challenges. These range from criminal prosecution of antitrust law breakers, to reviewing mergers that may harm competition, to using civil litigation to end business practices that have anticompetitive effects. We must prioritize our enforcement efforts to be successful.
As we decide how to deploy our resources, a key consideration is where our enforcement efforts are likely to have the most tangible benefit to American households. As Acting Assistant Attorney General Assefi has said, antitrust enforcement must be directed toward “ultimately ensuring the free market supports the American Dream.”[1] We are passionate in our belief that free markets — where firms compete with each other to provide goods and services at higher quality, higher quantity, and lower price, and where they innovate to bring new products and improvements to market — have brought prosperity and security to families across our great country for generations and will do so for generations to come.
For free markets to be truly free, however, they must be competitive. They must be free of restraints that harm competition and unjustified practices that enrich dominant firms at the expense of the rest of us. When firms avoid free competition and even look for ways to collaborate and collude, they cheat Americans of that to which we are all entitled. As antitrust enforcers, these are the areas where we can use our legal authority to protect and benefit Americans — or, as we call it in President Trump’s Administration, “America First” antitrust.
Still, choices must be made about how to use that authority. Americans properly insist that their government focus energy and resources on harms that raise the cost of living. President Trump and this Administration are committed to “invigorating our economy and making life more affordable for Americans.”[2] At the Antitrust Division, we are supporting the President’s affordability agenda by ramping up antitrust enforcement where offenders engage in conduct that raises the cost of the goods and services that are the most important in the lives of American families.
We are more focused than ever on affordability issues, and where we see an opportunity to confront conduct that raises prices, we take action.
Which brings me to healthcare — a subject of intense interest to this audience and to us at the Justice Department. Healthcare is a staple necessity of modern life. While we all hope to not have continual doctor visits and to avoid the need for acute care as much as possible, Americans depend on the healthcare system at all stages in our lives. Whether folks use prescription drugs to treat chronic or acute conditions, the reliability and affordability of the supply of those drugs, including how patients obtain them and access to trusted pharmacists, is a matter of intense concern. Moreover, most Americans also pay for health insurance, often through plans whose cost is shared with employers. Whether it is a monthly bill or a paycheck deduction, the cost of health coverage has been on the rise.
Under President Trump, the Antitrust Division is squarely focused on the challenges in healthcare markets and how antitrust enforcement has the potential to improve consumer choice and affordability in those markets. There are several reasons why antitrust enforcement is both necessary and challenging in healthcare.
First, it is because healthcare is a crucial and indispensable need. American families deserve the benefits of competition in meeting their needs for quality, affordable healthcare. As in other areas of the economy, competition is critical to driving the benefits of the American free market system. Where competition is healthy and not restrained by anticompetitive forces, it leads to lower prices, higher quality, and innovation that benefits us all. Unfortunately, in too many areas of the complex healthcare system, we have reason to believe that competition is being shackled by anticompetitive conduct and restraints. An important part of the Antitrust Division’s mission is to probe those facts and determine where we can take action to benefit healthcare consumers.
Second, the rising cost of healthcare, as important as it is to American families, risks further broad harm across the economy. Those costs are paid not only by individual households, but also by employers and, for important parts of the healthcare system, by the federal government. Over the past 25 years, the cost of employer-provided family health insurance coverage has grown three times faster than workers’ earnings.[3] Rising premiums disproportionately burden small businesses, which typically spend more per employee on health insurance than larger businesses and, accordingly, must incur those costs through higher operating expenses.[4] Rising health insurance premiums effectively tax employers, putting downward pressure on employment growth and deterring the creation of new businesses. The government, too, is faced with rising prices that jeopardize Medicare’s long-term financial health. Projections indicate that Medicare spending is expected to increase from 1% of U.S. GDP in 1975 to 5% by 2030.[5] As federal law enforcers, we take very seriously conduct that costs taxpayers and deprives the government of the benefits of a free market.
Third, healthcare markets are faced with a variety of complex features that affect the competitive dynamics. In contrast to many of the markets that we investigate, in healthcare markets, consumers often have little information about the prices of the services and medicine that they receive — sometimes because of practices that actively discourage price transparency. Moreover, incentives in healthcare markets operate in unusual ways because of the role of insurance and because market participants like insurers, employers, and individual patients frequently have distinct and potentially misaligned incentives. These features of healthcare markets have the potential to create opportunities for rent-seeking and to lead to worse health outcomes.
Fourth, an important recent trend in healthcare industries is the increasing prevalence of vertical integration, as formerly independent providers at different parts of the healthcare value chain have increasingly joined together through mergers and acquisitions. Although vertical integration has potential benefits in certain contexts, it also creates risks to competition in healthcare given the multiplicity of decisionmakers, distorted incentives, high market concentration, and lack of transparency. In the healthcare context, vertical integration can also give rise to conflicts of interest when a company gains leverage in the healthcare system — not always to the benefit of consumers. Because of the importance of healthcare to American families, we take these risks very seriously, especially when there is a possibility that anticompetitive practices may risk harming patients by making healthcare unaffordable or lowering its quality.
The Antitrust Division is not deterred by these complexities in healthcare. Far from it. We have a terrific staff of attorneys and economists with a deep reservoir of understanding of competition issues in healthcare markets. We are constantly learning, using what we learn in our investigations, and looking for opportunities to bring impactful enforcement actions that will benefit consumers. And we serve under a President and an Acting Attorney General who are committed to the role of competition in promoting affordable, quality healthcare.
To that end, I am proud that the first two enforcement actions that I brought as Deputy Assistant Attorney General with my stellar colleagues in the Antitrust Division go after anticompetitive conduct in healthcare. In these cases, we are challenging the anticompetitive contracting practices of two powerful hospital systems, OhioHealth and NewYork-Presbyterian.[6] As healthcare providers, these hospitals should be focused on saving lives and improving patient care. But they are also harming patients in central Ohio and New York City by using contractual restraints to block competition that would improve quality and lower prices.
Let’s start with a few basics. As we know, the cost of health insurance is on the rise. Healthcare plan sponsors, like employers and unions who bear some of the cost of health insurance and also have responsibilities to their employees and members, appropriately seek to lower the cost of insurance and offer plan participants options that provide high quality at an affordable cost. Likewise, many families who are covered by commercial health insurance plans, whether offered by their employer or purchased directly from the insurer, seek options that give them value for their dollars.
In response to these pressures, in competitive markets, employers have sought a variety of budget-conscious plans that leverage the power of competition to reduce the cost of healthcare. For example, some of these budget-conscious plans reduce the cost of health insurance by offering a narrow network of cost-effective providers, or a “tiered” network that rewards patients with lower out-of-pocket costs when the patients use providers that offer better value. Other innovative features include financial incentives for patients to utilize lower-cost sites of service or more efficient providers. Some budget-conscious plans also use an approach called “active transparency” to share out-of-pocket cost information with patients so that they can make an informed decision about whether to choose a more or less expensive provider.
Where these types of plans are available, American families who rely on commercial health insurance have more choices. Not all families will choose a budget-conscious plan, depending on their individual needs and preferences for healthcare, just as consumers choose between ordinary and premium grades of other goods and services. Not only is this choice a benefit of competition, but where budget-conscious plans exist, they put pressure on healthcare providers to compete against each other to offer higher quality care at lower prices — another benefit to patients — for all healthcare services.
This brings us back to the Division’s cases. In the complaints we filed in February and March 2026, we allege that OhioHealth and NewYork-Presbyterian are large and powerful hospital systems in their respective regions that use their market power to charge high prices — even higher than hospitals of comparable quality in the same areas. Those hospital systems also use contract restrictions to limit options available to employers.
What are these restrictions? Remember the innovations I described that allow payers to offer budget-conscious health plans. Health systems with market power effectively quash these budget-conscious health plans by prohibiting health plans from encouraging patients to seek lower-cost alternatives. Some of these restrictions, including OhioHealth’s, even impose a gag rule preventing insurers from providing patients with truthful information about the prices of healthcare services they may receive. This deprives patients of meaningful choice and shields dominant, high-cost hospital systems from competition that would provide patients with higher quality service at a lower price. That is why we have challenged these two hospital systems and will ask the courts to put an end to their ability to impose these anticompetitive restrictions.
These complaints build on the success of the Antitrust Division during the first Trump Administration. In 2018, the United States reached a settlement with Atrium Health, the dominant hospital system in Charlotte, North Carolina, that required Atrium to stop enforcing contractual restrictions similar to those in the Division’s recent cases.[7] Building on that history, we anticipate that our current cases will not only result in relief for health consumers in Ohio and New York, but they will also create precedent that will discourage hospital systems elsewhere from trying similar tactics and serve as a template for future challenges where hospital systems persist in them.
Of course, these enforcement actions in no way suggest that we will not carefully scrutinize self-preferencing by large insurers toward providers or other business owned by them. In those circumstances, the insurer has a potential conflict of interest that may encourage it to act in ways that raise costs to employers, reduce quality of care to patients, and foreclose competition.
I will also briefly note one of our recent wins for healthcare competition. In December, the Antitrust Division obtained court approval for a settlement addressing competitive concerns about UnitedHealth Group’s acquisition of Amedisys, a provider of home health and hospice services.[8] As this audience knows well, UnitedHealth is a vertically integrated health insurer, healthcare provider, and pharmacy benefit manager — one of the largest American companies in any sector of the economy. Our settlement, which followed nearly a year of hard-fought litigation, benefits seniors, hospice patients, nurses, and their families by requiring UnitedHealth to divest at least 164 home health and hospice care locations across 19 states, the largest divestiture ever required of outpatient healthcare services to resolve a merger challenge. The Antitrust Division will continue to review corporate transactions that threaten competition and will seek appropriate remedies or, when necessary, challenge them in court.
As a law enforcer, I cannot describe our ongoing investigations, but be assured that we are taking a close look at potentially anticompetitive conduct involving companies across the healthcare system. As we make the hard choices about how to deploy our limited enforcement resources, healthcare is a top priority.
Now I will turn to an issue that is close to this audience — the role of antitrust enforcement when it comes to pharmacy benefit managers (PBMs), the entities that manage prescription drug benefits on behalf of healthcare plan sponsors and insurers. As I will explain, I proceed with humility because of the specific role of the Antitrust Division. But I hope I will provide you with insight into the way that antitrust enforcers think about potential investigations and enforcement in this area.
First, let me stress that the Antitrust Division, as part of the Department of Justice, is a law enforcer, not a lawmaker or a regulator. As a law enforcer, it is not our role to craft policy decisions about how the healthcare system should function. Nor is it our role to design the detailed but essential rules that guide how market participants operate. On these incredibly important issues, we defer to other parts of the Executive Branch and to Congress. Instead, it is our task to enforce the antitrust laws, which protect economic liberty and free and unfettered competition.[9] The law of competition is our lodestar.
The Antitrust Division’s appreciation for our role does not, however, mean we ignore other actions in government affecting healthcare industries. As to PBMs, there have been important recent developments under the Trump Administration, as I am sure you are aware. In April 2025, President Trump signed an Executive Order on “Lowering Drug Prices by Once Again Putting Americans First.” Among other directives, this order required a review of “how best to promote a more competitive, efficient, transparent, and resilient pharmaceutical value chain that delivers lower drug prices for Americans.”[10]
The following month, the President took further action with an Executive Order on “Delivering Most-Favored-Nation Prescription Drug Pricing to American Patients.”[11] President Trump has reached agreements with pharmaceutical companies that put American patients first by delivering reduced costs for important life-saving and health-improving prescription drugs.[12] The Administration’s focus on prescription drug affordability remains unwavering to this day, including with yesterday’s announcement by President Trump of the expansion of TrumpRx.gov to provide price transparency and choice on generic drugs used by millions of Americans.[13]
The Consolidated Appropriations Act of 2026, which President Trump signed in February, includes significant reforms directly affecting PBMs.[14] As these reforms become effective, they will affect how PBMs receive renumeration and will expand the information they must disclose to the government and to plan sponsors. The law also provides civil penalties for non-compliance with its disclosure and notice provisions.
Moreover, the Trump Administration’s Department of Labor has released a proposed rule on fee disclosures for PBMs, designed to improve transparency between health plan sponsors and PBMs and their affiliated brokers and consultants.[15] The public comment period recently closed on this rulemaking. The Labor Department, like other agencies conducting rulemaking proceedings, will review and analyze comments received as it determines whether to modify the proposed rule or take other action.[16]
At the Antitrust Division, we are monitoring these developments and will be particularly attentive to how they affect market participants’ incentives in markets related to the prescription drug supply chain.
A second reason for humility is the Department of Justice’s role as one of two federal antitrust enforcement agencies. We share responsibility for enforcing the antitrust laws with our friends at the Federal Trade Commission. The FTC has historically taken an active role in investigating competition concerns involving PBMs. This does not mean that the Justice Department lacks an enforcement role with respect to PBMs, but the agencies defer to one another with respect to investigations into particular transactions or conduct under appropriate circumstances.
On that subject, however, I should emphasize the Antitrust Division’s depth of expertise when it comes to health insurance markets, healthcare technology, and healthcare provider services. We routinely investigate health insurance mergers and mergers involving insurers and providers of related products and services, as well as healthcare conduct matters. The world-class attorneys of our Healthcare and Consumer Products Section and the superb economists of our Expert Analysis Group have enormous experience applying the antitrust laws to transactions and conduct involving these markets and have litigated challenging cases. As we think about PBMs at the Justice Department, we therefore often consider their relationship to health insurance markets, including how market participants impact employers and other plan sponsors.
We also think about competition issues affecting PBMs through the same lenses that we apply to other areas of the economy. Thus, we find it noteworthy that the PBM industry has become highly concentrated, with the largest PBMs having high nationwide market shares.[17] That the largest PBMs are also vertically integrated with insurers. This vertical integration poses risks such as the possibility that PBMs may preference their affiliated companies and attempt to exclude rivals. Additionally, net prices for prescription drugs — like many other prices in healthcare — have been remarkably opaque. As Transparency Rx members well know, the largest PBMs and the industry in general have been criticized for pricing and contracting practices that pose a risk of hampering employers from making informed choices when purchasing benefits for their employees. Finally, given the special importance of healthcare to American families, we consider how restrictions and practices that limit competition have the potential to harm patients through lower quality of services and higher prices.
A final note about how we look at PBMs, and all other industries. As a law enforcement agency, we proceed deliberately and avoid jumping to conclusions. In all of our matters, we begin cautiously, seeking to understand the effect of conduct we review and whether it involves a violation of the antitrust laws. Only after we have investigated thoroughly, can we act boldly to remedy harm to competition. Thus, while I have described some of the issues that we look at when we consider healthcare markets, I must be clear that we have reached no conclusions except in our filed cases.
In nearly all of our investigations, not least in the healthcare sector, we depend on cooperation from companies and individuals who inform us about how competition works in their industries. Although the Antitrust Division has the authority to serve subpoenas to seek information from market participants, we depend significantly on voluntary cooperation. Thus, our staff attorneys and economists often reach out to market participants for interviews when they are investigating a particular issue. We also receive “citizen complaints,” where individuals who are aware of activity that they suspect harm competition bring them to our attention. We appreciate the participation and goodwill of all those who cooperate with our investigations, whether formally or informally. To that end, if you have information and concerns about anticompetitive practices involving PBMs or elsewhere in healthcare, please reach out to the attorneys in our Healthcare and Consumer Products Section or use our healthcare competition complaint portal, which can be found at healthycompetition.gov. We never know as much about any area of the economy as those who participate in it as their lives’ work, and our investigations are greatly enriched by citizen participation.
I will end where I started — it is a pleasure to be with you today and to learn more about Transparency Rx and your members’ perspective on important competition issues. I appreciate this opportunity to share our perspective on antitrust enforcement in healthcare. As I described, competition law enforcement is not the only tool to address the challenges in our nation’s healthcare system, but it is a vitally important one — one to which the Antitrust Division under President Trump is fully committed. Thank you very much for your time and attention this morning.
