December 11, 2017
The recently proposed merger of two giant players in healthcare — CVS Health, one of the nation’s largest pharmacies, and Aetna, one of the largest health insurance companies — will create a healthcare behemoth. With annual revenues of about $240 billion, the newly combined company will rank second only to Walmart among American companies. Will the merger fill unmet needs for access to healthcare, or is it going to create problems?
CVS, with its 10,000 pharmacy and clinic locations spread across the country, and Aetna, which covers about 22 million people, paint a rosy picture of how the combined company will deliver healthcare. Patients, they say, will have access to high-quality, low-cost care that’s as convenient as their corner drug store. Merging pharmacy and health insurance data, as they tell it, will help assure that patients don’t fall through the cracks, will improve the health of local communities, and will reduce overall health costs. Consumers will be the beneficiaries.
This, of course, is the case that the two companies must make to regulators. The emphasis in anti-trust enforcement is on the effect of the merger on efficiency — on whether synergies will reduce costs and benefit consumers. The effects of mergers on competition, consumer choice, and worker outcomes rarely concern the Federal Trade Commission or the Justice Department.
The conversation about the CVS–Aetna merger has focused on its effects on patient care and healthcare prices. Will the merger create “a new front door to health care,” as CVS’ chief executive claims? Or, will it further limit choices for consumers and restrict patients to silos with access only to a narrow set of pharmacies, doctors, and clinics?
Will the merger lead to lower health care costs? Or, will the market power they gain through consolidation allow them to charge prices that increase their profit margins?
As health economist Martin Gaynor has observed, retail clinics may be more convenient, but they have not yet demonstrated that they reduce overall healthcare costs. And, CVS is already one of three very large and highly profitable pharmacy benefit managers (PBM) which oversee drug coverage for insurers and hospital pharmacies. PBMs wield great power over drug companies by their ability to choose which drugs will be stocked by hospital pharmacies and considered “in the formulary” when purchased by insured patients. They have not used this power to bring down drug prices which, instead, have continued to rise.
Higher prices to consumers are not the only danger of market concentration. Consolidation may also increase a firm’s ability to hold down the wages of its workers. In the case of large employers with a national reach, not only are the wages of their own employees likely to be negatively affected, but there may be downward pressure exerted on wages throughout the industry — the so-called Walmart wage effect. Will the rapid expansion of employment in retail health lead to depressed wages for health-care workers in retail clinics and the industry more generally?
Healthcare workers’ wages are already stagnating or even falling, despite their rising educational levels and strong employment growth since 2005. Restructuring of the healthcare industry, characterized by both the consolidation of hospitals into large health systems and the decentralization of health services delivery to urgent care centers, surgicenters, and free-standing imaging and emergency departments may be part of the reason. Research I conducted with Cornell Professor Rosemary Batt found that median real wages of all full-time workers in outpatient facilities fell by almost six percent between 2005 and 2015. Median real pay of medical technicians was $4 an hour less in outpatient care centers than in hospitals, ($17.67 compared with $21.60) and the median real pay of health aides and assistants was $14.72 in hospitals and $14.28 in outpatient facilities.
Consolidation is already underway in healthcare, with the prospect of cuts to Medicare and uncertainty over the future of the Affordable Care Act (ACA) in Republican tax plans likely to accelerate this trend. Approval of the CVS–Aetna merger will provide incentives to other companies in different segments of the industry to combine in order to enter new markets or gain access to new consumers. Companies pursue consolidation to strengthen their market position and enhance their profits. It is up to the regulators charged with evaluating such mergers to examine the effects on workers, as well as patients, in deciding if they should be allowed to go forward.