When Breathing Becomes a Billing Code: Hospital Monopolies and the Price of Air

The Invisible Premium on Every Breath

For the roughly 16 million Americans living with chronic obstructive pulmonary disease, the 25 million managing asthma, and the growing population of long COVID patients with documented lung function impairment, respiratory care is not elective. It is survival infrastructure. Oxygen concentrators, nebulizer treatments, pulmonary rehabilitation programs, and ventilator services are as essential to their daily functioning as insulin is to a diabetic. And like insulin, the price of breathing has become, in much of this country, a function not of clinical necessity or manufacturing cost but of market power.

Hospital consolidation — the sustained, two-decade wave of mergers, acquisitions, and system expansions that has reshaped American healthcare geography — has concentrated respiratory services in ways that insulate dominant providers from price competition. According to the American Hospital Association's own data, the number of hospital mergers and acquisitions between 2010 and 2023 exceeded 1,600. In dozens of regional markets, a single health system now controls the majority of inpatient beds, outpatient specialty clinics, and affiliated home health providers. When that system also controls the only nearby pulmonology practice and the only in-network home oxygen supplier, the patient has no meaningful choice and the provider has no meaningful reason to compete on price.

The Numbers Behind the Disparity

The price variation data for respiratory services in the United States is extraordinary and underreported. A 2023 RAND Corporation study examining hospital pricing found that hospitals in highly consolidated markets charged, on average, 26 percent more for the same procedures than hospitals in more competitive regions — and the gap was wider for specialty services, including respiratory care. A home oxygen therapy setup that costs a patient $45 per month in a competitive urban market can run $180 or more in a rural county served by a single dominant health system.

Medicare and Medicaid set reimbursement floors, but commercial insurers — who negotiate rates privately with dominant systems — frequently pay two to four times Medicare rates in monopoly markets, costs that are then passed to patients through premiums, deductibles, and out-of-pocket maximums. The Kaiser Family Foundation has documented that the average annual deductible for employer-sponsored insurance now exceeds $1,700 for individual coverage. For a COPD patient requiring regular pulmonary care, that deductible is not a theoretical exposure. It is an annual certainty that arrives before the first covered claim.

Medical debt resulting from respiratory and pulmonary care has become a significant driver of personal bankruptcy filings. A landmark 2019 study in the American Journal of Public Health estimated that 66.5 percent of all personal bankruptcies in the United States had a medical cause. More recent analyses suggest that respiratory conditions — amplified by the long-tail health consequences of the COVID-19 pandemic — are an increasing component of that debt load.

COVID's Unfinished Bill

The long COVID crisis has added a new dimension to this structural failure. Conservative estimates from the Brookings Institution placed the number of Americans experiencing long COVID symptoms at over four million in 2023, with pulmonary complications — reduced lung capacity, exercise intolerance, recurring respiratory infections — among the most commonly reported. These patients are disproportionately working-age adults, many of whom were not previously high utilizers of healthcare. They are encountering a respiratory care system that was already strained, already monopolized in many regions, and already priced beyond the reach of anyone without robust employer-sponsored insurance.

For the uninsured and underinsured, the consequences are not abstract. They are deferred care, rationed oxygen, and the grinding calculus of whether this month's treatment is worth the debt it will generate. Emergency departments — typically the last resort for patients who cannot afford outpatient management of a chronic condition — are not equipped to manage long-term respiratory disease. They treat the acute crisis and discharge the patient back into the conditions that created it.

The Counterargument Examined

The healthcare industry's defense of consolidation rests on the argument that scale produces efficiency: merged systems can invest in technology, recruit specialists to underserved areas, and cross-subsidize money-losing service lines with profitable ones. In theory, the rural hospital that couldn't sustain a pulmonology department alone can offer it as part of a larger system.

This argument has genuine merit in specific contexts. Some rural consolidations have expanded specialty access that previously didn't exist. But the Federal Trade Commission's own enforcement record — and the academic literature it has produced — consistently finds that hospital mergers in already-consolidated markets raise prices without producing the promised quality improvements or access expansions. The efficiency argument is strongest where consolidation is creating access from nothing. It is weakest, and most frequently deployed, where it is eliminating the last remaining competition.

What Accountability Would Look Like

The Federal Trade Commission under Lina Khan moved aggressively to challenge hospital mergers before her departure in early 2025. That posture is now uncertain. Antitrust enforcement in healthcare is a long, expensive, and politically contested process — and the industry has significant lobbying resources deployed against it.

But enforcement is only one lever. Price transparency regulations, if actually enforced, would give patients and policymakers real data on regional pricing disparities. Expanding Medicare's negotiating authority to cover durable medical equipment and home health services — currently limited — would reduce the leverage dominant systems hold over respiratory care pricing. And a serious investment in community health centers and federally qualified health centers, which operate on a sliding-scale fee model, would create genuine alternatives for the millions of patients who currently have none.

The air in your lungs should not be subject to a monopoly markup. That a sentence like that requires writing is itself a measure of how far the American healthcare system has drifted from its stated purpose.