Executive Summary

Anti-steering, anti-tiering, and all-or-nothing contract mechanisms are tools by which dominant hospital systems insulate themselves from price competition: anti-steering prohibits insurers from directing patients to lower-cost providers; anti-tiering is one form of anti-steering that prevents insurers from placing a dominant system on a less favorable benefit tier; and all-or-nothing contracting requires insurers to accept every hospital and affiliated physician in the system or none at all. The Department of Justice complaints filed in February 2026 against OhioHealth and March 2026 against New York-Presbyterian allege that anti-steering restrictions are anti-competitive. Both cases are still pending.

This report expands on estimates of reductions in hospital and insurance premiums that would follow a nationwide ban on all three mechanisms collectively. We estimate that a ban would reduce hospital and affiliated physician prices by 18 percent (credible range 11 to 26 percent), or ~$4,100 on average per hospitalization, in directly affected markets through three channels: restoring insurer bargaining power, sorting patients to lower-cost providers, and further price relief over time as the removal of these provisions allows competing systems to become more credible alternatives to insurers. After accounting for the share of hospital and affiliated physician spending in total employer-sponsored insurance (ESI) costs (approximately 57 percent) and applying a 70 percent pass-through rate, ESI premiums in directly affected markets would fall by an estimated 6.5 percent (range 4 to 9 percent).

In directly affected markets, this premium reduction corresponds to savings of ~$1,800 ($1,100 to $2,500) per family annually and ~$600 ($380 to $860) per person (2025 dollars). Because the economic impact of ESI premiums falls on workers, these savings flow to employees through a combination of lower out-of-pocket premiums and higher take-home pay. Lower hospital insurance prices also increase wages and employment at non-healthcare employers and increase federal income tax revenues, with gains concentrated among low- and middle-income workers. We estimate that 24 percent of Americans covered by ESI operate in markets where these provisions are binding and consistent. Scaling our estimates to account for this fact shows that nationwide ESI premium savings of 1.6 percent represent approximately $45 billion ($29 to $63 billion) annually.

Expected effects vary by market structure. In markets with a dominant system and competitive insurers, we expect a 4 to 6 percent premium reduction. Where both the hospital system and insurer have market power, the estimated reduction is 2 to 3 percent. In more competitive markets with lower prevalence of these provisions, reductions are 1 to 2 percent. In rural communities, multi-market systems may use anti-steering and all-or-nothing contracts to extend urban market power to rural hospitals, thereby increasing prices in those communities. A ban could lower premiums for rural workers and employers, improve the negotiating position of independent rural hospitals, and exert minimal pressure on system-owned rural hospitals.

whitehouse.gov / gnews.cz