Antitrust Matters Episode 12: First, Do No Harm. Does the Business of Hospitals Follow this Creed?
Antitrust Matters provides engaging and timely conversations about competition policy in the digital age. Antitrust has always mattered to consumers and businesses, and to antitrust lawyers and economists, but today it also is in the political and public discourse more than ever. From the prices we pay for food, travel, financial services, payments to the way we interact daily using digital apps and platforms, antitrust touches each and every one of us in ways we may not even realize. Antitrust Matters brings you you perspectives of experts and visionaries in the field who discuss where antitrust law has been, where it is going and why it is so important to our current political discourse.
In this episode, Constantine Cannon partner, Matthew L. Cantor, discusses economic and antitrust issues raised by the conduct of certain large hospital systems. Joining him on the podcast as guests are Duke University Professor of Law, Barak Richman, and CEO of the policy group known as the Catalyst for Payment Reform, Suzanne Delbanco.
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Episode Transcript and Show Notes:
Jeff Shinder:
Welcome to Antitrust Matters, a Constantine Cannon podcast where we have engaging and timely conversations about competition policy in the digital age. My name is Jeff Shinder, and I’ll be your host. Antitrust has always mattered to consumers and businesses, but today it is also in the public discourse more than ever. From how we get our food on our plates, to how we travel, to the way we interact daily using digital apps and platforms, antitrust touches each and every one of us in ways we may not even realize. In Antitrust Matters, we bring you perspectives of experts and visionaries in the field who discuss where antitrust law has been, where it is going, and why it matters today more than ever before.
Matthew Cantor:
Hello, everyone. My name is Matthew Cantor, and I am a partner at Constantine Cannon. I specialize in antitrust and healthcare litigation. This podcast is dedicated to exploring the role that antitrust analysis plays in certain actions taken by hospital systems. It asks whether hospital systems, including those that identify as “not-for-profit systems” ever take actions that constitute an anti-competitive exercise of market power. It also asks whether certain arguments offered by hospital systems justify actions that would otherwise be deemed or held to be anti-competitive. And it asks how we should analyze certain hospital actions to determine whether or not they have caused or likely could cause consumer harm.
At the outset, we did want to note that this podcast does not consider the medical treatment performed by specific doctors or nurses or EMTs for specific patients, and it does not question whether hospitals do good things, of course they do, they treat patients, but even though this is the case, the law does not immunize nor should it immunize, in this commentator’s humble opinion, the economic actions of hospital systems from antitrust scrutiny. Hospitals are not permitted to harm consumers or competitors with impunity just because they treat people who are sick or injured. We must, therefore, consider whether certain hospital economic actions could likely harm those that pay hospital prices or try to compete with hospitals to treat patients.
Today I am joined by two true healthcare gurus, both of whom have substantial experience in considering the economic actions of hospital systems. They are, first, Professor Barak Richman. Professor Richmond is the Catherine D. Bartlett Professor of Law at Duke University Law School. He has a PhD in Business Administration from the Haas School of Business at the University of California Berkeley, and he has a law degree from Harvard. He focuses his academic work on antitrust issues raised in healthcare markets. Welcome, Professor Richman.
Barak Richman:
Thanks for having me.
Matthew Cantor:
We’re also, luckily, joined by Suzanne Delbanco. Now, Ms. Delbanco was the founding executive director of the Catalyst for Payment Report. That’s an independent nonprofit corporation working to catalyze employers, public purchasers, and others to implement strategies that produce higher value healthcare and improve the functioning of the healthcare market. She now serves as a strategic advisor for CPR. And previously, Suzanne was the founding CEO of the Leapfrog Group. Suzanne also holds a PhD in Public Policy from the Goldman School of Public Policy, as well as a Master’s of Public Health from the University of California Berkeley. Welcome, Ms. Delbanco.
Suzanne Delbanco:
Thank you.
Matthew Cantor:
Well, let’s get to it. I have some questions that I’d like to ask our guests, and I may have some comments from time to time as well. So Professor Richman, let me first ask you, does the average Joe or Josephine directly pay for hospital services that he or she consumes?
Barak Richman:
Well, it depends on what you mean by directly. I mean, economists have a very different term from direct than the normal person, you might say. When a person requires hospital care, there might be some kind of copayment, some kind of co-insurance. Now, I don’t want to belittle the size of those copayments, they can be quite significant, and they have on their own triggered a lot of economic harm, but the most significant way from a financial perspective, the most significant way the typical non-retiree, non-senior member of the population pays for healthcare/hospital care is through their insurance. Most people get insurance through their employer.
So the financial transaction goes like this: I work for my employer, my employer buys insurance on my behalf. That money, therefore, goes to the insurer, and then when I need hospital care, the insurer pays the hospital. If you’re asking from a transactional perspective, there are three intermediaries there: my employer, the insurer, and then he goes to the hospital. From an economic perspective, it’s quite direct. The vast majority of hospital revenues come from private insurance payments. Private insurance, even though it is paid for through the employer, directly comes out of the employee’s paycheck. For every dollar of insurance the employee gets, that’s $1 less that comes out of the employee’s paycheck. And therefore, from an economic perspective, the typical person, frankly, whether they get hospital care or not, are paying quite directly for the hospital care they may or may not need.
Matthew Cantor:
Given the way that people pay for hospital care, and I’m focusing based on the payments that go through premiums, do you think that the typical Americans should care about hospital prices? And if so, why?
Barak Richman:
The typical American should deeply care about hospital prices. Hospitals consume about 40%-45% of the total healthcare spend. From a per capita perspective, or from an insurance premium perspective, that’s about $16,000. Suzanne, is that about the right number now?
Suzanne Delbanco:
That someone pays on it for over a year?
Barak Richman:
A year’s worth of a insurance?
Suzanne Delbanco:
Yeah, that sounds about right.
Barak Richman:
So now, the $16,000 figure, in addition to being extraordinary, is especially pernicious precisely because the individual is not paying it directly, it’s mostly being paid out of their pockets indirectly through their employer, they don’t know how much it is. But if you figure about 45% of 16,000 goes to hospital care, that’s a lot of money every year for the typical insurance premium payer. So yes, to the degree that any individual cares about a $7,000 annual purchase, they should care about hospital prices.
Matthew Cantor:
I certainly care about it from my paycheck standpoint. So I care. Ms. Delbanco, let me ask you a question. Do you agree that employers pay for a good deal of the insurance premiums, which includes hospital costs?
Suzanne Delbanco:
Yeah, absolutely. At the end of the day, when a person is employed, they’re compensated for their work. Part of their compensation comes in the form of wages, and part of their compensation comes in the form of other benefits, including in many cases health insurance. But the more my health insurance costs, even if the employer pays a good portion of it, the less opportunity I have for my wages to go up. So there is a varying degree of cost sharing that the employer participates in, so they cover a portion of the premium, but the total premium, and even the proportion that the employer is willing to cover, is going to be impacted by how expensive that insurance is overall.
Matthew Cantor:
Ms. Delbanco, in the United States, to what extent are employers required to pay for healthcare expenses for their workers?
Suzanne Delbanco:
It depends on the nature of the employer and the size of the company. But really, employer-based health insurance started out as a voluntary thing. It was added to the offerings really around World War II to try to bring workers that had been lacking when everybody was off fighting war or building ships back into the workplace. And then it became this sort of arms race of, “How great can my benefits be so I can attract workers and retain them?” And so even to this day, a lot of the insurance, even though it’s regulated, is something that is essentially done as a way of luring workers to a given workplace and to trying to get them to stay.
Matthew Cantor:
So employers compete by offering healthcare benefits, is that right?
Suzanne Delbanco:
That’s right.
Matthew Cantor:
Professor Richman, I want to go back to your discussion on premiums. Do you know of any regulations that require or certainly indicate that the hospital costs that are incurred in this country are passed through by health insurers to their premium payers?
Barak Richman:
As a basic matter of economics, if you are a financial intermediary, you’re an insurer who collects premiums then pays for healthcare, everything you do is passed on. All you’re doing is taking money from one pocket and sending it to the other. I’m being a little disparaging when I say it’s all they do. But for sure, the prices of healthcare are immediately passed on to the people who pay insurance. It’s also passed on in the form of health generous set insurances. Prices go up for healthcare services and insurer either increases premiums or reduces the generosity with what the insurance product has. It might not cover certain outpatient services or they might increase cost sharing. So for sure, there is an immediate effect.
Now, are there regulations that require that or are there regulations that mitigate that pass-through? I mean, this is a heavily regulated sector, and you can imagine certain regulations affecting that pass-through. There is, for example, the medical loss ratio. This is a rule that was part of the Affordable Care Act that it sounds innocuous or even well-intentioned. It requires insurers to spend 85% of their total premiums, or total revenue, on healthcare. It basically, you might say, is a cap on how much insurers can keep either for administrative services or for profit. And who can argue with spending insurance money on healthcare? But one thing it does is it means that patients are especially vulnerable to price increases that providers and hospitals imposed. So there is even less discretion on what insurers can do. And frankly, there’s even less of an incentive on what insurers might want to do to counteract hospital prices.
I suppose, I’m sure we’ll get to this, you can consider antitrust law as a form of price regulation. You could think that antitrust law might be a source of regulation that would limit prices that hospitals can charge. But of course, that hasn’t done a very good job.
Matthew Cantor:
We certainly will get to remedies for hospital price increases later on in the program, but I appreciate your answer. Ms. Delbanco, I assume you agreed what I said at the outset that you believe that hospitals provide important functions to society.
Suzanne Delbanco:
Yes, absolutely. I can say that they helped me deliver two wonderful boys, and it helped us through a few other healthcare crises as a family, so absolutely.
Matthew Cantor:
Well, I have three children. They’re all rotten, but I love them nonetheless in any event. So your organization has certainly sought to limit hospital price increases certainly in certain instances, but don’t price increases allow hospitals to gain revenue and don’t they need revenue in order to provide quality care?
Suzanne Delbanco:
Hospitals absolutely need revenue. They have workers to pay, they have supplies to buy, they have insurance that they have to purchase. There’s a million expenses that go into running a hospital, so of course they need revenue. The question is, how much? That’s something that in truth not that many people really know because the way that accounting is done in a hospital or a health system is just one mystery on top of another. We know that in markets where there’s a lot of competition among hospitals they manage to deliver care at lower costs than in markets where there’s less competition. What that suggests to me is that if one can’t cover costs through prices or raising prices, one has to figure out how to root out unnecessary costs. It could be something as simple as where you’re sourcing the bed linens from. It could be something much more complicated like what are the financial incentives that your bedside providers have not to waste resources? But either way, we’re pretty certain that there’s a lot of room for cost-cutting in the delivery of care that means that hospitals could have a decent margin without the price increases that we’ve been seeing especially over the last decade.
Matthew Cantor:
When you say cost-cutting, do you mean cutting cost but also impacting quality negatively, or do you mean keeping quality flat but still having costs go down?
Suzanne Delbanco:
Keeping quality flat, but still having costs go down. There’s a lot of debate about whether improving the quality of care reduces costs. Or on the flip side, we could say reducing costs, could it improve quality? Let me give you a great example. We have too many unnecessary cesarean deliveries in this country. There’s all kinds of reasons for it from the OB-GYN who wants to have control over their schedule, to even a patient demanding to have a baby on a certain day. So there’s lots of reasons why we have unnecessary cesarean deliveries. But the truth is we pay about 50% more for cesarean delivery than a vaginal delivery. And as long as there’s an incentive to generate revenue at the hospital and we pay more for cesarean deliveries, there’s really not a lot of pressure on the hospital to change.
But we also know that cesarean deliveries can lead to worse outcomes for the baby, for the mother. They’re not much more dangerous than vaginal deliveries, but there are some issues that can arise, especially when it comes to the respiratory health of the newborn. And so, if we were to simply pay less for those cesarean deliveries, we might see a shift toward more vaginal deliveries and supporting women in labor. And people would, I think, wholeheartedly agree that that would be better quality. So it can go both ways in terms of costs and quality. Does higher cost equal higher quality? Does lower cost equal higher quality? It just depends on the clinical area and where the costs are getting cut from. But I think one thing that consumers often make the mistake of believing is that more expensive care is higher quality care, and the data shows there’s absolutely no correlation.
Matthew Cantor:
Ms. Delbanco, I want to stick with this issue for a second, and Professor Richman, you can feel free to comment on this too. But there’s one argument that hospitals make oftentimes that I’d like you both to comment on, and it’s this: many not-for-profit hospitals have to offer something called charity care, which I think listeners may not know, but that’s providing care to the uninsured, to the indigent who have no Medicaid, no insurance whatsoever in order to pay. And then, of course, hospitals also have to provide care to patients that are on Medicare. These are generally older patients for which the government insures, and Medicare rates are generally lower than rates that commercial insurers can negotiate with hospitals. So you have sort of higher commercial insurance rates, sort of lower Medicare rates, even lower Medicaid rates, or about the same as Medicare, and then you have no payment whatsoever that goes to the hospital in an uninsured payment. Hospitals will often say that they need higher commercial payments in order to cross subsidize these critical services that they provide to the elderly and to the indigent. To what extent do you believe that cross-subsidization argument holds water? And do you believe that it has justified price increases by any hospitals?
Suzanne Delbanco:
I’ve been working on behalf of employers and other big purchasers to push the healthcare system to deliver better value since 1999. One of the age-old debates is whether or not, the phenomenon you’re describing is cost-shifting, are employers getting saddled with extra costs because the government doesn’t pay enough? Or is it what an economist would call price discrimination, where the hospital will charge the most they can to any different payer, and if the payer’s willing to pay whatever the price is, then fantastic. And they don’t have to work as hard at being efficient at rooting out excess costs and they can just make things work by getting a higher price paid by someone who’s willing to pay it.
I personally believe it’s the latter. I’m sure there’s cost-shifting that happens. It goes back to that issue I raised before which is that if you were to really delve into the cost of operating a hospital and delivering care, hospitals don’t actually know what it costs to deliver a unit of care or a particular type of service because it’s all muddled together in the top line. What are our expenses? What do we want our revenue to be? What do we want our margin to be? And they negotiate at a very high level about that stuff.
Again, going back to what I mentioned earlier, there is some data that has been put out by the Medicare Payment Advisory Commission, a group that advises Congress, that suggests that hospitals in areas that are more competitive do just fine on those lower government rates. But it’s a hell a lot easier just to charge higher prices to those willing to pay than to actually have to figure out how to have a good margin on those lower rates.
Barak Richman:
I would put it even more strongly. I would say not only does it make more sense, but it makes no economic sense to suggest a cost-shiftings happens at all. It suggests that hospitals, unlike other organizations, including nonprofits, they’re not trying to maximize. They’re not trying to do whatever they can given the market environment that they have. It suggests that hospitals are behaving in distinctively uneconomic or economically irrational ways, and that for whatever reason, they’re the one lone exception to microeconomic theory.
Suzanne Delbanco:
I love that.
Matthew Cantor:
Just for the record on this program, I just want to say I and my firm have litigated various hospital matters where this has come up. We contend that in antitrust in particular, that it is impermissible to offset or to balance an anti-competitive effect in one market with a pro-competitive benefit in another. We don’t think that antitrust law should be doing that kind of weighing because that would lead to all sorts of very difficult outcomes to assess and would really reduce the enforcement aspects of the antitrust law. So that’s an issue, a legal issue that we have litigated. We think we’ve got the better view of the law on that. If you go with our view of the law, since government-insured patients are generally not deemed to be in the same market as commercially-insured patients, that kind of argument we don’t think is recognizable under antitrust law. But I find it an interesting economic and antitrust issue.
Professor Richman, we’ve talked about market power, and this is a phrase that I’m sure you’re very familiar with, can you define it for our viewership or for our listenership?
Barak Richman:
Yeah, so market power is the ability to control or dictate prices. If you are one of 1,000 lemonade stands on Main Street, if you price above the lemonade stand next to you, assuming all the lemonade tastes the same, you’re not going to get any business. You are a price taker. If you’re one of 1,000, you do not have any pricing power. If you’re one of three, you might have a little pricing power. And if you are the lone lemonade seller, you have entire pricing power, you set the price. Now, of course, you don’t set the price at the highest possible amount. You are still restrained to some degree by what the market will bear, but you have market power in the sense that it’s just you and the marketplace. It’s just you and the body of consumers. You can control prices without concern for our competition.
Now, I will add that, and I don’t think this has been recognized; certainly hasn’t been recognized as a matter of antitrust law. I don’t think it’s widely appreciated even in policy circles. But hospital market power, I have argued, is even more potent than just normal monopoly power. If you are the only lemonade seller in town, yeah, you can charge the monopoly price and maybe, especially if it’s a really hot and dry day, you can charge even more than that. But hospital care is a genuine must-have product. And for that matter, most of the margin of most hospital care is covered or clouded by insurance. There really is not a price that the lone hospital can charge that will price it out of the marketplace. So not only is market power in any market a real problem, you want competition, you want prices below the monopoly price, you want to close to the competitive price, but hospital market power is especially pernicious and especially costly.
Matthew Cantor:
Let’s talk, Ms. Delbanco, about certain remedies that your organization has advocated for in order to try to reign in hospital pricing. First of all, have you looked towards antitrust enforcement as a potential way to do so?
Suzanne Delbanco:
Yeah, so I guess what I would like to give as a image is that we’ve taken a belt and suspenders approach. You want to make sure those pants stay up, you got to have a backup plan. You’ve got the belt and you’ve also got the suspenders. We have done a lot of work to help employers and other big purchasers think about the way they buy healthcare and come up with strategies that can generate competition where it’s lacking. But when those strategies aren’t enough, antitrust enforcement is incredibly important. Honestly, I think we’re at a stage where in most markets, market forces alone, the way employers buy healthcare, is not likely to create the solution that we need. It’s complicated and there’s lots of reasons why it could get into that employers are unlikely to be bold organized actors. But at the end of the day, if the marketplace is broken and not working because we have an imbalance of market power, we’ve got a dominant provider and fractured almost individual purchasers of their services that are not organized and able to mount a market power battle, then we’re going to need some enforcement of their behavior.
I just want to add that I appreciate the narrow definition of market power focusing on price, but we’ve seen market power exhibited in other ways too. If you’re the only shop in town, you’re the only lemonade stand in town, your lemonade doesn’t have to taste that good. It has to taste decent, but you’re not going to be reviewed and compared to the other lemonade stand because you’re the only one. So if you’re the only hospital in town, everything from your customer service to the bedside manner to the quality doesn’t have to be that great because there’s not a choice that anyone has. And we’ve also seen market power exercise not just in sort of, “Oh, I don’t need to worry about quality as much or innovation in any way,” but we’re not going to just charge higher prices, we’re also going to restrict how those who buy our services can behave, where else they can send patients. There’s all kinds of complicated things that hospitals can try to do to exercise their market power beyond just the prices.
Barak Richman:
I accept that as a friendly amendment.
Matthew Cantor:
Well, I have a question for Professor Richman. This is a question that I’m asking to answer in a couple of minutes, but I recognize that we could be talking about this issue for years or decades, which is this: if Ms. Delbanco is correct, and most hospital markets are characterized by market failure and not competition, do you think that the only way to remedy the issue of rising hospital prices is via regulation? When I say regulation, I mean some type of price cap. And if so, what are the pros and cons of doing so? I understand that’s an unfair question for a couple of minutes by as the MC, I use my MC prerogative.
Barak Richman:
Right, okay. Let’s say you’re living in a town that only has one hospital and the hospital’s charging you monopoly prices, what sort of remedies are there? Well, I would first embrace the kind of remedies that Suzanne is suggesting. If you’re an employer and there’s only one hospital in town, maybe you’ll hire the equivalent of a school nurse or maybe you source some healthcare internally. Maybe you can try to figure out ways to send your employees that all need knee replacements to the hospital in another state. Maybe you can facilitate some kind of competition that normally isn’t there. The fact that you have only one hospital in town doesn’t mean there’s only one hospital in the state, and it might require some effort, some convincing of your employees to travel, it might require some creative contracting. But I would think that my first step would be Suzanne’s first step, which is, let’s see if we can really try to be creative and bring competition in a market that currently is this lacking.
If that doesn’t work, and for sure it wouldn’t work for certain things, you only have one place to deliver babies or you only have one place for emergency cardiac surgery, then there are a number of regulatory reforms that might bring prices down or usher in competition. One, it certainly could be price regulation. We’re only going to allow you to charge a certain amount for a delivery or a certain amount for a cardiac procedure. Another could be antitrust regulation or antitrust lawsuit. Suzanne was suggesting that often what hospitals do to exercise their market power is to foreclose entry, or they say, “If you want access to my emergency room, then therefore you have to let me control your outpatient facilities also,” that might be an antitrust violation. You might be able to carve out certain services from the monopolist through an antitrust lawsuit.
But there are others too. There are other ways to think creatively. Just like the employer or the purchaser can think creatively, the policymaker, the regulator can think creatively. We might be able to remove certain certificate of need laws, so we could build another hospital or build an ambulatory care surgical center. We might be able to liberalize licensure law so people can get telemedicine from people out of state. Maybe for even primary care, certainly for follow-up care, it would be a lot easier, for example, to get a knee replacement elsewhere if you can follow up with a doctor through telemedicine. And maybe also there are other kinds of regulatory liberalizations like expanded scope of practice for NPRN, for nurses, to provide primary care. A lot of the healthcare sector is regimented because of the regulatory environment that we have, and some of those laws prohibit competition, and some of those laws allow anti-competitive conduct. We have to think creatively with all every arrow that we have in our quiver.
Matthew Cantor:
Let me ask this last question of you both, and maybe this is more of a personal preference or political question than it is a legal or economic one, but in the last few years in the antitrust world, the headlines really have focused on technology. That’s not to say that some of the technology players may not have violated the antitrust laws or engaged in unfair methods of competition under Section 5 of the FTC Act, but that’s really where the headlines have been. Do you think that there should be a greater amount of discussion and a greater amount of enforcement efforts amongst the antitrust authorities to reign in hospital price than has occurred to date in this country?
Suzanne Delbanco:
I’ll take the first stab at that, and the answer is absolutely yes. We’ve done a variety of things in the antitrust space. I’ve served as an expert rebuttal witness, I’ve been a lay witness, I’ve written amicus briefs, and I have spoken to the National Association of Attorneys General. I have been called by many Offices of Attorneys General at the state level trying to learn more about healthcare. What I’ve learned through all of this is that antitrust enforcement has very limited resources and very few people that understand healthcare markets. And so, while I don’t think we’re going to solve our problems really through law enforcement, I think we do need a policy agenda, new laws, new regulations that make the markets work better. There’s no question that antitrust enforcement is very under-resourced. So yes.
Matthew Cantor:
Professor Richman, do you have a view on this?
Barak Richman:
It certainly is under-resourced. Part of the reason it’s under-resourced is because antitrust law has gotten really very, very complicated. You get very little bang out of your buck. But another thing that’s happening is that there really has never been a full appreciation for how costly uncompetitive healthcare markets are. One of my very first ventures into writing in this area looked at unsuccessful campaigns by the Federal Trade Commission to stop hospital mergers that really any economist would say should never have even been contemplated. The FTC ran into all sorts of legal barriers, not just complexities in the litigation process, but also just judges that were hostile to the claim. I think we’re turning the corner a little bit. Thanks, frankly, to a lot of the work that Suzanne’s been doing. Frankly, Matt, a lot of work that you’ve been doing also. I think that there’s now a greater appreciation for just how harmful hospital monopolies and concentrated hospital markets are, and there might be more fertile ground, more popular support for antitrust actions. But the law is still really complicated, and an antitrust claim is still really hard to win.
I would say that, yes, we need to pursue aggressive antitrust enforcement, we need to supply the Federal Trade Commission and state’s Attorneys General and other parties, including payers and employers, with a lot of enthusiasm and financial support for antitrust actions. But we also really need to look at other legal remedies also. To the degree that we think that antitrust law is the go-to law to stop monopolies, I’m not sure it is for healthcare monopolies. I think that other legal remedies, including basic contract law, including fiduciary law, including licensure law, all of these might even be easier legal remedies to usher in competition than antitrust law. There’s a lot of thinking to be done and a lot of work to be done. If there’s a reason for optimism, it’s probably because people like Suzanne have convinced state’s Attorneys General and others that this is a real problem that needs to be addressed. What’s nice is that there are lots of ways to do that.
Matthew Cantor:
Yeah, I’ll just end by giving my two cents on it. I mean, I obviously am a pro enforcement person, but I am consistently amazed by the statistics that I see where they compare the United States healthcare market and other countries. My understanding, and you guys can correct me if I’m wrong, if you compare our market to Japan, in Japan, the average lifespan is 10 years greater than the average American lifespan, and they spend about a third or a quarter as much on healthcare than we do in the United States. That’s an absolutely disturbing juxtaposition. I agree with Professor Richman, I think antitrust enforcement has a significant role here, it is complex, but I do believe that greater resources should be given to enforcers to try to halt price increases. But I think there are other levers that can be pulled by constantly discussing the fact that I think so-called not-for-profit health systems are really left off the hook with this ability to not have to pay federal or state income tax even when they have billions upon billions of dollars in investments and are receiving money under the CARES Act, notwithstanding this.
I think that there are things that can be done to ensure that price increases do not occur by saying, for example, under the tax code, “If you’re going to be not-for-profit, you have to do A, B, C, and D,” which is not an obligation that necessarily is placed on them today. So yes, I agree, Professor Richman, that there are other levers that we can pull to halt this. With that said, I really want to thank you, guys. I think this has been a really interesting discussion. You didn’t have to do this, but making your time available is great for me personally and for anyone who listens. So thanks so much for being a part of this.
Suzanne Delbanco:
Thank you.
Barak Richman:
Thanks for having us. And I guess the California Bears have been represented well in this podcast, right?
Matthew Cantor:
Yes.
Barak Richman:
Yes. Go Cal.
Matthew Cantor:
Take care, everyone.
Jeff Shinder:
That’s all for our show today. If you like the podcast, make sure to subscribe to Antitrust Matters and leave us comments on how we were doing or on the topics you would like us to cover going forward. You can also follow us on Twitter, or follow the Constantine Cannon antitrust team on LinkedIn. Until next time, be well, and remember antitrust matters.