“Market research is strategic in any industry where supply is outpacing demand or where the rate of change is so dramatic some will win and many will lose. That’s exactly where the health industry is today. Facing the 3 C’s: competition, consolidation and consumerism.
The three C’s are not unique to healthcare: The movie industry experienced them in the 70’s and the airline, banking and information technology industries are facing them right now. What makes healthcare unique is our products and services, not the dynamics of the market impacting them.”
Keckley, Paul H., Market Research Handbook for Health Care Professionals, American Hospital Publishing 1988.
I wrote this book early in my career and contributed proceeds to the American Hospital Association hoping it might stimulate more interest in market analysis. I believe, then and now, that navigating an uncertain future using quantitative and qualitative research tools is critical to organizational success.
I was fortunate to study at Oxford where the national health service was prominent in the country’s domestic policies and Ohio State where market analysis was foundational to positioning products (Proctor and Gamble, Wendy’s et al) and services (Nationwide Insurance, Riverside Methodist et al) presented as case studies to grad students. Professors taught that intellectual skepticism is vital, asking the right questions is the starting point, and data necessary to answering them. And they encouraged us to think outside the box and long-term, observing that market changes are rarely occur overnight but usually predictable.
In 8 days, U.S. voters will elect the 120th Congress and 36 states and territories they’ll choose their Governors. Polls indicate affordability will be the issue of most concern to a majority of voters, with healthcare among the top issues along with housing, groceries and fuel. In 9 days, speculation about Campaign 2028 will begin in earnest.
In most healthcare organization boardrooms and management team scrums, adjustments to current plans will be considered but major changes will not be made. But there’s growing recognition that the three C’s frame an uncertain future:
Competition: The structure of the U.S. system has calcified intramural competition within sectors i.e. hospital v. hospital, specialist v. specialist, home care service v. home care service, etc. In other industries, competition has been re-defined. Legacy banks now compete as diversified financial services conglomerates. Walmart competes with Amazon across multiple platforms and domiciles. But at every level of healthcare, protectionism against diversification is prominent: it’s reinforced in public policies and campaign promises. That’s not the future. The health and wellbeing industry of the future will be less facility-based, physician dependent, specialty-care focused, government financed, labor-intense, local and one size fits all. The new normal will feature new players that leverage capital, technology and marketing savvy to manage relationships with customers that understand their prices and value propositions.
Consolidation: According to the Department of Justice and Federal Trade Commission, the healthcare industry is highly consolidated. In its analyses, the concentration of economic activity controlled by a small number of organizations is applicable in the hospital, health insurance, pharmaceutical manufacturing, clinical information technology, pharmacy benefits management and many other healthcare sectors. Regulators in federal and state jurisdictions have correlated consolidation metrics* with higher prices, lower employee wages and diminished quality across the industry. Vertical and horizontal integration in healthcare is customarily justified to the public because the industry is underfunded and benefits accrue, but promised synergies (cost savings) aside from wage compression have been nominal. That means Consolidation in healthcare will get fresh attention as plaintiffs representing communities, employers, healthcare employees and others challenge promises made to lower costs, improve affordability, improve quality, justify executive compensation and employee wages and more.
Consumerism: The majority of healthcare operators, and public policies upon which U.S. healthcare operates, presumes that individuals who use the healthcare system are incapable or unwilling to make informed decisions about care for themselves or family members (except for minor ailments). Most healthcare provider organizations—physicians, hospitals, long-term care providers, therapists et al—pay lip service to ‘healthcare consumerism’ and most operate accordingly. While price transparency for hospitals, insurers and prescription drugs appear a nod to informed consumers, the evidence that price transparency has lowered costs or spending is sparse. The future of consumerism in healthcare is likely a dramatic departure from the past: employers, regulators and Gen Z consumers will force it.
I launched the weekly Keckley Report in 1986 through Capital Publications in DC. with the goal of educating stakeholders in healthcare about the trends and issues facing the industry’s future. Competition. Consolidation and Consumerism became my framework for analyzing healthcare from the outside in, and through the lenses of regulators, operators and investors.
AI traces its roots to 1956 long-before Meta and Open AI were imagined. GLP-1 roots trace to 2005, and technology-enabled self-care that improves diagnostic accuracy and patient adherence is 30-years old.
Healthcare’s future is not a repeat of its past: that’s confounding to some and exciting for most.
Paul
.*Usual metrics used in assessing industry consolidation: *CR4 (Four-Firm Concentration Ratio): share of industry sales controlled by the four largest firms, CR8, CR20, CR50, HHI (Herfindahl-Hirschman Index–sum of squared market shares across firms), Market share persistence: how long dominant firms retain leadership.
Quotables
HHS announcement on new fraud mitigation program October 22, 2926: “The U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice’s Civil Division recently launched a six-month Healthcare False Claims Act Self-Disclosure Pilot Program for healthcare companies that voluntarily disclose potential civil violations of the federal False Claims Act. Companies that meet the pilot’s requirements can resolve disclosed conduct through a coordinated civil release from liability under the federal False Claims Act and certain HHS administrative authorities…
To participate, companies must disclose all relevant details about the potential violations, provide documents showing the full nature and operation of the conduct, describe the remedial steps they have taken, and make a repayment calculated under the protocol, which applies a multiplier of 1.25 to 1.6.
The multiplier will vary based on factors such as the timeliness of the disclosure, the duration and scope of the misconduct, senior leadership involvement, the financial benefit to the company, and whether the company has successor liability for the misconduct but promptly remediated.”
Department of Health and Human Services and the Justice Department’s Civil Division Announce Anti-Fraud Healthcare Self-Disclosure Pilot Program October 22, 2026 https://www.hhs.gov/press-room/hhs-doj-launch-healthcare-false-claims-act-self-disclosure-pilot.
Barnes on China trade policy: “So, when a proposed Treasury rule came out last week that proposes to prohibit American companies from investing in Chinese companies that are using AI to develop drugs (I am paraphrasing and generalizing – it said other things), I tried hard to figure out what that meant. This is what I got: we are sure that we don’t want American companies directly investing in Chinese drug development, but we are NOT sure if licensing arrangements between U.S. companies and Chinese biotechnology companies is bad. There are pros and cons. Pro: Doing a deal with a Chinese company that has a breakthrough drug so an American drug company doesn’t have to start R&D from scratch seems like a good way to get cheaper and critical medicines here. Con: Doing business with China on something so important gives them leverage in future political or economic battles. If I were an American drug company, I would say to the Treasury what Albert Brooks says as his bewildered self in Lost in America: “I was on the road to nowhere. Do you know the road? It’s a nowhere road. It goes nowhere! You’re on it! You don’t know it?”
Only What Matters on Health Information Policy
7 Wire Ventures on technology enabled solutions: “Healthcare is moving quickly towards a breaking point, but a clear path forward is emerging through tech-enabled services. This next generation of healthcare companies won’t be defined by the sophistication of their tech stack but rather by their ability to integrate technology into the actual delivery of care to generate improved outcomes, expand access, empower providers, and take on economic accountability for doing all of the above.
Only with these aligned incentives across patient, provider, payer and policy will we be able to address the systemic challenges in healthcare. This is where our industry should be prioritizing our efforts and resources.”
4sightHealth.Shapiro_Shan_AI.Will.Save.Us.10_20_26.01.pdf
The Economist on the U.S. housing market “Although much of the American economy is running hot, the housing market is in a freeze. High mortgage rates are largely to blame. On October 15th Freddie Mac, a government-backed mortgage buyer, reported that the average 30-year fixed rate was 7.4%, just shy of its 25-year high of 7.8%. Many aspiring homeowners cannot afford to get on the ladder: first-time buyers now account for roughly 30% of purchases, compared with more than 40% in the 1990s and 2000s. Existing owners do not want to sell, since moving would mean swapping a cheap mortgage for a dearer one. If rates stay at 7.4%, our analysis suggests, this “lock-in” effect could prevent a fifth of sales that would otherwise have taken place.
Lock-in is largely a consequence of America’s peculiar mortgage system. Lenders typically offer 30-year loans at fixed rates. In most other rich countries homebuyers borrow at variable rates or at rates fixed for two, five or ten years. Even where long fixes are common, as in France, borrowers are often charged a penalty to refinance when rates fall. Americans can do so at relatively little cost, allowing them to secure cheap loans when rates are low and hold onto them when rates rise. But, unlike borrowers in Britain and Canada, Americans cannot generally “port” their mortgages to a new property, forcing those with cheap loans to pay higher rates when they move.”
Why Americans have stopped buying new homes
Trilliant on price transparency: “Price transparency enables value-based competition but does not ensure it, particularly since fewer than 30% of CMS’s quality measures focus on outcomes. The largest payers in the U.S. healthcare system, employers and Federal and state governments, now have publicly available data to identify hospitals that deliver better outcomes at lower prices, an opportunity to save money for themselves, consumers and the system as a whole. Why these stakeholders focus on costs rather than value, and increasingly seek to implement price caps, remains unclear. Under price caps, American healthcare consumers would continue to receive widely different value for services with the same price, without knowing it.
Price Transparency Enables but Does Not Ensure Value for Money in Hospital Care
McKinsey on private equity market: “Private equity (PE) is getting harder. For decades, the model was relatively simple: Use cheap debt and count on multiples to expand. It worked so well that returns of 20 percent or even higher were considered standard. Those days are over.
Over the past few years, PE returns have fallen into the high teens—and in some cases, even lower. For the third consecutive year, the sector has underperformed public markets. While the best funds still outperform broader equities, the underlying economics for PE have shifted.
This isn’t just a rough patch; it’s the sign of a maturing industry….PE exit values actually increased more than 40 percent in 2025 to $1.2 trillion, even while the number of exits declined by 15 percent. Those dynamics suggest that a few large deals are masking a broader liquidity problem. Cash is staying trapped longer, as more than half of all buyout-backed companies are now held for at least four years. Liquidity—measured by five-year rolling distributions—is at its lowest recorded level.”
Global Private Equity Report 2026 | McKinsey
Economy:
Study: Health spending 2007-2019: “Health care spending growth has long outpaced economic growth. However, during the period 2014–19 (before the COVID-19 pandemic), growth in per capita health care spending relative to per capita gross domestic product growth fell by 21% compared with 2007–14. We examined spending growth domestically and internationally to determine the causes of this slowdown. We decomposed spending growth by source of funds, compared four drivers of growth over time within the US and relative to fifteen Organization for Economic Cooperation and Development countries, and conducted a US-specific breakdown of utilization. We found that declining growth in health care prices and utilization were major drivers of the slowdown of health care spending. Slower growth did not appear to have been driven by across-the-board reductions in disease burden and input costs, although certain metrics fell. Utilization reduction was a major driver through technology allowing the use of alternative sites of care; greater use of preventive care that reduces costs; ongoing expansion of Medicare Advantage, managed Medicaid, and high-deductible health plans; and increased utilization management. This slowdown suggests the need to monitor trends more closely for signs of additional major shifts in spending growth.”
Altarum: Health Trend indicators: October 2026:
- In August 2026, national health spending grew by 6.5% year over year, down slightly from the revised July 2026 growth rate of 6.6%.
- GDP grew by 5.9% in August, year over year. As a result, national health spending in August constituted 18.4% of GDP, equal to the July value. National health spending was most recently below 18% of GDP in July 2024.
- Year-over-year growth in personal health care spending was 6.2% in August, year over year, slightly down from the revised July value of 6.3% and significantly lower than the 7.5% rate in August 2025. Utilization growth contributed nearly two-thirds of the increase, with price increases contributing one-third.
- Growth among major spending categories was highest in August for hospital care, at 8.0%, year over year, while spending for prescription drugs grew the slowest, at 1.3%. Drug spending growth has slowed significantly this year due primarily to a decline in drug prices; it stood at 7.8% in August 2025.
- Among the major health care categories, prices for dental care in September were the fastest growing at 6.0% year over year. This is an increase from a growth of 3.2% in September of 2025. At the other extreme, prescription drug prices fell by a record 4.5%—their ninth straight month of lower year-over-year prices.
October 2026 Health Sector Economic Indicators Briefs | Altarum
NYT on wealth disparity: “Few economists dispute that the wealth gap has grown in recent years, but the past two years have stood out. The richest 0.1% of Americans — about 250,000 people, with an average net worth of more than $140 million — has seen its wealth grow nearly 14% since President Trump returned to office, adjusted for inflation, according to data compiled by economists at the University of California, Berkeley, and the Paris School of Economics. The richest 0.01%, about 25,000 people, did even better. Middle-class households have seen their wealth grow by less than 3% over the same period…
Lower-income households have been hit especially hard by prices at the pump because gas makes up a larger share of their monthly expenditures. And higher interest rates on credit cards and car loans are taking a toll on households that must borrow to make ends meet.”
Pete Ricketts’s Wealth Puts Class at the Center of Nebraska’s Senate Race – The New York Times
Hospitals
Kaufman Hall Hospital Flash Report August 2026: Key findings:
- “Converging pressures strain hospital performance. August was notably weaker for hospital performance than the prior four months, with year-to-date operating margins dipping to 2.5% when including allocations.
- Non-labor expenses are a major pain point. Non-labor expense per adjusted discharge rose 6% year-to-date compared with 2025, and supply and drug expenses rose 5% and 6%, respectively, compounded by inflation in food and energy costs.
- Nearly half of hospitals are in the red. Roughly 43% of hospitals are currently operating at a loss, compared with roughly 33% before the COVID-19 pandemic.
KaufmanHall.com
Modern Healthcare on sale-lease-back activity: “Health systems’ growing interest in real estate divestitures is part of a broader push to sell assets that aren’t part of their core business, such as long-term care, skilled nursing and home health. This year, hospital sale-leaseback transactions are on pace to reach the highest number of deals since 2021…
Under these agreements, health systems often sell their real estate to real estate investment trusts, or REITs. REITs typically charge annual rent increases — sometimes fixed or tied to inflation — over a long-term contract. Providers can get a higher sale price by paying for building maintenance and upgrades. Others choose to take less money by shifting real estate upkeep to another owner, reducing their capital expenses…
Meanwhile, states such as Connecticut and Massachusetts have recently passed laws designed to increase transparency of REIT-linked healthcare deals. Under a law signed by Connecticut Gov. Ned Lamont (D) in May, certain hospitals are banned from pursuing sale-leaseback transactions starting in July.”
Why hospitals face more risk in sale-leaseback real estate deals – Modern Healthcare
Insurers
Commonwealth Fund Biennial Health Insurance survey: Results of CF’s survey of 9,350 adults, published Oct. 22:
- “The uninsured rate for working-age adults (ages 19–64) rose between 2024 and 2026. The increase was statistically significant. During this time, both ACA marketplace coverage and individual insurance market enrollment declined. Medicaid coverage rates also fell, a decline that began after 2022.
- Uninsured rates rose for young adults between 19 and 34 and for low-income working-age adults — those with household incomes under 200% of the poverty level ($31,300 for an individual and $64,300 for a family of four). Both groups experienced declines in ACA and Medicaid coverage.
- 46% of working-age adults inadequately insured in 2026: 11 % were uninsured, 12% had a coverage gap during the year, and 23% were underinsured, meaning they had coverage but their plan didn’t provide affordable access to care.
- More people delayed or avoided getting health care because of the cost, with the rate climbing from 46% in 2022 to 50% in 2026.
- 73% of adults age 19 and older believe the federal government has a responsibility to ensure all Americans have coverage, including 45% of Republicans, 93% of Democrats, and 76% of Independents.”
State of Health Insurance Coverage 2026 Biennial Survey | Commonwealth Fund
Report: UnitedHealth Group scale: “The latest edition of the Sunlight Report on UnitedHealth Group reveals the 2,807 entities that make up the world’s largest health care conglomerate, including 376 additional entities identified since the previous report in 2025.” Note: 94 of these are domiciled on other countries.
“UnitedHealth Group’s empire is constantly changing, and not every entity it acquires or establishes remains part of it. The company has shuttered brick-and-mortar medical practices and has struggled to maintain its international businesses.
In other cases, federal antitrust regulators have forced UnitedHealth to shrink its footprint, including requiring the divestiture of at least 164 home health and hospice locations across 19 states as a condition of its $3.3 billion acquisition of Amedisys.”
The true size of UnitedHealth Group https://sunlightreportinsurance.com/
Polling
KFF Tracking Poll: KFF surveyed 1,328 U.S. adults, including 1,013 registered voters, from Sept. 16-21, 2026. The sampling error is plus or minus 3 percentage points for all adults and plus or minus 4 points for voters. Results:
- 60% of registered voters said they are worried about affording health care for themselves and their families, tying gasoline and transportation costs (59%) at the top of their money worries weeks before the Nov. 3 midterm elections.
- 66% of U.S. adults favor a national health plan, often called Medicare for All, in which all Americans would get their insurance from a single government plan. That is the highest share KFF has recorded since it began asking about the idea in 2016, up from 53% when it last asked, in October 2020
KFF Tracking Poll: October 20, 2026 https://www.kff.org/series/health-information-and-trust-tracking-poll/
KFF Employer Poll released October 22: KFF surveyed 1900 employers about their health benefits plans. Results:
- Premiums: Workers contributed an average of $7,471 toward the annual cost of family coverage in 2026, up 9.1%. Employers contributed $20,832, up 3.4%. It’s the second consecutive year premiums for single coverage increased by 5%. Workers contributed $1,672 on average.
- Deductibles: Deductibles stayed stable compared with the prior year for workers at firms with fewer than 200 workers, while employees at larger companies saw a 6.1% increase on average. Nevertheless, employees at small companies pay much larger deductibles overall. The average 2026 deductible is $2,624, versus $1,772 at larger companies.
- GLP-1s: Employers remain resistant to adding prescription drug coverage for weight loss. Just 18% of large employers offer coverage of GLP-1s, or glucagon-like peptide-1 receptor agonists, for weight loss, down 1 percentage point. Only 1% of large employers say they are “very likely” to cover the drugs next year, which is the same as last year.
2026 Employer Health Benefits Survey https://www.kff.org/
Population Health
Study: state direct payments as subsidies for primary care: “We used Centers for Medicare and Medicaid Services preprints from the period 2023–25 to estimate Medicaid managed care payments for primary care services and professional services at academic medical centers. For primary care services not performed in academic medical centers, most SDPs raised Medicaid managed care payment levels toward Medicare rates. In contrast, SDPs for services performed at academic medical centers varied widely across states and often raised payments well above Medicare rates, placing them above the caps established by the One Big Beautiful Bill Act. These patterns suggest that SDPs are being used both to bolster primary care payment and to deliver large supplemental payments to academic medical centers, underscoring a need for monitoring and policy guardrails to align SDPs with access and value in Medicaid.”
Study: Measles vaccine efficacy: “At 6 months of age, most U.S. infants no longer had detectable levels of maternal neutralizing antibodies for measles, potentially leaving them at risk of an infection months before their first dose of the measles, mumps, and rubella (MMR) vaccine at 12 months of age, according to a retrospective analysis…
At 6 months, the proportions of infants who were seropositive for the three measles strains were 8.7% for the Edmonston strain (A), 19.6% for Maryland. USA/18.18 (B3), and 17.4% for Missouri. USA/15.18 (D8) …
The findings come as the U.S. grapples with its worst measles case total since 1991. As of Oct. 22, the CDC reported 4,588 cases, already doubling last year’s total of 2,289. Nearly all (96%) of this year’s cases have happened in people who were unvaccinated or whose vaccination status was unknown. While the CDC reports three measles deaths this year, Pennsylvania alone has reported five measles-associated deaths.”
Infants’ Maternal Measles Protection May Not Last Until First MMR Dose | MedPage Today
Study: Effectiveness of in-home health risk assessments on disease recognition: ”Among 21,496,506 Medicare Advantage beneficiaries diagnosed with a cardiovascular risk factor or disease, the proportion diagnosed during in-home HRAs increased between 2018 and 2022 for hypertension (45.9% to 47.7%), hyperlipidemia (57.8% to 66.7%), diabetes (47.8% to 51.6%), atrial fibrillation (30.0% to 36.0%), ischemic heart disease (37.2% to 41.6%), peripheral vascular disease (64.5% to 73.9%), and heart failure (34.7% to 42.6%). Racial and ethnic minority beneficiaries and those enrolled in lower-rated plans were more likely to receive HRA-based diagnoses. Treatment rates were substantially lower after HRA-based diagnoses across all conditions…
Among Medicare Advantage beneficiaries, an increasingly large share of cardiovascular conditions is being diagnosed through in-home HRAs, but treatment rates after these diagnoses are consistently lower than after facility-based encounters.”
Study: Effectiveness of large language model-based treatment recommendations: “To evaluate whether commercial LLMs appropriately call for restraint or action from scenarios based on Choosing Wisely recommendations.
Benchmark evaluation. Fifteen Choosing Wisely recommendations were used to develop 225 scenarios (per recommendation, 10 in which restraint was appropriate and 5 in which action was appropriate). Six commercial LLMs (3 runs each) generated 4050 responses to the 225 scenarios, using a prompt from the clinician perspective.
Production application programming interfaces of OpenAI, Anthropic, and Google from February to March 2026.
The LLMs rarely withheld recommendations for treatment when it was appropriate. Overuse was concentrated in 2 recommendations.”
CDC: U.S. Fertility Rate Hits a New Record Low: The steady decline of the U.S. fertility rate continued last year with another record low, according to a new report from the Centers for Disease Control and Prevention: Number of births: 3,628,934 · Birth rate: 10.7 per 1,000 population · Fertility rates: 53.8 births per 1,000 women ages 15–44 · Percent born low birthweight: 8.52%
CDC https://www.cdc.gov/nchs/fastats/births.htm
Study: delayed treatment for cognitive care: “Alzheimer disease and related dementia (ADRD) treatments are most effective when started early1; however, the mean interval from symptom onset to diagnosis is 3.5 years. Wait time for obtaining an appointment with a neurologist can frequently be many months and contributes to the prolonged patient journey for cognitive care in the US…Cognitive care waits times contribute to a patient journey that already approaches 4 years from symptom onset to diagnosis. Our findings add evidence that specialist access constrains ADRD care delivery, with quoted waits substantially exceeding the median 34-day referral-to-visit wait among Medicare beneficiaries seeing a neurologist for any indication, although our estimates reflect first-available access without an active referral… Delays may render patients ineligible for treatment or clinical trials, increase health care utilization, and lead to worse outcomes.”
Wait Times for Initial Cognitive Care Appointments | Neurology | JAMA Network Open | JAMA Network
Prescription Drugs
ICER-West Health Report: Key findings from the report include:
- The median net launch price of drugs rose sharply, by 35%, from $190,000* in 2022 to $257,000 in 2025 (adjusted for inflation).
- About one in four drugs introduced in 2025 had an annual net price exceeding $500,000, while an additional 34% were launched at prices between $200,000 and $500,000.
- Only about one in three newly approved drugs previously reviewed by ICER are priced at or below ICER’s recommended price benchmark, with the remainder exceeding their estimated value.
The data showed the complexity of patient access during the first-year post-approval, with only one-third of outpatient prescriptions ultimately filled within 30 days of attempting to fill them. Opinions from West Health-Gallup Center on Healthcare July 2026 poll:
- Nearly 40% of Americans were “concerned” or “very concerned” (compared to 25% in July 2022);
- Among those aged 65+, 36% were “concerned” or “very concerned”;
- Among those with 3 or more chronic conditions, 49% were “concerned” or “very concerned.”
