A knee replacement that costs about $16,000 under a Blue Cross Blue Shield plan at Catawba Valley Medical Center in Hickory, North Carolina, runs roughly $40,000 for the identical procedure and plan at Mission Hospital in Asheville, an hour's drive away, according to KFF — a gap health economists trace to a 1998 merger that left Asheville with a single dominant hospital system.

The disparity is no longer just anecdotal. Since 2021, hospitals have had to publicly post negotiated prices under a CMS disclosure rule, and the agency has since tightened those requirements, mandating that hospitals report actual median, 10th-percentile, and 90th-percentile allowed amounts rather than estimates, according to CMS. That data, compiled by pricing firm Serif Health, now allows researchers to directly measure the costs of consolidation to patients and employers, according to KFF.

The pattern repeats elsewhere: in Melbourne, Florida, Holmes Regional Medical Center, part of the dominant Health First system in Brevard County, charged insurer Cigna twice what a hospital two hours north charged for the same knee replacement this year, and in Colorado, Banner North Colorado Medical Center billed a UnitedHealthcare patient $20,000 more for the same surgery than a system an hour south in Denver, according to KFF.

What the research shows

The link between market power and higher prices is not new, but the evidence has grown. "What the data shows pretty clearly is that when hospitals have bargaining power, they tend to have higher prices," said Zack Cooper, a Yale University economist who has studied hospital monopolies for more than a decade, according to KFF. Cooper says hospital prices have risen faster than any other economic sector over the last 25 years, with consolidation as a primary driver.

Academic estimates vary but point in the same direction. A synthesis of consolidation research published in the Journal of Economic Perspectives found that mergers generally raise commercial prices by roughly 6% to more than 20%, according to a review by a Policy Scientist. Cross-market merger research found average increases of 12.9%, rising to 16.3% for serial acquirers, according to a summary by Brown University, while a 2025 HHS synthesis cited by BPC put the range at 6% to 65%.

RAND's long-running Hospital Price Transparency Study offers a national benchmark: in 2022, employers and private insurers paid hospitals an average of 254% of what Medicare would have paid for the same services, according to RAND. In Asheville, RAND figures show that Mission Hospital billed at 334% of Medicare rates in 2024, compared with 237% at Catawba Valley and a statewide benchmark of 280%, according to KFF.

How Asheville became a case study

Mission Hospital was created in 1998 when North Carolina authorized merging the city's two acute-care hospitals, St. Joseph's Hospital and Memorial Mission Medical Center. Anticipating the combined system would gain outsized pricing power, regulators required Mission to accept limits on spending and profit margins, according to KFF. In 2015, Mission lobbied the legislature to remove those restrictions; three years later, HCA Healthcare, the nation's largest hospital corporation, purchased Mission Health outright. "This put a prepackaged monopoly into the hands of the world's largest for-profit hospital corporation," said Mark Hall, a Wake Forest University professor emeritus who has documented the merger's history, according to KFF.

Serif Health's data show the gap spans many procedures: for a breast biopsy, UnitedHealthcare pays $7,500 at Mission versus $1,700 at Catawba Valley — and for a hernia repair, $17,700 versus $9,600, according to the KFF analysis. A UnitedHealthcare spokesperson acknowledged hospital prices are "one of the leading drivers of rising healthcare costs," while Mission's spokesperson disputed the comparisons as misleading, noting Mission is nearly three times the size of Catawba Valley and serves as a Level 1 trauma center for a different patient population.

Marcelle Crago, a nurse who tore her meniscus while cross-country skiing, said Mission quoted her more than $9,000 for surgery to remove damaged cartilage — a bill she avoided by having the procedure done at an independent outpatient center for less than a third of that price, according to paperwork filed with North Carolina's Consumer Protection Division and described to KFF. An attorney representing Mission and HCA said charges reflect the cost of supporting an entire episode of care, including investments in technology, training, and staffing.

The cost eventually reaches everyone with insurance

Higher hospital prices do not stay contained to patients who use those hospitals: insurers facing higher negotiated rates generally pass the cost through to everyone who buys coverage as higher premiums, a mechanism KFF illustrates with figures showing the full cost of an employer-sponsored family plan rose to more than $27,000 in 2025, up from $21,000 six years earlier. Restaurant co-founder Katie Button argues in a pending 2021 class-action lawsuit that she has effectively subsidized Mission's pricing power because any local plan must include the hospital. "We are where we are because we don't have a choice of hospitals," Button said. "There is no other option."

Merger activity has not slowed: hospitals and health systems announced 46 mergers and acquisitions last year, five of which were valued above $1 billion, according to Kaufman Hall figures cited by KFF.

Oversight has varied over time, not by party

Antitrust oversight has shifted with changing federal priorities, and concern about consolidation spans both major parties rather than breaking along partisan lines. The FTC intervened in only about 1% of hospital mergers between 2002 and 2020, according to a Yale study cited by KFF. The current administration revoked a 2021 directive urging agencies to more aggressively challenge harmful mergers, yet FTC Chairman Andrew Ferguson issued a March 2026 memorandum forming a Healthcare Task Force to address consolidation, he said has led to "higher prices, decreased quality, less access and transparency, and stifled innovation," according to the FTC. The task force has since backed challenges to five additional hospital mergers, and Oregon, California, and Minnesota have each passed laws since 2021 aimed at curbing anticompetitive mergers, according to KFF, though none have reversed the broader trend.

Mission Hospital has also drawn scrutiny over care quality. State inspectors working for CMS have issued "immediate jeopardy" findings — the designation for problems posing imminent risk of serious injury or death — three times at Mission since 2024, including a case in which an 88-year-old woman recovering from hip surgery died after going a night without a needed blood transfusion, according to KFF. A hospital spokesperson said Mission has proposed a corrective plan to address the findings.

State Sen. Julie Mayfield, who helped launch the nonprofit Reclaim Healthcare WNC, called Asheville a warning for other communities facing similar consolidation. "Unregulated monopolies have never gone well for the public," she said, according to KFF. Nearly two-thirds of adults nationally said in an April poll they worry about affording healthcare, according to KFF — a worry the new disclosures suggest has a measurable driver in many regions.