Recent enforcement actions and a new report from the Trump Administration’s Council of Economic Advisers (CEA) show heightened enforcement risks and antitrust scrutiny of certain terms in health care provider contracts with insurers (“payers”). In the latest settlement in a case brought by the Department of Justice (DOJ), as well as the Ohio Attorney General’s Office, a provider agreed to stop using anti-steering, anti-tiering, and all-or-nothing contract provisions. Days later, the CEA released a report arguing that banning these terms could generate significant savings for payers and workers—and potentially spur legislation.
Together, these developments signal that payer contracts with providers—especially large multihospital health systems—will remain a focus of antitrust enforcement.
United States and the State of Ohio v. OhioHealth
Plaintiffs’ allegations
In February 2026, the DOJ and the state of Ohio sued OhioHealth Corporation for violating Section 1 of the Sherman Act and state law by allegedly imposing contract terms that restricted payers’ ability to form “budget-conscious” health plans and provide price transparency information to members, which would have encouraged patients to use lower-cost health care providers. In particular, the government alleged:
Market position
The DOJ and the Ohio Attorney General’s Office alleged that OhioHealth is the dominant hospital system in the Columbus area and a must-have health system that payers must include in at least some commercial networks. According to the complaint, OhioHealth’s share of inpatient general acute care discharges and beds in a two-county central Columbus market and an alternative 10-county Columbus metropolitan statistical area market was over 35%.
Contract terms challenged
The complaint alleges that the contracting restrictions included:
- All-or-nothing contracting, forcing payers to include all OhioHealth providers or none of them.
- Anti-steering terms that restricted narrow networks that excluded OhioHealth.
- Anti-tiering terms that required OhioHealth to be in the most-favored tier of any tiered networks.
- Site-of-service steering restrictions that limit incentives for patients to use lower-cost sites of care such as outpatient facilities.
- Reference-based pricing restrictions that inhibited payers from establishing a fixed rate, often based on a local average rate, for services, with patients bearing additional cost-sharing if they selected providers whose services cost more than the reference price.
- Center-of-excellence restrictions that inhibited incentives for patients to use high-quality, cost-effective providers.
- Active transparency restrictions that prevented payers from sharing pricing information with members.
Competitive harm
The government alleged that these restrictions reduced plan choice, insulated OhioHealth from price competition, limited patients’ ability to select lower-cost providers, and increased costs for patients and employers. The plaintiffs further alleged that the restrictions impeded rivals’ ability and incentive to gain patient volume, lower prices, improve quality, and enter or expand in the marketplace.
OhioHealth’s key defenses
OhioHealth filed a motion to dismiss the complaint, raising several arguments in defense of its contracts, including the following:
Vertical contracting and “competition for the contract”
OhioHealth argued that contracts between hospitals and insurers are vertical agreements negotiated by sophisticated parties and that its contracts reflected legitimate bargaining for favorable network placement—i.e., competition for the payer contract—not unlawful exclusion.
No market power or harm to competition
OhioHealth argued that the alleged 35% share was insufficient to establish market power, citing case law requiring 50%-plus shares, and that the complaint merely alleged harm to competitors, not competition.
Anti-steering provisions are not inherently anticompetitive
Relying on the Supreme Court decision in Ohio v. American Express, OhioHealth argued anti-steering provisions are not inherently anticompetitive and can “stem negative externalities” like free-riding and “promote interbrand competition.”
Other arguments
OhioHealth argued that any high prices reflected its quality, breadth of services, reputation, and negotiated value.
Key terms of the proposed settlement
In mid-June 2026, the DOJ announced a proposed settlement that would end OhioHealth’s use of the challenged contracting terms. The proposed settlement includes:
Core prohibitions
The proposed settlement voids existing OhioHealth contract provisions that prohibit, deter, prevent, or impose penalties for: (1) steering, meaning incentives for members to seek care at a provider or provider type; (2) steered plans, which include narrow network and tiered plans and plans with reference-based pricing, site-of-service, or center-of-excellence components; or (3) transparency about price, cost, quality, or patient experience.
Additionally, the proposed settlement prohibits OhioHealth from seeking or obtaining these restrictions in the future, including seeking prior-approval requirements for new benefit plans or requirements that OhioHealth be in the most-preferred tier.
No retaliation or penalties
OhioHealth may not penalize or threaten to penalize a payer for providing transparency, engaging in steering, or designing, offering, expanding, or marketing a steered plan.
Permitted conduct
OhioHealth, however, can seek to participate in the most-preferred tier of a network (but not require it), restrict steering within a narrow network in which it is the most-prominently featured provider, communicate with a payer’s members about considerations that may be important for patients’ choice of a provider or service, review payer transparency documentation to ensure it is accurate and challenge any inaccurate information, and enforce certain confidential agreements.
Compliance obligations
OhioHealth must notify payers of the final settlement and its terms, provide quarterly compliance reports for five years, distribute the final settlement to its directors, officers, employees, and agents, agree to the appointment of a compliance monitor for five years, and implement compliance procedures.
Duration
Unless extended, the settlement expires 10 years after entry, with possible early termination after five years if the DOJ determines continuation is no longer necessary or in the public interest.
CEA Report
Two days after the proposed OhioHealth settlement was issued, the CEA issued a news release and 10-page report, “Effects of Banning Hospitals’ Anti-Steering, Anti-Tiering, and All-or-Nothing Contracts.” Relying primarily on academic studies, the report frames these provisions as tools that dominant hospital systems use to insulate themselves from price competition. Key aspects of the report include:
Estimated reimbursement-rate reductions
The report estimates that banning the three contracting terms would reduce hospital and affiliated-physician prices by 18% in markets directly affected by these terms, resulting in average savings of approximately $4,100 per inpatient admission.
Savings mechanisms
The report attributes expected rate reductions to three “channels”: (1) “restored insurer bargaining leverage” with health systems to negotiate lower rates; (2) patient volumes moving to lower-cost providers; and (3) longer-term price concessions as competing health systems become more credible alternatives for insurers.
The report also describes a spillover mechanism where removing all-or-nothing and anti-steering clauses can prevent a hospital system from using market power in one market to raise its prices in other markets.
Premium, employer, and worker impact
The report estimates that a ban would cause employer-sponsored insurance premiums to fall by 6.5%, assuming payers pass through 70% of the estimated savings, resulting in savings of approximately $1,755 per family and $606 per individual per year. The CEA report concludes that these savings would, in turn, result in lower premium contributions and higher take-home wages for workers.
National savings estimate
The report estimates national aggregate premium savings of approximately $45 billion per year.
Rural-market conclusions
The report also states that rural workers and independent rural hospitals would be “net beneficiaries.” The report contends that eliminating these clauses would lower premiums and raise wages for rural workers, improve independent rural hospitals’ negotiating position, and impose minimal pressure on system-owned rural hospitals.
Takeaways
The OhioHealth enforcement action, CEA report, and several ongoing government and private class actions against other health systems for alleged use of similar contracting terms show that antitrust scrutiny of contracting among large multihospital health systems and payers has intensified. Key takeaways include:
- Assess a health system’s market position. The OhioHealth and other enforcement actions arise in the context of contracting by multi-hospital health systems with market shares of approximately 35% or higher (although a share of 25% is alleged in another ongoing case). A system’s share in potential markets can indicate whether anti-tiering/steering and other restrictions could create antitrust risks.
- Review contracts for steering/tiering and transparency restrictions. The OhioHealth settlement and other enforcement actions broadly target a wide range of provisions that could inhibit steering, tiering, narrow networks, site-of-service and reference-based pricing terms, center-of-excellence designations, and transparency initiatives with patients. Assess terms that would give the provider the right of prior approval before a payer could market a particular plan design or that require a provider to be in the most-favored tier of any commercial network.
- The OhioHealth settlement offers a roadmap. The proposed OhioHealth settlement provides a template for what government enforcers may seek to strike from provider-payer contracts, at least for those involving dominant multihospital health systems. The appendix to the proposed settlement includes anonymized contract terms that indicate the types of provisions that may draw scrutiny. Assess current contracting practices and terms against this template to gauge potential risks and consider alternatives to minimize risk.
- Watch for potential legislative action. The CEA report does not specifically call for legislative action but does emphasize the estimated savings from a national ban. By linking a ban on these terms with major savings in one of the largest parts of the economy, the report may spur Congress and state legislatures to consider legislation to restrict these terms. State legislatures have been passing various laws stemming from federal antitrust enforcement actions and efforts, including premerger notification laws, bans or limits on employee noncompete agreements, and restrictions on private equity investments in health care. It is possible that future legislative activity could target these contracting terms.
If you have any questions, or would like additional information, please contact one of the attorneys on our Antitrust team or one of the attorneys on our Health Care team.
You can subscribe to future advisories and other Alston & Bird publications by completing our publications subscription form.