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Andy Jassy, CEO of Amazon since July 2021, is seen during a business conference in December 2019.
Last Thursday, Amazon announced that it would purchase One Medical, a private equity-backed network of primary-care clinics, for $3.9 billion. It’s part of the company’s concerted effort to capture the health care market. Given that health care represents about one-sixth of the U.S. economy, it would be impossible for Amazon to realize its goal of sitting in between every economic transaction without getting involved in medicine. “We think healthcare is high on the list of experiences that need reinvention,” is the more euphemistic way that one of their senior vice presidents put it.
Once you start thinking about the layers of integration Amazon could exploit by adding health clinics, you realize that this merger, the first major one in the post-Bezos era, should not be allowed. Amazon already owns a pharmacy, a diagnostics company, a platform for selling retail medical products, a telehealth provider for businesses, and a back-end IT service that health companies use. This clinic network grows its presence in another area. Consolidation in health care has been at the root of the America’s distinctly poor outcomes and high prices. At some point, merger authorities have to say enough is enough.
Amazon’s new CEO Andy Jassy has expressed a particular interest in health care. He personally manages Amazon Care, a virtual primary and urgent care service open to company employees. Last year, Amazon Care was opened up to other businesses, and several have signed up. This is the business One Medical is in; it offers virtual appointments and wellness apps to individuals and businesses.
Moving from telehealth to physical clinics has been an ambition for Amazon, and One Medical has 188 offices around the country, significantly bolstering a tiny Amazon Care network of neighborhood health centers. One Medical also has a relationship with over 8,000 companies to provide both in-person and virtual care. (Amusingly, some One Medical facilities serve Google employees inside Google office buildings.) It also offers an annual membership for primary and urgent care at $199 a year that sounds somewhat like Amazon Prime for health. One Medical subsidiary Iora Health also operates a privatized version of Medicare on contract with the government.
Integrating all that into Amazon Care’s current offering is one more manifestation of its usual “growth through acquisition” approach. You can envision a subscription-based product, sold to individuals or businesses as convenient access to medical treatment. Amazon has plenty of other health-related business lines ready to bolt onto that experience.
In 2018, Amazon bought Pill Pack, an online pharmacy. Any medications offered through One Medical/Amazon Care could be routed to Pill Pack for fulfillment. Amazon has a nascent diagnostic service that grew out of the pandemic; One Medicare/Amazon Care tests could go through that, or patients could be required to use its at-home screenings and tests. Plus, Amazon sells medical devices and services at its website. Just requiring One Medical procurement to go through Amazon would increase sales.
Making Amazon a bigger purchaser of medical services generally could raise the cost of health care, which is generally what happens when a more powerful middleman enters the transaction chain. And since Amazon would benefit from more of those transactions, that could lead to overtreatment.
Sen. Amy Klobuchar (D-MN) brought up another potential harm in a letter to the Federal Trade Commission asking for close scrutiny of the Amazon/One Medical deal. “Amazon has a history of engaging in business practices that raise serious anticompetitive concerns, including forcing small businesses on its site to buy its logistics services as a condition of preferred platform placement,” Klobuchar noted. You could see Amazon offering One Medical/Amazon Care to the million-plus small businesses that operate on its site, and using control of the “Buy Box” or some other inducement to persuade those businesses to sign up. You could see the same dynamic with a Prime bundle, which reaches hundreds of millions of people. In this sense, Amazon would become more of an integrated insurance provider. This is known as tying, which violates the antitrust laws, but it’s essentially what Amazon does with Prime and third-party fulfillment services right now.
Perhaps even more important to Amazon, One Medical has data through its own electronic medical records system. Amazon can do a lot with data inside and outside of health care. The company’s growing targeted advertising business would have 15 years of patients’ medical histories from which to draw for product pitches. That data can also be used more generically for product development. Imagine Whole Foods knowing a profile of a Prime member’s health history. (Amazon has said it will not share individual medical data, but even aggregate data could be useful.)
There’s another more hidden aspect to this purchase. Amazon Web Services is the cloud computing provider to many health-related businesses. Baxter, which makes most of the nation’s IV bags, has a multi-year deal with AWS, as does biotech company Gilead. This is another way Amazon can insinuate itself into the health care space. By providing data integration and software services, AWS is critical infrastructure for the health system, which already provides the company with a way to close in on involvement in all health transactions. AWS even opened its own health accelerator for startups, seemingly grooming young companies for acquisition by the mothership.
Amazon has purchased 118 companies over the past 25 years. Rather than waiting to see a conglomerate develop, agencies could act to cut off such behemoths before they grow.
In addition to creating the potential for self-preferencing its own doctors, providers, and pharmacies, consolidating data can, as Krista Brown of the American Economic Liberties Project notes, add security risks. Hackers only have to be right once to crack AWS and gain access to a large trove of health data. Amazon’s data security practices have come into question in the past.
It's true that One Medical is not a major health care player at this point. But this is an early move by a company that desperately wants to get involved in this industry and has the scale to do so. Amazon is using precisely the same vertical integration that has put the industry’s current dominant players in an entrenched position. CVS has a pharmacy network, an insurance company (Aetna), and a network of “minute clinics” for primary care services. That’s indistinguishable from Amazon’s effort, and other examples of vertical integration abound. The difference is that Amazon simply has more data than any other company, and would have opportunities to leverage that in the health space, its insistence on privacy notwithstanding.
Vertical deals have in recent years gotten little scrutiny from the antitrust authorities, but the new leadership at the FTC and the Justice Department’s antitrust division have vowed to change that. Amazon has purchased 118 companies over the past 25 years. Rather than waiting to see a conglomerate develop, agencies could act to cut off such behemoths before they grow.
That Amazon hasn’t fully obliterated every single industry it’s tried to enter isn’t a reason for leniency when an attempt to monopolize could be its aim. The FTC already has a pending decision on whether to challenge Amazon’s purchase of movie library MGM. That one company could own both the James Bond franchise and the company you get your blood pressure medication from is just one part of a very big problem.
