Those new markets, known as exchanges, rely on private insurers to offer health plans. The Obama administration has had to contend with companies including UnitedHealth Group Inc., the largest in the industry, exiting many markets after suffering losses. The president wrote an article published this week in the Journal of the American Medical Association suggesting that a so-called “public option” or government-run health plan could help increase competition in some markets.

“More can and should be done to enhance competition in the marketplaces,” the president wrote. “Congress should revisit a public plan to compete alongside
private insurers in areas of the country where competition is limited.”

Burwell said Friday in an interview in Des Moines that there are some markets where competition is “challenging,” without naming them. She said competition can foster innovation and create a healthy balance in negotiations among doctors, hospitals and insurers.

“Competition needs to be at a provider level and needs to be at an insurer level,” Burwell said. “When there’s competition in both settings, that creates an even playing field for both sets of players.”

Antitrust scrutiny

While the Obama administration hasn’t publicly signaled how it views the mergers, the Justice Department’s No. 3 official has said he’s taking a close look at the health insurer deals, which he has called a “game changer.” The official, Bill Baer, has stopped a string of mergers during his tenure, including Halliburton Co.’s proposed takeover of Baker Hughes Inc., which would have combined the second- and third-largest oil-services firms in the industry.

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In June, Baer told a group of antitrust lawyers that combining the country’s largest health insurers would lead to “substantial consolidation” in the industry, and antitrust enforcers “cannot afford to let up.”

Burwell’s department can weigh in on the deals with the Justice Department, which has the final say on whether to attempt to block the deals because of their impact on competition. Burwell declined to comment on those discussions. “We support as asked,” she said.

Employer market

Federal antitrust officials at the Justice Department are reviewing Aetna’s proposed $37 billion takeover of Humana and Anthem’s $48 billion bid for Cigna. The combination of Anthem and Cigna would create the biggest U.S. health insurer by membership, topping UnitedHealth. Together, the firms would have a large position in the market for coverage sold to big companies and other employers.

Aetna’s bid for Humana would allow the buyer to expand in the market for private health plans for the elderly, called Medicare Advantage. Humana is already a leader in Medicare Advantage and the combined firm would be by far the biggest in those policies.

The Justice Department has told Anthem that the Cigna deal threatens competition and that selling parts of the business probably wouldn’t sufficiently address that issue, people familiar with the matter said last month. That raises the possibility that the U.S. will sue to block the merger, which may lead the companies to a court fight or push them instead to seek deals with other, smaller insurers.

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