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The U.S. pharmaceutical industry’s aggressive and often unlawful efforts to prevent competition and keep drug prices elevated cost American patients, insurers, and federal health programs more than $40 billion in 2019 alone, according to a report released Tuesday.

The new report—put out by the American Economic Liberties Project and the Initiative for Medicines, Access, and Knowledge (I-MAK)—focuses specifically on pharmaceutical companies’ antitrust law violations, which the groups say are a key reason why U.S. drug prices are astonishingly high compared to those of other rich nations.

Examining the 100 top-selling drug products in Medicare Part D—which covers prescription medicines—and Medicaid, the report estimates that Big Pharma’s antitrust violations “increased Part D gross spending by 14.15%, or $14.82 billion, and increased Medicaid gross drug spending by 9.05%, or $3.15 billion, in 2019 for the top 100 drugs in each.”

Assuming that pharmaceutical companies’ antitrust violations similarly affected retail brand drug spending, the report estimates that “U.S. patients and payers spent an additional $40.07 billion on pharmaceuticals in 2019.”

“American families are paying far too much for prescription drugs, in large part due to rampant corporate lawlessness,” said Erik Peinert, research manager and editor at the American Economic Liberties Project.

The report highlights 10 illegal anticompetitive schemes that U.S. pharmaceutical companies deploy to juice their profits and keep prices high, including horizontal collusion, patent fraud, no-generics agreements, and sham citizen petitions aimed at convincing regulators to delay approval of potential competitor drugs.

“This report documents the many ways Big Pharma is manipulating and breaking the law to expand corporate profits at the expense of patients and taxpayers,” said Peinert. “The Federal Trade Commission has begun fighting back, but it needs more assistance from Congress and other agencies to crack down on these illegal practices and deliver for patients.”

Shortly following the new report’s release, the FTC sued to stop the biopharmaceutical giant Amgen from acquiring Horizon Therapeutics, warning that “rampant consolidation in the pharmaceutical industry has given powerful companies a pass to exorbitantly hike prescription drug prices.”