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Aetna chief executive Mark Bertolini got his start in the health care industry in the late ’70s as an emergency medical technician in his native Detroit. He spent four years as a department coordinator in one of the city’s trauma center emergency rooms while earning an undergraduate degree in business administration and finance from Wayne State University. When he decamped for Cornell University in 1982 to get an MBA, he swore never to return to what he considered to be a broken industry. Today the 59-year-old says his early dissatisfaction resulted from the fact that he wasn’t in a position to do anything about the U.S.’s troubled health care system.

Not any longer. As CEO of Hartford, Connecticut–based Aetna, Bertolini is responsible for the health care coverage for 24 million Americans, a number that would grow to 33 million if the company’s recently announced deal to buy Louisville, Kentucky–based rival Humana for $34.1 billion in cash and stock is approved. After the deal closes, which Aetna management expects will happen as soon as the second half of next year, the company would be the U.S.’s second-largest health insurance provider by revenue, with $115 billion in annual sales, behind only UnitedHealth Group.

Post-merger, 56 percent of Aetna’s revenue will come from its government-related business — an attractive segment as the number of baby boomers aging into Medicare grows. But even as opportunities tied to Medicare continue to expand, the Affordable Care Act is pressuring insurers’ margins. “The regulations that are embedded in the law are regulating the profitability of the industry in a stringent manner — much more so than they ever have before,” says Ana Gupte, a health care analyst at Boston-based investment bank Leerink Partners. “Here you have this huge revenue opportunity [in Medicare], but you have to be much better at adding value if the price points are being contained as a result of all this regulation.”

Bertolini says bringing Humana and Aetna together will allow him to do just that. He expects the company to save an annual $1.25 billion in cost synergies starting in 2018 and to post low double-digit percent accretion to operating earnings per share by that year.

Bertolini, who was recruited to Aetna in 2003 by then-CEO John Rowe to fix its pharmacy, behavioral health and dental businesses and ascended to the top spot in 2010, also trumpets the deal’s potential to drive down health care costs for consumers. That will become increasingly important as individuals head to online marketplaces to compare insurance plans post-ACA. In June, the Supreme Court upheld the legality of subsidies paid to individuals who purchase insurance from the federal exchange.