Here goes:

The little-understood roots of the American health care catastrophe

We need to understand where it went wrong if we’re going to fix it.

John E. McDonough, a professor of practice at the Harvard T.H. Chan School of Public Health, worked for the late US senator Ted Kennedy in creating the Affordable Care Act. He is the author of “America’s Wrong Turn: US Healthcare in the Neoliberal Era.”

American patients face daunting challenges: frightening medical debt, sky-high premiums and deductibles, massively consolidated providers and insurers, private equity takeovers, burned-out physicians and nurses, and dismal health outcomes.

What can explain such wide-ranging awfulness?

I have spent decades studying the American health care system. I was part of the drafting process that led to the Affordable Care Act, the landmark health care legislation enacted by President Obama in 2010. And I have been a professor at Harvard for years. From what I’ve seen, all of those disparate problems trace their origins back to a single source — neoliberalism, the radical free-market revolution that transformed American society starting in the 1970s and 1980s.

The neoliberal ideas of figures such as economist Milton Friedman and President Ronald Reagan have gotten a bad rap on both the left and the right in recent years, and for good reason. Reagan’s obsession with cutting taxes and repealing regulations encouraged laissez-faire policies that damaged families and communities, supercharged income and wealth inequalities, and wreaked havoc on the environment, just for starters.

But while these outcomes have been recognized for years, neoliberalism’s damage to our health care system has not been as well understood.

The hallmarks of neoliberal excess, though, are all there: Elite players have reaped vast rewards through financial gamesmanship, stock manipulation, corporate takeovers, and political bribery. Huge megahospital systems (for-profit and nonprofit), vertically integrated insurers, pharmaceutical giants, and a dizzying array of invisible financial middlemen have come out on top — all resulting in the most expensive health care system in the world.

I could write a book on all of neoliberal’s disastrous effects on our collective health. And in fact I have: “America’s Wrong Turn: US Healthcare in the Neoliberal Era.” But here, I’ll offer a brief on just three of them:

Corporate consolidation. In his influential 1978 book “The Antitrust Paradox,” neoliberal activist Robert Bork — best known for his later failed US Supreme Court nomination — called for abandoning nearly a century of US antitrust enforcement. Government, he argued, should greenlight any takeover or merger that resulted in lower prices for consumers. In 1982, the Reagan administration rewrote the nation’s federal antitrust guidelines to implement his ideas.

His views came to dominate health care, just as they did in many other sectors of the US economy. Today, roughly 90 percent of hospital markets, 74 percent of health insurance markets, and 65 percent of specialized physician markets are categorized as “highly concentrated” according to one common measure of market concentration. As antitrust expert Phil Longman told the news site Axios: “America’s health care crisis is brought to you by monopoly.” This sort of concentration can now be seen in just about every corner of the health care industry. For example, more than 90 percent of all US dialysis provider revenue goes to just two companies.

Private Equity. It’s not just mergers. The neoliberal affinity for private equity has invaded medical care. Though private equity emerged in the 1990s, the sector mostly avoided health care until the 2000s. Since then, its penetration has been astonishing: from $41.5 billion in activity in 2010 to $120 billion in 2019, according to researchers at the American Antitrust Institute; the University of California, Berkeley; and the University of California, Los Angeles, with a total of $750 billion in investments over the course of that decade. Only recently have researchers documented the impacts: higher prices, poorer quality, closed facilities, disempowered and discouraged workers.

Privatization. Neoliberalism’s impact is also evident in the privatization of public goods. Medicare is the New Deal-era pillar that provides health insurance to 65 million seniors and persons with disabilities. But 55 percent of beneficiaries are enrolled in its privatized part, called Medicare Advantage. That program’s principal “advantage” accrues to vertically integrated private insurance giants such as UnitedHealth Group and Humana, which together enroll 46 percent of all Medicare Advantage enrollees.

These are just a few of the tangible legacies of neoliberalism in US health care. There is also something less tangible: Between 1975 and 2026, according to Gallup, Americans’ trust in our medical care system deteriorated badly. The share of Americans with “a great deal” or “quite a lot” of confidence in US medicine dropped from 79 percent in 1975 to 28 percent in 2026. That’s bipartisan: just 26 percent of Democrats and 30 percent of Republicans have “a great deal” or “quite a lot” of confidence in the system. Reversing this distrust cannot happen overnight. But what can we do in the long run?

Vermont Senator Bernie Sanders’s “Medicare for All” bill offers one solution — establishing a Medicare fee-for-service system for all Americans. Our health care system’s original sin is its wasteful fragmentation among employer-sponsored insurance, Medicaid, Medicare, Affordable Care Act coverage, Veterans Health, Indian Health Services, and more. No other advanced nation divides coverage into such an inefficient and inequitable mess.

Perhaps Sanders’s proposal will become a national mandate for our next president in 2029, and perhaps not. Other steps are needed and shouldn’t wait. Here are just a few I cover in my book:

The president and Congress must reverse the extraordinary consolidation of US health care. Congress must provide the Federal Trade Commission and the Department of Justice with greater authority and resources to bust up monopolies. Private equity should be prohibited from involvement in patient-facing medical care organizations.

A new and updated patients’ bill of rights should protect patients from a neoliberal system run amok. Consumers need relief from excessive premiums and copays. Drug prices should be regulated at the time of product launch, not years later.

During his term, President Joe Biden implemented dramatic reversals to neoliberal policies in health care and across the economy by strengthening antitrust enforcement, consumer protections, progressive tax policy, and more. President Donald Trump has rejected some key neoliberal planks while advancing others, such as deregulation and tax cuts for corporations and the wealthy.

What comes next, when Trump passes from the scene, is crucial.

The underlying diagnosis of our system’s ailments is clear: The neoliberal revolution sickened us. Getting better will be difficult. But get better we must.

How Did So Many Nonprofit Hospitals Become So Profitable?

In June the Private Equity Stakeholders Project (PESP) released a new report documenting more than 500 joint ventures between private equity firms and U.S. nonprofit hospitals. A growing volume of research demonstrates that private equity ownership leads to higher costs, lower quality, lost services, and in some case closed facilities. Private equity exists to provide maximum financial returns to shareholders and owners, competing directly with medical care’s primary mission of service to patients. The new PESP report re-opens the question: Why are nonprofit medical care institutions doing this?

Another recent report from the journal Health Affairs documents how nonprofit hospitals have become “increasingly active participants in financial markets,” holding nearly $300 billion among 2,366 institutions in investment securities in 2023, a 56.6 percent increase since 2010. “Our analysis suggests that nonprofit hospitals are not merely passive participants in this transformation but are themselves financial actors, allocating substantial resources to complex investment instruments and increasingly resembling institutional investors.”

A 2021 Trilliant Health analysis found that 40 nonprofit hospital and health systems would have qualified for the Fortune 500 list had they been for profit. Appelbaum and Batt pose a key question: “…whether these hospitals engage in for-profit activities mainly to supplement their operating income and shore up their finances or whether they have become essentially financial services enterprises with a nonprofit hospital attached to protect their tax status.” (See Trilliant Health chart below.)

In my new book, America’s Wrong Turn: US Healthcare in the Neoliberal Era, I review the history, growth and spread of free market values and practices across U.S. medical care, especially during the neoliberal (aka free market fundamentalist) era between 1980-2020. I include nonprofit health and hospitals in that trend. One clear fact I identified is that federal policies aided and abetted the explosive growth of market forces inside our health systems that also transformed nonprofit medical care.

What were these policy changes? Here are the more significant ones in loose chronological order:

• Community Benefits: Before 1969, the Internal Revenue Service (IRS) required nonprofit hospitals to provide free or below-cost “charity care” to medically indigent persons to keep their 501(c)(3) charitable status. Following Medicare and Medicaid’s creation in 1965, the IRS issued Revenue Rule 69-545 replacing charity care with a broader, amorphous “community benefit” standard permitting hospitals to use their resources to attract commercially insured patients under the rubric “health promotion.”

• Tax Exempt Municipal Bond Financing & Leasebacks: In the 1970s, new federal and state policies allowed the use of tax-exempt municipal bonds to finance hospital capital projects, allowing nonprofit hospitals, for the first time, to retain facility ownership after debt retirement. To gain low-interest bond ratings, hospitals had to maintain corporate-style balance sheets, high profit margins, and more corporatized boards.

• Retention of Intellectual Property Rights and Commercial Patents: The 1980 Bayh-Dole Act permitted universities, academic medical centers, and non-profit research institutes to own the patents for new drugs and medical devices that they developed using National Institutes of Health (NIH) and other federal research funds. Research entities established technology transfer offices to patent new discoveries and license them to pharmaceutical and other firms while taking equity stakes in the commercial startups. Bayh-Dole transformed medical research from a pure public good into a lucrative corporate revenue stream, triggering explosive innovation and growth.

• Profit Making Commercial Ventures: Two major IRS rulings, in 1981 and in 1998, changed the landscape by which nonprofit hospitals could engage commercially. In 1981, the IRS ruled (PLR 8134021) that nonprofit hospitals could create new taxable for-profit subsidiaries that would not jeopardize their tax-exempt status, triggering a nationwide restructuring wave. A 1998 ruling, (Redlands Surgical Services & Rev. Rul. 98-15), opened the door for “whole hospital” joint ventures between nonprofit hospitals and for-profit companies.

• 340B Drug Pricing Program: Created in 1992 under the Public Health Service Act, Section 340B requires drug makers to sell outpatient drugs at heavily discounted prices to covered entities, mostly public and nonprofit safety net hospitals and health centers. It neglected to require that savings be passed onto consumers or their insurance plans. Once high-cost specialty drugs entered the market, nonprofit hospitals made outpatient drug administration among their most profitable business lines. The 2010 Affordable Care Act broadly expanded the population of hospital providers eligible for 340B discounts.

• “Efficiencies” Defense to Block Non-profit Anti-Trust: In 1996, the Federal Trade Commission and the Department of Justice rewrote their anti-trust guidelines to assert that nonprofit hospitals could never use monopoly power to raise prices because they lacked shareholders. This novel and naïve interpretation greenlit the modern era of health system mega-mergers evident today among the 40 non-profit systems whose revenues put them into the Fortune 500 class.

• “Provider-Based” Outpatient Billing: The 1997 Balanced Budget Act codified a new, lucrative mechanism called “provider-based status” so that a hospital acquiring a standalone physician practice or clinic can redesignate it as an “outpatient department of the hospital.” The hospital then can charge two bills for the same visit, a standard physician fee plus a “facility fee.” This launched a wholesale buying spree of independent primary care and specialist physician practices

These seven federal policies provided flexibilities and revenues to nonprofit hospitals creating the financial foundation we recognize today. These policy shifts altered the culture of nonprofit healthcare. By loosening charity care mandates, granting access to Wall Street tax-exempt debt markets, permitting for-profit corporate subsidiaries, incentivizing patent commercialization, and more, federal policy created incentives for nonprofit hospitals to prioritize market share, capital accumulation, and corporate financialization.

Many of these policies provided stability to enable hospitals to meet essential responsibilities. They also set the framework for today’s rich nation/poor nation world of nonprofit hospitals. In particular, academic medical centers taking advantage of Bayh-Dole patents became the corps of elite mega-providers while community hospitals struggle to survive.

In the early 1980s, the Institute of Medicine commissioned a study of “For-Profit Enterprise in Health Care” that also explored nonprofit care in the new environment. We need a reassessment of our health care system’s structural elements, including our nonprofit systems.

First, on May 9th, I posted “Preventing Medical Errors: Are Better Days Ahead?” This was about a proposed program to be run by the state’s Betsy Lehman Center to test “automated adverse event monitoring” of medical errors in a small set of Massachusetts acute care hospitals to create real-time monitoring of adverse events. The Center was seeking about $2.5 million to launch the demonstration. After several years of unsuccessful attempts, Governor Healy and the Legislature approved the appropriation in their recently completed state budget, see below:

So it’s a done deal as far as the state is now concerned and it’s up to the Lehman Center to recruit six participating hospitals. Though the event monitoring system has been used in about a dozen US hospitals, this will be the first public and transparent test of the technology and program. If it works as promised, it should be of national importance. Much more to come, and kudos to Mass. state government for this breakthrough. I’m going to keep watching this and reporting back to you here on it.

AND…if quality of care is not your thing, might I suggest this bracing and effective commentary from Dr. Sherry Glied, Dean of New York University’s Robert F. Wagner Graduate School of Public Service. The title is: “Hospital Quality Is a Choice: Policymakers Should Insist on It” in the August 13 JAMA. Here’s her conclusion:

Hospital quality matters. Quality is actively produced by hospital leaders and managers and the staff they recruit, develop, and promote. Policymakers should stop treating poor quality as an inevitable consequence of a hospital’s external circumstances. Propping up persistently poor-quality hospitals without demanding organizational change does little to serve the communities that depend on them. Instead, policymakers should condition financial support on credible commitments by hospital boards and managers to implement transformational organizational changes that improve quality.

Worth your time and worth passing around.

The Amazon book description describes it well: “How forty years of neoliberal policy choices created an American health care system that prioritizes profit over people.”

This is my fourth book. I’ve done one per decade since the 1990s including this new one. The seed of the idea for this one got planted around 2012 when I started as a faculty member at the Harvard School of Public Health and frequently taught an earlier version of this chart:

“What the heck happened to US health care spending in the early 1980s,” I would get asked. I didn’t have a convincing answer until I began exploring the history and literature on the global neoliberal revolution that hit the US with full force in the early 1980s under President Ronald Reagan.

I do know now and it’s all in this book. In many ways, it’s a book about ideas and the power they can wield over society for better (during the New Deal era, 1933-1980) and for worse (in the neoliberal era, 1981-2020). I dedicated this book to my former, current, and future students who are so eager to save US health care and to save the world. One of my favorite quotes, from Pres. Harry Truman, is: “The only thing you don’t know is the history you haven’t read.”

I hope you can check it out. And if you do, please consider leaving a review on the book’s Amazon webpage. If you have any suggestions for spreading the word about it, please let me know. And sincere thanks to so many who helped me get to this spot!

We know that many nonprofit medical care providers find themselves as targets for private equity acquisition, and resist folding into their grasp if possible. Private equity’s only goal is to achieve maximum profits for their shareholders. Medical care’s goal is, according to the physician Hippocratic Oath, the well-being of patients. That’s the irreconcilable conflict between medicine and private equity; maximum profit conflicts with the ethics of medical care.

Private Equity Owned US Hospitals

(source: PESP Hospital Tracker, July 29 2026)

Now for some depressing and surprising non-profit and private equity news from two different sources:

First, earlier this month, the Private Equity Stakeholder Project (PESP—a talented and principled organization) released a new report on “Private Equity’s Joint Venture Takeover of Nonprofit Healthcare.” PESP’s researchers identified more than 500(!) non-profit health and medical care facilities that are now collaborating with private equity firms in joint ventures. Other key findings from the report:

· Fully 21.4% of private equity-owned hospitals are owned through joint venture arrangements with nonprofit health and hospital systems;

· Nonprofit/PE joint ventures involve hospitals, inpatient rehab, hospice, home health, behavioral health, ambulatory surgical centers, urgent care facilities, and more.

Some key learnings from the report include: 1. Joint ventures enable PE companies to gain access to new markets by trading on the reputation of academic or well-known non-profit systems; 2. Joint ventures can enable PE firms to evade state laws such as those banning the “corporate practice of medicine”; 3. Joint ventures can enable nonprofit providers to obtain tax free profits from for-profit partnerships. Because PE firms have been found to harm quality and facility conditions along with service reductions and higher prices, a non-profit’s patients and customers may experience adverse effects.

The always-present impact of federal and state public policies matters here, especially because of two Internal Revenue Service (IRS) rulings from 1998 and 2004. In 1998, growing interest in “whole hospital” joint ventures involving nonprofit and for-profit parties, led to IRS Rule 98-15. This set guardrails for how a nonprofit hospital can engage in such a venture without risking its 501(c)(3) charitable status: 1. The non-profit must “control” the governing board; 2. Joint venture documents much assert a community health obligation superior to profit generation; and 3. The joint venture management agreement must block any management company’s control over operations.

In 2004, in Rule 2004-51, the IRS cleared a pathway for non-whole hospital joint ventures if the collaboration furthers the nonprofit’s charitable purposes, retains non-profit control, and avoids mission-inconsistent activities. This arena is murky and high-risk and drew a recent warning from the audit and tax consulting firm Crowe this past March to “heighten the urgency for hospital organizations to review JVs” and confirm which ventures meet IRS requirements or not.

Who are some of the bigger players identified in the PESP report? Here are three:

· Lifepoint Health, owned by PE giant Apollo Global Management, has created joint ventures with at least 137 acute, rehab, and behavioral health hospitals;

· Ascension, one of the largest Catholic non-profit systems in the US, was one of the earliest nonprofits to create a venture capital arm, known as Ascension Capital, working with the PE firm, Towerbrook Capital, among others.

· Ardent Health owns 30 acute care hospitals with more than 280 care sites, with over 2,000 providers in Texas, Oklahoma, New Mexico, New Jersey, Idaho, and Kansas. Its majority owner is Equity Group Investments along with Ventas, a real estate investment trust (REIT). In its 2026 annual report, Ardent reported that its numerous JV partners “offer us significant recognition, and scale that enable us to accelerate market penetration.”

PESP’s documentation of 500+ such joint ventures is jaw-dropping. I had heard of these efforts and mentioned them in my new book (“America’s Wrong Turn: US Healthcare in the Neoliberal Era”—chapter 5). I had no idea how big the scope of these arrangements had become. The pressures for non-profit care organizations to commercialize inevitably collides with these institutions’ core mission. Federal and state governments need to pay attention to this trend and its implications for health system costs and quality of care.

Here’s a second new development of note: the Washington DC-based Campaign for Accountability released a report in late June: Overbilled and Overtreated: Private Equity and the Healthcare Affordability Crisis. The research team’s analysis of new hospital data showed that “private equity-owned hospitals netted $669 more per patient than comparable hospitals with other ownership structures.” Other studies have identified a percent increase in health system costs associated with private equity ownership, i.e. a 32% increase in a 2023 study. This is one of the first and most recent I’ve seen that put a precise dollar figure to the cost escalation in private equity owned hospitals.

On July 14th, Gallup released its latest survey so here we go. In 1975, 79% of Americans indicated a great deal or quite a lot of confidence in the US medical system. That number dropped to 51% in 1993. In this year’s survey, the number has dropped to 28%. Unlike a lot of measures, it’s not a number shaped by partisan differences: 30% of Republicans, 28% of Independents, and 26% of Democrats feel the same way.

It is true that confidence in all US institutions has sagged significantly. Here’s the overall table:

It is also true that of the 14 sectors, only only 3 rank more highly than the medical system: the military at 61%, the police at 45%, and the church/organized religion at 33%. And even those 3 have all seen declines of 20% of more since the 1990s. Also noteworthy, unlike the other 13 sectors, trust in the medical system in 2026, according to Gallup, has never been lower; the trust level in medical care in 2024 was 34%, so this year’s result meets Gallup’s threshold of statistical significance.

So who is working on restoring trust? Just google “US health care” and “trust” and you will find loads of analysis and reports and prescriptions. President Trump, HHS Secretary Kennedy, and Centers for Medicare & Medicaid Services all came in promising to “restore trust,” though far fewer than half of Americans indicate support. Restoring trust is hard when Americans feel more and more harmed because of the system’s rising costs and insurance coverage losses that hit them directly — see the additional Gallup chart below. Actions matter more than words, and the actions from the Trump Administration are uniformly making things worse for many millions of Americans.

If you would like to see more granular analysis, you have a cornucopia of Gallup survey results available here, like this:

If you don’t know this story, you’re missing something grand. Briefly, in the 1940s, a group of mostly southern African American physicians (including Theodore Roosevelt Mason Howard, MD, Sonnie Wellington Hereford III MD, Reginald Hawkins DDS, W Montague Cobb MD PhD, Charles Watts MD, and George Simkins Jr. DDS) decided to challenge Jim Crow medical segregation, similar in ways to how African American parents and civil rights lawyers were challenging public school segregation. A 1959 study documented that only 6% of southern US hospitals offered medical care on an integrated basis.

Like the school activists, the docs chose to make their challenge a federal case. Their target was 1946 law called Hill-Burton, the largest commitment ever to that point by the feds to support building and expanding the nation’s hospital infrastructure. While the law required all participating hospitals to serve everyone, including African Americans, it nullified that rule by allowing facilities to receive funding if they offered “separate but equal” services for Black Americans. It was more of the same in Jim Crow America. In 1954, a unanimous Supreme Court ruled in Brown vs. Board of Education declared that “separate but equal” public schools were illegal.

The physicians’ case reached the Supreme Court in 1957. Though they suffered a 6-3 loss, the plaintiff physicians cheered as they felt the tide of history turning in their favor, and began looking for their next case to challenge Hill-Burton.

Meanwhile, a growing civil rights movement barreled across the South and the nation, picking up steam, exploding in the early 1960s, leading President John Kennedy to introduce comprehensive civil rights legislation in June 1963, months before his assassination. His successor, Lyndon Baines Johnson (LBJ) picked up the cause telling a joint session of Congress in 1964 that “we shall overcome.”

The physicians’ 2^nd case, Simkins v. Cone, won at the appellate level in 1963, and in 1964 the Supreme Court refused to hear the hospitals’ appeal, thus overturning “separate but equal.” It was the first-time federal courts applied the 14^thamendment’s Equal Protection clause against racial discrimination by a private entity, according to Karen Kruse Thomas. In July 1964, LBJ signed the historic Civil Rights Act into law, prohibiting in the law’s Title VI discrimination by any program or entity that received federal funds.

But what would precipitate national desegregation of hospitals? Officials at the U.S. Department of Justice promptly began writing regulations though without a clear “focusing event” to call the question. Unexpectedly, the 1965 creation of Medicare to provide health insurance for most Americans over age 65 turned out to be the trigger. Beginning on July 1, 1966, the program would open for all acute care hospitals wanting payment for elderly beneficiaries. Would the federal government enforce the Civil Rights Act as applied to all US hospitals and deny funding to segregated facilities? Might that doom successful implementation of Medicare?

With less than 12 months to prepare, President Johnson decided that the Civil Rights Act would apply to all acute care hospitals and directed his Administration to make it happen. Secretary of Health, Education, and Welfare John Gardner and his key officials organized the campaign and required visual inspections of every hospital to ensure elimination of segregation. His department recruited more than 1,000 federal bureaucrats to fan the nation to do the inspections, drawing volunteers mostly from the Social Security Administration and the Public Health Service including NIH bench scientists, veterinarians, pharmacists, managers of Social Security field offices, venereal disease investigators, even “a medical officer from the Indian Health Service complete with an Eskimo secretary,” according to David Barton Smith’s account.

Some hospitals, knowing when inspectors would show up, removed all signs and other indicators of segregation, and then put them back after inspectors left. So inspectors began to return unannounced later in the day or the next day to catch the deception. Some hospital administrators quietly expressed support for the mandate, knowing that they could never have convinced their boards of directors or staff to go along. Now they could blame the change on the federal government to do what they could not accomplish themselves.

Of special note was the action of the non-profit Blue Cross & Blue Shield Association, the largest providers of health insurance in all 50 states. In early 1966, Association leaders announced in a letter to all their participating hospitals that post July 1, they would not pay for hospital services for senior citizens in segregated hospitals, meaning hospitals had no safe harbor if they refused to desegregate. While this move was vital, it was already clear that BCBS plans would be the administrative backbone for Medicare in all 50 states. It was a compelling example of how public interest and self-interest can align.

President Johnson played a front and center role, addressing the nation on television just before final implementation. Earlier, one hospital leader from his home state of Texas contacted him personally to request a waiver from desegregating because of the backlash he was facing. Instead, at his next home trip to Texas, LBJ made time for a public in-person visit to that hospital to celebrate their early desegregation.

Backlash to the change was both intense and muted. A glaring exception was the shooting death in January 1967 of Dr. Jean Cowsert who was shot to death in her front yard in Mobile Alabama. Though police concluded that she had accidentally shot herself, prior to her death she had been a confidential informant to HEW officials concerning the Mobile Infirmary’s public efforts to thwart desegregation in their facilities.

* * *

If you want to know more about this amazing story, the best single volume narrative is: “The Power to Heal: Civil Rights, Medicare, and the Struggle to Transform America's Health Care System” by David Barton Smith. Also, a 58-minute documentary was made in 2015 about the case, also called “The Power to Heal,” narrated by Ozzie Davis. Every fall, in the first session of my United States Health Policy course at the Harvard Chan School of Public Health, I teach this episode as the first case in the course. My core source is: PP Reynolds: “The federal government’s use of Title VI and Medicare to racially integrate hospitals in the United States, 1963 through 1967.” American Journal of Public Health. October 7 2011.

“…the most iconic work of American Art? A French sculpture, of course, assembled in Paris, and then again in New York harbor,” in 1886 at 151 feet tall. It is an Americanized image of the term “Liberté” and “(i)n French, the noun is feminine.” The conceptualizer, the designer, and the implementer was Frédéric-Auguste Bartholdi. The official name of the Statute of Liberty is “Liberty Enlightening the World.” Starting his thought process in 1865, Bartholdi and his French liberty compatriots “envisioned a gift, a really big gift for America’s centennial, one that will also rally their cause at home.”

Bartholdi first pitched his idea to Americans during his initial trip to the U.S. in 1871. In 1979, he received a US design patent for the statue. On July 4th, 1880, the statue was officially delivered to America’s ambassador to France. On October 28 1886, the Statue was formally presented as a joint gift by French and American people, installed on Bedloe’s Island in New York Harbor. So it was on that day that Lady Liberty became a naturalized US citizen!

Bartholdi’s inspirations came from many quarters beyond France, including Egypt, Turkey, and other sources. Farago writes that “She was a metallic incarnation of France’s own republican rebirth” and “one of the greatest engineering feats of the 19th century.” Perhaps its only rival in that era was the Eiffel Tower in Paris which was completed shortly after using the same engineering strategies. “The Statue of Liberty is, as literally as I can say, an American Eiffel Tower.” In other words, the Statue of Liberty is the Eiffel Tower in a dress, built like an erector set with no weight carried by the statue’s feet.

In the wake of the US Civil War, Americans inaugurated the statue as a monument to freedom, “years before the US set up a depot for other immigrants on nearby Ellis Island … These arrivals … recast Liberty as an allegory of world wide welcome.” Emma Lazurus wrote her historic poem “The New Colossus” in 1883 to help raise funds to construct the statue’s enormous pedestal:

Not like the brazen giant of Greek fame,
With conquering limbs astride from land to land;
Here at our sea-washed, sunset gates shall stand
A mighty woman with a torch, whose flame
Is the imprisoned lightning, and her name
Mother of Exiles. From her beacon-hand
Glows world-wide welcome; her mild eyes command
The air-bridged harbor that twin cities frame.
“Keep, ancient lands, your storied pomp!” cries she
With silent lips. “Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!”

At the end of Farango’s unforgettable piece, like Emma Lazarus, he reaches for the stars:

Life, liberty, the pursuit of happiness: the formula for democracy is a thing of multiple parts. At its core is nothing solid, just a framework, on which pieces brought across oceans would be conjoined. From many, one. …It is all matter of creative engineering. Of real and ideal. Of coming up with something meaningful, and then figuring out how to make it stand.

Happy July 4th, 250, everyone. This one I’ll remember.

KFF first got involved well before the end of Apartheid in the mid-1990s. “We decided to get directly and heavily involved instead, helping South Africa prepare for and then build a democracy and a health system for the whole population. We trained leaders, built institutions, and supported a free press,” notes Altman.

(KFF photo memoriam to Nelson Mandela)

One noteworthy moment involved a meeting with KFF Program Director Michael Sinclair and two KFF board members, former Congresswoman Barbara Jordan (D-TX) and former HHS Secretary Joe Califano, who “were asked to meet with a top general in the South African armed forces. The meeting took place in a hotel. After explaining their position on their nuclear weapons they had developed and eventually destroyed so as to not incinerate their country along with the ANC and its allies, and covering other territory distasteful to the general, he abruptly said, ‘Look, I want you to know that I don’t like what you people are doing in my country, and I am prepared to give my life to stop the blacks from taking over our country.’ Barbara, the great orator, sitting in her wheelchair, had not said a word in the meeting. She answered, ‘Well sir, we may just need to take you up on that kind offer,’ and wheeled from the room, ending the meeting.”

KFF played an essential role helping to facilitate the transition to black majority rule, training countless new officials for their government roles, working in tandem with newly elected leader Nelson Mandela who served as President between 1994-1999.

When Mandela’s successor as Prime Minister, Thabo Mbeki, refused to address the severity of the intense AIDS crisis in South Africa, KFF launched the loveLife program in September 1999. They worked with leading South African organizations and community organizations, media groups, including the South Africa Broadcasting Corporation (SABC), and foundations. “loveLife combined a highly visible and sustained national multi-media HIV education and awareness campaign with countrywide adolescent-friendly service development in government clinics, and a national network of outreach and support programs for youth. We set it up as an independent non-profit organization governed by its own board so it could eventually be folded into the operations of a friendlier government,” noted Altman.

Early in the South African government’s existence, the new government stated their goal to achieve universal health insurance for all, and including that commitment in their new Constitution. Despite repeated efforts over more than 30 years, including Mandela’s passing in 2013, that commitment remains unfulfilled. KFF’s involvement in South Africa was a difficult journey and well worth taking. I appreciate Drew Altman’s recollecting that engagement for all of us.

• In the 16 months, between January 2025 and April 2026, (the first 16 months of the Trump2 Administration), the number of all noncitizen immigrant workers declined by about 4% from 15.4 million to 14.8 million, (or 600,000) even though the total number of all immigrant workers held steady.

• In this same time period, the number of naturalized citizen workers increased by over 800,000, or about 6%, from about 15.2 to 16.0 million.

• And in this same time period, the number of U.S.-born workers increased by about 1.1 million, or 1%, (from 125.6 to 126.7 million).

• Within medical care, the nation saw a total increase of 1% or 130,000 workers from 19.4 to 19.6 million. This reflected increases of U.S-born (16.0 to 16.1 million) and noncitizen immigrant workers (961,000 to 1.2 million) that offset a drop among naturalized citizen workers (2.5 million to 2.3 million).

• While immigrants accounted for 19%, or 31 million, of the total US workforce, they accounted for 17% of the health care work force (28% of physicians, and 30% of direct care workers in long-term setting.)

• It’s a richly diverse set of nations that provide health care workers to the US. The largest numbers of immigrant health care workers came from the Philippines (12%), Mexico (11%), and India (7%). China, Jamaica, Cuba, and Haiti contribute 4% each of immigrant health workers. One in five (21%) of immigrant physicians and surgeons, come from India, 6% from China, 5% each from Canada and Pakistan, and 4% are from Philippines. Among immigrant direct long-term care workers, one in seven (14%) are from Mexico, 7% each are from Dominican Republic and Philippines, and 6% each are from Jamaica, China, and Haiti. No nation dominates.

  

• Within hospitals, immigrants of all kinds play a major role in non-clinical operations such as building cleaning and maintenance workers (29%).

Americans should thank our lucky stars that so many hard-working and ambitious immigrants want to come and make their lives here. (My late parents were two of them.) Immigrants are high-value contributors to our society, caring for our most vulnerable and frail residents.

And we don’t treat them well. According to another recent KFF report, about half (46%) of undocumented immigrant adults and one in five (21%) lawfully present immigrant adults reported being uninsured compared to less than one in ten naturalized citizen (7%) and U.S.-born citizen (6%) adults. The Trump Administration has moved aggressively to restrict lawfully present immigrants’ access to health coverage, and “immigrants across all statuses have become more fearful about accessing health coverage and care due to increased immigration enforcement actions.”

Back in 2023, the World Economic Forum released a report: “Why It’s Time to Rethink Migration.” Working-age populations in high-income and many middle-income countries are steadily shrinking. “This unprecedented demographic shift will see more countries turning to migrants to fill labour shortages.” As we treat immigrants under the Trump Administration like criminals, we will increasingly find them unwilling to come to the US at all, taking kinder and more generous offers from other nations.

The title is: America’s Wrong Turn: US Healthcare in the Neoliberal Era. In the midst of my teaching and other commitments, it took me about 6 years to get my final manuscript to Hopkins Press. I sense that the timeliness and relevance of the book’s message is still as urgent as ever.

Large numbers of Americans are upset and angry at various manifestations of our health and medical care crisis, including: private equity financialization; monopoly and growing corporate concentration; pushback against diversity, equity, and inclusion; extreme and ever-increasing levels of cost sharing on patients; excessive prior authorization mandates; privatization of public goods such as Medicare and Medicaid; victimization of workers and consumers via non-disclosure agreements, non-compete clauses, mandatory arbitration clauses, and more. On and on.

Many Americans see these manifestations as discrete and disconnected. I see them as inter-connected manifestations of a national and global phenomenon: the neoliberal politico-economic movement that captured the US and large portions of the world starting in the 1970s and taking off like a rocket in the 1980s under President Ronald Reagan.

Health and medical care were not direct targets of the neoliberal revolution. Still, the broad impact of this revolution could not leave our health and medical care systems unaffected. The results are the distress and mess that we see all over US health and medicine today.

I conclude that the neoliberal era’s dominance came to an end by late 2020 even though many of its manifestations endure, just as elements of the prior New Deal Era have lasted way beyond the end of that era in 1980.

How and why did the neoliberal revolution happen? How serious and ongoing has been the damage to our health and medical care systems? Where do the Trump 1, the Biden, and the Trump 2 Administrations fit into this story? What are the prospects for change and improvement today? These are the topics I cover in the book that will be available on August 11.

I hope that this book will help Americans to make sense of our health and medical care systems’ failures and point the way to a better future. I’m hoping for a vigorous public conversation in which I hope YOU can take part. Please feel welcome to contact and connect with me about this and thanks for subscribing to my Substack column where I will communicate about the ups and downs of my publishing journey.

I’ve been examining how public policies have facilitated the transformation of America’s health and medical care systems into today’s financialized and commercialized realities. While some new public policies trigger major systemic shifts right out of the gate, others get less attention and take more time to show results. Policies can have predictable or surprising impacts, good or bad. Changes happen not just through new laws, but also through regulations, executive actions, judicial decisions, and more. Over time, memories of them fade and younger folks never learn about how changes happened, taking each as a given.

Many Americans wonder how we got to our current reality where US health and medical care have become so profit oriented and corporatized. No single public policy change decreed that free-market competition (aka: neoliberalism) would rule. The emergence of private equity, consolidated mega-companies, privatization, sky-high deductibles and other cost sharing methods, suppression of health equity and organized labor, and so much more, often happened discretely, quietly, and unnoticed by most.

Out of many public policy changes that transformed our system, I believe these three have had noteworthy significance in moving US health and medical care to our current deplorable state. Many readers will have other legitimate nominees for inclusion, but I don’t have space here to be encyclopedic.

1. How did private equity accumulate the financial resources to capture so much of the US economy, particularly in health and medical care?

Today, private equity investments and ownership penetrate every crack and crevice of US medical care, from hospitals and physician groups to home health care and hospices to veterinarians and autism treatment programs—more than $1 trillion over the past decade. Results have produced bankruptcies, layoffs, closures, loss of local control, higher prices, and diminished quality. Where did private equity get the dough they needed to invade US medical care?

In 1974, President Gerald Ford signed a law known as ERISA (Employee Retirement Income Security Act), which provided federal regulation of private employer pension plans to prevent abuses that had harmed current and retired workers. In 1979, under President Jimmy Carter, the US Department of Labor relaxed a key ERISA provision called the “prudent man” rule to permit ERISA-governed pension plan trustees to invest their accumulated capital into riskier targets, including the small and then slowly growing private equity arena. In 1996, the National Securities Market Improvement Act went further, enabling nearly unlimited private and organizational funds to be invested in private equity and other alternative investment hands.

Today, pension plans, public and private, are the dominant sources of investment capital for private equity globally and in the US, financing the acquisition of community hospitals and other health system assets. According to the American Investment Council, private equity’s lobbying force, fully 89% of public pension plans invest at least some of their holdings in private equity investments equaling about one-third of all private equity investment capital.

Bottom line, two obscure federal policy changes from 1979 and 1996 provided the gasoline that lit private equity fires across the nation, including into US medical care. Whether you like or despise private equity, public policies engineered the PE medical revolution.

2. How did nonprofit universities and academic teaching hospitals develop into the wealthy institutional behemoths that we see today?

Prior to 1980, when a university or teaching hospital made a discovery or invention that involved federal research funding, mostly from the National Institutes of Health (NIH), the federal government took ownership of the resulting patent. The federal government turned out to be ineffective in turning those patents into new products or technologies, so that by 1980, they had licensed fewer than 5% of their 28,000 held patents.

The 1980 Bayh-Dole Act (aka the Patent and Trademark Law Amendments Act) turned this structure on its head. The law allowed universities, academic teaching hospitals, nonprofit research labs, and small businesses to patent and own (“elect title”) federally funded Intellectual Property (IP) and to license private sector partners (such as pharmaceutical companies) to develop and commercialize usable end products. Profits had to be shared with inventors, and institutional shares had to be “plowed back” into scientific research and education. Also, the federal government retained “march-in” rights to reclaim licenses if an owner failed to bring an invention to the public on “reasonable terms.”

This was a transformational step that turned American academic hospitals and universities into powerhouse innovation engines, generating an estimated $1.3 trillion revenues and 4.2 million jobs into the US economy as of 2024. At least 200 new drugs and vaccines have been developed using university technology transfer, as well as high-definition TV, the nicotine patch, the Google algorithm, and much more.

The law also generated criticism. How many of the new high-priced drugs involved “reasonable terms?” Why has the federal government never enforced its “march-in” rights to challenge high drug prices? Did the law result in the commercialization of American academia, “hollowing out” or side-lining other vital academic missions and priorities? Have the law’s commercial and financial incentives distorted the access and quality of care missions of American major medical care institutions when a single new blockbuster drug can produce more surplus revenues than does its medical care?

And that’s not all. In 1981, the US Internal Revenue Service ruled that a nonprofit California hospital would not lose its NFP status when it undertook profit-making ventures such as “a medical office building, a shopping center, a restaurant, and a contract management consulting firm,” wrote Paul Starr in his 1982 book, The Social Transformation of American Medicine. It even appears that the profit-making subsidiaries of a nonprofit hospital can sell stock to investors, as long as the tax-exempt and taxable organizations are kept separate.”

If it appears difficult to distinguish nonprofit and for-profit medical institutions, that’s not an accident. While the benefits of Bayh-Dole are evident and impressive, as academic medicine has become commercialized, corporatized, and financialized, what has been lost?

3. Why has corporate consolidation spread so rapidly across the US economy and across US health and medical care sectors since the 1980s?

Americans’ instinctive opposition to monopolies, trusts, and oligopolies gained public expression with the passage of the Sherman Antitrust Act of 1890. Over 90 years, it went through changes that strengthened its effectiveness, especially with the establishment of the Federal Trade Commission (FTC) in 1914. Through numerous successes and failures, Americans supported the public value of governmental action to prevent and to remedy harmful corporate consolidation.

In the 1950s, the neoliberal movement based in the economics department of the University of Chicago began challenging this national consensus, arguing that antitrust should only matter when consumers faced higher prices from a merger or takeover, the so-called “consumer welfare standard.” In the 1970s, these ideas blossomed, especially through the advocacy of Robert H. Bork whose 1976 book, The Antitrust Paradox, gained acclaim among Republicans, conservatives, and more than a few Democrats.

In 1982, the new Reagan Administration rewrote the federal “antitrust guidelines” issued by the FTC and the Antitrust Division of the US Department of Justice (DOJ) to establish consumer welfare as the new standard for judges and other officials in evaluating merger cases. No debates in Congress marked the break with 90 years of precedent regarding harmful market power. It was a clean “inside job” with little to no objection. President Joe Biden’s Administration engineered a major break and course correction during his four years under the leadership of Lina Khan at FTC and Jonathan Kanter at DOJ.

The consumer welfare standard reigned for 40 years as the governing principle for when to challenge corporate takeovers. In that period, we saw the largest wave of mergers and acquisitions since the late 19^thcentury. As Americans grapple with health and medical care affordability challenges today, researchers increasingly understand that one of the major causes—perhaps the major cause—of health care’s affordability crisis has been the wave of consolidation across the entire medical care sector since the late 1970s.

* * *

Four to five decades ago, these and other public policy changes planted the seeds and sprouts for the creation and evolution of today’s corporatized health and medical care states. While these and other changes were noted in some media at the time, none generated the controversy they might and should have if our powers of prediction had been sharper. We know and understand so much more today than we did back then. We have no more excuses for inaction.

John E McDonough’s new book, America’s Wrong Turn: US Healthcare in the Neoliberal Era, will be published in August by Johns Hopkins University Press.

California’s Gov. Gavin Newsom signed legislation in October 2025 to require that private equity dealmakers—plus their Management Service Organizations (MSOs) and other hedge funds—must report any new acquisitions to the State’s Office of Health Care Affordability at least 90 days prior to closing.

Massachusetts enacted a new law in early 2025 to expand the range of regulated health care transactions, broadening the definition of “material change” to include private equity and other new corporate investments. The Mass. State law was the first to ban so-called sale-leaseback deals between health care facilities and Real Estate Investment Trusts (REITs) that enrich PE firms while requiring hospitals to pay rent for property they formerly owned. This new law happened just as the state was digging out from the wreckage created by Steward Health Care’s private equity triggered bankruptcy.

As of July 2025, New Mexico now mandates a rigorous 120-day preclosing notice filing that requires explicit state approval for health care acquisitions. In March 2026, Washington State expanded their required reporting to include any new contracting affiliations, including with private equity.

In 2025, Maine enacted a new law placing a strict temporary moratorium until June 15 2029 to block any private equity or Real Estate Investment Trust (REIT) from gaining ownership or effective control of any hospitals within the state.

Vermont is on the verge of passing H.583 focusing on medical care clinical decision-making. It seeks to ensure that clinical decision-making is only managed by licensed health care providers. It prohibits private equity groups and hedge funds from influencing clinical judgments, hiring or firing staff based on clinical competency, and setting clinical standards or pricing for services. It requires health care facilities and MSOs to report ownership and control structures to the Green Mountain Care Board, particularly if private equity groups or hedge funds are involved.

Perhaps the most interesting moves are happening in Oregon. The state set new reforms addressing oversight of health care transactions and strengthening their “Corporate Practice of Medicine” (CPOM) law so that licensed clinicians hold authority over clinical and operational decisions regarding patient care, not corporate managers. Because PE firms previously had devised ways to circumvent CPOM laws by hiring “friendly physicians” who are only nominally in charge, in 2025 Oregon passed a law go strengthen CPOM requirements that ban this practice and outlaw noncompete, nondisclosure, and nondisparagement requirements against clinicians.

Oregon is now on the frontline in facing PE industry pushback. In February, the non-profit health system PeaceHealth announced a plan to switch its emergency department staffing firm to an out-of-state PE affiliated staffing group called ApolloMD. In March, a local Oregon physicians group sued to block the switch relying on the 2025 law that allows doctors sue to block management agreements that usurp their authority to run medical practices and direct patient care. The lawsuit alleged that ApolloMD was using the “friendly physician” model. On the 4^th day of the trial in early May, US District Court Judge Mustafa Kasubhai said that two key PE witnesses “were being dishonest with the court.” That same day, PeaceHealth announced that it would recontract with the prior physician group. On May 14th, PeaceHealth announced the firing of its Oregon CEO who engineered the Apollo deal.

Beating the bullies is no longer impossible for those prepared for hardball.

A growing network of experts is helping states to devise strategies to protect their health and medical systems from private equity exploitation. Even red states such as Texas and Indiana are taking actions, indicating that this is a trend extending beyond just blue states. That’s a key indicator for a trend that has staying power.

National attention to patient dumping came from two articles both written by physicians at Cook County Hospital in Chicago detailing the same practice at that facility. Most Cook transfers involved minority and unemployed patients. The reason given for the transfer by sending institutions was lack of insurance in 87% of cases. Only 6% of patients had given written informed consent for their transfer.

So I noticed a lack of recognition on April 7th of the 40th anniversary of the signing of a law known as EMTALA, the Emergency Treatment and Active Labor Act, done as a section in that year’s federal Consolidated Omnibus Budget and Reconciliation Act (COBRA). (If you google “COBRA” and 1986, what comes up first is a Sylvester Stallone movie of the same name and year with the tagline “Crime is a disease. Meet the cure.”) Below is a photo of Ronald Reagan signing the COBRA bill into law, surrounded by laughing white guys.

Still in effect today, EMTALA mandates that every hospital that accepts federal Medicare payments (meaning nearly all of them) must provide an appropriate medical screening examination for anyone seeking emergency medical treatment for any condition regardless of legal status, citizenship, or ability to pay. Hospitals may not transfer or discharge patients in need of emergency care without the patient’s informed consent or unless the patient had stabilized or unless the patient requires transfer to a better equipped hospital to administer effective treatment. It’s important to mention that the federal government provides zero dollars to implement EMTALA — one of America’s leading “unfunded mandates.”

The hospital must provide stabilizing treatment if the patient is determined to have an “emergency medical condition.” An EMC is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs."

Civil penalties of up to $50,000 can be imposed for each violation (up to $25,000 for hospitals with fewer than 100 beds) plus responsible physicians can be fined up to $50,000 for each violation, and injured patients may also sue for damages. A 2018 study found that settlements due to EMTALA violations dropped 87% between 2002 (46 cases settled) and 2016 (6 cases settled. The annual average settlement was $31,734, for a total of $5.3 million over the 14 years. “Settlements declined prior to and after implementation of the Affordable Care Act.”

A 2001 retrospective study concluded: “Although only 4 pages in length and barely noticed at the time, EMTALA has created a storm of controversy over the ensuing 15 years, and it is now considered one of the most comprehensive laws guaranteeing nondiscriminatory access to emergency medical care and thus to the health care system … the statute now potentially applies to virtually all aspects of patient care in the hospital setting.”

Successes and Shortcomings

1. Access to medical care as a right? EMTALA has been called America’s de facto “universal healthcare law” for emergencies. It established as a legal principle that in a moment of life-or-death crisis, a human being’s medical need supersedes their commercial or financial value to a hospital system. And the law has often been oversold: e.g.: in 2007, President George W. Bush responded to a question about the uninsured, saying: “I mean, people have access to healthcare in America. After all, you just go to an emergency room.”

Important as EMTALA is, it only assures diagnosis and stabilizing treatment. Hospitals can and do bill for their provided services, and aggressively pursue collection services for unpaid bills. EMTALA was better than nothing, and it was more than nothing, certainly for the hospital industry. And it is no excuse for the hardships coming on Americans now from President Trump’s huge cuts to Medicaid and to ACA affordability.

2. The diminution of overt “patient dumping.” Consensus opinion is that EMTALA mostly eliminated the brazen, callous street-level dumping that had been visible in the 1970s/1980s. Federal penalties and the threat of losing Medicare provider agreements required that hospital administrative behaviors shift toward compliance. According to a 2025 report from MED-IQ, about 4% of US hospitals are cited each year by the federal Centers for Medicare and Medicaid Services (CMS) for EMTALA violations.

Of particularly concern are obstetric emergencies, a leading source of EMTALA violations. MED-IQ’s review of settlements between 2002 and 2018 found that one in six EMTALA settlements involved obstetric emergencies and one in five of those cases involved a pregnant minor. More to come on this below…

3. Development of a national uniform safety net. EMTALA triggered creation of a rigorous, uniform protocol for inter-hospital transfers. Subsequent regulations required that receiving hospitals with specialized capabilities (such as burn units or neonatal intensive care) must accept transfers if they have capacity, thus compelling wealthy hospital systems not to exclude specialized care from public patients.

4. The expensive and unfunded mandate. Maybe the laughing guys in the photo were pleased that Congress could mandate that hospitals had to treat everyone, while providing zero federal funds to pay for that care. Will we see more mention of EMTALA as the cuts to Medicaid and the ACA plans hit more deeply later this year and into next? I would not be surprised.

Though EMTALA did become a classic unfunded mandate, emergency departments began growing quickly in the 1950s, well before EMTALA. Into the 1980s, EDs grew into a costly, inefficient safety net for millions of primary-care-deprived, uninsured Americans. Emergency medicine still accounts for tens of billions of dollars in uncompensated care annually, a trend that has accelerated the closings of vulnerable community and rural hospitals.

One more crucial issue—reproductive rights.

Since the 2022 Supreme Court decision overturning the constitutional right to abortion in the Dobbs v. Jackson Women’s Health Organization case, abortions bans have been created in many states. Some states created exceptions based on the gestational age, assault, or medical necessity. Twelve states created near-total abortion bans with urgent implications for patients and medical providers who give reproductive care services, especially emergency department physicians.

As Emily Van Court notes in a 2025 policy brief:

The issue arises in cases where an abortion is determined to be medically necessary for the stabilization of a patient by a provider in an emergency setting. Pregnancy complications are the fifth most common reason that women between 18 and 65 visit the emergency room, with 84% of women visiting the emergency room at some point during their pregnancy. Due to the breadth of procedures that fall under the clinical term “abortion,” many medical procedures required for emergency obstetrics care fall under the abortion umbrella. Often, these procedures are life-saving and needed for even the most basic stabilization of a pregnant patient, such as in the case of ectopic pregnancy.

In the wake of the Dobbs decision, on July 11 2022, CMS issued new guidance stating that under EMTALA, physicians would be protected for providing medically necessary abortions for the stabilization of emergent patients. In June 2025, President Trump rescinded that guidance. In 2024, the Biden Administration sued the state of Idaho to protect a woman’s right to pregnancy termination if needed to save life or avoid serious health consequences. In 2025, the Trump Administration dropped the suit. In a Texas lawsuit, the Supreme Court ruled that the federal government can’t require hospitals to provide pregnancy terminations when it would violate that state’s abortion ban. Similar to the Idaho case, the Supreme Court did not rule whether federal law supersedes a state’s abortion ban.

* * *

If you thought that EMTALA was yesterday’s news and now irrelevant, please think again. EMTALA was both a triumph of human rights and a symptom of health system failure. In the mid-1980s, a decade after establishment of Medicare and Medicaid, instead of building a universal primary care infrastructure, Congress chose to fortify the emergency room door. EMTALA was and still is vital and life-saving, and yet another example of our commercialized health and medical system that chases dollars above and beyond public and population health improvement.

Happy birthday, EMTALA, anyway.

Here’s a detailed list just for 2025:

Total 2025 compensation for the 7 individuals was $190.5 million. The oddity on the list is Helmsley as Fortune Magazine helpfully details:

He will get a base salary of $1 million a year—big money but actually below the usual salary for CEOs of such large companies. More important, he would get a one-time $60 million grant of stock options, with a twist: He would get the payoff only if he remains CEO for three years. He would get no other stock-based awards in that period…

…he got the whole thing on day one. Hemsley also got the award just as bad news was pounding the share price down to its lowest in nearly five years, meaning he might get “a windfall” for a mere “rebound in the share price.”

Let’s look at the compensation breakdown for one of the other listed CEOs, David Cordani of the Cigna Group. Notice the breakdown and keep in mind that all the listed CEOs show similar breakdowns:

Notice that “Salary” is the smallest or next-to-smallest category. That is standard top executive practice across America. Stock or option awards always make up the largest portion of compensation. In olden times, CEOs were paid salaries like the rest of us. Into the 1970s at the beginning of the neoliberal era, economist Milton Friedman opined that the only obligation of the for-profit corporation should be the highest possible return to shareholders. Michael Jensen, a former Friedman student, proposed that CEOs should be paid in company stock so that they would have an economic incentive to pay attention to increasing their company’s stock value. Mission accomplished! Be careful what you wish for because you might just get it!

Today, on average, about 80% of for-profit CEO compensation is stock or option awards. As the Fortune excerpt above shows, the value will be manipulated by the owner for his or her maximum return. So while the value of Helmsley’s options may say $60 million, that number will be whatever the price is when Helmsley chooses to cash in, and he won’t do so when the number is down.

In 1993, in his first year as President, Bill Clinton got Congress to eliminate corporate tax deductions for salaries that exceeded $1 million. The provision exempted “performance based” compensation such as achieving higher levels of company stock value. This provision helped to accelerate the move away from salaries to stock and option awards.

Notice how little to no difference exists between non-health and health/medical related for profit companies. Health and medical care organizations used to be different, hewing to higher goals than simply achieving Friedman’s maximum returns on equity. Hard to see that in existence anymore…

The 1999 Institute of Medicine report, “To Err Is Human,” captured national attention with its estimate of as many as 98,000 deaths per year of hospitalized patients due to medical errors. In 2004, Massachusetts state government launched the Betsy Lehman Center for Patient Safety to hold all stakeholders accountable. Though many medical sector professionals worked diligently over time to advance the cause of patient safety, the issue lost its salience and largely disappeared from general public view.

In 2023, Dr. David Bates and colleagues from Mass. General Brigham provided an updated analysis of the persistence of “adverse events” in the January 11 New England Journal of Medicine, in an article titled “The Safety of Inpatient Health Care.” Researchers tracked 2809 inpatient admissions in 11 Massachusetts acute care hospitals during 2018. What they found was horrifying. Among the admissions, “we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher.”

Preventable adverse events occurred in 191 (6.8%) of admissions, and 1% had a preventable adverse event with a serious or higher severity level. Adverse drug events were the most common (39% of all events), followed by surgical or other procedural events (30.4%), patient care events (i.e. falls and pressure ulcers (15.0%), and health care associated infections (11.9%). Across the 11 hospitals, adverse events accounted for 15.1 to 47.0 events per 100 admissions. Larger hospitals were found to have higher rates than smaller one.

A parallel 2024 study on “The Safety of Outpatient Health Care,” looking at 3103 patients at 11 Massachusetts outpatient sites, found that 7.0% of patients had at least one adverse event. Adverse drug events, again, were most common (63.8%), health care associated infections at 14.8%, and surgical or procedural events at 14.2%; 17.4% of events were serious, and 2.1% were life threatening.

Barbara Fain, head of the Betsy Lehman Center, reports that each harm event, on average, costs payers (Medicare, Medicaid, private insurers) $12,000, amounting to over $2 billion in excess costs in Massachusetts per year, increasing the average length of stay for injured patients by 6.6 days, and contributing to hospital inpatient overcrowding.

In short, lots of work needs to be done to address this problem. The standard approach among U.S. hospitals to patient injuries involves voluntary reporting. This approach leads to non-reporting of 85% of incidents to authorities according to a 2012 US Inspector General Report. Cost estimates (i.e., $2 billion in Massachusetts) do not include any evaluation of financial impacts on patients and families in terms of care bills and lost wages.

So what’s the good news?

An outfit known as Pascal Metrics has developed an innovative “Automated Adverse Event Monitoring” (AAEM) system that can continuously scan “every patient’s EHR (electronic health record) to detect harm in real time, enabling hospitals to respond and prevent future harm,” according to the Lehman Center. “Early-adopter hospitals in other states are achieving unprece­dented reductions in patient harm — around 25 percent overall, and 60 – 80 percent of certain types of harm.”

Currently, about a dozen US hospitals are using this system, though not disclosing their identities, and only producing aggregate results. In Massachusetts, the Lehman Center has partnered with 35 stakeholder groups, including the Mass. Health & Hospital Association, the Mass. Medical Society, and the Mass. Association of Health Plans, to launch an open and transparent 18-month demonstration of this system at 6-8 Massachusetts acute care hospitals. A rigorous evaluation of the demonstration is part of the plan.

The demonstration will cost about $3.5 million, with funding provided in the 2027 Massachusetts state budget (with benefits estimated at $55 million). Both the House of Representatives and the State Senate have included the $3.5 million in their versions of the FY27 state budget. While nothing is ever certain in budget politics, this is looking positive.

If this happens, Massachusetts will be the first state to embrace this approach, and perhaps establish a national model to address this urgent and neglected concern.

BTW, in 2024, the Biden Administration’s Center for Medicare and Medicaid Services (CMS) established a new “Patient Safety Structural Measure Protocol” mandating hospital reporting of “how well hospitals have implemented strategies and practices to strengthen their systems and culture for safety.” First reports are due by May 15th. While any action on this matter is welcome, the CMS approach suffers from the same problems of existing reporting systems by which hospitals miss 85% of their adverse incidents. The AAEM approach has the potential to put meaningful accountability into the CMS reporting structure.

Personally, I was still a member of the Mass. House of Representative when Betsy Lehman died in 1994 and recall the devastating statewide and national response to it. I was heartened when I read the 1999 report, “To Err Is Human.” And I’ve been mostly disappointed since then. The AAEM approach is the most promising development I’ve seen this front in this century. Let’s hope it works, and kudos to the Betsy Lehman Center, the Mass. Health & Hospital Association, MMS, MAHP, and the other stakeholder organizations. Kudos also to legislative leaders in the Mass. Senate and House for prioritizing this.

I’m going to keep on top of this as it unfolds and plan to report back here. Too much is at stake to ignore this.

(Correction: earlier version listed Dr. David Bates key study as 2003 — that was a typo and the actual date was 2023. My bad!)

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In the 2023-24 US federal elections cycle, independent expenditure groups, many of them dark money super PACs, spent more money than what was spent by all Congressional candidates combined. Sirota reports that that one in five Super PAC dollars came from groups that don’t disclose their donors, totally $2 billion in so-called “independent spending.”

Among the victims of the damage to our nation’s political system, that list must include the US health care system, which has generated more than its share of dark donations and accompanying corruption. The chart below shows health sector contribution levels from individuals, political action committees (PACs), and soft money outside groups, between 1990-2024:

Chart from Open Secrets: https://www.opensecrets.org/industries/indus?ind=H

Believe it or not, change might be coming to confront this despicable reality. It may come as the result of a hugely successful 2024 ballot initiative passed by nearly 75% of voters in the state of Maine to limit permissible contributions to Super Pacs. As expected, conservative groups have challenged the initiative’s constitutionality, and the first major challenge to Citizens United is now in play in federal courts. In July 2025, a federal district court magistrate permanently enjoined Maine from enforcing the law. The case is now pending before the First Circuit Court of Appeals. One way or another, this case is likely to reach the Supreme Court.

While many of us have learned to know and despise “Citizens United,” most of us are unaware that a related legal principal/case is an even bigger part of the problem. Citizens United, famously, struck down limits on Super Pac spending; Justice Anthony Kennedy, a former corporate lobbyist, wrote the 5-4 decision, stating: “Independent expenditures, including those made by corporations, do not give rise to corruption or the appearance of corruption.”

About two months following that 2010 decision, the DC circuit federal court in SpeechNow v. FEC further banned any limits on contributions to Super Pacs as violations to the 1^st Amendment. Sirota notes, “In 2010, the Obama justice department had a chance to challenge SpeechNow when the ruling was handed down…but the Attorney General, Eric Holder, opted against a challenge,” asserting that the case would “affect only a small subset of federally regulated contributions.”

Looking at Citizens United compared with Speech Now, it is obvious that limiting contributions is far more consequential and important than limiting spending. E.G.: if Elon Musk were to be limited in how much he can donate/contribute, that matters a lot more than how his money would be spent. In fact, the Citizens United decision (issued only months prior to Speech Now) upheld the longstanding prior doctrine that contributions can be limited if the possibility of corruption exists.

So 14 years later in 2024, Maine voters overwhelmingly approved their ballot initiative to limit Super Pac contributions. The initiative was designed purposefully by Harvard Law Professor Lawrence Lessig and his allies to bring the Speech Now matter before the US Supreme Court. (Lessig’s nonprofit, Equal Citizens, is an indispensable source of information.) Now they’ve got the case. The 2010 SpeechNow ruling presumed that Super Pacs would be independent from political candidates, meaning that their donations could not be seen as quid pro quo corruption schemes. The vast body of corruption over the past 16 years has turned that justification into a sham.

The name of the case is DTA v. Schneider. It’s not a slam dunk case, and it’s not for nothing and bears close warching. Hurray for the voters of Maine and Larry Lessig — thanks!

As for the health care sector, here are numbers from Open Secrets on soft money political donations from the past several years:

Recent Soft Money Super PAC donations from health sector organizations:

2020 — $87.8 million

2022 — $49.9 million

2024 — $64 million

The health sector/industry is part of this problem. If we want to restore Americans’ trust in our heath system, political reform must be part of the equation.

Rosenthal is a Harvard-trained physician who spent 22 years writing medical journalism for the New York Times, and has worked at KFF Health News since 2016 as editor-in-chief and now as a senior contributing editor. Her 2017 book, “An American Sickness: How Healthcare Became a Big Business and How You Can Take It Back,” is a superb treatment of the profit-driven madness of the US health system.

“I will not go to the emergency room” was her husband Andrej’s mantra. But, “emergency department boarding is in many ways a result of today’s business models and pressures,” she writes. In the Commonwealth Fund’s regular series comparing the US health and medical system with those of 10-12 other advanced nations, the US scores well on only one out of six categories, “quality of care,” usually coming in 2nd best. It is difficult to affirm that conclusion based on Rosenthal’s gripping account.

Might this verdict matter in confronting continuing high levels of mergers and acquisitions in health and medical care spaces? It could be, and in surprising ways.

If you missed the case, here are some pertinent details:

· The Obama Administration green lighted the merger back in 2009. At the time, Ari Emanuel, brother of Obama’s Chief of Staff Rahm Emanuel, sat on Live Nation’s Board of Directors and lobbied the White House to approve the deal.

· In ensuing years, Live Nation became a despised symbol of monopolies running amuck, especially during the 2023 Taylor Swift ticketing fiasco. The trial exposed confidential messages showing Live Nation executives and managers mocking their customers and squeezing every possible dollar from them.

· President Joe Biden’s Dept. of Justice initiated the suit seeking to break up the company. The Trump Administration inherited the suit in January 2025 and seemed poised to press the case forward.

· Just one week into the trial, President Trump agreed to settle after hearing from insider lobbyists Mike Davis and Kelly Anne Conway, plus Ari Emanuel. No forewarning was provided to his federal legal team pressing the case, nor to 40 state attorneys general, nor to the presiding judge. Judge Arun Subramanian expressed disbelief that neither he nor the federal and state legal team had been informed. Right before the trial, Trump fired his DoJ antitrust chief, Gail Slater.

· In a surprise move after the feds’ withdrawal, 34 state AGs (including DC’s) decided to press the case on their own with only days to hire a new chief counsel, Jeffrey L. Kessler, to prepare their case.

· Defendant Live Nation used typical hardball tactics, accusing a state witness of perjury and moving for dismissal. In evidence, messages were unsealed that revealed Live Nation employees bragging about charging excessive fees for upgrades and parking, with one bragging about “robbing the baby blind.” Others bragged of requiring ticket holders with lawn passes to pay to rent chairs and forbidden to bring their own.

· The unanimous jury verdict, which found that Ticketmaster overcharged consumers by $1.72 per ticket, is not the end of the process. A separate trial to assess damages will happen next. And Live Nation appeals are certain.

So what have we learned from this episode?

It was an all-too-rare moment that real citizens, 12 jurors, heard the evidence and produced a dramatic and unanimous verdict. Monopolists and oligopolists are now warned. CEOs may find themselves in the witness chair.

Though the Trump 2 Administration made some pro-antitrust soundings in early 2025, we can now see this as a pose, a bargaining position to extract favors from challenged monopolists. If the Trumpists will cave on a high-profile and watched trial such as this, they’ll cave on anything when the price is right including in the medical care space.

Bully for state attorneys general! They have a constitutional role in antitrust and they seem to have no desire to cave to Trump Administration insider dealmaking.

God bless juries! Though the details can get maddening, real citizens show that they are up to the task, uninfluenced and unbought by corporate and lobbyist donations. Let’s bring more of these to trial.

Hospital and Health System M&A Transactions in Quarter 1, 2018-2026

Meanwhile, mergers and acquisitions in health and medical spaces are regaining momentum, as evidenced by the above-chart from Kaufman Hall showing M&A activity for the 1^st quarter of 2026 compared with the 8 prior years. Kaufman Hall also reports that Q1 activity is a continuation of a steady recovery in M&A activity that began in the second half of 2025.

The message has been out that it’s an auspicious time to merge or consolidate during Trump 2. The message from the Live Nation trial is “not so fast.” For at least the time being, we need to look to state AGs for accountability to uphold the nation’s antitrust laws.