Authors: Alexandra Allen, MSPPM, Britt Sanderson, MS, MPH

Executive Summary

The financialization of the U.S. health care sector has fundamentally reshaped the way care is delivered and paid for, worsening medical debt and deepening imbalances. Building on systemic barriers that creates racially stratified health insurance products^[1],[2] and suppresses the political and economic power of people in neighborhoods inhabited by majority low income people of color,^[3] these  financial strategies incentivize health care systems to prioritize privately-insured patients over publicly-insured patients to increase revenue and improve bond ratings for capital projects and mergers and acquisitions, as well as closing unprofitable hospitals primarily serving communities of color.

Consolidation and market concentration then enable hospitals and health systems to negotiate higher prices, which insurers pass on to patients through increased premiums, deductibles, and out-of-pocket costs. These burdens fall disproportionately on people of color and other groups who are disenfranchised, including low-income families, individuals with disabilities, and LG B communities, who are more likely to lack the financial resources to absorb rising costs.

State-level survey data and case studies reveal that medical debt is widespread, persistent, and closely linked to structural racism, insurance design based on employment and class of labor, and aggressive billing practices at the heart of a system driven by profit, disproportionately affecting black and brown communities. In response, states are advancing policy reforms and communities are engaging in grassroots advocacy to strengthen oversight, limit private equity’s influence, regulate artificial intelligence in billing, and expand Medicaid, offering a potential blueprint for achieving affordability and transparency in health care.

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Overview

Introduction

The financialization of the health care sector involves the transformation of health care into tradable assets from which investors may extract capital. Researchers have argued that financialization represents a fundamental shift in the organizing principles of health care systems, with negative implications for health and health justness.^[4],[5] Following regulatory changes in the 1970s and 1980s, hospitals began adopting financial strategies to maximize profit for shareholders and other financial actors with a vested interest in hospitals’ economic performance. Among these are consolidation and private equity management, both of which are associated with increased prices charged to patients and medical debt.^{[6],[7],[8], [9]}

Private equity refers to an investment strategy in which large amounts of capital are leveraged to purchase, restructure, and ultimately sell companies for profit.  Although financialization has impacted both the for-profit and non-profit sector, this brief focuses on for-profit and private equity owned and managed hospitals and other health care entities, as well as consolidation and closure of hospitals, for profit and non-profit alike, as a financialized tactic that is backed by major financial actors.

The relationship between financialization and medical debt is complex but is reinforced in the pursuit of market dominance through consolidation. Evidence shows that increased hospital market concentration harms consumers and generally raises prices as hospitals with fewer competitors leverage market power to negotiate higher prices from insurers. These higher prices can then be passed on to patients, increasing the chance that people either incur medical debt due to challenges paying higher bills or forgo care altogether, potentially leading to worse health outcomes and even higher medical debt in the future.

Although medical debt declined across most US counties between 2012 and 2022 due to the passage of the Affordable Care Act and Medicaid expansion, research into the relationship between consolidation and medical debt has found that counties where larger increases in hospital market concentration has occurred experience smaller declines in the share of residents with medical debt. ^[10],[11] In these ways, the growing influence of financial institutions and for-profit partnerships in health care further embeds medical debt as both a cause and a consequence of unbalanced health outcomes.

Medical Debt’s Impact on Disenfranchised Groups

Medical debt is a persistent burden, disproportionately affecting Black, Hispanic/Latino, Native American, low-income, disabled, elderly, and LG B individuals. Health insurance design, gaps in coverage, and economic inequality combine to expose these groups to higher rates of medical debt. Additionally, groups who are disenfranchised often lack the financial resources to absorb rising health care costs, leading to difficult choices such as foregoing care, depleting savings, or sacrificing basic needs like food and housing. The consequences are far-reaching, and illustrate that medical debt undermines financial wellbeing and contributes to poorer health outcomes, increased stress, and long-term hardship. These patterns reinforce existing disparities and make it harder for vulnerable populations to achieve and maintain well-being.

Findings from Case Studies

Case studies and survey data from Altarum’s Consumer Healthcare Experience State Survey reveal the widespread and persistent nature of medical debt across the United States. In several states, as many as half of respondents reported experiencing financial hardship due to medical bills. Families described depleting savings, borrowing money, and going without basic needs like food, heat, or housing to pay for care. The research also highlights how hospital mergers and insurance design further restrict access and affordability, forcing many to delay or avoid necessary medical treatment and resulting in long-term debt. These findings underscore the deep and lasting impact of medical debt on household stability and health equity, with marginalized communities facing the greatest risks.

Community Advocacy and Policy Interventions

States are taking action to address medical debt and health care financialization through a combination of policy reforms and response to pressure from grassroots advocacy. Regulatory measures include stronger oversight of health care mergers, limits on private equity ownership, Medicaid expansion to protect low-income residents, and new laws governing the use of artificial intelligence in billing and claims management. These policies aim to safeguard patients from rising costs, surprise billing, and aggressive debt collection. At the same time, community groups, labor organizations, and local leaders have mobilized to challenge hospital closures, mergers, and reductions in essential services. Their efforts have helped preserve safety-net hospitals and maintain access to care for groups who are disenfranchised furthest from opportunity. Together, these strategies reflect a growing commitment to transparency and patient-centered care.

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Financialization, Structural Barriers, and Medical Debt

The increasing role of financial strategies in health care has helped create a system where economic decisions play a significant role in decision-making, impacting affordability and contributing to rising patient costs and medical debt in some communities. The financialization of for-profit and private equity-owned entities in the health care sector involves the transformation of health care into tradeable assets from which investors in the financial sector may extract capital.^[12] Under this model, the function of health care organizations is to extract profit and transfer it to shareholders and investors, rather than reinvesting it in patient care or community health initiatives. Researchers have argued that financialization represents a fundamental shift in the organizing principles of health care systems with negative implications for health and parity.^{[13],[14],[15]}

Starting in the 1970s and 1980s, hospitals began adopting financial strategies to maximize profit for shareholders in response to changes in corporate governance and federal regulation. Changes included reduced government reimbursement for Medicare services, which encourage hospitals to look elsewhere for revenue; increased use of stock option pay for executives, reorienting decision-making around boosting share price; and antitrust deregulation, encouraging consolidation.^[16],[17]

As a result of these changes, many hospitals have pursued mergers and acquisitions in part to increase efficiencies of scale, but also to increase market power and leverage higher reimbursement rates from private insurers.^[18],[19] At the same time, private equity and other financial instruments became increasingly exempted from federal oversight, and shifts in the broader economy resulted in large pools of readily available funds that investors began directing to the health care sector. These changes resulted in a rapid increase in consolidation and private equity investments in the health care sector with a goal of maximizing returns.

Financialization’s Impact on Disenfranchised Groups

Financial strategies in health care can reinforce structural barriers by allocating resources in ways that devalue members of racial and ethnic minority groups, resulting in unfair access to high-quality health care.^[20] U.S. financial systems are historically rooted in extracting capital from Black, Indigenous and other People of Color in ways that reproduce health disparities.^[21] This pattern continues in modern financial markets, which incentivize health care entities to prioritize white patients over patients of color in various ways.

Building on racially stratified health insurance product design,^[22] health care providers seeking to increase revenue and improve hospital credit scores by attracting more privately insured patients, who are disproportionately white. Pricing dynamics may also be reoriented in ways that channel funding away from hospitals with more Medicaid patients, who tend to be disproportionately non-white.^[23] In addition, S&P and other bond rating organizations assign credit scores to hospitals that determine whether they can sell tax-exempt bonds to finance capital projects and mergers and acquisitions and what interest rate they will pay. Payer mix and demographic and income composition of the community where the hospital is located are among factors taken into consideration.^[24],[25]  In short, racial bias fundamentally influences how money flows within the health care system.

Illustrating this are several high-profile examples of hospital systems acquiring facilities that serve large low-income and Black or Hispanic populations and then closing them as part of a broader financial strategy.^[26] Steward Health, a private equity owned system, is one such example. The system sought investments from private equity firm Cerberus to fund major capital investments, with the firm gaining nearly full ownership of the system. Cerberus then used debt to fund the purchase, which it then transferred to Steward Health.

To cover the debt, Steward Health closed eight hospitals between 2014 and 2024, disproportionately affecting low-income, Black, and Hispanic communities. Hospitals under its management also suffered from chronic staffing shortages, lack of medical supplies, and neglected infrastructure, which directly contributed to patient deaths and declining health outcomes in these communities.^[27] This case illustrates how private equity firms and hospital administrators treating health care services and facilities as a tradeable assets to be bought and sold for financial gain, rather than community assets intended to improve patient care and outcomes, directly harms groups who are disenfranchised. 

Financialization similarly affects other groups who are disenfranchised, such as people with disabilities. Private equity-backed firms have increasingly acquired intellectual and developmental disability service providers due to their high profit margins and recession resistance. They then engaged in cost-cutting tactics like reducing services and failing to maintain facilities, leading to lower quality of care and unsafe living conditions for patients and facility residents.^[28]

Consolidation and Private Equity’s Relationship with Medical Debt

Consolidation is associated with increased prices charged to patients and, subsequently, increased prevalence of medical debt.^{[29],[30],[31]} Consolidation leads to higher market concentration, which can increase the burden of medical debt on communities. Although medical debt declined across most US counties between 2012 and 2022, in part due to the passage of the Affordable Care Act and Medicaid expansion, counties with larger increases in hospital market concentration experienced smaller declines in the share of residents with medical debt.^[32],[33]

Additionally, highly consolidated hospital systems often use their market dominance to negotiate higher payments from insurers, who then shift these costs to employers and patients in the form of higher premiums, deductibles and cost-sharing obligations.^{[34],[35],[36],[37]}Employers are then left to balance these increased costs by lowering wages and providing less generous benefits for their workers, leaving workers with fewer resources to pay increasingly high out-of-pocket costs.^[38],[39]

Similarly, private equity management in health care also contributes to higher financial obligations for patients.^[40] In recent years, PE firms have become increasingly involved in transactions involving hospitals, physician practices, behavioral health and long-term care facilities.^[41] In many cases these firms utilize acquisition models and business practices, such as closing unprofitable hospitals and rapidly acquiring (“rolling up”) private practices, that raise prices, increase market concentration, and contribute to increased costs for patients.^{[42],[43],[44],[45],[46],[47],[48],[49],[50]} Patients treated at hospitals managed by private equity firms are often charged higher prices relative to those found at other hospitals.^{[51],[52],[53]} While all for profit organizations try to maximize revenue, publicly-held companies generally have a long-term time horizon. In contrast, private equity-owned entities generally have a short-term outlook focused on rapidly increasing valuation for resale. In the health care system, this manifests with PE companies rapidly purchasing health care entities, stripping them of assets, and saddling them with institutional debt to fund the purchases.

There is further evidence of negative impacts of PE acquisitions on the prevalence of patient medical debt. Over the years, PE firms have acquired a large share of national staffing companies and medical transport services, enabling them to negotiate steep out-of-network rates with hospitals that outsource emergency department staffing.^[54] These charges are often passed on to patients as surprise medical bills. The passage of the No Surprise Act alleviated some of the negative impacts on patient financial security; however, ground ambulance services remain a concern as these services were exempted from federal law.

PE firms have also become heavily involved in the revenue cycle management (RCM) sector, which govern how health care facilities handle billing, collections, and financial operations. Over the past decade, PE firms have acquired several of the largest and fastest-growing RCM companies in the United States, including Athenahealth, FinThrive, NextGen, AGS Health, and R1 RCM.^[55] There is some evidence that RCM companies backed by private equity more frequently utilize aggressive billing and collections practices compared to hospitals themselves.^[56] The integration of artificial intelligence (AI) into RCM systems raises further concerns. Within a financialized health care system that incentivizes shifting costs to individuals, AI not only automates billing and claims management, but can automate denials, mask errors, accelerate collection, and reinforce existing biases at the expense of quality, access and affordability.^[57] These strategies can lead people into medical debt, particularly already vulnerable patients.^[58]

Medical Debt’s Impact on Disenfranchised Groups

The financialization of health care, including extractive consolidation and aggressive medical debt collection practices, exacerbates the prevalence of medical debt in groups who are disenfranchised.^[59] Medical debt affects two in five American adults, but it is not evenly distributed across the population.^[60],[61] The “typical” American with medical debt is a middle-aged, white, working-class woman in the South with health insurance. This reflects the overall demographics of the country: 60% of the United States is white^[62], half is middle class,^[63] and nearly one in five adults with health insurance have high out-of-pocket costs that make it difficult to afford care.^[64]

However, other groups that make up a smaller share of the population are at greater risk of incurring medical debt.^[65] Black, Hispanic/Latino, and Native American people, uninsured individuals, low-income households, the elderly, people with disabilities, and people in poor health are disproportionately impacted by medical debt.^{[66],[67],[68],[69]} This exposure to medical debt can be linked to embedded racial bias and other forms of inequality. For example, evidence shows that residential segregation of Black Americans is associated with increased risk of chronic illness and other adverse health outcomes, placing them at higher risk of incurring substantial medical expenses. At the same time, embedded racial bias in housing, credit, and employment opportunities reduce the economic resources available to communities of color, making it more difficult to manage medical bills.^[70],[71]

Medical debt directly impairs health and access to care outcomes as well as financial security. It is associated with worse physical and mental health, more premature deaths, and higher mortality rates,^[72] and people with medical debt more frequently report foregoing medical care due to cost concerns.^[73] They also more frequently experience food insecurity, difficulty paying rent or utility bills, and being subjected to eviction or foreclosure.^[74],[75] Low-income people are also at a disproportionate risk of being subjected to other stressful encounters related to medical debt . For example, third-party firms hired to collect outstanding medical debt often engage in aggressive collection strategies, including suing low-income patients and violating debt collection laws.^[76] These issues highlight the far-reaching negative impacts high medical bills and medical debt have on health access and outcomes across the lifespan.

Case Studies: Medical Debt, Consolidation, and Health Care Related Financial Burdens

State-level surveys show that medical debt and the corresponding financial burdens are prevalent across the United States.^[77] Among states surveyed by the Altarum Healthcare Value Hub, between 26% and 50% of respondents reported incurring medical debt, depleting savings, and/or sacrificing basic needs like food, heat or housing due to medical bills (see Figure 1). In addition, 18% to 35% of respondents reported that they or a household member had outstanding medical bills (see Figure 2).

Many respondents also indicated that medical costs have led to additional financial hardship, such as being contacted by a collection agency; depleting savings; having to borrow money, get a loan, or remortgage their home; incurring large amounts of medical debt; going without basic needs like food, heat, or housing; and being placed on a long-term payment plan (see Table 1). These figures suggest medical costs and outstanding medical bills may contribute to ongoing financial challenges including housing instability, food insecurity, and accruing more debt through loans and credit, which can increase both financial and health-related risks. These same challenges are often caused/exacerbated by systemic barriers and other forms of system-wide marginalization.

Four surveys conducted in 2025 illustrate some of the impact of medical debt and its prevalence across different communities in these states. The size of these debts varied among respondents. Among those with outstanding medical bills, the most commonly reported amounts were less than $500 (21% to 67%) and $1,000 – $2,499 (9% to 29%), Still, 2% to 4% of respondents reported owing over $10,000 in medical debt.

Differences in Prevalence and Reasons for Medical Debt

Medical debt is in part a product of a for-profit health insurance system that covers only part of the cost of coverage and/or denies claims to save money. Hospitals and other health care providers operating under a financialized business model then direct those charges to patients who cannot afford the bills, thus accruing debt. Medical debt affects people across demographic characteristics, however, outstanding medical bills were generally more prevalent among respondents with Medicaid and employer-based or individually purchased insurance, low and middle incomes, or a disabled household member, as well as respondents of color, women, and LG B respondents (see Table 2).

Coverage Type

Although medical debt tends to be more common among uninsured people, in part because they are responsible for the full cost of care, unaffordable medical bills and high cost-sharing also pushes insured patients into debt.^{[78],[79] [80]} To receive care, Americans with private coverage must often meet high deductibles, pay rising premium costs, and cover high copayments, and even with coverage, an unexpected illness or emergency can quickly generate bills that are unaffordable.^{[81],[82],[83],[84]}

Meanwhile, Medicaid is supposed to protect against medical debt by offering low or no cost-sharing for core services, but coverage for many services such as dental care is voluntary and varies by state, exposing enrollees to high out-of-pocket costs and potential debt. In addition, enrollees face a lack of providers who will accept their insurance, again leaving patients few choices but to pay out-of-pocket for care. Similarly, Medicare enrollees have access to robust networks, but it generally pays only 80% of health care costs; it lacks coverage for crucial services like dental, vision, and hearing, forcing enrollees to either pay out-of-pocket or pay increasingly expensive premiums and cost-sharing for Medicare Advantage plans for these gap services.^{[85],[86],[87],[88]} Notably, insurance design reinforced a hierarchy of access to quality care based on income, employment, and type of labor, with low-wage industries where people of color are overrepresented choosing not to provide insurance for workers, who then face unaffordable private coverage or underfunded public coverage with the above limitations.^[89]

Results from surveys conducted in 2025 illustrate that medical debt affected insured people across insurance types due to lack of coverage and/or unaffordable cost-sharing (see Figure 3). Some reported incurring medical debt because their insurance did not cover the service, which has been captured in other research on the role of coverage denials.^[90] Still, respondents across insurance types more frequently reported that high cost-sharing was the cause of their medical debt.

Income

Race and Ethnicity

The American health care system has evolved within political, economic, and social structures built on unfair policies that have restricted access to affordable care, comprehensive health insurance coverage, financial resources, and consumer protections for people of color. Echoes of Jim Crow era policies are still apparent in wage disparities between white, Black, and Hispanic Americans, while current debates over Medicaid eligibility and benefits are often accompanied by unsubstantiated claims that immigrants are misusing the social safety net.^[91]

Acknowledging the racial bias embedded in both the historical and contemporary political environments in which our health care system has evolved, survey results reveal clear disparities in the prevalence and amount of medical debt. Across survey states, 18% to 43% of respondents of color reported outstanding medical bills compared to 10% to 38% of white, non-Hispanic respondents (see Table 2). The available literature supports these findings, illustrating that across the country Black and Hispanic consumers are burdened by medical debt at a higher rate than white, Non-Hispanic consumers.^[92],[93]

Disability

The reasons behind this disparity are well-documented. People with disabilities often need more frequent, intensive, and specialized care, yet they face persistent structural obstacles that limit their ability to afford it.^[94] For instance, they often struggle with finding and maintaining stable employment, which reduces their income and results in higher poverty levels.^[95],[96] They are also more likely to experience limitations on wealth-building, such as lower rates of homeownership and restrictions on income and assets tied to benefit eligibility.^[97] All of these factors increase their exposure to medical debt.

Sex and Gender

Survey data show that medical debt is slightly more common among women than men, with 16% to 45% of women reporting outstanding bills compared to 17% to 31% of men (see Table 2). A variety of factors may contribute to these disparities; for example, women are more likely to earn lower wages, shoulder unpaid caregiving responsibilities, and face higher out-of-pocket costs for reproductive and preventive care. ^[98] In addition, the complex genetic, hormonal, and social factors that contribute to women’s higher rates of depression and anxiety also shape health needs, outcomes, and costs.^[99] Additionally, system-wide imbalances in care, such as “medical gaslighting,” lead to women’s symptoms being more often dismissed early on, leading to delayed diagnoses, poorer outcomes, and higher costs.^[100]

Likewise, members of the LG B community also report a higher burden of medical debt compared to other patients: Among the states surveyed. Between 25% and 41% of LG B respondents reported outstanding medical bills, compared to 16% to 29% of respondents not identifying as a part of the LG B community (see Table 2). These disparities may stem from the unique challenges this community faces accessing health care as a result of lower coverage rates, as well as high costs and legislative obstacles to transition-related medical services exacerbating financial strain and health disparities.^[101],[102] Members of the LG B community are also more likely to report being diagnosed with a chronic condition, behavioral health concerns, and disability, all of which increase health care costs.^[103],[104]

Policy and Advocacy Approaches to Financialization

Medicaid expansion is perhaps the most straightforward example. To date, 41 states and the District of Columbia have expanded Medicaid eligibility to cover more low-income residents, which remains one of the most effective tools for preventing medical debt. Compared to the states that did not expand Medicaid in 2014, the states that opted in to expansion when it became available saw a 34% greater reduction in average annual medical debt in the preceding years through 2020.^[107] By increasing access to comprehensive coverage, Medicaid expansion shields low-income individuals from catastrophic out-of-pocket costs and helps limit debt accumulation.

In an effort to minimize the amount of private equity transactions in health care, other states have begun to implement laws granting state regulators additional oversight over corporate and private equity proceedings. For example, Oregon law grants state regulators the authority to approve, set conditions for, or block health care transactions, including prohibiting management service organizations from financing takeovers of medical entities.^[108],[109]

Other states have instituted formal review criteria to ensure that proposed consolidation transactions are fair and will not harm the community the hospital serves. For example, oversight entities in California and Vermont include affordability criteria when reviewing proposed mergers and acquisitions, ensuring that regulators consider whether deals will increase costs or restrict access to services.^{[110],[111],[112],[113]} Similarly, Massachusetts and Oregon include cost growth benchmarks in their review criteria when determining whether to approve or deny a proposed health care transaction.^[114]

Some states have also introduced legislation to limit or ban private equity from operating in health care. Indiana, for example, passed a law granting the attorney general the authority to approve or reject healthcare transactions involving private equity partnerships regardless of the total assets included in the proposed transaction. ^[115] In 2025, Connecticut lawmakers considered several bills that would have restricted or prohibited private equity ownership of health care facilities, though these measures did not ultimately pass.^[116],[117]  Alternatively, states may also consider strengthening laws that restrict corporations and other non-medical entities from practicing medicine or employing providers (“Corporate Practice of Medicine” laws).^[118] In New York, for example, for-profit companies are prohibited from operating hospitals, and California law prohibits corporations from practicing or facilitating the practice of medicine.^[119]

While consolidation oversight and regulatory efforts can be beneficial in less concentrated markets, these policies prove insufficient in many regions where a few dominant systems already exert significant market power. Unfortunately, consolidation is already widespread; by 2016, nearly 90% of Metropolitan Statistical Areas were considered highly concentrated in terms of hospital markets.^[120] In these cases, states may consider legislation restricting anti-competitive contracting practices.

Common anti-competitive contracting practices include all-or-nothing clauses, most favored nation clauses, anti-tiering, and anti-steering provisions, all of which disadvantage consumers and smaller providers. States including Nevada and Massachusetts have banned all-or-nothing clauses in either all, or some, situations.^{[121],[122],[123]} Arkansas, Michigan, and Kentucky have restricted most favored nation agreements.^{[124],[125],[126]} Connecticut, Massachusetts, and Nevada have acted to prohibit anti-tiering and anti-steering clauses, making it harder for dominant players to steer patients to costlier care or suppress competition.^[127],[128]

Finally, some states have also made legislative efforts to curb the flow of health care dollars to corporate shareholders. Between 2001 and 2022, 92 health care companies listed on the S&P 500 distributed $2.6 trillion in shareholder payouts, an increase of 315% over the twenty-year period reviewed in the study.^[129] In 2024, federal lawmakers introduced a bill that would hold private equity and investment firms accountable if their management decisions led to patient harm by empowering the Department of Justice and state attorney generals to recover executive compensation from the acquiring entities and affiliated health care organizations for a 20-year period surrounding such events. However, this legislation did not advance.^[130]

As financialization rapidly alters the operation of health care, several states have also begun to address the rise of artificial intelligence (AI) in billing and claims management.^[131] AI has the potential to automate claim denials, obscure errors, accelerate aggressive collection practices, and reinforce biases.^[132] Recognizing these risks, California passed the “Physicians Make Decisions Act” (SB 1120) in 2024, which prohibits coverage denials based solely on AI.^[133] Similarly, Nebraska passed LB 77 in 2025, which bans claims denials based on AI-decisions and mandates the disclosure of AI use in utilization review.^[134] Arizona, Connecticut, and Texas also passed bills during their 2025 sessions to regulate AI in clinical decision-making, granting them the ability to proactively address the possibility that AI will increase the prevalence of medical debt.^{[135],[136],[137]}

Community groups also play an active role in challenging hospital decisions that reduce access to services. In Illinois, community members, labor groups, hospital staff, and local organizations rallied against the proposed closure of Chicago-area Bronzeville Hospital. These advocates pressured decision-makers, demanding representation on the hospital’s governing board and insisting on accountability from the new management. Their mobilization helped facilitate a deal in which Mercy Hospital was sold for $1 to the non-profit Insight Chicago, with terms that preserve its safety-net functions. According to supporters, this outcome illustrates the effectiveness of sustained community advocacy in maintaining access to health care in under-resourced areas.^[138]

Advocates have also rallied to save not-for-profit health facilities from financialized business tactics. When the Beth Israel Deaconess and Lahey Health hospital systems merged to create Beath Israel Health, the system chose to close the North Shore Birth Center.^[139] This decision sparked significant opposition from residents who valued the center as a less medicalized, lower-cost birthing option.^[140] In response to community concerns, the hospital pledged to enhance natural birthing services, construct a birthing tub, lease the closed facility to an independent midwife, and invest in new freestanding birth centers. However, a 2023 review found that most of these commitments, including the promised tub and replacement facilities, had not materialized.^[141] This absence calls to mind existing challenges in enforcing promises made during the Certificate of Need (CON) process^.[142]

Although most birthing women in the region still have reasonable access to care, the closure likely reduced options for those wanting to give birth in a birthing center rather than a hospital.^[143] However, this example still reflects how community advocacy has become an essential force in preserving access to care and holding health systems accountable. Through a combination of legislative reforms, regulatory oversight, and grassroots efforts, states and communities are demonstrating that it is possible to push back against some of the effects of private equity-backed financialization. By prioritizing affordability, transparency, and patient well-being, these strategies offer a pathway to a health care system that serves everyone.

Conclusion

As health care entities increasingly prioritize profit through financial strategies and private equity ownership, operation, or investment, patients across the United States, particularly people of color and those who are low-income, individuals with disabilities, and members of the LG B community, face mounting medical debt and diminished access to affordable care. The evidence presented in this report illustrates how financial motives are rooted in extractive economic systems and amplify existing disparities, leaving at-risk populations disproportionately burdened and exacerbating health disparities that undermine overall well-being.

Addressing the potential harm of health care financialization requires a multifaceted policy approach. States have begun to respond by strengthening regulatory oversight of mergers and acquisitions, setting affordability benchmarks, restricting anti-competitive contracting practices, and expanding Medicaid eligibility to protect low-income residents from catastrophic costs. Innovative legislation targeting the use of artificial intelligence in billing and claims management, as well as efforts to limit private equity’s influence, demonstrate a growing commitment to patient-centered reform. Community advocacy also plays a powerful role in holding health systems accountable, helping to ensure that local voices drive decisions that affect access and affordability.

Together, these strategies offer a blueprint for rebalancing the health care system-prioritizing affordability and transparency over short-term financial gain and restoring the core mission of health care: to serve and improve the lives of all patients. Only through coordinated policy action and sustained community engagement can we address the root causes of medical debt and build a health care system that meets the needs of every individual.

Appendix

Survey Methodology

Altarum’s Consumer Healthcare Experience State Survey (CHESS) is designed to elicit respondents’ views on a wide range of health system issues, including confidence using the health system, financial burden, and possible policy solutions.Information about Dynata’s recruitment and compensation methods can be found here. The survey was conducted in English and Spanish and restricted to adults ages 18 and older. Respondents who finished the survey in less than half the median time were excluded from the final sample.

Percentages in the body of the brief are based on weighted values, while the data presented in the demographic table is unweighted. An explanation of weighted versus unweighted variables is available here. Altarum does not conduct statistical calculations on the significance of differences between groups in findings. Therefore, determinations that one group experienced a significantly different affordability burden than another should not be inferred. Rather, comparisons are for conversational purposes. The groups selected for this brief were selected by advocate partners in each state based on organizational/advocacy priorities. We do not report any estimates under N=100 and a co-efficient of variance more than 0.30.

For detailed demographic tables of the surveys included in this brief, please visit the Healthcare Value Hub’s website: https://healthcarevaluehub.org/consumer-healthcare-experience-state-survey/

Surveys Referenced

Supplemental Figures

References

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[2] Yearby, R., Clark, B., & Figueroa, J. F. (2022). Structural racism in historical and modern US health care policy. Health Affairs, 41(2), 187–194. https://doi.org/10.1377/hlthaff.2021.01466

[3] Lioz, A. (2015, July 23). Stacked Deck: How the Racial Bias in Our Big Money Political System Undermines Our Democracy and Our Economy. Demos. https://www.demos.org/research/stacked-deck-how-racial-bias-our-big-money-political-system-undermines-our-democracy-and

^[4] Hunter, B. M., & Murray, S. F. (2019). Deconstructing the Financialization of Healthcare. Development and Change, 50 (5), 1131–1483. https://doi.org/10.1111/dech.12517

^[5] Friel, Sharon et al. Financialisation: a 21st century commercial determinant of health equity, The Lancet Public Health, Volume 9, Issue 9, e705 – e708. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(24)00187-7/fulltext

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^[7] Furukawa, M. F., Kimmey, L., Jones, D. J., Machta, R. M., Guo, J., & Rich, E. C. (2020). Consolidation Of Providers Into Health Systems Increased Substantially, 2016–18. Health Affairs, 39 (8), 1321–1325. https://doi.org/10.1377/hlthaff.2020.00017

^[8] Fuse Brown, E. C. (2023). Health Care Consolidation: Background, Consequences, and Policy Levers.

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^[9] Appelbaum, E. (2022, February 1). Private Equity in Healthcare: Profits before Patients and Workers. https://cepr.net/publications/private-equity-in-healthcare-profits-before-patients-and-workers/

[10] Kluender R, Mahoney N, Wong F, Yin W. Medical Debt in the US, 2009-2020. JAMA. 2021 Jul 20;326(3):250-256. doi: 10.1001/jama.2021.8694. PMID: 34283184; PMCID: PMC8293024.

^[11] Johnson, N., Wekulom, A., Blavin, F., Braga, B. (2024). Is Hospital Market Concentration Related to Medical Debt. The Urban Institute. https://www.urban.org/urban-wire/hospital-market-concentration-related-medical-debt

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[129] Kreier, F. (2025, February 10). Health Care Company Payouts Favor Shareholders, New Research Shows. Yale School of Medicine. https://medicine.yale.edu/news-article/health-care-company-payouts-favor-shareholders-new-research-shows/

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