October 24, 2025
Dear Interested Readers,
Sharing A Little Common Ground With Some on the Right, and a Few Positive Aspects of the Corporatization of Healthcare, As We Endure the “Shutdown.”
In several editions of this weekly letter during July, August, and September, I reviewed a series of articles on the “corporatization” of healthcare that were published in the “Perspectives section” of The New England Journal of Medicine. A NEJM subscription is not required to access articles in the “Perspective” section. If you are interested in reviewing my comments on those articles, you can click here and have easy access to my letters of July 11, August 15, and September 5, and links to the articles they reference.
Other, more immediate issues intervened since that last article on “corporatization” on September 5, and even though the latest article in the “corporatization” series appeared online on September 27 and was printed in the October 2nd edition of the NEJM, I have not yet returned to the subject. Now, as we anxiously await the resolution of the government shutdown, it seems to me like a good time to catch up on the series. Democrats strongly believe that the shutdown is their most effective tool in their efforts to maintain affordable care for tens of millions of Americans and avoid further damage before the midterm elections of 2026 to block further efforts to implement the plans in Project 2025 that undermine efforts to improve the Social Determinants of Health from the MAGA-enthused Republicans. There is so much uncertainty coming from Trump’s chaotic administration and the uncertainty of which party voters will ultimately hold accountable for the shutdown that I don’t feel like there is much point in trying to look into a very cloudy crystal ball and try to guess whether the move by Democrats to emphasize and defeat the destructive nature to healthcare access of the “One Big Beautiful Bill” and the uncertainties to the market supports of the ACA will be successful.
In the midst of all the darkness and uncertainty surrounding the shutdown, I am encouraged that some Trump loyalists, like Senator Jeff Hawley of Missouri and Congresswoman Marjorie Taylor Greene, are thinking twice about how implementing Trump’s agenda will harm many of their constituents. I should add Senator Rand Paul to the short list of Republicans who have been willing to confront and try to resist the president’s attack on healthcare access. This week, I read in my local paper an analysis presented in a Washington Post opinion piece, “Why Marjorie Taylor Greene is defending Obamacare subsidies,” by Henry Olsen, a senior fellow at the Ethics and Public Policy Center. The Ethics and Public Policy Center is an interesting organization that was founded in 1976. Its mission is stated as:
In pursuit of our mission, we work closely with Americans at all tiers of society, advising policymakers and religious leaders alike, engaging the courts and the education system, and working closely with parents and other culture-makers to apply the truth in daily life. We equip Americans who cherish our founding ideals and our nation’s rich Jewish and Christian heritage to think through the ethical, political, and cultural questions facing them in the twenty-first century, and find the help they need to live those truths out.
The website goes on to declare that its views are “conservative.” Applying religious principles to public issues can often backfire since history tells us that there is as much controversy in religion as there is in politics, as you might realize if you have read John Fugelsang’s book, The Separation of Church and Hate. Reading further on the Ethics and Public Policy Center’s website, we find that their declaration of principles suggests they are interested in supporting disadvantaged populations. I see an “across the aisle” opportunity. If its principles align with both Hebrew and Christian scripture, I applaud its existence, even though I may disagree as we seek to label ourselves. I would describe myself as a reader of the same literature and as having some of the same religious values, but what I have learned from my Christian experience causes me to describe myself as a “progressive liberal” and not a conservative.
Labels often fail to reveal the variations in the life experiences of well-meaning searchers for improvement in the lot of humankind. I take the same scripture that Christian Nationalists might cherry-pick to abuse the LGBTQ community and immigrants, and use it to encourage me to be a defender of diversity, equity, and inclusion. In my reading of scripture, DEI is a three-letter summary of the points Jesus outlined as the right relationship with everyone during his brief life and ministry. The “Sermon on the Mount” in Matthew chapters 5-7 reads to me like an introduction to the principles of DEI. It is encouraging to me that, even as our political leanings may differ in terms of methodology and politics, Mr. Olsen and his conservative colleagues at the Ethics and Public Policy Center may share my vision of desirable outcomes. I have no problem finding common ground with Mr. Olsen, Senators Hawley and Paul, and Congresswoman Greene on the need for affordable, equitable, high-quality healthcare.
If Mr. Olsen’s article underlines how difficult it is to label healthcare issues as conservative or liberal and how outcomes are situational and location dependent, it would be naive to imagine that a subject as broad as “corporatization” of healthcare is all good or all bad. It is probably correct to say that as long as we honor the basic principles of our founding documents, productive disagreements are our greatest national asset. Our country is so broad and diverse that what might be good in one place, like much-needed rain in the West, can produce disastrous floods in the Midwest and Southeast. A new piece of legislation can be a boon to cities while pushing rural communities one step closer to economic failure. International trade might have increased the value of my 401 (k) account while it robbed an Ohio factory worker of a paycheck that supported a middle-class life.
When the New England Journal published the first article on the “Corporatization” of U.S. healthcare in early July, it also published a companion editorial outlining the series’ objectives. The opening paragraphs of the editorial gave notice that “Corporatization” was a big problem. In the first two paragraphs, they wrote:
Whether one is examining health disparities within the United States or between it and other high-income countries, probing U.S. patients’ frustrations with their health care experiences, or exploring the causes of widespread burnout among U.S. physicians and other health care workers, one quickly arrives at allegations against a single (if vast and nebulous) culprit: the corporatization of the U.S. health care system.
Though there is undoubtedly truth to the “no margin, no mission” axiom — without adequate ongoing funding, no health care system is sustainable — the trends toward corporate ownership of health care organizations, market consolidation and concentration, and emphasis on the bottom line are widely seen as primarily benefiting corporate executives and their shareholders. Clinicians are becoming increasingly demoralized and are either seeking viable ways out of a system that they feel treats them as cogs in a wheel or attempting to fight back with collective bargaining. Patients of financial means are following their doctors to concierge practices. And lower-income patients are getting increasingly lost amid ballooning patient panels, the prioritization of checklists and billing over humanistic care, byzantine insurance requirements and administrative burdens, and ever narrower provider networks.
A retired healthcare CEO, Steven Lipstein, wrote the latest article in the “Corporatization” series, “THE CORPORATIZATION OF U.S. HEALTH CARE; Insight into Corporate Governance — What Motivates Hospitals and Delivery Systems.” It is clear from the tone of his first paragraphs that he sees some positive benefits in “corporatization” as long as we remain in our current funding framework. He begins:
Over the course of four decades, I held leadership positions at several prominent academic health systems. Yet until I was asked to write this article, I had not heard the word “corporatization” used to describe what happens in my line of work. I am retired; no doubt things have changed in recent years, and corporatization seems to have become the culprit for everything wrong with U.S. health care.
In part, the concern revolves around big corporations or private investors buying up and aggregating health care assets that previously were independently owned and operated. I was the chief executive officer (CEO) of BJC HealthCare in St. Louis for 18 years. BJC came into being when a dozen or so hospitals joined together, and recently BJC combined with St. Luke’s Health System in Kansas City to create an even larger health care delivery enterprise. This aggregation of clinical assets (28 hospitals, $10 billion in revenue) may be an example of corporatization.
Critics of such large-scale combinations argue that when clinical assets are aggregated within contiguous geographic areas, there is market consolidation. And market consolidation leads to anticompetitive behaviors, resulting in higher prices without concomitant quality improvements, fewer small innovative providers left to disrupt the status quo, and depressed wages for health care workers.
Delivery system leaders view asset aggregation in a different way — as a vehicle for efficient deployment of human, physical, and financial capital to achieve a health care mission. Upsizing by means of mergers and consolidation, hospitals and delivery systems realize benefits that come with economies of scale, spreading fixed operating costs (finance, revenue-cycle management, information technology, human resources administration, legal services, supply chain) over a larger base of patient care revenue. Aggregating hospitals and physician practices within contiguous geographic areas enables systems to make large investments in facilities and technology that serve more people and avoid costly duplication…
From personal experience as a healthcare CEO who had executive responsibility for the care of over 750,000 people living in Eastern Massachusetts with numerous practice locations, thousands of doctors, mid-level providers, nurses, and other health professionals with complex relationships with hospitals, insurers, and medical support services, and revenues of around 2 billion dollars a year, I know that “corporatization” is not a simple subject.
To begin with, whether the corporation is “for-profit” or is a non-profit charity makes a difference. Sister Irene Kraus, CEO of an extensive Catholic hospital system and the first female “Madame Chairman” of the American Hospital Association, is credited by many with promoting the concept “No margin, no mission” as justification for non-profits to become business-savvy. Not as well-known was her “five-point value system.” If you clicked on her name above, which was a link to her 1998 obituary in The New York Times, you would have read:
…at the time of her death, [she] said her proudest achievement was developing a five-point value system for the national chain. The first four, including treating people with respect and serving the impoverished, sounded like familiar religious principles. The fifth, ”Be Creative to Infinity,” sounded exactly like Sister Irene.
While I was a CEO, we did try to be creative. We soon learned that we did not need to be the hospital’s largest source of patients to gain preferential pricing and service. We just needed to be large enough for our business to be their margin. With insurers, we learned we could gain favorable contracts if we served as a hedge, partially protecting them from the pressures of a larger system that dominated our market. Like Mr. Lipstein, we recognized that by expanding, we could spread fixed infrastructure overhead costs over a larger base, thereby reducing “per member per month” administration costs. Executive pay was never an objective. My compensation and that of the management staff were consistently lower than those of many of our physicians, whom we tried to keep close to the “market” for their specialties. Holding my total compensation below that of many of our clinicians meant it was below 10% of “the market” for healthcare CEOs of systems of similar size for the majority of my tenure.
Our objective was the Triple Aim —the effort to provide patient value, not to maximize a shareholder’s return. We recognized that our staff — those who faced the public and those who supported them — were our greatest asset. That idea was not an empty platitude; it was as much an operating principle as “No Margin, no mission.” As a result, and based on the hard work of the original 8,000 recipients of this weekly letter, we always posted a minimal margin, about 2% of revenue, which was reinvested in efforts to continuously improve the service of our mission and do our part to move the world closer to the Triple Aim. During those years, the Atrius Health practices had one of the lowest costs of care in our market while consistently ranking among the highest in quality, patient satisfaction, and employee satisfaction. We ranked in the top ten nationally on many quality metrics.
I hope that you read the whole article. Progress in healthcare toward concepts like universal coverage, lower cost, health equity in a patient-centric environment, and improvement in the work environment of healthcare professionals will require some aspects of “corporatization” as long as we continue to be primarily a fee-for-service, market-driven system that poorly recognizes how the challenges of care delivery vary across different populations, different cultures, and different geographies across this beneficially diverse country. What will work in Boston might not work in the Mississippi Delta or on the plains of Nebraska. What I do believe is a challenge is consistently harmonizing the needs of patients and staff with corporatization of care. I have more confidence in the possibility of that harmony in mission-driven “non-profits” than in for-profit systems that are focused on “shareholder value.”
Having a world where everyone is doing the “right thing” is always hard, and probably impossible. But we can move closer to an equitable world with continuous effort. One of the frequently misused “quotes” from Christ is “For ye have the poor always with you…” found in Matthew 26:11 and also in the gospels of Mark and John. We may always have the poor among us, and their healthcare, as well as the care of the more affluent, may always need improvement. Jesus also described the barriers of wealth to helping the poor in his encounter with “the rich, young ruler,” which is in Matthew 19:16-26. We find that the account ends with Jesus telling his disciples:
It is easier for a camel to go through the eye of a needle, than for a rich man to enter into the kingdom of God.
He followed that pessimistic statement with:
With men this is impossible; but with God all things are possible.
You do not need to be a Christian, religious, or even devoted to your own personal spirituality to recognize the story’s wisdom. You don’t need to believe in Heaven to want a better world now. I have always conceptualized “The kingdom of God” as a reference to the here and now. We do live in the continuum of “eternity.” I don’t think it is heresy to think of healthcare equity and the Triple Aim as part of “the kingdom of God,” or just a better world, and to hope that “all things are possible.” Some things are just more likely in the future than in the moment, but what happens in this moment will position future possibilities.
So, we must accept the great challenge to take on what may seem like an impossible effort to improve healthcare—in this time and in this space. What follows will depend on what we do now. We can make choices now to preserve what we have, even as we must wait a few years to seek and to establish policies that someday may allow us to do better.
We have plenty of examples of “better” from other developed economies. I do believe that if we are doomed to live with “corporatization” in healthcare for the foreseeable future, the shutdown will not be the last challenge for everyone whose life touches the care process — patients, providers, and healthcare administrators and leaders. Oh, and let us not forget that the challenge to create better health for all Americans extends to politicians, their staff, and government employees who articulate and administer government policies and programs.
For me, it has always seemed that the “road to better” is uphill, narrow, and full of potholes and unexpected boulders. Undoubtedly, this government shutdown, which we are enduring, will differentially hurt more poor people than the wealthy, for whom it is a philosophical annoyance. I hope it will be seen in the end as an unavoidable, difficult “leg” of that journey toward better healthcare. I believe its intent is positive. Over the next few weeks, I hope we discover that it accomplishes its objectives and that what was gained was worth the pain.
It’s Fully Fall
Last weekend was lovely. At the end of the week, we had some rain, and then the weather was perfect for the “No Kings” event on our Town Common. My wife and I parked our lawn chairs near the bandstand and enjoyed hearing the speeches and protest songs. There were many hilarious posters and costumes. The crowd included many of my age, and we commiserated with friends about all of Trump’s oppressive moves, but what was most encouraging to me was the number of young families who attended. What was also true was that some anti-protest protesters drove by and hurled insults at those of us seeking to exercise our right to assemble.
Their behavior of our hecklers was far eclipsed by our “dolt-in-chief,” who responded to the more than seven million people who attended the more than 2500 rallies in all fifty states with an obscene AI-generated video clip posted on the Truth Social site of “dear leader,” which shows him wearing a crown while bombing the crowd in Times Square with feces from his low-flying jet fighter. That seems to me to be a new “low” which our Speaker of the House justified as “political satire.” It is certainly evidence that “free speech” still exists at least for some, which should be good news for Stephen Colbert and Jimmy Kimmel.
After “No Kings,” I spent a beautiful Sunday working with help from my neighbor, taking sailboats, rowboats, and kayaks out of the water as we prepared for the dock to be removed for the winter. Today’s header was taken early this week in the foggy aftermath of another much-appreciated gift of rain. I think the fall colors are getting brighter as we move toward November, which is a surprise given that “peak color” is usually around the long holiday weekend that some call Columbus Day and others call Indigenous Peoples’ Day. As you can see below, the ancient and frail Japanese maple in my front yard is just now coming into its annual glory. Every year that it survives, with the help of a talented arborist, is a joy for me.
This weekend in New Hampshire is predicted to be bright and sunny, but cool. The peak temps will be in the mid forties. That is good walking weather, but a little chilly for the bike. I hope that wherever you are, you will be able to avoid stress and get ready for what is coming. These days, we never know what to expect next!
Be well,
Gene
