Pluralistic: For-profit healthcare is the problem, not (just) private equity (13 Nov 2025)


Today's links


A black and white photo of an old hospital ward. A bright red river of blood courses between the beds. Dancing in the blood is Monopoly's 'Rich Uncle Pennybags.' He has removed his face to reveal a grinning skull.

For-profit healthcare is the problem, not (just) private equity (permalink)

When are at to the library, you are a patron, not a customer. When you are at school, you're a student, not a customer. When you get health care, you are a patient, not a customer.

Property rights are America's state religion, and so market-oriented language is the holy catechism. But the things we value most highly aren't property, they cannot be bought or sold in markets, and describing them as property grossly devalues them. Think of human beings: murder isn't "theft of life" and kidnapping isn't "theft of children":

https://www.theguardian.com/technology/2008/feb/21/intellectual.property

When we use markets and property relations to organize these non-market matters, horrors abound. Just look at the private equity takeover of American health-care. PE bosses have spent more than a trillion dollars cornering regional markets on various parts of the health system:

https://pluralistic.net/2024/02/28/5000-bats/#charnel-house

The PE playbook is plunder. After PE buys a business, it borrows heavily against it (with the loan going straight into the PE investors' pockets), and then, to service that debt, the new owners cut, and cut, and cut. PE-owned hospitals are literally filled with bats because the owners stiff the exterminators:

https://prospect.org/health/2024-02-27-scenes-from-bat-cave-steward-health-florida/

Needless to say, a hospital that is full of bats has other problems. All of the high-tech medical devices are broken and no one will fix them because the PE bosses have stiffed all the repair companies and contractors. There are blood shortages, saline shortages, PPE shortages. Doctors and nurses go weeks or months without pay. The elevators don't work. Black mold climbs the walls.

When PE rolls up all the dialysis clinics in your neighborhood, the new owners fire all the skilled staff and hire untrained replacements. They dispense with expensive fripperies like sterilizing their needles:

https://www.thebignewsletter.com/p/the-dirty-business-of-clean-blood

When PE rolls up your regional nursing homes, they turn into slaughterhouses. To date, PE-owned nursing homes have stolen at least 160,000 lost life years:

https://pluralistic.net/2021/02/23/acceptable-losses/#disposable-olds

Then there's hospices, the last medical care you will ever receive. Once your doctor declares that you have less than six months or less to live, Medicare will pay a hospice $243-$1,462/day to take care of you as you die. At the top end of that rate, hospices have to satisfy a lot of conditions, but if the hospice is willing to take $243/day, they effectively have no duties to you – they don't even have to continue providing you with your regular medication or painkillers for your final days:

https://prospect.org/health/2023-04-26-born-to-die-hospice-care/

Setting up a hospice is cheap as hell. Pay a $3,000 filing fee, fill in some paperwork (which no one ever checks) and hang out a shingle. Nominally, a doctor has to oversee the operation, but PE-backed hospices save money here by having a single doctor "oversee" dozens of hospices:

https://auditor.ca.gov/reports/2021-123/index.html#pg34A

Once you rope a patient into this system, you can keep billing the government for them up to a total of $32,000, then you have to kick them out. Why would a patient with only six months to live survive to be kicked out? Because PE companies pay bounties to doctors to refer patients who aren't dying to hospices. 51% of patients in the PE-cornered hospices of Van Nuys are "live discharged":

https://pluralistic.net/2023/04/26/death-panels/#what-the-heck-is-going-on-with-CMS

However, once you're admitted to a hospice, Medicare expects you to die – so "live discharged" patients face a thick bureaucratic process to get back into the system so they can start seeing a doctor again.

So all of this is obviously very bad, a stark example of what happens when you mix the most rapacious form of capitalist plunder with the most vulnerable kind of patient. But, as Elle Rothermich writes for LPE Journal, the PE model of hospice is merely a more extreme and visible version of the ghastly outcomes that arise out of all for-profit hospice care:

https://lpeproject.org/blog/hospice-commodification-and-the-limits-of-antitrust/

The problems of PE-owned hospices are not merely a problem of the lack of competition, and applying antitrust to PE rollups of hospices won't stop the carnage, though it would certainly improve things somewhat. While once American hospices were run by nonprofits and charities, that changed in 1983 with the introduction of Medicare's hospice benefit. Today, three quarters of US hospices are private.

It's not just PE-backed hospices; the entire for-profit hospice sector is worse than the nonprofit alternative. For-profit hospices deliver worse care and worse outcomes at higher prices. They are the worst-performing hospices in the country.

This is because (as Rothermich writes) "The actual provision of care—the act of healing or attempting to heal—is broadly understood to be something more than a purely economic transaction." In other words, patients are not customers. In the hierarchy of institutional obligations, "patients" rank higher than customers. To be transformed from a "patient" into a "customer" is to be severely demoted.

Hospice care is a complex, multidisciplinary, highly individualized practice, and pain treatment spans many dimensions: "psychological, social, emotional, and spiritual as well as physical." A cash-for-service model inevitably flattens this into "a standardized list of discrete services that can each be given a monetary value: pain medication, durable medical equipment, skilled nursing visits, access to a chaplain."

As Rothermich writes, while there are benefits to blocking PE rollups and monopolization of hospices, to do so at all tacitly concedes that health care should be treated as a business, that "corporate involvement in care delivery is an inevitable, irreversible development."

Rothermich's point is that health care isn't a commodity, and to treat it as such always worsens care. It dooms patients to choosing between different kinds of horrors, and subjects health care worker to the moral injury of failing their duty to their patients in order to serve them as customers.

Hey look at this (permalink)


A shelf of leatherbound history books with a gilt-stamped series title, 'The World's Famous Events.'

Object permanence (permalink)

#20yrsago New Sony lockware prevents selling or loaning of games https://memex.craphound.com/2005/11/12/new-sony-lockware-prevents-selling-or-loaning-of-games/

#20yrsago Dr Seuss meets Star Trek https://web.archive.org/web/20051126025052/http://www.seuss.org/seuss/seuss.sttng.html

#20yrsago Sony’s other malicious audio CD trojan https://memex.craphound.com/2005/11/12/sonys-other-malicious-audio-cd-trojan/

#15yrsago Will TSA genital grope/full frontal nudity “security” make you fly less? https://web.archive.org/web/20101115011017/https://blogs.reuters.com/ask/2010/11/12/are-new-security-screenings-affecting-your-decision-to-fly/

#15yrsago Make inner-tube laces, turn your shoes into slip-ons https://www.instructables.com/Make-normal-shoes-into-slip-ons-with-inner-tubes/

#15yrsago Tractor sale gone bad ends with man eating own beard https://web.archive.org/web/20101113200759/http://www.msnbc.msn.com/id/40136299

#10yrsago San Francisco Airport security screeners charged with complicity in drug-smuggling https://www.justice.gov/usao-ndca/pr/three-san-francisco-international-airport-security-screeners-charged-fraud-and

#10yrsago Female New Zealand MPs ejected from Parliament for talking about their sexual assault https://www.theguardian.com/world/2015/nov/11/new-zealand-female-mps-mass-walkout-pm-rapists-comment

#10yrsago Councillor who voted to close all public toilets gets a ticket for public urination https://uk.news.yahoo.com/councillor-cut-public-toilets-fined-094432429.html#1snIQOG

#10yrsago Edward Snowden’s operational security advice for normal humans https://theintercept.com/2015/11/12/edward-snowden-explains-how-to-reclaim-your-privacy/

#10yrsago Not (just) the War on Drugs: the difficult, complicated truth about American prisons https://jacobin.com/2015/03/mass-incarceration-war-on-drugs/

#10yrsago Britons’ Internet access bills will soar to pay for Snoopers Charter https://www.theguardian.com/technology/2015/nov/11/broadband-bills-increase-snoopers-charter-investigatory-powers-bill-mps-warned

#10yrsago How big offshoring companies pwned the H-1B process, screwing workers and businesses https://www.nytimes.com/2015/11/11/us/large-companies-game-h-1b-visa-program-leaving-smaller-ones-in-the-cold.html?_r=0

#5yrsago Anti-bear robo-wolves https://pluralistic.net/2020/11/12/thats-what-xi-said/#robo-lobo

#5yrsago Xi on interop and lock-in https://pluralistic.net/2020/11/12/thats-what-xi-said/#with-chinese-characteristics

#5yrsago Constantly Wrong https://pluralistic.net/2020/11/12/thats-what-xi-said/#conspiratorialism

Upcoming appearances (permalink)

A photo of me onstage, giving a speech, pounding the podium.


A screenshot of me at my desk, doing a livecast.

Recent appearances (permalink)


A grid of my books with Will Stahle covers..

Latest books (permalink)


A cardboard book box with the Macmillan logo.

Upcoming books (permalink)

  • "Unauthorized Bread": a middle-grades graphic novel adapted from my novella about refugees, toasters and DRM, FirstSecond, 2026

  • "Enshittification, Why Everything Suddenly Got Worse and What to Do About It" (the graphic novel), Firstsecond, 2026

  • "The Memex Method," Farrar, Straus, Giroux, 2026

  • "The Reverse-Centaur's Guide to AI," a short book about being a better AI critic, Farrar, Straus and Giroux, 2026


Colophon (permalink)

Today's top sources:

Currently writing:

  • "The Reverse Centaur's Guide to AI," a short book for Farrar, Straus and Giroux about being an effective AI critic. FIRST DRAFT COMPLETE AND SUBMITTED.

  • A Little Brother short story about DIY insulin PLANNING

This work – excluding any serialized fiction – is licensed under a Creative Commons Attribution 4.0 license. That means you can use it any way you like, including commercially, provided that you attribute it to me, Cory Doctorow, and include a link to pluralistic.net.

https://creativecommons.org/licenses/by/4.0/

Quotations and images are not included in this license; they are included either under a limitation or exception to copyright, or on the basis of a separate license. Please exercise caution.

How to get Pluralistic:

Blog (no ads, tracking, or data-collection):

Pluralistic.net

Newsletter (no ads, tracking, or data-collection):

https://pluralistic.net/plura-list

Mastodon (no ads, tracking, or data-collection):

https://mamot.fr/@pluralistic

Medium (no ads, paywalled):

https://doctorow.medium.com/

Twitter (mass-scale, unrestricted, third-party surveillance and advertising):

https://twitter.com/doctorow

Tumblr (mass-scale, unrestricted, third-party surveillance and advertising):

https://mostlysignssomeportents.tumblr.com/tagged/pluralistic

"When life gives you SARS, you make sarsaparilla" -Joey "Accordion Guy" DeVilla

READ CAREFULLY: By reading this, you agree, on behalf of your employer, to release me from all obligations and waivers arising from any and all NON-NEGOTIATED agreements, licenses, terms-of-service, shrinkwrap, clickwrap, browsewrap, confidentiality, non-disclosure, non-compete and acceptable use policies ("BOGUS AGREEMENTS") that I have entered into with your employer, its partners, licensors, agents and assigns, in perpetuity, without prejudice to my ongoing rights and privileges. You further represent that you have the authority to release me from any BOGUS AGREEMENTS on behalf of your employer.

ISSN: 3066-764X

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.