Mou e, Ch is ophe ; Go sky, Shai
Wo king Pape
"No place o be sick": Coop a ion and con e gence in he
US hospi al ca e sec o
Wo king Pape s on Capi al as Powe , No. 2025/02
P o ided in Coope a ion wi h:
The Bichle & Ni zan A chi es
Sugges ed Ci a ion: Mou e, Ch is ophe ; Go sky, Shai (2025) : "No place o be sick": Coop a ion and
con e gence in he US hospi al ca e sec o , Wo king Pape s on Capi al as Powe , No. 2025/02,
Capi al as Powe - Towa d a New Cosmology o Capi alism, s.l.
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WORKING PAPERS ON
CAPITAL AS POWER
No. 2025/02
‘No Place o Be Sick’
Coop a ion and Con e gence in he US Hospi al Ca e Sec o
Ch is ophe Mou ´
e and Shai Go sky
July 2025
’No Place o Be Sick’: Coop a ion and Con e gence in
he US Hospi al Ca e Sec o
Ch is ophe Mou ´e and Shai Go sky
Abs ac
This pape ies o answe he ques ion: in wha ways does he logic o capi al accumula ion shape
he o ganiza ion o hospi al ca e in he US – a sec o cha ac e ized by a p eponde ance o bo h public
and p i a e ’no - o -p o i ’ ins i u ions? Ra he han aking di e en hospi al owne ship ypes as ou
analy ical s a ing poin , o answe his ques ion, we app oach he dynamics o he sec o as a s uggle
be ween ’capi alized ca e’ and o ganized esis ance o i . Taking inspi a ion om he capi al as powe
poli ical economic app oach, we de ine ’capi alized ca e’ as a sys em o heal h ca e in which ca e is
subo dina ed o he ongoing accumula ion o powe and p o i . We map ou in es iga ion o o ganized
powe on o ou empi ical dimensions, ocusing on he yea s 2011-2021: o ganized esis ance o capi alized
ca e; dis ibu ion o hospi als by owne ship ype; ela i e size and concen a ion o hospi al sys ems; and
ela i e in la ion o p ice ma kups. We ind ha hese dimensions a e closely connec ed, sugges ing ha
he hospi al sec o a la ge is deeply caugh up in he logic o capi al accumula ion. While ma ginal,
o ganized esis ance o capi alized ca e con inues o shape he o he dimensions o he hospi al landscape
– namely, he balance o powe be ween o -p o i (FP) and no - o -p o i (NFP) hospi al sys ems, he
p o i abili y and concen a ion o la ge hospi al sys ems, p ice in la ion and medical deb . No jus FP
hospi als, bu also public and NFP hospi als ha e become igh ly in eg a ed in o an o e all logic o
capi alis accumula ion wi hin he sec o , leading o inc easing consolida ion, p ice in la ion, heal h ca e
inequali y, and pa adoxically, a la ge and g owing public cos o heal hca e.
The heal h ca e sec o in he US is cha ac e ized by a complex en anglemen o go e nmen , no - o -p o i
(NFP) and o -p o i (FP) o ganiza ions. Cu iously, while mos o he aspec s o heal h ca e a e domina ed
by la ge FP i ms (e.g., pha maceu ical p oduc ion), gene al hospi al ca e p o ision is domina ed by NFP
o ganiza ions.1Because o his, he ques ion o he ole(s) o no - o -p o i o ganiza ions in capi alis o ga-
nized heal h ca e is a cen al one o unde s anding he poli ical economic dynamics o he sec o . Acco ding
1In his a icle, we use ’hospi als’ o deno e bo h hospi als and hospi al sys ems, wi h he la ges ’hospi als’ being hospi al
sys ems consolida ed unde a single co po a e en i y.
1
o neoclassical economis s, NFP o ganiza ions should be iewed as an al e na i e o go e nmen se ices,
a ising om he go e nmen ’s inabili y o p o ide sa is ac o y ”collec i e-consump ion goods” (Weisb od,
1975, 181-182). These goods (e.g., heal h ca e) a e assumed o be d i en by ’social’, a he han indi idual
u ili y, and hus p i a e i ms a e deemed ’socially ine icien ’ a p o iding hem.2Consequen ly, ”when he
go e nmen is able o p o ide hese se ices in o ms and amoun s ha o e s wan , li le ole exis s o
nonp o i s” (Weisb od,2000, 3). Howe e , ”when popula ions a e e y di e se, se ices ha sa is y he ma-
jo i y may lea e many people se e ely unde sa is ied [sic]” and NFP o ganiza ions become appealing ”as an
al e na i e mechanism o p o iding public- ype se ices” (3). Due o ’ o e -consume s’ dissa is ac ion wi h
he ’go e nmen ma ke ailu e’ o publicly o ganized se ices, indi iduals seek o p ocu e hese collec i e
goods om he p i a e, no - o -p o i ma ke (Weisb od,1975, 182). Ano he way o pu ing his claim (in
neoclassical e ms) is ha FP i ms a e conce ned wi h ’e iciency’, whe eas go e nmen s and NFP i ms
a e conce ned wi h ’equi y’ (Rosen hal and Newb ande ,1996, 207). Acco ding o his accoun , NFP hos-
pi als a e si ua ed somewhe e be ween hese wo sphe es, ’ illing he gap’ be ween mee ing opposing equi y
and e iciency conce ns. Echoing his logic, he OECD de ines NFP o ganiza ions as a ” hi d sec o ” lying
”be ween s a e and ma ke , ul illing bo h economic and social missions” (OECD,2003, 10).
Se e al issues challenge his heo y in he case o he US hospi al sec o . Fi s , i is incomple e. While
he neoclassical explana ion may explain why NFP o ganiza ions domina e in ce ain sec o s, i does no
explain why he p e alence o NFP o ganiza ions like hospi als di e s om s a e o s a e. In some s a es,
like Delawa e, no - o -p o i hospi als own nea ly 100% o hospi al beds. In o he s, like Alabama, NFPs
own less han 20%, go e nmen o ganiza ions own 50%, and o -p o i hospi als own he es . This accoun
mus he e o e o e a u he explana ion o why o e -consume s o ganize collec i e goods in such di e se
con igu a ions, wi h mos s a es con aining all h ee ypes o o ganiza ion. Second, he e is he ques ion
o whe he he hospi al landscape can be conside ed a ’ma ke ’ a all. Hospi al ca e in he US is s ic ly
egula ed by he ede al go e nmen —which is also o e whelmingly he la ges heal h ca e paye . Hospi al
sys ems ope a ed by s a e and municipal go e nmen s canno be assumed o beha e in he same manne as
p o i -maximizing i ms, u he ’dis o ing’ hei in e ac ions. In addi ion, mos s a es’ hospi al landscapes
a e domina ed by a ew la ge hospi al sys ems, and mos popula ions li e geog aphically close o only a hand-
ul o hospi als (and some a e no close o any), gi ing many hospi als signi ican p icing powe (Gua dado,
2021). As a esul , he hospi al landscape can ha dly be desc ibed as compe i i e in he neoclassical sense o
he e m. Thi d, gi en he ’dis o ing’ e ec s o la ge, concen a ed and go e nmen egula ed ins i u ions,
he assump ion ha heal h ca e o ganiza ions a e shaped by indi idual consume choice is implausible. Indi-
iduals ha e li le powe o a ec he heal h ca e sys em as s and-alone ac o s. I is only h ough collec i e
mobiliza ion and o ganiza ion ha heal h ca e use s can hope o shape he hospi al landscape. Finally, as
2In Weisb od’s example o a collec i e-consump ion good, na ional de ense, he indi idual consump ion good o a handgun
is an in e io subs i u e o he collec i e-consump ion good o he hyd ogen bomb. Consequen ly, indi iduals con ac he
go e nmen o p ocu e nuclea weapons (1975, 180).
2
we show below, he p e alence o go e nmen and FP hospi als a e posi i ely associa ed, complica ing he
concep ual ela ionship be ween public and NFP o ganiza ion and ma ke ailu e. In some cases, la ge NFP
hospi als a e e en mo e p o i able han hei FP coun e pa s—which would indica e ha hey a e mo e
(neoclassically) ’e icien ’ han FPs!
To sum up, he di e si y o owne ship and concen a ion ac oss s a e hospi al landscapes; he lack
o a ’pe ec ly compe i i e’ ma ke ; he implausibili y o heal h ca e consume ’so e eign y’; as well as
empi ical e idence agains he ma ke ailu e hypo hesis, all sugges he need o an al e na i e app oach o
unde s anding he sec o .
Ins ead o explaining he di e si y o owne ship and p o i abili y among US hospi als by e e ence o
consume p e e ences o ma ke dynamics, we p opose o map he US hospi al landscape om he pe spec i e
o o ganized powe . O ganized powe , in his con ex , e e s o he ela i e con ol o compe ing social g oups
o e he p o isioning o and bene i om hospi al-based ca e. By hospi al landscape, we mean he dis ibu ion
o capaci y be ween di e en owne ship ypes, he ela i e sizes o hospi al g oups and he e ms on which
hese o ganiza ions in e ac wi h he unde lying popula ion. F om ou pe spec i e, he ole o di e en
o ganiza ional o ms wi hin he hospi al ca e sec o is an open heo e ical ques ion. We do no s a wi h
he assump ion ha di e en ypes o owne s—go e nmen , NFP and FP—deno e dis inc , opposing, o
e en pe manen ly ixed in e es s and goals. Ra he , we s a om he assump ion ha capi alis socie y is
d i en by he con lic ual s uggle o and agains hie a chical social powe , and ha as such, each o hese
ins i u ions mus be examined in ela ion o he mo e gene al dynamics o capi alis accumula ion, including
his con lic ual s uggle. Ou en a i e hypo hesis is wo- old. Fi s , a he han an ahis o ically de ined
unc ional di ision be ween p i a e and public logics o heal h ca e o ganiza ion, FP, NFP and go e nmen
hospi als a e becoming ”inc easingly in e wined o gans o he same capi alis mode o powe ” (Bichle and
Ni zan,2021). Second, his p ocess is no occu ing equally ac oss US s a es bu is shaped by he exis ence
o o ganized esis ance.
I may seem odd o speak abou o ganized esis ance o capi alized ca e in he US, gi en he ex en o
which he heal h ca e sec o is domina ed by capi alis ideology. Howe e , we a gue ha , while ce ainly
agmen ed, ma ginalized and lacking a isible p esence on a na ional scale, o ganized esis ance o capi alis
con ol o heal h ca e con inues o shape he hospi al landscape. To illus a e his shaping, we measu e he
ela ionship be ween wo quan i a i e measu es, as ough p oxies o he le el o o ganized esis ance a
he s a e le el. These a iables —popula and wo ke -o ganized esis ance o capi alis con ol o heal h
ca e—a e mean only as ough p oxies o a hypo he ical causal mechanism, and we do no mean o sugges
ha hey, and o ganized esis ance mo e gene ally, a e necessa ily he sole o ce de e mining he hospi al
landscape. The absence o s ong democ a ic poli ical ins i u ions in he US sugges s he opposi e: namely
3
ha he o e iding ac o s shaping heal h ca e a e he changing in e es s o dominan capi al and he
di e en ial s uggle o powe be ween ins i u ions, including o -p o i and no - o -p o i hospi al g oups;
doc o ’s associa ions; and municipal, s a e and ede al go e nmen agencies – all o which may con lic o
coo dina e on di e en issues and a di e en imes. Ne e heless, he empi ical e idence shows ha he
ex en o which he hospi al landscape is domina ed by capi alized ca e is closely ela ed o he exis ence
o popula and wo ke -o ganized esis ance. We belie e his in e ac ion be ween powe and esis ance is
especially impo an o un angling he oles o go e nmen and NFP hospi als in he cu en landscape o
hospi al ca e.
We ocus on union densi y as ou i s measu e o o ganized esis ance because o he his o ical sig-
ni icance o he labo mo emen in he expansion o public heal h capaci y and access in he US (Klein,
2014). While he eme gence o la ge scale, p i a e NFP heal hca e ose in pa om a coali ion o physicians
a emp ing o shield hei p o i -making om go e nmen con ol, hese la ge and powe ul physician g oups
we e in u n checked by wo ke -o ganized heal h ca e, du ing a ime when wo ke powe in he US was a o
nea i s 20 h cen u y peak (Hend icks,1991,Klein,2014). To be su e, NFP heal h ca e was in many ways
a comp omise be ween wo ke s and owne s o capi al, as a as US capi alis s ha e success ully p e en ed
he c ea ion o a uni e sal public heal h ca e sys em. Hen y Kaise , o ins ance, sough o coop wo ke -
o ganized heal h ca e plans in he 1930s and 1940s—conduc ing an i-communis pu ges and ma ginalizing
union-backed doc o s—a he same ime as seeking a cheape al e na i e o ee- o -se ice physician ca e
o main aining a ’heal hy’ ( ead: p oduc i e) wo k o ce (Hend icks,1991). Simila ly, al hough he NFP
model, as well as majo expansions in public heal h spending like he Medica e Ac , we e la gely designed
o p omo e he p i a e o ganiza ion o hospi al ca e, hese changes occu ed in esponse o massi e public
p essu e o public heal h ca e (Klein,2014). Based o his his o ical legacy and he ongoing powe o
unions o ma shal poli ical esou ces in suppo o popula demands, we hypo hesize ha he pe sis ence o
o ganized labo in he US con ibu es o he public o ien a ion o he heal h ca e landscape by ac ing as a
limi ing o ce o esis ance o he subjuga ion o ca e in pu sui o p o i .
We chose a s a e’s adop ion da e o he A o dable Ca e Ac ’s (ACA) Medicaid expansion p og am
as a second measu e o o ganized esis ance because he Medicaid expansion ep esen s a widely popula ,
majo edis ibu ion o public esou ces o he poo es and mos ulne able. While he A o dable Ca e Ac
ell sho in many ways, he Medicaid expansion had an unques ionable e ec o inc easing public insu ance
co e age by 13 million and had signi ican inancial e ec s o low-income and younge adul s (Manchikan i
e al.,2017,Hamil on,2024) This expansion o public unding c ea ed a mo e egali a ian dis ibu ion o
esou ces and hus we assume ha i occu ed soone in s a es ha ha e a s onge poli ical esis ance
o capi alized ca e. By con as , we would expec s a es wi h li le o no o ganized poli ical esis ance o
capi alized ca e o ac o p ese e o e en inc ease he ulne abili y o he poo and uninsu ed o p eda ion.
4
In Figu es 1and 2, we use hese wo a iables o so s a es in o high and low esis ance g oups and
hen compa e he dis ibu ion o e enue and numbe o beds by owne ship ype. The compa ison e eals
a signi ican di e ence, wi h high union densi y and ea ly Medicaid expansion ( he da k blue obse a ions)
associa ed wi h a highe p opo ion o NFP beds and e enue and a lowe p opo ion o bo h FP and
go e nmen beds and e enue. Con e sely, s a es wi h lowe union densi y ha delayed o e used he
Medicaid expansion ( he o ange obse a ions) show a signi ican ly highe p opo ion o FP and go e nmen
beds and e enue, wi h a lowe p opo ion o NFP beds and e enue.
Figu e 1: Hospi al Landscape in S a es G ouped by High and Low Union Densi y
P opo ion o numbe o beds and ne pa ien e enue o No - o -P o i (NFP), Fo -P o i (FP) and Go e nmen
(GVT) hospi al sys ems in each s a e. Ho izon al ba s indica e 95% Boo s ap con idence in e als o he mean
p opo ion in s a es wi h union densi y abo e he 40 h pe cen ile and o s a es wi h union densi y below he 40 h
pe cen ile. Da a o he yea 2021, da a o o he yea s can be iewed a h ps://casp-lab.shinyapps.io/no_
place_ o_be_sick/
5
Figu e 2: Hospi al Landscape in S a es G ouped by Ea ly s Delayed Medicaid Expansion
P opo ion o numbe o beds and ne pa ien e enue o No - o -P o i (NFP), Fo -P o i (FP) and Go e nmen
(GVT) hospi al sys ems. Ho izon al ba s indica e 95% Boo s ap con idence in e als o he mean p opo ion
in s a es ha adop ed Medicaid expansion ea ly (in 2014) and o s a es ha did no adop Medicaid expansion
ea ly (adop ed in 2015 o la e , o ne e adop ed). Da a o he yea 2021, da a o o he yea s can be iewed a
h ps://casp-lab.shinyapps.io/no_place_ o_be_sick/
Wha is pa icula ly no able abou his di ide is he ac ha ela i e go e nmen and FP hospi al
p e alence a e posi i ely co ela ed, highligh ing he analy ical di icul y in iewing owne ship dis ibu ion
h ough he lens o neoclassical economics. F om a neoclassical pe spec i e, he p e alence o go e nmen
se ices deno es a ’ma ke ailu e’. Howe e , FP hospi als end o do be e in s a es wi h a la ge go e nmen
hospi al p esence, sugges ing he exis ence o public hospi als is con ibu ing o he ’ma ke success’ o hese
i ms. No only do he FP hospi als ha e a highe p opo ion o beds and e enue, hey also enjoy a highe
p o i abili y in s a es wi h a la ge go e nmen p e alence. In addi ion, highe go e nmen hospi al p e alence
is pa adoxically associa ed wi h low in e es in publicly unded ca e among elec ed o icials, ep esen ed by
he delay o e usal o he Medicaid expansion.
This appa en ambigui y sugges s wo hings. Fi s , a poli ical economic analysis o he hospi al land-
scape should no assume ha di e en owne ship ypes can be analyzed indi idually as ul illing p e-de ined
unc ions (e.g., ixing a ma ke ailu e, exp essing consume choice) o ha ing au onomous in e es s (e.g.,
go e nmen hospi als se e an ’equi y’ unc ion). Ra he , he e seems o be a complex ela ionship be ween
di e en ypes o hospi als ha is no immedia ely sel -e iden . Second, o ganized esis ance o capi alized
ca e clea ly s ill plays a ole in he sec o a he s a e le el, wi h g ea e wo ke o ganiza ion and poli ical
suppo o public heal h unding a o ing NFP hospi als.
6
To explo e mo e ully he ela ionship be ween he hospi al landscape and he dynamics o capi alized
ca e, we also look a how he abo e o ganized esis ance a iables shape he ela i e powe and p o i abili y
o la ge hospi als. To examine his ela ion, we measu e hospi al ma kup and he ’social cos ’ o capi alized
ca e, indica ed by he p e alence o people wi h high medical cos s.
Ma kups a e an impo an measu e o social powe , as highe ma kups deno e g ea e capaci y o
inc ease p ices o e cos s. The e a e many ways o measu e ma kup, each wi h di e en ad an ages and
disad an ages. Fo ins ance, because he accoun ing p ac ices and egula ions di e be ween FP, NFP and
go e nmen i ms, measu es o he p o i ma gins in he hospi al sec o a e no meaning ully compa able.
A mo e app op ia e measu e o ma kup is cha ges as pe cen o cos s (CPC).3The CPC measu es he
ela i e p ice a hospi al cha ges o a gi en p ocedu e o e he Medica e-allowable cos . CPCs a e a mo e
eliable way o compa e ma kup be ween di e en owne ship ypes bo h because hey a e used by all ypes
o hospi als, and because he e a e ewe egula ions a ound how hey a e used (Bai and Ande son,2015, 2).
NFP hospi als, unlike FP hospi als, a e es ic ed in how hey accoun o p o i in o de o main ain hei
ax-exemp cha i able s a us, making con en ional p o i abili y measu es (like p o i ma gin) less meaning ul.
Because he e a e no such es ic ions on CPC, his measu e is mo e di ec ly compa able be ween FP, NFP
and go e nmen hospi als.
The e is some deba e abou he signi icance o his in e nal ma kup measu e. Hospi al CEOs end
o a gue ha hey a e meaningless because mos ins i u ional paye s, whe he go e nmen o p i a e, can
nego ia e lowe p ices in p ac ice (Bai and Ande son,2016, 2). While he ange o ”ac ual” p ices paid
in p ac ice a e unknown, se e al s udies e eal consis en pa e ns in he dis ibu ion o cos o cha ge
di e ences, sugges ing ha hese in e nal ma kups ma e . Fo ins ance, one s udy o hospi als cha ging he
highes ma kups ound ha almos all he hospi als in he sample a e un by he la ges and mos p o i able
FP hospi als sys ems, Communi y Heal h Sys ems and HCA (Bai and Ande son,2015, 3). Indi idual
hospi als in hese hospi al sys ems cha ge as much as 12.6 imes he Medica e-allowable cos s (4). In ano he
s udy he au ho s ound ha ”a one-uni inc ease [in he CPC] was associa ed wi h $64 highe pa ien ca e
e enue pe adjus ed discha ge” (Bai and Ande son,2016, 1). A 2024 s udy ound ha hospi als end o aise
CPCs a e swi ching o FP owne ship, and ha on a e age, FP hospi als ”exhibi [CPCs] app oxima ely
1.61 imes o 161% highe han go e nmen al hospi als and nea ly 0.997 imes o 99.7% highe han non-
p o i (NFP) hospi als” (Beniwal and Shakya,2024, 4). These ex a cha ges, mo eo e , show no ela ion o
pa ien ou comes (Zande e al.,2024).
Following his li e a u e, we use CPC as a measu e o he abili y o hospi als sys ems o in la e p ices
3Cha ges as pe cen o cos s (CPC) is he in e se o he mo e commonly used ’cos o cha ge a io’ (CCR). Highe cha ges
as pe cen o cos s a e equi alen o a lowe cos o cha ge a io. Much o he li e a u e ci ed he e uses he e m ’cos o cha ge’
a io, bu un o una ely i is used a iously o desc ibe bo h CPC and CCR.
7
Figu e 6: Go e nmen Spending on Heal hca e s Di ec Go e nmen P ocu emen o Heal hca e
Domes ic gene al go e nmen heal h expendi u e (% o cu en heal h expendi u e) s p opo ion o go e nmen beds
(US)
Re u ning again o he case o NFP hospi als, he abo e analysis has shown ha hese o ganiza ions
a e a om immune o he logic o accumula ion. Fa om p omo ing a public and uni e sal sys em o
equi able ca e, he NFP sys em has his o ically se ed as a highly o ganized poli ical o ce agains he public
p o ision o hospi al ca e (S e ens,1989). NFP hospi als’ his o ical o igins and con inuing associa ion wi h
o ganized esis ance o capi alized ca e sugges s ha hei exis ence and impo ance es s on a p eca ious
poli ics o comp omise and coop a ion, pa icula ly whe e la ge NFP hospi als wea he man le o public
se ice while p io i izing p i a e in e es s. Ga ney e al no e ha among he di e en o ms o heal h ca e
p o ision, he communi y hospi al is he one a ea o heal h ca e p o isioning ha has emained la gely NFP
(Ga ney e al.,2023, 341). Howe e , he clea and g owing hie a chy wi hin he sec o sugges s ha many o
he bigges NFP hospi als ha e in e nalized he logic and s a egies o FP co po a ions (Mou ´e and Go sky,
2023). The supposed ’dominance’ o p i a e NFP hospi als appea s o es on an inc easingly limsy p e ense
o public-se ice o ien a ion and a subs an i e emula ion o he accumula ion s a egies o capi alized ca e.
In he abo e, we ha e ied o mo e beyond some o he con en ional analy ical dis inc ions o heal h
ca e poli ical economy while unpacking some o he salien ea u es and dynamics o he US hospi al ca e
landscape. Despi e he lack o a powe ul o cohe en na ional mo emen o uni e sal heal h ca e, we ound
ha his o ical and ongoing o ganized esis ance o capi alized ca e con inues o play an impo an , i gene ally
o e looked ole in he s a e con igu a ion o hospi al ca e. The p edominance o NFP communi y hospi als
in he US as he lone excep ion o an o he wise widely FP heal h ca e sys em is a s iking es amen o ha
esis ance, as a e lowe p ices and lowe medical cos s in high esis ance s a es. Howe e , he connec ion
14
be ween esis ance o capi alized ca e and NFP hospi als is only pa o he s o y. The di e si y o NFP
ins i u ions includes many la ge hospi al sys ems whose o ien a ion owa d he accumula ion o powe and
p o i is simila o i no indis inguishable om la ge FP i ms. Go e nmen hospi als also appea o suppo ,
a he han compe e wi h capi alized ca e.
In e ms o u he s udy, we sugges ha poli ical economic s udies o he hospi al sec o should no
ake he dis inc ion be ween ypes o hospi als as unc ionally o analy ically sel -e iden . The in e wined
unc ions and o ien a ions o di e en hospi al ypes, as well as hei his o ically con ingen de elopmen
also calls in o ques ion he analy ical use ulness o he ’public/p i a e’ dis inc ion. Mo eo e , he neoclas-
sical dicho omy be ween FP i ms seeking ’e iciency’ and public and p i a e NFP i ms seeking ’equi y’
inadequa ely explains he dynamic e olu ion o capi alis heal h ca e in he US. Ou concep o ’o ganized
esis ance’ came in pa om his e o o ind a new concep ual ’ou side’ om which o de ine he unc ion
and o ien a ion o ins i u ions whe e he public/p i a e dis inc ion seems o lose much o i s meaning. Unde
mode n capi alism, os ensibly public o ganiza ions ha e been coop ed and eshaped in suppo o , a he
han de ense agains p i a e abuses. As a esul , i is likely ha a new concep ual language is needed bo h
o analyze hese dynamics and as well as o imagine adical al e na i es.
15
Key Findings
•While agmen ed a he na ional le el, o ganized esis ance o capi alis con ol o heal h ca e con inues
o shape he hospi al landscape a he s a e le el.
•In s a es wi h ’high’ esis ance o capi alized ca e (measu ed as highe union densi y and ea ly Medicaid
expansion) NFP o ganiza ions cons i u e a highe p opo ion o hospi al beds and e enue.
•Pa adoxically, in s a es wi h ’low’ esis ance o capi alized ca e (lowe union densi y and e used o
delayed Medicaid expansion) bo h FP and go e nmen hospi als cons i u e a highe p opo ion o beds
and e enue.
•In s a es wi h ’low’ esis ance o capi alized ca e, he e is a highe p e alence o people wi h high
medical cos s.
•In s a es wi h ’low’ esis ance o capi alized ca e, la ge hospi al sys ems ha e a g ea e di e en ial
abili y o aise p ices: low esis ance is associa ed wi h highe ela i e p ice ma kups o he op 5
•Among NFP hospi al sys ems, g ea e co po a e concen a ion is associa ed wi h g ea e di e en ial
ma kups, sugges ing ha despi e hei os ensibly public unc ion, la ge NFP hospi als may emula e,
a he han oppose he logic o capi alized ca e.
•The inc easingly ’la ge-ye -subjuga ed’ ole o public and la ge NFP hospi al sys ems in suppo ing
(o a leas no unde mining) he capi aliza ion o hospi al ca e has impo an heo e ical and me hod-
ological implica ions. Namely, poli ical economic analyses o he US hospi al sec o should no assume
ha exis ing legal dis inc ions be ween owne ship ypes deno e unc ional au onomy. I is mo e ui ul
o look holis ically a how he sec o as a whole has his o ically de eloped and con inues o de elop
ou o he con lic ual p ocesses o capi al accumula ion mo e b oadly.
16
Re e ences
Ge Bai and Ge a d F. Ande son. Ex eme ma kup: The i y us hospi als wi h he highes cha ge- o-cos
a ios. Heal h A ai s, 34(6):922–928, 2015. doi: 10.1377/hl ha .2014.1414. URL h ps://doi.o g/10.
1377/hl ha .2014.1414.
Ge Bai and Ge a d F. Ande son. Us hospi als a e s ill using cha gemas e ma kups o maximize e enues.
Heal h A ai s, 35(9):1658–1664, 2016. doi: 10.1377/hl ha .2016.0093. URL h ps://doi.o g/10.1377/
hl ha .2016.0093.
Suk i i Beniwal and Shishi Shakya. Hospi al owne ship changes and cha ge- o-cos shi s. Economics Le -
e s, 241:111742, 2024. doi: 10.1016/j.econle .2024.111742. URL h ps://doi.o g/10.1016/j.econle .
2024.111742.
Shimshon Bichle and Jona han Ni zan. Dominan capi al and he go e nmen , Oc 2021. URL
h ps://bna chi es.ne /id/ep in /716/2/20211005_bn_dominan _capi al_and_ he_go e nmen _
we b.h m.
B. E ans, T. Richmond, and J. Shields. S uc u ing neolibe al go e nance: The nonp o i sec o , eme ging
new modes o con ol and he ma ke isa ion o se ice deli e y. Policy and Socie y, 24(1):73–97, 2005. doi:
10.1016/S1449-4035(05)70050-3. URL h ps://doi.o g/10.1016/s1449-4035(05)70050-3.
B yan E ans and John Shields. The Thi d Sec o and he P o ision o Public Good: Pa ne ships, Con ac -
ing, and he Neo-Libe al S a e, pages 305–18. Ox o d Uni e si y P ess, 2 edi ion, 2010.
Adam Ga ney, S e ie Woolhandle , and Da id U. Himmels ein. Cen u y-long ends in he inancing and
owne ship o ame ican heal h ca e. The Milbank Qua e ly, 101(2):325–348, 2023.
Jos´e R. Gua dado. Policy esea ch pe spec i es: Compe i ion in hospi al ma ke s, 2013-2021. Tech-
nical epo , Ame ican Medical Associa ion, 2021. URL h ps://www.ama-assn.o g/sys em/ iles/
p p-compe i ion-in-hospi al-ma ke s.pd .
Ch is al Hamil on. The impac o he 2014 medicaid expansion on he heal h, heal h ca e access, and
inancial well-being o low-income young adul s. Heal h Economics, 33(8):1895–1925, Augus 2024. doi:
10.1002/hec.4839. URL h ps://doi.o g/10.1002/hec.4839.
Xuesong Han, Xin Hu, Zhiyuan Zheng, Kewei Syl ia Shi, and K. Robin Yab o . Associa ions o med-
ical deb wi h heal h s a us, p ema u e dea h, and mo ali y in he us. JAMA Ne wo k Open, 7(3):
e2354766–e2354766, 03 2024. doi: 10.1001/jamane wo kopen.2023.54766. URL h ps://doi.o g/10.
1001/jamane wo kopen.2023.54766.
17
Rickey Hend icks. Medical p ac ice emba led: Kaise pe manen e, he ame ican medical associa ion, and
hen y j. kaise on he wes coas , 1945-1955. Paci ic His o ical Re iew, 60(4):439–73, 1991. doi: 10.2307/
3639872. URL h ps://doi.o g/10.2307/3639872.
Da id Himmels ein, Samuel Dickman, Danny Mcco mick, Da id Bo , Adam Ga ney, and S e ie Woolhan-
dle . P e alence and isk ac o s o medical deb and subsequen changes in social de e minan s o heal h
in he us. JAMA Ne wo k Open, 5(9):e2231898, 2022. doi: 10.1001/jamane wo kopen.2022.31898. URL
h ps://doi.o g/10.1001/jamane wo kopen.2022.31898.
Renee Y. Hsia, A hu L. Kelle mann, and Yu-Chu Shen. Fac o s associa ed wi h closu es o eme gency
depa men s in he uni ed s a es, 2011. Calhoun: The NPS Ins i u ional A chi e.
Ca he ine A. Jackson and Amanda Bea y. O ganiza ion and Financing o Indigen Hospi al Ca e in Sou h
Flo ida. RAND Co po a ion, San a Monica, 2004.
Jenni e L. Klein. F om he ai deal o he g ea socie y. In Ox o d Handbook o U.S. Social Policy,
olume 1. Ox o d Uni e si y P ess, 12 2014. doi: 10.1093/ox o dhb/9780199838509.013.029. URL h ps:
//doi.o g/10.1093/ox o dhb/9780199838509.013.029.
L. Manchikan i, I.S. Helm, R.M. Benyamin, and J.A. Hi sch. A c i ical analysis o obamaca e: A o dable
ca e o insu ance o many and co e age o ew? Pain Physician, 20:111–138, 2017.
Kyle J. Moon, Ka he ine E. M. Mille , Sand o Galea, and Ca he ine K. E man. Medical deb and o gone
men al heal h ca e due o cos among adul s. JAMA Heal h Fo um, 6(4):e250383–e250383, 04 2025. doi:
10.1001/jamaheal h o um.2025.0383. URL h ps://doi.o g/10.1001/jamaheal h o um.2025.0383.
Ch is ophe Mou ´e and Shai Go sky. Unheal y p o i s, Dec 2023. URL h ps://www. hemin magazine.
com/unheal hy-p o i s/.
OECD. The non-p o i sec o in a changing economy. Technical epo , ”Local Economic & Employmen
De elopmen (LEED). OECD”, 2003. URL h ps://doi.o g/10.1787/9789264199545-en.
Ge ald Rosen hal and William Newb ande . Public policy and p i a e sec o p o ision o heal h se -
ices. The In e na ional Jou nal o Heal h Planning and Managemen , 11(3):203–16, 1996. doi:
10.1002/(SICI)1099-1751(199607)11:3⟨203::AID-HPM432⟩3.0.CO;2-0. URL h ps://doi.o g/10.1002/
(SICI)1099-1751(199607)11:3<203::AID-HPM432>3.0.CO;2-0.
Rosema y S e ens. In Sickness and in Weal h: Ame ican Hospi als in he Twen ie h Cen u y. Basic Books,
New Yo k, 1989.
Elsa R. T e eisen, Rahela Aziz-Bose, Anisha U. Gundewa , Nou M. Hammad, and Cindy W. Leung. The
associa ion be ween medical deb and ood insecu i y among uni ed s a es amilies wi h child en. The
18
Jou nal o Pedia ics, 283:114631, 8 2025. ISSN 0022-3476. doi: 10.1016/j.jpeds.2025.114631. URL
h ps://doi.o g/10.1016/j.jpeds.2025.114631.
Bu on A. Weisb od. Towa d a Theo y o he Volun a y Non-P o i Sec o in a Th ee-Sec o Economy, page
171–196. Russell Sage Founda ion, New Yo k, 1975.
Bu on A. Weisb od, edi o . To P o i o No o P o i : The Comme cial T ans o ma ion o he Nonp o i
Sec o . Camb idge Uni e si y P ess, Camb idge, 2000.
Tyle Zande , Melissa A. Kendall, Ha oon M. Janjua, Paul C. Kuo, and Emily A. G imsley. Hospi als wi h
dec easing cos - o-cha ge a ios bill g ea e su gical cha ges o simila ou comes. Su ge y, 176(4):1123–
1130, 2024. doi: 10.1016/j.su g.2024.06.018. URL h ps://doi.o g/10.1016/j.su g.2024.06.018.
Da a Appendix
Ou sou ce o da a on hospi als and hospi al sys ems is he Na ional Academy o S a e Heal h Policy’s
(NASHP) Hospi al Cos Tool, downloaded om ool.nashp.o g on May 14, 2024. The da a se co e s
he yea s 2011-2022. Mos o he hospi al le el a iables in his da a se a e d awn om he Cen e s o
Medica e & Medicaid Se ices (CMS) Heal hca e Cos Repo In o ma ion Sys em (HCRIS). Hospi al sys em
iden i ie s in i a e d awn om he Agency o Heal hca e Resea ch and Quali y (AHRQ) compendium o
U.S. Heal h Sys ems da abase.
Union Densi y es ima es by s a e o 1977-2021 we e downloaded om www.unions a s.com on July
29, 2024.
Da a abou Medicaid implemen a ion by s a e was downloaded om KFF’s S a us o S a e Medicaid
Expansion Decisions a www.k .o g on May 30, 2023.
Es ima es on pe cen o people wi h a high medical cos bu den om 2010-2023 we e downloaded om
he S a e Heal h Access Da a Assis ance Cen e (SHADAC) p og am o he School o Public Heal h a he
Uni e si y o Minneso a a s a eheal hcompa e.shadac.o g on Janua y 8, 2025.
Es ima es on domes ic gene al go e nmen heal h expendi u e as pe cen o cu en heal h expendi u e
o he US a e om he Wo ld De elopmen Indica o s o he Wo ld Bank, se ies SH.XPD.GHED.CH.ZS,
downloaded May 21, 2025.
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P ep ocessing
Ou heo e ical ocus in his pape is on hospi al sys ems as business uni s, and on he ” op” hospi al sys ems
in each US s a e. This ocus in ol es se e al challenges: de e mining owne ship ype o a hospi al sys em,
compu ing inancial in o ma ion o hospi al sys ems ha span mul iple s a es in each s a e sepa a ely, and
iden i ying ” op” hospi al sys ems and compu ing measu es ha compa e ” op” hospi al sys ems in a s a e
wi h he es o he hospi al sys ems in ha s a e.
De e mining he hospi al sys em owne ship ype is no a i ial ask: FP en i ies may own NFP sub-
sidia ies and ice e sa. In addi ion, he de ini ion o a hospi al sys em as p o ided by he Compendium
o U.S. Heal h Sys ems coun s hospi als in he same hospi al sys em h ough common owne ship o join
managemen , which allows hospi als o di e en owne ship ypes o be coun ed in a single sys em. Ou
app oach o de e mining he owne ship ype o a hospi al sys em is based on compu ing he p opo ions o
NFP/FP/GVT hospi als in a sys em and classi ying a sys em o one o hese owne ship ypes o he p o-
po ion ha is abo e 70%. I no owne ship ype p opo ion is abo e 70%, we classi y a sys em as ”Hyb id”.
Ano he complica ion is ha when hospi als change owne ship on a da e which is no hei iscal yea end,
hey appea wice (o mo e) in an annual cos epo . To sol e he issue o changes in owne ship mid- iscal
yea we only coun he owne ship ype o a hospi al a e he change o owne ship.
Financial in o ma ion on indi idual hospi als is eadily a ailable om he CMS Cos Repo s. Some
da a on hospi al sys ems a a na ional le el is a ailable om sou ces like he Ame ican Hospi al Associa ion.
Howe e , no in o ma ion is a ailable ega ding he inancial pe o mance o hospi al sys ems ha span
mul iple s a es in each s a e sepa a ely. Fo example, o a gi en hospi al sys em ha owns hospi als in
se e al s a es, we a e in e es ed in being able o de e mine wha is he ne pa ien e enue om hese
hospi als in each o he s a es. To answe his and ela ed ques ions we choose a bo om-up app oach: using
he hospi al sys em iden i ie we g oup oge he hospi als in a s a e (independen hospi als a e conside ed as
a one-hospi al hospi al sys em). We sum all he addi i e a iables (pa ien e enue, ne income, numbe o
hospi al beds e c.) o all hospi als in a s a e ha a e in he same hospi al sys em and conside hese sums
o be he alues o he same a iables o a hospi al sys em in a s a e. Va iables ha a e compu ed as a ios
(cha ges as pe cen o cos s, ma kup e c.) a e hen compu ed as a ios o he espec i e summed a iables.
Va iables ha a e no addi i e o compu ed as a ios o addi i e a iables a e omi ed om ou da a se .
Once we ha e de e mined owne ship ype and compu ed inancial sizes o hospi al sys ems (o po ions
he eo ) in each s a e, we con inue o compu e addi ional di e en ial a iables ha compa e ” op” hospi al
sys ems in a s a e wi h hose ha a e no conside ed ” op.” The e a e se e al ways o concep ualize and
20
compu e such di e en ial a iables. In his manusc ip , we use wo such measu es.
Fo he i s , used in Figu es 3and 4, we compa e he mean alue o a a iable o he g oup o he op
5% hospi al sys ems in a s a e anked by ne income ega dless o hei owne ship ype o he mean alue
o all o he hospi al sys ems in a s a e.
Fo he second, used o he end analysis and in Figu e 5, we compa e he mean alue o a a iable
o he g oup o he op 10% NFP hospi al sys ems in a s a e anked by ne income o he mean alue o all
o he hospi al sys ems in a s a e ega dless o hei owne ship ype.
21
