The Path Forward: Day 7:
A 7-Day Exposé, A $906 Million Lobby, and A Once-in-15-Years Chance to Fight Back
The Week in Review
For six days, I’ve shown you how American healthcare was captured.
Here’s what we exposed:
Day 1: The 50-State Map
We classified all 50 states plus DC into four categories: Captured, Contested, Competitive, and Reform.
The finding: 44 out of 51 markets are controlled or contested by nonprofit hospital systems.
Competition is the exception, not the rule.
Average premiums in Captured states: $701/month.
Average premiums in Competitive states: $580/month.
When nonprofits control the market, prices rise. Every time. To put it in perspective, this increase means that in states where nonprofits dominate, a family might end up paying an extra $1,452 per year in premiums.
Day 2: The 25 Most Powerful Nonprofit Health Systems
We named the players.
Combined revenue: $527 billion.
Tax exemptions: $37 billion annually.
Federal income tax paid: $0.
These systems, dubbed “The Untaxed Titans,” evade federal taxes entirely while commanding vast revenues. They symbolize a monumental challenge in reforming healthcare finance.
Six of the top ten are religiously affiliated — Catholic and Adventist systems built through decades of aggressive consolidation.
The geographic monopolies are the business model:
UPMC controls ~70% of Pittsburgh
Mass General Brigham controls ~65% of Boston
Intermountain controls ~65% of Utah
When you control the market, you set the price.
Day 3: The Politicians Who Protect the Monopolies
We published the Senate Healthcare Scorecard.
70 senators represent CON states.
Three questions for every politician:
Do you support site-neutral payments?
Do you support CON law repeal?
Do you support lifting the ban on physician-owned hospitals?
Most won’t answer. Their silence tells you everything.
The healthcare industry spent over $1 billion lobbying Congress to keep the system exactly as it is. This expenditure equates to the potential funding for 17 million primary-care visits that were never realized. By visualizing lobbying dollars as foregone services, the scale of financial influence becomes clearer and more troubling.
Day 4: The Law That Ate American Healthcare
We told the origin story of Certificate of Need.
1974: Ted Kennedy federalized CON laws. Any state without one would lose federal health funding.
1987: Congress repealed the federal mandate after the evidence showed CON laws didn’t control costs — they protected monopolies.
What happened? Most states kept their CON laws anyway. Because by then, the hospitals wanted them.
Today: 35 states still have CON laws. Minnesota hasn’t allowed a new hospital without legislative approval since 1984. Forty years. 35 exceptions. Each one required a lobbyist.
The Triple Moat:
CON laws block competition
Facility fees guarantee higher payment
340B provides subsidized drug profits
Stack all three, and you have the most protected business in America.
Day 5: The $150+ Billion Systematic Advantage
We followed the money.
The 11 Pillars of Systematic Advantage:
Annual Value
- 340B Drug Pricing: $54B
- Nonprofit Tax Exemption$37.4B
- Supplemental Medicaid (UPL/DSH) $30+ B
- GME Funding $30+ B
Quantified Total
$150 B+
Plus the non-quantified moats: tax-free bonds, site-neutral violations (145% payment differential), the POH ban, vertical integration into health plans, and regulatory capture.
Independent physicians are not failing because of the market.
They’re failing because they pay full taxes, buy drugs at full price, get lower reimbursement, can’t access tax-free financing, and can’t open new hospitals.
The game is rigged by policy.
Day 6: Academic Medical Centers
We exposed the apex predators.
AMCs charge 47% more than community hospitals for the same procedures. Not because outcomes are always better. Because they can, the brand is the moat.
Medicare pays $16+ billion for Graduate Medical Education. Residency slots have been capped since 1997. AMCs control the supply of doctors. The shortage is a feature, not a bug.
The names:
Cleveland Clinic: $15.9B revenue. Nonprofit.
Mayo Clinic: $19.8B revenue. Nonprofit.
UPMC: Controls 70% of Pittsburgh, CEO makes $11M+. Nonprofit.
For most conditions, AMCs don’t deliver better outcomes than community hospitals. The prestige justifies the pricing. The data often doesn’t.
The Lobbying Battlefield: 23-to-1
Now let me show you why nothing changes.
We analyzed federal lobbying expenditures from 2010 through Q3 2025 for the key organizations in this fight.
The finding: For every $1 spent by physician-owned hospital advocates, the hospital and insurance lobby has spent $23
CoalitionTotal (2010-2025)Annual Average
Anti-POH Coalition
$906.6 Million
$56.7M/year
Pro-POH Coalition
$39 Million
$2.6M/year
The players:
The AHA alone has spent $371 million since 2010 to protect the ban it lobbied to create.
This is not a legislative debate. It’s a financial war of attrition where one side is out-resourced by a factor of more than 23 to 1.
BREAKING: The First Real Shot in 15 Years
This Tuesday, House Republican leadership unveiled its end-of-year healthcare package.
For the first time since the Affordable Care Act’s passage in 2010, physician-owned hospitals are included in a congressional package.
The package includes at least a partial reversal of the ban that has blocked patients from accessing physician-led hospitals for 15 years.
This is not a drill.
The Hospital Lobby Is Already Mobilizing
Make no mistake: opponents of physician-led hospitals are already pounding the halls of Congress.
They have $906 million in cumulative lobbying power.
They have captured regulators.
They have senators on speed dial.
They will fight this with everything they have.
Because they know what’s at stake: if physicians can compete, the hospital monopoly model collapses.
The Evidence Is Clear
Physician-led hospitals consistently deliver:
Exceptional quality
Lower costs
Higher patient satisfaction
Multiple studies found that POHs outperformed hospital peers without physician ownership in these categories.
As Dr. Carlos J. Cardenas, President of Physician-Led Healthcare for America, said this week:
“Allowing POHs to compete immediately in our nation’s communities would give patients more choices, drive down costs, and raise the bar on quality. Increased competition is also a powerful tool to counter today’s growing consolidation crisis and restore balance to America’s healthcare system.”
He added: “Opponents of POHs have had 15 years since the Affordable Care Act’s handcuffs were placed on POHs to increase more options, higher-quality care, and lower costs. Instead, we have witnessed the opposite unfold. We stand unified against hospital monopolies and are steadfast in our resolve that when physicians can compete, patients win.”
The former President of Physician Led Healthcare for America had this to say about Physician Owned Hospitals.
What You Need to Do NOW
If Congress does not hear from its constituents on physician-led hospitals, it will be easy for them to drop us from the final package.
Two Critical Action Items:
1. Contact Your Members of Congress
Call the Washington office and ask for the healthcare legislative assistant.
What to say:
Thank your member of Congress for including physician-led hospitals in the legislative package
Tell them why POHs are important for their constituents and community
Ask them to ensure POH provisions remain in the final package
This is the only effective way of communication. They must hear directly from you.
2. Amplify the Message on Social Media
Congress does pay attention to your posts on X, LinkedIn, and other platforms.
Share why physician-owned hospitals matter:
They’re key to making healthcare more affordable
They’re a ready-made solution for underserved patients in rural America
They’re a free market driver to combat consolidation
The hospital lobby has $906 million. We have voices. Use yours.
The Path Forward
The path forward is competition. Transparency. Physician independence. Patient choice.
For six days, I showed you how the system was captured:
The map
The players
The enablers
The laws
The money
The apex predators
Today, Congress has a bill in front of them that could start to reverse it.
The hospital lobby will fight with its $906 million.
We have to fight with the truth.
Contact Congress. Amplify the message. Don’t let this moment pass.
When physicians can compete, patients win.
This concludes the 7-day series on the structure of American healthcare.
Tomorrow (Saturday, paywall): The Physician Playbook — practical strategies for building outside the system. Direct contracting. Coalitions. ASCs. DPC. Taking risk.
This Sunday 5:30 PM: The Five Families
You know the names.
United. CVS. Elevance. Cigna. Centene.
The five for-profit giants that control American healthcare. The ones everyone loves to hate.
But here’s what most people don’t understand:
They didn’t build this system. They inherited it.
Sunday at 5:30 PM, I’m releasing The Five Families — the definitive breakdown of the for-profit villains, how they captured the system, and why they’re only half the story.
Because once you understand the Five Families, you’ll be ready for what comes next:
The Five Dynasties — the nonprofit architects who built the castle that the Five Families now occupy.
Same denials. Same prior auths. Same moats. Different tax status.
Sunday. 5:30 PM Central.
If this work resonated with you — if you want journalism that exposes the hospital lobby and fights for physician independence — become a paid subscriber. Your support funds the work they don’t want published.
Dutch Rojas is a healthcare entrepreneur, board member of Physician-Led Healthcare for America, and the publisher of The Rojas Report. He is the author of a new book, "Too Big To Care: How Nonprofit Health Systems Hijacked Healthcare.” Coming soon to bookstores near you.
References
Lobbying Data:
OpenSecrets.org, retrieved December 12, 2025
American Hospital Association: $371,113,817 (2010-2025 Q3)
American Medical Association: $333,020,785 (2010-2025 Q3)
America’s Health Insurance Plans: $163,330,000 (2010-2025 Q3)
Federation of American Hospitals: $39,145,000 (2010-2025 Q3)
Physician-Led Healthcare for America: $2,550,000 (2010-2025 Q3)
POH News:
PHA Action Alert, December 10, 2025
House Republican Conference End-of-Year Healthcare Package, December 2025
We wrote a Substack Note to publicize the call to action re: POHs: https://tinyurl.com/mtzyvvhe
We included the following information, since we didn't know exactly which House bill was being discussed. Grok helped us find this bill.
H.R.4002 - Patient Access to Higher Quality Health Care Act of 2025: https://www.congress.gov/bill/119th-congress/house-bill/4002
This repeals ACA restrictions on physician-owned hospitals.
SEC. 2. Repeal of health care reform provisions limiting Medicare exception to the prohibition on certain physician referrals for hospitals.
Sections 6001 and 10601 of the Patient Protection and Affordable Care Act (Public Law 111–148; 124 Stat. 684, 1005) and section 1106 of the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152; 124 Stat. 1049) are repealed and the provisions of law amended by such sections are restored as if such sections had never been enacted.