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Medical Capture by Nonprofit Hospitals — The 50-State Nonprofit Healthcare Map: Where Hospitals Dominate and Where Physicians Still Compete. By Dutch Rojas (12/04/25) Last update 12/05/25
America doesn’t have a healthcare system.
It has fifty, and nearly all of them are built around the same structural flaw: dominant nonprofit health systems controlling local markets, setting prices, and squeezing independent physicians out of existence. Once you step back and look at the country as a whole, the pattern becomes impossible to ignore. — Dutch Rojas
We offer a summary of this situation followed by our take.
Summary (Grok ai, edited; images from article)
U.S. healthcare markets across 50 states and Washington, D.C., fall into four categories
Captured
Contested
Competitive
Reform
These categories are based on:
Dominance by nonprofit hospital systems.
Data on premiums.
Ambulatory surgery centers (ASCs).
Certificate of need (CON) laws.
Market control.
NATIONAL SNAPSHOT After classifying all 50 states and Washington, D.C., Rojas research identified:
22 Captured States
22 Contested States
6 Competitive States
1 Reform State
44 out of 51 markets are controlled or partially controlled by hospital systems.
PREMIUMS FOLLOW POWER
Premiums rise 20–40% when nonprofits control the market.
Premiums fall when physicians compete.
Premiums drop fastest in reform states.
ASC PENETRATION: THE TRUE MEASURE OF COMPETITION Competitive states have seven times more ASCs than Captured states. ASCs provide choice, transparency, lower prices, physician autonomy, reduced facility fees, and competition.
CON STATUS: THE SCAR TISSUE OF AMERICAN HEALTHCARE 35 jurisdictions have CON laws. 16 states do not. Captured states are CON states. Competitive states are not.
NCSL: Certificate of Need State Laws (includes map, shown in images below): ncsl.org/health/certifi…
ECONOMIC REALITY: WHAT CONSOLIDATION ACTUALLY DOES
When a market becomes captured:
Prices rise due to dominant system charging.
Physicians lose leverage with one employer.
Employers and families pay more, with premiums tracking market power.
BOTTOM LINE
America is 44-for-51 captured or partially captured.
Premiums are highest where nonprofit systems control the market.
Competition thrives where ASCs and independent physicians are strong.
CON laws correlate with monopoly pricing and declining physician autonomy.
Healthcare was engineered this way.
Our Take
Non-profit hospitals can stifle competition, increase costs, and lower the quality of medical care. States must encourage competition and should not offer tax breaks to non-profit hospitals, which enable this captured system.
Major non-profit hospital systems in Idaho:
St. Luke’s Hospital (embarking on a huge expansion in downtown Boise): Website: stlukesonline.org/en | Expansion project: tinyurl.com/yxxws53n
St. Alphonsus (aka St. Al’s): saintalphonsus.org
Independent Doctors of Idaho listed facilities: idid.independentdocsid.…
Related:
🆕 25 Most Powerful Nonprofit Health Systems in America. $527 billion in revenue. $125 billion in tax exemptions. Zero accountability. Dutch Rojas (12/05/25): tinyurl.com/5s597h4n
Resources > Independent Medical Resources: tinyurl.com/bdfbcrbp
