Medical Capture by Nonprofit Health Systems — 25 Most Powerful Nonprofit Health Systems in America. $527 billion in revenue. $125 billion in tax exemptions. Zero accountability. Dutch Rojas (12/05/25)

dutchrojas.substack.com…

Dutch Rojas explains the bottom line:

1. 25 nonprofit systems control $527 billion in annual healthcare revenue

2. Six of the top ten are church-affiliated systems built through aggressive merger

3. They receive $125+ billion annually in structural advantages independent physicians cannot access

4. Geographic monopolies are the business model—50%+ market share in their core regions

5. Insurance integration is accelerating—Kaiser, UPMC, and others control both premium and provider revenue

6. Executive compensation rivals Fortune 500 companies—while charity care obligations go unenforced

Summary (Grok ai, edited; images from article)

The top 25 nonprofit health systems in America generate over $527 billion in annual revenue and receive $125 billion in tax exemptions, operating as tax-exempt entities without direct state funding.

These systems, many religiously affiliated, have consolidated through mergers. They dominate local markets, integrate insurance, and leverage academic prestige, while acquiring physician practices and benefiting from structural advantages unavailable to independent physicians.

TOP 25 BY REVENUE (extracted from article’s first image below)

1. Kaiser Permanente

2. CommonSpirit Health

3. Advocate Health

4. Providence St. Joseph

5. UPMC

6. Ascension

7. Trinity Health

8. Mass General Brigham

9. AdventHealth

10. Cleveland Clinic

11. Northwell Health

12. Banner Health

13. Sutter Health

14. NewYork-Presbyterian

15. Intermountain Health

16. Mayo Clinic

17. BJC HealthCare

18. Yale New Haven Health

19. Ochsner Health

20. Atrium Health

21. Duke Health

22. Johns Hopkins

23. Froedtert ThedaCare

24. Spectrum Health (Corewell)

25. Sanford Health

📌 ED NOTE

10 largest health systems in Idaho, by revenue (per Grok)

1. St. Luke's Health System - $4.1 billion

2. Saint Alphonsus Health System - $2.1 billion

3. Kootenai Health - $944 million

4. HCA Healthcare (Idaho operations) - $489 million

5. Portneuf Health (Ardent) - $390 million

6. Mountain View Hospital - $382 million

7. St. Joseph Regional Medical Center - $168 million

8. Bingham Memorial Hospital - $165 million

9. Northwest Specialty Hospital - $120 million

10. Treasure Valley Hospital - $115 million

PATTERNS

1. Church Systems Built Empires Through Merger

Six of the top ten are religiously affiliated (only 5 listed, perhaps because CommonSpirit was formed from merger of Dignity Health and Catholic Health Initiatives):

• CommonSpirit (Catholic) with 19,009 beds

• Providence (Catholic) with 10,282 beds

• Ascension (Catholic) with 11,975 beds

• Trinity (Catholic) with 10,903 beds

• AdventHealth (Seventh-day Adventist) with 9,564 beds.

These systems merged aggressively, forming monopolies across states, controlling nearly 100,000 beds, and acquiring independent physician practices.

2. They Don’t Receive or Need State Funding

Private nonprofit hospitals receive no direct state funding. They benefit from:

• $37 billion in tax exemptions

• $35 billion in 340B drug discounts

• $30 billion in Graduate Medical Education funding

• $10 billion in Disproportionate Share Hospital payments

• $5 billion in supplemental payments

• $5 billion in tax-exempt bond savings

• $3 billion in charitable contributions Total: $125+ billion annually in structural advantages that independent physicians cannot access.

3. Geographic Monopolies Are the Business Model

These systems dominate locally with 50%+ market share in 44 out of 51 U.S. healthcare markets, dictating prices without competition.

4. Insurance Integration Is the Endgame

Systems including Kaiser, UPMC, Geisinger, Intermountain, Sentara, and Spectrum integrate as both providers and payers, controlling premiums, care, and authorizations.

5. Academic Medical Centers Are the Prestige Play

Academic systems include:

• UPMC (University of Pittsburgh Medical Center)

• Mass General Brigham

• Cleveland Clinic

• NewYork-Presbyterian

• Mayo Clinic

• BJC HealthCare/Washington University

• Yale New Haven

• Duke Health

• Johns Hopkins.

They receive over $30 billion in Graduate Medical Education funding and justify premium pricing.

TAX EXEMPTIONS

Nonprofit hospitals received $37.4 billion in tax benefits in 2021, including federal and state income tax exemptions, local property tax exemptions, sales tax exemptions, and tax-exempt bond financing. Many spend less on charity care than the value of exemptions.

ED NOTE
St. Luke’s Health System in Boise, Idaho, is the largest health system in Idaho. It was founded in 1902 by the Episcopal Diocese of Idaho (per Grok).

We asked ChatGPT about St. Luke’s Health System statistics. The answers are complicated due to differences in reporting of charitable activities and tax breaks. 

ChatGPT conversation link: chatgpt.com/share/69344…

Lots of numbers from our AI friend! We aren't numbers people but perhaps this will be useful to those who are.

PHYSICIAN IMPACT PLAYBOOK

• Acquire physician practices

• Convert doctors to employees

• Add facility fees

• Restrict referrals

• Eliminate competition

These activities results in states being dominated by: independent physician rates under 20%, low ambulatory surgery center counts, and high premiums.

THE EXECUTIVES

CEO compensation:

• Lloyd Dean (CommonSpirit) at $35.5 million

• Rod Hochman (Providence) at $10.5 million

• Joseph Impicciche (Ascension) at $13.6 million

• Kevin Lofton (CommonSpirit) at $11.3 million

• Candice Saunders (Wellstar) at $6.4 million

Average primary care physician earns $260,000; CEOs earn 50-70x that.

Related:

• 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): tinyurl.com/y6knrzvx

• Resources > Independent Medical Resources: tinyurl.com/bdfbcrbp