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Illustration: Lazaro Gamio/Axios

Not-for-profit hospital systems increasingly operate more like corporate titans on the stock exchanges than the charities they promote themselves to be.

The big picture: As hospital systems have gotten larger, they have hosted more investor calls, released more financial data and attended more conferences and roadshows to attract banks and municipal debt buyers — all while health care spending continues to soar.

Where things stand: Almost 60% of community hospitals are private and nonprofit, and therefore don't pay income or property taxes. But hospitals are more on par with pharmaceutical giants and insurance companies than soup kitchens.

  • Most hospitals are part of larger systems after years of frenetic merger and acquisition activity.
  • Kaiser Permanente ranks just behind Johnson & Johnson in revenue — which would make it one of the 50 largest corporations in the country.
  • More than two dozen private, not-for-profit hospital systems would sit in the Fortune 500 rankings.

The intrigue: Hospitals that want to erect new buildings or buy new technology issue debt in municipal bond markets instead of the public markets. And more hospital systems "increasingly are trying to sell themselves to investors as they expand and become more complex to ensure they get the best rates when they borrow," the Wall Street Journal reported in 2016.

  • The 2008 financial meltdown led to more regulations for banks and investment firms in the municipal markets. As a result, those groups have been pushing for more disclosure and transparency from hospitals, said Eb LeMaster, a managing director at health care financial advisory firm Ponder & Co.
  • Hundreds of hospitals, ranging from small $100 million facilities to $20 billion behemoths, now regularly post financial documents and other data on municipal bond sites.

Yes, but: While transparency has increased, it's still not perfect.

  • CommonSpirit Health, the new hospital system that merged Catholic Health Initiatives and Dignity Health, held an investor day in Chicago this week — an event normally conducted by companies trading on the public markets.
  • The investor day comes roughly a month before CommonSpirit executives will tour London, New York, Boston, Chicago and Los Angeles to gin up interest in a $6 billion bond offering. That offering will include tax-exempt bonds, which the public subsidizes.
  • However, media were excluded from attending the investor day. A CommonSpirit spokesperson justified the policy by saying "it was important ... to provide information directly to those who have purchased the health system's bonds."

The bottom line: "Not-for-profit" does not mean "no profit."

  • Hospitals are swimming in cash, which has attracted investors to them. But hospitals' financial pursuits have raised concerns about whether they are continuing to chase revenue and inflate health care costs at the expense of patients.

Go deeper: How banks and law firms make millions from hospital debt

Go deeper

2 hours ago - Health

Boris Johnson announces month-long COVID-19 lockdown in England

Prime Minsiter Boris Johnson. Photo: NurPhoto / Getty Images

A new national lockdown will be imposed in England, Prime Minister Boris Johnson announced Saturday, as the number of COVID-19 cases in the country topped 1 million.

Details: Starting Thursday, people in England must stay at home, and bars and restaurants will close, except for takeout and deliveries. All non-essential retail will also be shuttered. Different households will be banned from mixing indoors. International travel, unless for business purposes, will be banned. The new measures will last through at least December 2.

Updated 2 hours ago - Politics & Policy

The massive early vote

Illustration: Sarah Grillo/Axios

Early voting in the 2020 election across the U.S. on Saturday had already reached 65.5% of 2016's total turnout, according to state data compiled by the U.S. Elections Project.

Why it matters: The coronavirus pandemic and its resultant social-distancing measures prompted a massive uptick in both mail-in ballots and early voting nationwide, setting up an unprecedented and potentially tumultuous count in the hours and days after the polls close on Nov. 3.

Updated 3 hours ago - Politics & Policy

Coronavirus dashboard

Illustration: Sarah Grillo/Axios

  1. Health: Ipsos poll: COVID trick-or-treat.
  2. World: Greece tightens coronavirus restrictions as Europe cases spike — Austria reimposes coronavirus lockdowns amid surge of infections
  3. Economy: Conference Board predicts economy won’t fully recover until late 2021.
  4. Technology: Fully at-home rapid COVID test to move forward.
  5. States: New York rolls out new testing requirements for visitors.