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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

Updated 28 mins ago - Politics & Policy

"Horrified": AP, Al Jazeera condemn Israel's bombing of their offices in Gaza

A ball of fire erupts from the Jalaa Tower as it is destroyed in an Israeli airstrike in Gaza. Photo: Majdi Fathi/NurPhoto via Getty Images

The Associated Press and Al Jazeera on Saturday condemned the Israeli airstrike that destroyed a high-rise building in Gaza that housed their and other media offices.

What they're saying: The White House, meanwhile, said it had "communicated directly to the Israelis that ensuring the safety and security of journalists and independent media is a paramount responsibility," according to press secretary Jen Psaki.

Updated 49 mins ago - World

Biden in call with Netanyahu raises concerns about civilian casualties in Gaza

Photo: Ahmad Gharabli/Nicholas Kamm/Getty Images

President Biden spoke to Israeli Prime Minister Benjamin Netanyahu Saturday and raised concerns about civilian casualties in Gaza and the bombing of the building that housed AP and other media offices, according to Israeli officials.

The big picture: At least 140 Palestinians, including dozens of children, have been killed in Gaza since fighting between Israel and Hamas began Monday, according to Palestinian health officials. Nine people, including two children, have been killed by Hamas rockets in Israel.

Bryan Walsh, author of Future
1 hour ago - Health

The COVID lab-leak theory goes mainstream

The Wuhan Institute of Virology. Photo: Hector Retamal/AFP via Getty Images The COVID lab-leak theory goes mainstream

A group of high-profile scientists published a letter calling for renewed investigation into the origins of COVID-19 — including the theory that it spilled out of a virology lab.

Why it matters: The possibility that SARS-CoV-2 was created in a Chinese lab and accidentally escaped — rather than emerging naturally from an animal — was initially dismissed as a conspiracy theory. But the letter shows a potential lab leak is increasingly being taken seriously.