Obesity has long been associated with an increased risk of health problems, including cancer. However, researchers have recently discovered that a specific body measurement in men could serve as a strong predictor of their cancer risk.
Although Body Mass Index (BMI) serves as a strong indicator of health adversities, a recent study published in The Journal of the National Cancer Institute suggests that waist circumference is an even stronger predictor of cancer risk in men.
The study found that with an additional 4-inch increase in waist size, the risk of cancer rises by 25 percent in men. In comparison, an increase in BMI by 3.7 kg/m² (like going from 24 to 27.7) only raised the risk by 19%. So, even when taking BMI into account, a large waist circumference was still linked to a higher risk of developing obesity-related cancers in men.
This is because unlike BMI, which only measures body size, waist circumference reflects abdominal fat, a key factor linked to increased health risks like insulin resistance, inflammation, and abnormal blood fat levels. This explains why even with the same BMI, differences in fat distribution can lead to varying cancer risks.
However, the study showed that for women, both waist circumference and BMI had similar effects on the risk of obesity-related cancers, but the link was weaker than for men. For example, a 12 cm increase in waist size (like going from 80 cm to 91.8 cm) or a 4.3 increase in BMI (like going from 24 to 28.3) both raised the risk by 13%.
Researchers attribute the difference in cancer risk between men and women to the way fat is distributed in the body. Men tend to accumulate more visceral fat around the abdomen, which is more metabolically active and linked to higher health risks, including cancer. On the other hand, women typically store fat more evenly in peripheral areas like the hips and thighs, where it poses a lower risk.
“Our study provides evidence that waist circumference is a stronger risk factor than BMI for obesity-related cancers in men, but not in women. Additionally, waist circumference appears to provide additional risk information beyond that conveyed by BMI in men,” the researchers wrote in the news release.
“Future research incorporating more precise measures of adiposity, along with comprehensive data on potential confounding factors, could further elucidate the relationship between body fat distribution and cancer risk,” they added.
Can weight loss be always the answer to obesity? While it’s well-known that gaining weight increases the risk of heart disease and death, scientists have now found that losing a significant amount of weight can also carry its own set of dangers.
In a recent study, researchers from the Anglia Ruskin University (ARU) in the U.K. found that for individuals with obesity, “maintaining a stable weight, even within the obese range,” can help reduce the risk of death, particularly for those with heart disease risk factors.
“It was perhaps unsurprising that significant weight gain was associated with higher mortality, but interesting that a similar association was found among those who lost a lot of weight,” said researcher Dr. Jufen Zhang in a news release.
The study analyzed data from over 8,000 obese participants from the UK Biobank study, all of whom had been diagnosed with cardiovascular diseases. These individuals were tracked over nearly 14 years, with researchers closely monitoring changes in their weight throughout the period.
The findings revealed that participants who gained more than 10 kg during the study had a threefold increase in the risk of cardiovascular death and nearly double the risk of dying from any cause, compared to those who maintained a stable weight.
However, the study uncovered an even more striking finding: those who lost more than 10 kg faced a 54% higher risk of all-cause mortality. This suggests that, while weight loss is often encouraged for obese individuals, significant weight loss may have adverse effects, particularly in those already at risk for cardiovascular issues.
“This study is the first of its kind to examine the link between weight change and all-cause mortality in obese individuals with cardiovascular disease,” Dr. Zhang.
While more research is needed to fully understand the underlying mechanisms behind the link between both weight loss and weight gain and increased death risk, Dr. Zhang advises that “clinicians should be cautious, especially with new drugs on the market that are promoted for rapid weight loss.”
“While weight loss is generally recommended for obese adults, those in at-risk groups, like these individuals, should only pursue weight loss under the close guidance of their doctor,” Dr. Zhang added.
If you’re scheduled for surgery, here’s an interesting study you should know about: Researchers have found that the risk of death from surgery can depend on the time of week it’s scheduled, identifying the worst day for an operation.
The study published in JAMA Network highlights an important trend known as the “weekend effect,” in relation to surgeries. Researchers found that patients undergoing planned surgeries on Friday, just before the weekend, face a significantly higher risk of death, complications, and readmission compared to those scheduled after the weekend.
“Hospitals and health care systems have variations in operational structure and organization during the transition from weekdays to weekends. The weekend effect refers to the potential for worse patient outcomes during the weekends, compared with weekdays. In surgery, this concept may also apply to those undergoing surgery immediately before the weekend, who receive postoperative care during the weekend,” the researchers wrote.
The findings were based on an analysis of large-scale data from 429,691 adult patients in Ontario, Canada, who underwent one of 25 common surgical procedures between 2007 and 2019, with a one-year follow-up.
Of the 429,691 patients studied, nearly 46.5% had surgery before the weekend and researchers noted that they were more likely to experience negative outcomes, including complications, readmissions, and death compared to the pre-weekend group.
The risk of mortality increased by 9% at 30 days, 10% at 90 days, and a striking 12% at one year for patients who underwent surgery just before the weekend.
The study suggests that negative outcomes may be linked to differences in hospital staffing and fewer specialists available on weekends, which could impact post-surgery care. To improve outcomes, researchers recommend future studies focusing on ensuring high-quality care for all patients, regardless of when their surgery is scheduled.
However, interestingly, the researchers noted a contrasting trend regarding unplanned, urgent surgeries. While scheduled or elective procedures performed before the weekend were linked to worse postoperative outcomes, urgent, unplanned surgeries tended to show slightly better outcomes when performed before the weekend.
“Our findings underscore the need for a critical examination of current surgical scheduling practices and resource allocation. One approach for consideration is the optimization of perioperative care pathways to mitigate adverse outcomes,” the researchers noted.
What are the effects of plant-based meats on premature puberty, childhood obesity, and hip fracture risk?
As noted in an editorial in the Journal of the American Medical Association on plant-based meats, if you look only at the nutrition facts information for a conventional burger versus a Beyond Meat or Impossible Burger, as seen here and at 0:20 in my video Plant-Based Meat Substitutes Put to the Test, you wouldn’t necessarily be able to predict the health consequences without further studies.
We’ve had plant-based meats in the marketplace for more than a century, though, as you can see in this ad for “good eating” Protose, below and at 0:35 in my video. Dr. John Harvey Kellogg filed a patent for Protose, what he called “the modern vegetable meat,” in 1899.
Of course, products like tempeh and tofu have been eaten throughout Asia for centuries, but I think of those as separate foods in their own right, as opposed to products intentionally designed to mimic the taste and texture of meat. With such a rich history, harkening back to the days of pass-the-Proteena—another great ad here and at 1:06 in my video—you’d think there’d be some studies of consumers—and indeed, there are.
Researchers have found, for example, that girls who eat meat may start their periods six months earlier than girls who don’t. Is the earlier menstruation because the meat-eating girls were eating a lot of protein and fat? No, because vegetarian girls who instead ate meat analogs, like veggie burgers and veggie dogs, were able to delay menstruation by nine months. Of course, it’s hard to tease out how much of that is just from avoiding meat, but compared with girls who ate meat a few times a week, those who ate meat a few times a day had a significantly earlier age of first menstruation. This may help explain why childhood meat consumption is linked to breast cancer later in life, since the earlier you start your period, the higher your lifetime risk.
Now, obesity itself may contribute to the early onset of puberty in girls, so that could be another factor. Studies have suggested that “vegetarian children tend to be lighter and leaner than nonvegetarian children,” but veg kids aren’t smaller in general, though. Vegetarian boys and girls may measure to be about an inch taller than their classmates; they just aren’t as wide. So, the fact that girls who eat plant-based meats may be less likely to experience premature puberty may, in part, be because they were leaner.
Indeed, as shown here and at 2:48 in my video, childhood obesity research found that meat consumption seems to double the odds of schoolchildren becoming overweight, compared to plant-based meat. Now, whole plant food sources of protein, such as beans, do even better and are associated with halving the odds of kids becoming overweight.
This is why I consider plant-based meats like the Impossible Burger and Beyond Meat more of a useful stepping stone towards a healthier diet, rather than the endgame ideal. The same amount of protein in a bean burrito would be better in nearly every way, as you can see here and at 3:05 in my video.
Similarly, in terms of hip fracture risk, in the Adventist Health Study–2, which followed tens of thousands of men and women for years, researchers found that daily intake of plant-based meats appeared to reduce the risk of hip fracture by nearly half, but daily intake of legumes—beans, split peas, chickpeas, and lentils—may drop the risk of hip fracture by even more—by nearly two-thirds.
This is the fourth in a nine-part series on plant-based meats. If you missed the first three, see the related posts below.
The first time Adele Routliff tried communicating with her Deaf mother in public using sign language, her mother, she says, “put her hands on mine and placed [them] back in my lap. In other words, no, we don’t sign in public.” Her mother had grown up in a residential school for the Deaf where sign language was forbidden—enforced by physical punishment—and had internalized the idea that signing was only safe in private settings. Adele didn’t understand her mother’s resistance and so continued signing, even as her mother’s eyes grew wide with fear. “I didn’t understand it then,” she says. “But I know now it was shame.”
Now a certified American Sign Language-English interpreter, Adele actively works to raise awareness of deafness by bridging the communication gap and highlighting the importance of mental health in Deaf communities. Her lived experiences have motivated her in becoming a trained mental health interpreter, in providing mental health interpreting workshops for those looking to develop their skills, and in designing and implementing a curriculum for training new interpreters through Canadian Hearing Services.
Historically, Deaf mental health has been overlooked, and it received minimal attention until the past decade. Dr. Cathy Chovaz—director of the Centre for Deaf Education and Accessibility Forum (CDEAF) and an associate professor of psychology at King’s University College (Western University)—provides mental health care to Deaf individuals. She has led research that suggests that Deaf people face heightened risks of depression and anxiety, compounded by significant barriers and poorer outcomes within the justice system, mainstream education, and healthcare settings. Dr. Chovaz’ research shows that many healthcare professionals aren’t trained to recognize mental health conditions in Deaf patients. As a result, Deaf individuals are often misdiagnosed or go undiagnosed, even though they face unique challenges that put them at higher risk, such as limited early access to sign language, communication barriers within their families, neurological conditions linked to certain causes of deafness, and experiences of trauma or abuse.
The Challenges of Mental-Health Interpreting
Considering the challenges faced by Deaf individuals, it’s not surprising that sign language interpreters working in medical and mental health settings also face heightened risks.
Sign language interpreting requires the interpreter to use their face and their body to communicate, both with the Deaf person and to the hearing person, an experience that can be emotionally and physically taxing. Sign language interpreters also have to remember that their job is to relay every word exactly as it’s signed—no matter how uncomfortable it makes them. One mental health interpreter, who wishes to remain anonymous—we’ll call her Jane—shared how challenging this can be: “There have been times I felt like I needed to wash my mouth out with soap,” referring to the language she had to interpret. “You almost want to say, ‘It’s not me, it’s them.’”
You walk into the most intimate moments in people’s lives as an interpreter. I’ve been at births, I’ve been at deaths, I’ve been at funerals. I’ve been there when families have blown up.
Jane explained that while interpreters are trained to remain impartial, it’s hard not to have a natural human reaction to some of the distressing things they hear in medical and mental health settings. “You’re told you’re just there to convey the language—to maintain professionalism, set boundaries, and be mindful of how you come across,” she said. This is especially crucial in high-stress or emotionally charged situations, which interpreters often find themselves navigating. As Adele said, “You walk into the most intimate moments in people’s lives as an interpreter. I’ve been at births, I’ve been at deaths, I’ve been at funerals. I’ve been there when families have blown up.”
The Health Risks of Helping People Be Heard
Medical interpreters who work with hearing people play a critical role in helping patients with limited English access and navigate the healthcare system, but the job can bring with it significant emotional strain. They often find themselves in high-stress situations: delivering difficult news, bridging cultural gaps, and facilitating conversations between doctors, patients, and families. Research shows that interpreters, especially those working with cancer patients and children, experience high levels of stress and struggle to manage their own mental health while supporting others.
Research shows that interpreters, especially those working with cancer patients and children, experience high levels of stress and struggle to manage their own mental health while supporting others.
And this emotional burden isn’t unique to spoken language interpreters—it also extends to sign language interpreters, who face their own distinct challenges in medical settings. Although research findings are mixed, recent studies indicate that regular exposure to emotionally charged or traumatic content significantly increases sign language interpreters’ vulnerability to vicarious trauma and secondary traumatic stress, with poor mental health outcomes reported in as many as 83% of interpreters. Jane shared with me a particularly stressful assignment: “I recognized I was no longer able to manage my emotions and it was affecting my ability to interpret in a neutral manner. So I had to take a step back.”
Mindful Skills May Help Sign Language Interpreters
Those working in emotionally charged settings, particularly medical and mental health contexts, could benefit from preventive measures. One promising approach is the use of mindfulness practices. While it is an understudied area, some research suggests that mindfulness can help interpreters manage work-related stress. A recent study adapted Mindful Practice® in Medicine (MPIM)—an evidence-based mindfulness program created by two physicians to improve coping skills and combat burnout—for medical interpreters.
The findings showed that the program effectively reduced distress in both spoken and sign language medical interpreters. The study also found that most participants valued the opportunity to share their stressors in an open and understanding environment with fellow medical interpreters. This sense of community not only helped them become more empathetic listeners but also provided a supportive space to debrief and develop mindful strategies for managing the challenges of their work.
Incorporating mindfulness-based practices into interpreter training programs and providing ongoing professional development can help interpreters better handle emotionally charged situations, enhance self-awareness and emotional regulation, build resilience to burnout, and, like Jane, recognize when an assignment exceeds their capacity. Jane, though not formally trained in mindfulness practices, shared that using mindfulness has helped her. Even something as simple as parking her car further away from her workplace, requiring a longer walk, was helpful to her in processing her day. Similarly, Adele has gained the ability to check in with herself and know what her limits are. While both have been lucky enough to find mindfulness in their own lives, the industry could benefit from offering interpreters formal mindfulness training, which could significantly reduce the stress of challenging interpretation work.
Staying active is one of the most effective ways to support long-term health and lower the risk of dementia. However, not everyone has the time, ability, or motivation for structured workouts every day. Here’s some good news- new research suggests even small amounts of movement can still give significant protection against dementia.
A recent study published in the Journal of Post-Acute and Long-Term Care Medicine found that just 35 minutes of moderate to vigorous physical activity per week, which is about 5 minutes a day, lowered the risk of developing dementia by 41% compared to those who never exercised.
“Our findings suggest that increasing physical activity, even as little as five minutes per day, can reduce dementia risk in older adults. This adds to a growing body of evidence that some exercise is better than nothing, especially with regard to an aging-related disorder that affects the brain that currently has no cure,” said lead author Amal Wanigatunga in a news release.
The findings were made after following up nearly 90,000 adults with an average age of 63, for about 4.4 years. During the study period, the researchers tracked the physical activity levels and health of the participants and noted that 735 of them developed dementia. On average, participants engaged in 126 minutes of moderate to vigorous physical activity per week.
The study found that for every additional 30 minutes of moderate to vigorous physical activity per week, the risk of developing dementia decreased by 4%. While even small amounts of movement help, the researchers noticed a clear pattern, a dose-response relationship between exercise and reduced dementia risk. This means that more people exercised, the greater the benefits.
Those who engaged in 36 to 70 minutes of moderate to vigorous activity per week saw their dementia risk drop by 60%, while those who exercised for 71 to 140 minutes experienced a 63% reduction. The biggest impact, however, was among individuals who exceeded 140 minutes per week, slashing their risk by an impressive 69%.
“Our results suggest engaging in any additional amount of MVPA [moderate to vigorous physical activity] reduces dementia risk, with the highest benefit appearing among individuals with no MVPA. These associations are not substantially modified by frailty status,” the researchers concluded.
Are you considering sugar substitutes as a safer alternative to sugar? Think again. Recent research has found that a common artificial sweetener used in diet sodas and other zero-sugar food items may actually increase your risk of heart attacks and strokes.
In a recent study published in the journal Cell Metabolism, researchers evaluated mice fed aspartame, a common sugar substitute, for 12 weeks and compared them with mice without a sweetener-infused diet. The amount of aspartame the mice consumed (daily doses of food containing 0.15%) was equivalent to about three cans of diet soda per day for humans.
The results revealed that mice fed with aspartame had increased inflammation and “larger and more fatty plaques” in their arteries, two main factors that could raise the risk of cardiovascular diseases.
The researchers also noted that the mice’s blood had an insulin surge after aspartame entered their system. They then determined that elevated insulin levels may be the key link between aspartame and cardiovascular health.
“Aspartame triggers increased insulin levels in animals, which in turn contributes to atherosclerosis—buildup of fatty plaque in the arteries, which can lead to higher levels of inflammation and an increased risk of heart attacks and stroke over time,” the researchers noted in a news release.
The study identified a specific immune signal, CX3CL1 that gets activated under insulin stimulation as the key factor for inflammation and plaque buildup.
“Because blood flow through the artery is strong and robust, most chemicals would be quickly washed away as the heart pumps. Surprisingly, not CX3CL1. It stays glued to the surface of the inner lining of blood vessels. There, it acts like a bait, catching immune cells as they pass by,” said senior author Yihai Cao.
Cao believes that the same immune signal, CX3CL1, could be a potential target for treating other chronic conditions that involve blood vessel inflammation, like stroke, arthritis, and diabetes. Developing agents that block the functions of this immune signal could provide a new way to treat and prevent common and deadly diseases in humans.
“Artificial sweeteners have penetrated almost all kinds of food, so we have to know the long-term health impact,” Cao cautioned.
For years, health experts have debated if Body Mass Index (BMI) is the best measure of a person’s health. While waist size has been highlighted as a key factor in predicting heart disease, a recent study reveals that neither BMI nor waist measurement is the ultimate predictor.
Instead, a hidden factor, intermuscular fat, the fat stored inside muscles might be a more accurate indicator of heart disease risk. Researchers noted that those having higher amounts of this particular type of fat face a greater risk of death and hospitalization from heart attacks or heart failure, regardless of BMI or waist size.
“Obesity is now one of the biggest global threats to cardiovascular health, yet body mass index – our main metric for defining obesity and thresholds for intervention – remains a controversial and flawed marker of cardiovascular prognosis. This is especially true in women, where high body mass index may reflect more ‘benign’ types of fat,” Professor Viviany Taqueti, who led the study said in a news release.
The study analyzed how different muscle and fat compositions affected the small blood vessels or “microcirculation” of the heart and influenced the risk of developing heart failure, heart attack, and death.
The research involved 669 patients at Brigham and Women’s Hospital, with an average age of 63, who were assessed for chest pain or shortness of breath but had no evidence of obstructive coronary artery disease.
The patients underwent cardiac PET/CT scans to evaluate heart function and CT scans to analyze body composition, including fat and muscle distribution in the torso. Researchers introduced a new measurement called the fatty muscle fraction, which quantifies the ratio of intermuscular fat to total muscle and fat.
The participants were followed up for around six years to check for outcomes including hospitalization and deaths from a heart attack or heart failure.
The analysis revealed that higher levels of fatty muscle fraction were linked to a 2% increased risk of coronary microvascular dysfunction (CMD) and a 7% higher risk of future serious heart disease, with every 1% increase in fatty muscle fraction, regardless of other risk factors and BMI.
“Compared to subcutaneous fat, fat stored in muscles may be contributing to inflammation and altered glucose metabolism leading to insulin resistance and metabolic syndrome. In turn, these chronic insults can cause damage to blood vessels, including those that supply the heart, and the heart muscle itself,” Professor Taqueti explained.
Turning to supplements to boost your overall health? This seemingly harmless wellness trend is now being questioned by a cancer dietitian, who advises you to evaluate whether you really need them or if whole foods might be a better choice.
“Many of us turn to supplements like apple cider vinegar, collagen, skin/hair/nail gummies, turmeric, and Vitamin C for quick fixes, but did you know excessive doses can do more harm than good?,” Nichole Andrews, a registered dietitian and nutritionist specializing in oncology, said in a video she posted on Instagram.
“As a cancer dietitian, I’m here to tell you that relying on supplements for health can lead to imbalances and even increase cancer risk in some cases. Whole foods should always be your go-to for nutrients!,” she said.
Andrews suggests that supplements are essentially for those who cannot get adequate nutrients from their routine diet and she would not take them unless recommended by a doctor. The key concern she raises is the risk of consuming high doses of these nutrients from supplements, which can be harmful, while the same nutrients are absorbed safely in smaller amounts from food.
“I do not take any supplements unless my doctor recommends it, I get all my nutrients from food. Do not seek out supplements to reduce cancer risk because in fact high doses of supplements can increase cancer risk,” she said in a viral video on TikTok. She also emphasized avoiding alcohol and processed foods to reduce the risk.
Although Andrews does not pinpoint the specific supplements that are linked to cancer, she highlights a few that could be avoided and shares recommendations for healthier alternatives.
1. Apple Cider Vinegar Capsules: These capsules, made from apple cider vinegar, are rich in antioxidants and are often praised for benefits like weight loss, reducing acid reflux, lowering cholesterol, and managing blood sugar levels. However, Andrews warns, “The high acidity can irritate your digestive system, and these are not regulated like food and drugs.” For those seeking alternatives, she recommends natural options like lemon water and fermented foods such as kimchi or sauerkraut.
2. Collagen Supplements: These supplements have gained popularity for their potential benefits, ranging from building muscle mass and preventing bone loss to relieving joint pain and improving skin health. However, Andrews notes that collagen supplements are not necessary unless there is a deficiency. She also cautions that excessive collagen intake can interfere with nutrient absorption. Instead, she suggests incorporating whole foods rich in collagen, such as chicken, fish, eggs, and vitamin C-packed citrus fruits and berries, into the daily routine.
3. Skin/Hair/Nail Gummies: “High doses of biotin can cause imbalances and interfere with lab tests. Choose eggs, nuts, leafy greens, avocados, and sweet potatoes for balanced vitamins,” Andrews noted.
4. Turmeric Supplements: These are supplements vouched for several health benefits, such as reducing inflammation and improving metabolic syndrome. However, high doses of turmeric can irritate the stomach and affect liver function, Andrews noted. As a healthier alternative, she suggests taking turmeric in food and choosing healthy fats like olive oil or coconut milk to improve the absorption.
5. Vitamin C Supplements: Known for immune boosting benefits, many people take vitamin C supplements to ward off cold and flu viruses. But, taking “Over 200% of the daily value can lead to kidney stones and digestive issues,” Andrews said. “Choose: Oranges, strawberries, bell peppers, and broccoli for natural, balanced Vitamin C,” she added.
Home / News / Private equity’s appetite for hospitals may put patients at risk
Illustration: Traci Daberko
In the wake of the Steward Health Care crisis, corporate and private equity ownership of health care has come under new scrutiny. Here, Harvard health policy experts weigh in on the growing corporatization of the U.S. health care system and what it means for patients, practitioners, and public health.
Throughout 2024, eye-opening news headlines from around the country trained a spotlight on the collapse of Steward Health Care:
As Steward hospitals teeter, CEO’s $40 million yacht is docked in the Galapagos Islands
Sick patients collapsed waiting for care in overwhelmed Steward hospital’s emergency department
Steward Health Care files for Chapter 11 bankruptcy
Steward owned more than 30 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, and Texas. Its volatility and eventual crash jeopardized access to health care for millions of patients.
How did Steward, at one point the largest private for-profit health system in the U.S., go belly up?
The long and short: In 2010, private equity firm Cerberus Capital Management purchased Caritas Christi Health Care, a struggling eastern Massachusetts hospital system, from the Archdiocese of Boston, converting it from non-profit to for-profit and rebranding it as Steward Health Care. In 2016, after years of continued financial instability, Steward signed a sale-leaseback agreement with Medical Properties Trust (MPT), selling the land and buildings occupied by its hospitals to the real estate investment trust then leasing them back. Steward made $1.25 billion from the agreement—enough to steady its financial footing, pay off Cerberus, and fund a growth spree. The next year, the company purchased 26 more hospitals across the country. But with the agreement came what many viewed as inflated rents.
By 2020, Cerberus, having made $800 million in profit on its initial investment, decided to sell Steward hospitals to a group of its physicians, essentially transferring ownership back to Steward’s management team, led by CEO Ralph de la Torre. Over the next several years, concerns about patient care and safety at Steward hospitals mounted as the company opted to cut costs and neglect bills in order to keep up with its rent payments to MPT. In January 2024, MPT announced that Steward was $50 million behind on those payments. By May, the company filed for bankruptcy. Financial documents made clear that the company had paid hundreds of millions to investors and leadership, including de la Torre, who enjoyed a lavish lifestyle while patients at Steward hospitals faced increasingly unsafe conditions. De la Torre was subpoenaed by Congress in July; he failed to appear.
After months of tense negotiations between state governments, Steward, MPT, and potential buyers, by November, most Steward hospitals had found new owners, a mix of non- and for-profit hospital systems and private equity firms. But two hospitals didn’t survive: Carney Hospital, which served Boston’s low-income, majority Black and Hispanic southern neighborhoods, and Nashoba Valley Medical Center, which served 17 suburban and rural communities across central Massachusetts. Thousands of patients and hundreds of staff have been left to find health care and jobs with new providers farther away.
The Steward meltdown has captured the attention of the public and policymakers not as an outlier, but as an object lesson. Its story shines a light on the growing role of private equity in the U.S. health system, helps explain rising discontent among patients and clinicians, and lays bare the dangers of prioritizing profits over people in health care.
A ‘core contradiction’
John McDonough, professor of the practice of public health at Harvard Chan School, calls private equity “the sharp end of capitalism.”
“It’s otherwise often described as ‘capitalism on steroids,’” McDonough said. “It’s for-profit business in its most aggressive form. [Private equity firms] seek returns on their investment as high as possible as quickly as possible, then rush to sell off that investment and go on to their next conquest.”
After decades establishing a presence everywhere from manufacturing, to telecommunications, to grocery stores, in the mid 2000s private equity firms began targeting health care. It was a natural next step: The industry is worth nearly $5 trillion in the U.S., offering significant, dependable cash flow. Firms saw the potential for profits and began buying up physician practices and health facilities, from hospitals to nursing homes to fertility clinics, looking to at least double their initial investment and then sell within a short time, often three to seven years.
Private equity’s foothold in health care has continued to grow. In 2021, according to researchers at UC Berkeley, 5,779 physician practices, specializing in everything from primary care to oncology, were owned by private equity firms—up from 816 in 2012. Nonprofit watchdog the Private Equity Stakeholder Project (PESP) reported that, as of February 2024, nearly 460 U.S. hospitals were owned by private equity firms. These hospitals—which include non-specialty acute care hospitals, rehabilitation hospitals, psychiatric facilities, and long-term acute care facilities—represent 8% of all private (not owned by the government) hospitals and 22% of for-profit hospitals.
5,779
physician practices were owned by private equity in 2021—up from 816 in 2012
22%
of for-profit hospitals—460 in total—are currently owned by private equity
80%
of physicians are employed by a hospital system or corporation—up from 60% in 2019
But ownership by private equity is just the latest version of capitalism’s creep into health care. Its way was paved by corporations entering the industry in the 1980s as an era of free market fundamentalism emerged and the “maximizing shareholder value” movement began to boom. Publicly traded companies began buying up hospitals and health facilities, as well as physicians and physician practices, to establish their own health systems. Today, nearly a quarter of U.S. hospitals are run by for-profit entities that promise to bring business smarts and a flow of capital to health care delivery.
“The pitch is that corporations can raise capital and invest in improving the business—quality of care, operations, professional management—in a way non-profits can’t,” said Meredith Rosenthal, C. Boyden Gray Professor of Health Economics and Policy. “But the challenge is that because health care is so important, the public expects these corporations to prioritize public interest over profits. And that’s not what they’re built to do.”
Because health care is so important, the public expects corporations to prioritize public interest over profits. And that’s not what they’re built to do.
Meredith Rosenthal, C. Boyden Gray Professor of Health Economics and Policy
“Medical care has always had a for-profit element. Physicians were mostly small businesspeople,” McDonough said. “But there’s a difference between a sole proprietor or small business and a mega-corporation that believes its only purpose in the world is return on equity to shareholders. Hold that belief up against a medical provider’s belief that patients come first, and right away there’s conflict. It’s this core contradiction that I think American society has never sufficiently grappled with.”
Non-profits like profits, too
It’s not just corporate health care providers producing this dilemma. Non-profits, which remain the majority of U.S. hospitals and health care facilities, sometimes prioritize profits over their social missions—and community benefit requirement cementing their tax-exempt status—in order to grow, and even just survive, in a tight economy and increasingly competitive health care market.
“Economists have studied whether non-profits behave differently than for-profits. Do they provide more charity care [free or discounted medical services for poor patients]? Do they invest more in community well-being? The answer generally has been no,” Rosenthal said.
One study, conducted in 2020 by Joseph Bruch, PhD ‘21 and David Bellamy, PhD ’23, indeed found no significant difference between what non-profit and for-profit hospitals spend on charity care as a percent of their total expenses.
“It’s getting harder and harder to tell the difference between a non-profit and for-profit board of directors,” McDonough said. “It’s this for-profit ethos that has swarmed and swamped the U.S. medical space. Many people think the system can prioritize patients and profits at the same time and that it will be okay. But then we look at calamities like Steward, and we think to ourselves, maybe it can’t. And maybe it won’t be okay.”
Consequences of cost-cutting
For Steward patients, it wasn’t okay. Reports of poor-quality care and compromised patient safety ran the gamut: from understaffed emergency rooms and ill-equipped maternity wards, to stairwells infested with bats, to cancelled surgeries and suspended trash service due to unpaid invoices. These extreme examples represent what a growing body of research suggests: Health care quality declines when private equity and its extreme for-profit approach take over.
A 2023 study found that Medicare patients at private equity-owned hospitals suffered a 25% increase in hospital-acquired complications compared to Medicare patients at hospitals not owned by private equity. These complications included a 38% increase in bloodstream infections from central lines—longer-term, surgically inserted ports through which patients can intravenously receive fluids, medications, and blood—despite 16% fewer central lines placed. Similarly, the rate of surgical site infections doubled at private equity-owned hospitals while those at the control hospitals decreased. And while falls at hospitals not owned by private equity have been trending downward—a product of a nationwide, decades-long hospital safety movement—falls at private equity-owned hospitals have remained steady, amounting to a 27% relative increase.
“We believe [these findings are] largely explained by staffing cuts,” said the study’s senior author Zirui Song, PhD ’12, associate professor at Harvard Medical School and Massachusetts General Hospital. “The unique financial pressures private equity-owned hospitals face, such as new debt placed on them from the acquisition and expectations of profitability in the short run, may lead to cutting the costs of delivering care—such as through reducing staffing. But while you may be able to substitute people with machines in other industries, health care remains human-labor intensive, especially inpatient care. Cutting staff can have salient consequences for quality of care and patient outcomes.”
Another study by Song and colleagues found that private equity-owned hospitals earned 27% more income after acquisition than hospitals not owned by private equity. That financial gain was fueled by increasing charges—the asking prices for hospital services—by between 7% and 16%, depending on the department, as well as by issuing more charges per day and seeing fewer patients enrolled in Medicare, which provides lower reimbursements than commercial insurers.
A “Save Our Hospital” sign is displayed outside the former Nashoba Valley Medical Center, which was part of the bankrupt Steward Health Care company and closed on Aug. 31, 2024. (Charles Krupa / AP Photo)
Exacerbating disparities
What type of hospitals does private equity tend to target?
New evidence from Song and colleagues suggests that firms typically set their sights on financially healthier—rather than struggling—hospitals, compared to similar peer hospitals that were not acquired. That’s because private equity firms tend to place new debt onto acquired hospitals, and those on stronger financial footing are better able to take on that debt.
There are examples, however, of hospitals serving mostly uninsured or publicly insured patients being taken over by private equity firms. These takeovers may exacerbate health disparities, as many of these disadvantaged patients belong to racial or ethnic minorities and already suffer worse health outcomes, said Song. When discontinuation of hospital services—or total closure—occurs, it has an outsize impact in communities where access to health care is already limited. Carney Hospital is one such example; in an op-ed, Harvard Chan School’s Alecia McGregor, assistant professor of health policy and politics, called its closure “a matter of life and death” that threatens to deepen Boston’s already extreme racial disparities in health.
“I don’t think there is enough evidence to definitively say that private equity targets hospitals that mostly serve people of color. But in some cases, these financially vulnerable facilities may fit their business model,” McGregor said. “And when private equity backed acquisitions lead to closures, this is when marginalized communities often hurt the most. Take Hahnemann University Hospital, for instance—a historic facility serving mostly low-income Black and Hispanic Philadelphians that was closed by its private equity owner after less than two years. Many viewed the closure as a maneuver for the hospital’s prime city real estate.”
PESP also reports that a quarter of private equity-owned hospitals serve rural populations, whose health care alternatives are sparse if they’re unsatisfied with quality or costs and whose outcomes are jeopardized if the only hospital in town closes. Since Nashoba Valley Medical Center was closed, first responders travel around 15 miles to transport patients to emergency care, according to a local fire chief. They used to travel three.
Policy potential
“Theoretically, there could be benefits to private equity investments in health care. They could provide facilities and clinicians with an infusion of capital, but also with managerial know-how and business acumen that might improve health care, such as through making care more ‘efficient,’” Song said. “Unfortunately, however, the current evidence base does not support that. Rather, evidence seems to suggest that by cutting the human labor and other inputs that make care delivery possible—also seen in private equity acquisitions of physician practices and nursing homes—the care might just become less safe.”
Song published a series of policyrecommendations for officials looking to reduce corporate influence, specifically that of private equity, over health care delivery and outcomes. His recommendations for state policy included reviving or enforcing corporate practice of medicine laws, which, in their aim to protect physicians as independent practitioners, can go as far as prohibiting corporations from hiring physicians or influencing medical decisions. His recommendations for federal policy included:
Strengthening fraud and abuse protections
Improving Federal Trade Commission staffing and bandwidth, in order to improve oversight over health care acquisitions and mergers
Discouraging risk-taking behavior by corporate owners (sometimes referred to as moral hazard), through measures like legally affiliating private equity firms with their rolled-up set of acquired entities, limiting the percent debt a firm can use to make an acquisition, and reforming the tax benefit that allows private equity proceeds to be taxed at 20% (rather than the regular corporate business rate, which is higher)
Regulating health care prices and prohibiting surprise billing
Increasing public transparency into private equity acquisitions
Some policymakers have already begun efforts to enact these recommendations. In June, Massachusetts senators Elizabeth Warren and Edward Markey introduced the Corporate Crimes Against Health Care Act, which would penalize private equity firms if a health facility they own closes or has poor finances resulting in injury or death to a patient. A month later, Markey proposed another bill, the Health Over Wealth Act, which would require greater transparency for private equity firms and for-profit companies that own health care entities.
Meanwhile, in the last year, several congressional committees—including the Senate Budget Committee, the Senate Committee on Homeland Security and Governmental Affairs, and the House Committee on Ways & Means—have launched investigations into and held hearings on the role of private equity in health care. On a state level, legislation to regulate private equity in health care is pending in Massachusetts, New Jersey, New York, and Pennsylvania. California, Indiana, Minnesota, New Mexico, and Oregon already have programs that do so. (In September, California Governor Gavin Newsom vetoed a bill that would further intensify regulations.)
Protesters gather in front of the Massachusetts State House to advocate for keeping Nashoba Valley Medical Center and Carney Hospital open. (Steve LeBlanc / AP Photo)
Deeper changes
These regulations—if passed—could help protect physicians as well as patients. One of the significant changes from the corporatization of health care is that, increasingly, physicians are no longer working for themselves. In the 1980s, most doctors owned their own small clinics. Today, nearly 80% are employed by a hospital system or corporation—up from just over 60% in 2019, according to Avalere Health.
“If you’re a physician working in a hospital, chances are you don’t work for the hospital. You work for a corporation,” McDonough said. “And when you sign on with the corporation, you sign a non-compete clause. You can’t criticize anybody or raise your voice even as your workload keeps growing, even when you’re the only physician in the emergency department with multiple traumas, even when you’re seeing patients being put at risk and your colleagues being exploited.”
As this hypothetical proves reality for more and more physicians, many are banding together to advocate for some of the policies Song recommends. A physician advocacy group called Take Medicine Back, for instance, is working to garner support for corporate practice of medicine laws.
Burnt out, frustrated—and organizing
In November, primary care physicians employed by Massachusetts’ largest health system, non-profit Mass General Brigham, cited the “corporatization of medicine” among their reasons for pushing to unionize. Across the country, a small number of doctors—around 70,000, representing 8% of the profession—already belong to a union. But that number has been growing steadily, and will likely continue to do so with the arrival of a new generation of physicians. Currently, 20% of medical residents—more than 32,000—belong to a union, a number that has doubled since 2019.
But tighter regulations on private equity and corporations in health care can only achieve so much. Many experts believe deeper changes to health policy and investments in public health are equally needed. Examples include:
Higher reimbursements for public insurance, so that, in McGregor’s words, “small community hospitals that serve populations largely on Medicare or Medicaid can better meet their costs and remain in business without the private sector filling in”
Simplified health insurance systems, like those in the Netherlands and Switzerland, that use private insurance plans that are streamlined, with fewer choices, making them more transparent and easier to understand and regulate
Funding for non-medical social care, such as housing and food—in Rosenthal’s words, “social supports that make a big difference in people’s lives and that, when underinvested in, drive up our health care costs”
‘One of the biggest lies we’ve ever been told’
These additional policy levers could help diminish for-profit health care’s influence, but by how much is a matter for debate.
“At the end of the day, I think we’re always going to have this kind of mixed public and private system,” Rosenthal said. “Politically, it would be very challenging for us to go in a more government-focused direction. There’s just a lot of distrust. And the one big thing that’s quite different about our country is that we don’t consider health a right. It’s not in our constitution like it is for many of our peers.”
But significant change may be on the horizon, driven by public discontent around health care and growing visibility, brought by cases like Steward, into the consequences of a system where profits can come at the expense of patient care.
When health care follows the money, we get sicker and sicker.
Alecia McGregor, assistant professor of health policy and politics
“As a country, we’ve become desensitized to this notion that health care is the same as any ordinary commodity, and that the provision of health care can be run like any other business,” McGregor said. “I think this is one of the biggest lies we’ve ever been told, because we’ve seen health care costs skyrocket in a way that’s different from any of our wealthy country counterparts, yet our outcomes—life expectancy, maternal health, infant mortality—are abysmal. When health care follows the money, we get sicker and sicker.”
“Surrendering our health care system to the for-profit marketplace was a fundamental error that we’re paying the debts of right now,” McDonough added. “But I see people working on it, reassessing the role and value of for-profits and asking what a post-neoliberal health care system might look like.”
In the meantime, the story of Steward, now under new ownership and a new name, continues to unfold. Its physician network, made up of 5,000 doctors, was recently purchased by Rural Healthcare Group and rebranded as Revere Medical. Rural Healthcare Group is owned Kinderhook Industries, a private equity firm.
For concerned patients, Rosenthal offered some concrete advice. “Find a provider you trust and be skeptical. Always ask about the benefits of an intervention. Because more services, more tests, more treatments are not always beneficial—but they’re always profitable.”
