As private equity firms expand across the healthcare system, rural communities need protections against investment and ownership models that can extract resources, weaken care, and leave entire regions with fewer options in an emergency.
Investment is welcome in communities where capital can be scarce. But healthcare is different: when a hospital closes, lives are put at risk.
Private equity firms have rapidly increased their presence throughout healthcare, and rural communities are especially vulnerable because often they cannot afford to lose even one hospital, clinic, or emergency service.
When they come into town, private equity firms acquire a local provider, extract as much value as possible, and take off, leaving the community to deal with the consequences. In fact, between 2019 and 2023, private equity completed 65% of all physician-practice acquisitions.
For too long, private equity in health care has been treated like a story about Wall Street dealmaking. A new Campaign for Accountability report found that private equity-owned hospitals collected an average of $669 more per patient than hospitals under other ownership models, without a meaningful increase in the cost of delivering care. Much of the difference came from higher prices, particularly for privately insured patients.
Since 2005, 197 rural hospitals have closed or converted to other uses. Roughly half are operating at a loss, and 418 are considered vulnerable to closure. In communities with so little margin for error, unstable ownership and rising costs can determine whether care remains available at all.
Every rural family should be concerned.
In many small towns, the hospital is both a medical lifeline and one of its largest employers. When it’s weakened, patients face higher prices, reduced services, longer travel times, and fewer options for emergency, maternity and behavioral healthcare, among others.
And concerns about quality are not merely anecdotal.
A 2023 study published in JAMA examining more than 660,000 hospitalizations found that hospital-acquired conditions – including patient falls and bloodstream infections – increased by 25% after private equity acquisition, even as those same harms were declining nationally.
The consequences are measurable. As of 2023, private equity firms owned at least 130 rural hospitals in at least eight states and had invested heavily in emergency department staffing, medical transport, behavioral health and hospital management companies. Yet a 2026 study in Annals of Surgery found that rural hospitals acquired by private equity experienced increases in postoperative mortality and complications compared with similar hospitals that were not acquired.
The risks extend well beyond hospital walls. Private equity backed firms now staff nearly a quarter of all U.S. emergency department visits. In emergency transportation, private equity companies control 64% of the Medicare helicopter air-ambulance market, and charge substantially higher rates than competing operators. In behavioral health – a critical service in areas with limited alternatives.
Access problems continue to worsen as well. Since the end of 2020, 139 rural labor-and-delivery units have closed, leaving fewer than half of rural hospitals still delivering babies. In that environment, any ownership model that prioritizes short-term returns over long-term stability should raise serious concerns.
The collapse of Massachusetts’s based Steward Health Care offers a cautionary example. After its private equity owner and executives hauled off an estimated $1.3 billion, the system entered bankruptcy in 2024 with more than $9 billion in liabilities. Closures, layoffs and uncertainty followed, leaving communities to pick up the pieces.
None of this means that rural hospitals do not need investment. They do.
Rural communities understand better than anyone the financial challenges these institutions face. But there is a profound difference between investors committed to strengthening hospitals in the long term and investors seeking to maximize short-term returns.
Public officials should require full disclosure of hospital and acquisition-related debt, scrutinize real estate and management-fee arrangements, and track whether staffing, prices, services, and patient outcomes improve or deteriorate after an acquisition. In 2025, Indiana passed HB 1666 to increase oversight on mergers and acquisitions involving a healthcare entity with total assets of at least $10 million.
Rural hospitals are not financial assets to be traded. They are community lifelines. Rural Americans deserve a healthcare system built around care, stability, and accountability— not profit extraction.
Niel Ritchie is a community outreach and development consultant and past president of the League of Rural Voters, a national nonprofit organization advocating for the needs and priorities of rural communities across America.
The post Commentary: Private Equity is Coming for America’s Rural Hospitals appeared first on The Daily Yonder.
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