If you were to do an Internet search on the largest U.S. employers, you would likely be unsurprised by the first two juggernauts (Walmart and Amazon) to pop up on the list.1 However, such rankings mask the influence of other major behind-the-scenes players, notably the shrouded-in-secrecy private equity (PE) industry. According to one calculation, 7 percent of the U.S. labor force works for businesses backed by PE,2 making PE giants like KKR (Kohlberg Kravis Roberts & Co.), Carlyle and Blackstone the third, fourth and fifth largest U.S. employers, respectively.3 In fact, as federal prosecutor Brendan Ballou explains in his 2023 book, Plunder: Private Equity’s Plan to Pillage America, the PE industry “owns more businesses than all those listed on US stock exchanges combined.”3
Private equity—an industry with historical roots in the leveraged buyout (LBO)4 and “junk bond” free-for-all of the 1980s—is a powerful and ubiquitous player in today’s financialized economy, having more than doubled in size just between 2019 and 2024.5 Unfortunately, it remains woefully invisible to many of those most affected by its shenanigans: workers, customers, patients, pensioners and small businesses. As authors Gretchen Morgenson and Joshua Rosner explain in their own 2023 book about the PE industry and the “modern-age robber barons” who run it (These Are the Plunderers: How Private Equity Runs—and Wrecks—America),2 “The economic wreckage caused by the takeover titans is real and measurable. Except now they call their industry private equity—a name that conveys suave sophistication but none of its brutality.” It is important for members of the public to grasp the private equity game, so that they can demand accountability and push back against a business model that the Solari Report’s Catherine Austin Fitts characterizes as “destructive and even criminal.”6
AN EXTRACTIVE MODEL
What is private equity? According to Ballou, the “simple” PE business model operates something like this:
“Private equity firms invest a little of their own money, a lot of investors’ money, and a whole lot of borrowed money to buy up companies (typically making them the sole, or private, owner, hence the name). They then use various tactics to extract money from those companies, with an eye toward reselling them for a profit a few years later.”
As explained in These Are the Plunderers, PE firms often “sicken” companies that were previously healthy, “load[ing] them with debt while bleeding them of assets and profits.”2 In a January 2026 interview with Fitts,6 Tiffany Cianci—a former small business owner whose up-close-and-personal experience with PE turned her into an expert on the industry—put herself in a hypothetical private equity firm’s shoes, offering an example of how the debt would work if the firm (first-person “I” in her example) decided to buy “Catherine’s Tire Center”:
“If I want to buy Catherine’s Tire Center, I’m going to borrow most of the money to do that…. I’m never going to owe that money back. Catherine’s Tire Center is going to owe that money back. I have no liability whatsoever, even though I retain all decision-making authority…. All the leverage is foisted upon Catherine’s Tire Center to repay, even though I’m the one that made the decision, my fund is the one that created it, my fund is the one that borrowed it, my fund is the one that convinced the bank.”
In Ballou’s definition, “extract” is the critical verb to pay attention to. Egregiously, as he notes, PE firms start by extracting exorbitant fees from the companies they buy merely “for the privilege of being owned by [PE].” In addition, they often sell off the lucrative—and generally paid-off—real estate that the purchased companies are sitting on, forcing the businesses to rent back the very properties they once owned.3 (The Steward hospital chain had to file for bankruptcy after a sale-leaseback agreement with private equity left it $50 million in arrears on rent payments.7) Equally cleverly, Morgenson and Rosner explain, “The plunderers also arrange to have the entities they buy do business with other companies they own, guaranteeing several streams of income from their investments.”2 In short, P E firms “take money from productive companies, their employees, and their customers and redistribute it to themselves.”3
Not infrequently, as the Steward hospital story illustrates, the short- or medium-term result of a PE takeover is business collapse and bankruptcy. Companies acquired by private equity have bankruptcy rates ten times higher than for other types of acquisitions, with enormously damaging ripple effects on workers and households, effects that include not just lost jobs but loss of health insurance, potential loss of home, and family stress and dislocation.2 In the first quarter of 2025, seven out of ten of the largest bankruptcies (with “largest” defined as companies with over $1 billion in liabilities) were filed by PE-owned companies, as were 54 percent of the largest bankruptcies and 11 percent of all corporate bankruptcies in 2024.8 Thanks to legal insulation tactics, these bankruptcies not only tend to leave the PE owners untouched but, says Ballou, can “counterintuitively. . . be desirable, even profitable.” Following a bankruptcy, it is the PE firm that gets paid first (while employees and small-business creditors get the shaft); PE firms can also use bankruptcy as an attractive tax write-off and “come out ahead overall.”5 Catherine Austin Fitts describes the bankruptcies as part and parcel of PE’s “extraction model,” saying, “that’s not a performance issue, that’s a plan.”6
Looking back at 2020, let’s recall that the forced shutdowns of “non-essential” businesses were a disaster for Main Street, resulting in the disproportionate failure of the small businesses that are the job creators and dynamic engines of a productive economy. Instead, America witnessed a “sharp concentration of market share among larger businesses,”9 including those owned by private equity. While non-PE-backed firms struggled to obtain additional financing and stay afloat, resulting in a “higher incidence of liquidation,”10 the so-called “pandemic” was a bonanza for private equity. Not only did the PE industry fare well, going on a bargain basement shopping spree buying up distressed businesses (while thrusting the knife even deeper into the suffering workforce by aggressively cutting costs at the new acquisitions),11 PE billionaires’ personal wealth also surged, beginning in the pandemic’s earliest months.12 By October 2021—a year that Forbes enthusiastically characterized as “stellar” and “record-breaking”— twenty-one leading private equity billionaires were worth a combined $154 billion.13 As of 2025, the “finance and investments” sector that includes private equity remained the “dominant billionaire factory,” responsible for the wealth of 15.3 percent of all billionaires, even surpassing the tech sector (13.2 percent).14
THE SILENT PARTNER: GOVERNMENT
During Covid, hospitals and other PE-owned healthcare institutions raked in billions in government payments. This highlights the most important point at the core of Ballou’s book (a fact with which Morgenson and Rosner fully agree): PE could not thrive without government help. At the most obvious level, this should be unsurprising, because nearly nine in ten members of Congress (88 percent) receive campaign donations from private equity,15 with PE having spent a whopping $150 million on the 2024 elections.16 An analysis that year found that twenty-six of the wealthiest senators and representatives (from both political parties) also had personal PE investments worth over $150 million; because of limited disclosure requirements, the analysts believe this amount to be “almost certainly a significant undercount.”16
Ballou comments about government involvement in private equity, “[T]he stunning success of private equity is all happening with the support of the government, whose various arms. . . have not only allowed private equity to grow and dominate but have actively encouraged it.” When it comes to the federal government, not only has it been “extraordinarily solicitous” of PE firms—including dropping major lawsuits about PE ripoffs of federal money on the eve of trial17 and abandoning whistleblowers to their fate—but it actually subsidizes private equity’s depredations in a variety of ways. The government “gravy train,” explain Morgenson and Rosner, includes subsidies, contracts, federal loans, loan guarantees, bailouts, tax loopholes and more. And nowhere is the ignominy of this unacknowledged “public-private partnership” more apparent than in private equity’s devastating incursions into healthcare.
“FULL-THROTTLE ASSAULT” ON HEALTHCARE
Private equity’s reach “extends from cradle to grave,” note Morgenson and Rosner, with its tentacles entering sectors ranging from pre-K learning centers to rental housing to podcasts to online betting to supermarkets. For nearly three decades, however, healthcare and hospitals have been particular PE magnets, with private equity playing an instrumental role in reshaping and restructuring the healthcare industry.18 According to some estimates, the PE industry has spent $1 trillion on healthcare acquisitions since 2000.19
In the U.S., as of April 2025, PE owned nearly one in ten private hospitals (9 percent) and almost one in four proprietary for-profit hospitals (23 percent).20 Twenty-three percent of PE-owned hospitals as of last year were psychiatric facilities, and at least 28 percent served rural populations.20 Again illustrating the silent partnership with government, rural hospitals apparently make especially attractive PE targets because most of their funding comes from Medicaid and Medicare, “which guarantees a level of income.”15
Alongside ownership of hospitals, PE has invaded emergency departments (EDs)—a push facilitated by “a lot of regulatory cracks in the system.”21 Nationally, a recent study estimated that one in four ED visits takes place in emergency departments staffed by private equity, and in some states, the PE market share for ED visits exceeds 30 percent.22 Other long-standing PE favorites include ambulance services, nursing homes, outpatient physician practices (with a 600 percent increase in PE takeovers of physician-owned practices from 2012–202115), urgent care, ambulatory surgery centers, maternal health, home care services, rehabilitation services, hospices and specialties ranging from dermatology to dentistry.
In recent years, PE has branched out to other “fast growing and niche market segments,”18 scooping up fertility clinics,23 health information technology companies,24 clinical trial entities,25 autism therapy centers26 and medical billing and debt collection services (euphemistically called “revenue cycle management” or RCM).27 According to the nonprofit watchdog group Private Equity Stakeholder Project (PESP), PE’s entry into the RCM arena has led to more aggressive debt collection efforts as well as attempts to collect “wrong amounts” or even debts that are not owed at all!28
By all accounts, PE ownership has “ravaged”29 healthcare institutions and significantly lowered the quality of care they provide. This is documented in a growing number of publications,18 and even medical insiders are appalled. A retired professor of medicine wryly suggests that private equity’s goal—facilitated by ample financial resources and “arcane financial engineering strategies”—has been “to maximize profits by manipulating the fiscal opportunities in the management of business dealings surrounding care without providing any actual care for patients.”29 More bluntly, the current president of the American Academy of Emergency Medicine, Vicky Norton, MD, has stated that while PE firms’ clear goal—maximize profits “above all else”—may not be, in and of itself, evil, “when you mix it into healthcare, it is inherently evil.”21 As if to bear out Norton’s statement, a study published in 2025 announced that after private equity acquires a hospital, the emergency room Medicare population experiences 13 percent increased mortality compared to the death rate before the acquisition.30 Morgenson and Rosner put it this way: “While the impact of private equity on industries tends to be negative, in healthcare it can be deadly.”2
Critics argue that private equity’s presence in the healthcare arena has also resulted in more expensive services. One study found that from one year to the next (2017–2018), Americans spent 4.6 percent more on healthcare—but they did so due to higher prices, not because they were going to the doctor or hospital more often.18
Cost-cutting actions that PE owners commonly take after an acquisition include:
- Cutting inpatient staffing (and slashing salaries) so that fewer and less-well-paid staff have to care for more patients
- Pressuring outpatient clinicians to increase daily patient volumes
- Substituting less skilled staff (such as replacing a doctor with a physician’s assistant or full-time employees with contractors)
- Not keeping up with equipment needs (or using shoddier supplies and equipment)
- Reducing training and supervision
- Hospitalizing patients unnecessarily
- Over-ordering diagnostic tests and procedures, or ordering more costly tests than required
- Booking patients for treatments they don’t need
- Demanding more aggressive coding on insurance claims
- Using “surprise medical billing” as a business model31 (that is, billing patients at out-of-network rates when services were delivered at an in-network facility)
- Providing loans (“via medical credit cards, high-interest payment plans, and strategic partnerships with financial service providers”) that trap patients in unpayable medical debt19
The net effect of these cost-cutting and revenue-boosting measures is that assets once used for patient care are transferred “to investor profits, leaving behind a medical practice or hospital less able to provide medical care to patients.”5 As a physician observes, “Cutting corners to gain a competitive advantage is inherent in the PE strategy.”23 This leads to dangerous mistakes and shortfalls for patients, including, for example, medication errors, poor management of bed sores, unskilled performance of critical procedures and, for more debilitated patients or nursing home residents, withdrawal or unavailability of assistance with eating and personal hygiene.
ASSISTED REPRODUCTION TAKEOVER
One out of every thirty-seven babies born in the U.S. is conceived using an assisted reproductive technology (ART) such as in vitro fertilization (IVF), with the number of ART births increasing by 23 percent between 2020 and 2022.32 This growth has attracted private equity’s attention. As Spanish assisted reproduction expert A.A. Zadeh23 explains:
- The “fragmented yet resilient [fertility] industry combines steady revenue streams with significant growth potential.”
- The industry anticipates growth due to “trends such as delayed family planning, high self-pay rates, increasing demand from LGBTQ+ individuals, and [IVF] profitability.”
- The “strong private pay component” ensures “an attractive reimbursement profile.”
- The industry anticipates “consistent demand,” helping to make it “recession-resistant.”
Thus, as of 2023, over 32 percent of U.S. fertility clinics were “private equity affiliated”—double the proportion owned by PE in 2018—and those clinics carried out 54 percent of all in vitro fertilization cycles (versus 29 percent of IVF cycles five years earlier).23,33
Zadeh also notes that PE ownership increases pressure to promote add-on treatments that often are “medically obsolete, lacking robust evidence of clinical benefit, yet highly profitable.”23 He comments that while pushing add-ons is not exclusive to PE clinics, “the scale and aggressiveness of their promotion have significantly increased under PE ownership,” where “commercial teams—rather than clinicians—often drive the inclusion of such treatments in the clinic’s portfolio.” He concludes, “The controversy lies not in the existence of these add-ons, but in how they are marketed, incentivized, and presented to patients.”
ANOTHER EMERGING NICHE: CLINICAL TRIALS
In late 2025, the Private Equity Stakeholder Project (PSEP) warned that private equity is now moving into the clinical trial industry, with clinical trial sites considered “among the most sought-after segments of the pharmaceutical services industry.”25 A worried PESP points out that private equity involvement in clinical research could “reshape how medical studies are conducted and overseen,” and that growing consolidation of research sites raises concerns about trial safety and long-term impacts on patients.
According to PESP, two PE-backed firms also control much of the institutional review board (IRB) process that is an essential step in evaluating whether proposed research in humans is ethically acceptable. As of 2021, the two PE-backed IRBs reviewed fully 92 percent of all drug trials overseen by independent IRBs—a concentration, PESP comments, “that could compromise objectivity.” When one of the PE-backed IRB firms approved a trial for an Alzheimer’s drug, it used a “secrecy provision” to circumvent certain aspects of informed consent, and the result was disastrous: the drug ended up causing brain bleeding or swelling in 37 percent of participants and killed two of them.
NO EXIT?
Until now, the general pattern has been for PE firms to hold companies for an average of ten years and then sell the companies off. Increasingly, however, they are having trouble exiting. For a variety of complex reasons, they are currently “choking on their portfolios” and, according to Tiffany Cianci, sitting on a $4 trillion backlog.
Even the mainstream financial press and other media are now pointing to worries about “rot” in the private equity industry. Fitts and Cianci suggest that this is prompting the PE industry to invent new shenanigans. Cianci comments, “I don’t know a better way to explain it than they’ve run out of ways to cash out, every single vehicle they’ve used isn’t working, and so now it’s just whoever can come up with the newest thing that’s not illegal yet.” One of the “newest things” is a Ponzi-scheme-type practice called “continuation funds.” Continuation funds allow PE “to hold on to assets beyond the typical fund term and, instead of selling the assets to third parties, sell them to their own newly established fund”—that is, to themselves.34 As the authors of a University of Chicago business school paper wrote in January 2024 in surprisingly honest terms, the strategy raises a “labyrinth of concerns” about conflicts of interest that “cast a shadow” on continuation funds’ growing prevalence.34
Unfortunately, as the business school authors wrote, “the ‘house always wins’ is a major part of private equity managers’ incentives.” In August 2025, the PE “house” won in a big way with a new executive order35 signed by President Trump that allows 401(k)s to invest in “alternative assets” that include PE, a move that augments the already sizable risks that retirees face from underperforming state pension funds’ incautious devil’s bargain with private equity.36
These undesirable macro-level developments do not mean that ordinary people are powerless to push back. In the face of private equity’s shaky stranglehold on business and investment, Fitts and Cianci have one ready answer: Stop investing in and spending money on unproductive and extractive entities, and redirect your investments and spending toward productive, high-integrity entities that build real wealth, including the local businesses where you live. As Cianci explains, “Every time a private equity firm acquires a business in your community, 94 percent of the money you give that company leaves your community and never comes back. But if you support a small business in your community, that small business keeps $0.68 to $0.74 [of every dollar] in your community. It stays in your town.” (Individuals with pension funds and 401(k)s should also call their fund administrators and make it clear that they want their investments to be private-equity-free.)
When it comes to healthcare, a simple solution is likewise available: stay healthy so that you do not have to interface with an untrustworthy healthcare system. The Weston A. Price Foundation and Wise Traditions offer numerous resources, including a helpful article by Dr. Andrew Kaufman that describes how to stay out of the emergency room.37 And let’s be honest: the pharma-dominated healthcare system that private equity has run roughshod over was never all that safe or health-promoting to begin with.
SIDEBARS
THE POISONING BUSINESS MODEL
Families victimized by vaccine injury and other forms of medical harm have begun to understand that medical poisoning is a business model. Private equity’s timely entry into autism services illustrates that PE, too, understands the model. Pharmaceutical companies poison children, cause neurological damage and create a market for services to manage the damage—while private equity buys up the industry providing those services.
Catherine Austin Fitts also speculates that private equity’s careful advance positioning in hospitals and other critical healthcare infrastructure may have been a necessary (or at least helpful) ingredient facilitating the medically unethical and murderous practices that took place in hospitals during Covid.
WHY DO THEY SELL?
Given the often-disastrous patient and business outcomes that follow a private equity acquisition, one could be forgiven for wondering, why does anyone sell to PE to begin with? In healthcare, some authors chalk up physicians’ sale of their practices to the fact that “they were trained to be doctors and healthcare professionals, not business people.”18 As those authors suggest, “On-going financial pressures and heightened contestation over reimbursements by the government and third-party payers have led some providers to view private equity buyouts of their practices as welcome relief.”
In addition, private equity’s “cash enticement” to doctors can be powerful: “Private equity typically pays 15 times the physician’s annual income to acquire it entirely. . . . That purchase price may then be taxed at the lower capital gains rate, leaving the physician with a handsome payday and an opportunity to retire early.”5 That observer, general counsel of the Association of American Physicians and Surgeons (AAPS) Andrew Schlafly, cautions, however, that there are “onerous strings attached” and “fine print” that can make the embrace of private equity “the equivalent of jumping out of a frying pan and into a fire.”5
REFERENCES
- https://stockanalysis.com/list/most-employees/
- Morgenson G, Rosner J. These Are the Plunderers: How Private Equity Runs—and Wrecks—America. Simon & Schuster, 2023, pp. 4, 12-14, 18, 26, 175, 176, 186.
- Ballou B. Plunder: Private Equity’s Plan to Pillage America. PublicAffairs, 2023, pp. 3-5.
- Singh H. Evolution of leveraged buyouts: a new era or back to square one? New York University Journal of Law & Business, Jan. 18, 2020.
- Schlafly A. The harm from private equityʼs takeover of medical practices and hospitals. Mo Med. 2024 Sep-Oct;121(5):328-332.
- Fitts CA. Private equity: see the game, change the game with Tiffany Cianci. The Solari Report, Jan. 6, 2026. https://solari.com/private-equity-see-the-game-change-the-game-with-tiffany-cianci/
- Brownstein M. Private equity’s appetite for hospitals may put patients at risk. Harvard School of Public Health, Dec. 16, 2024.
- Dabos V. Private equity behind 70% of large U.S. bankruptcies in the first quarter of 2025. Private Equity Stakeholder Project, Apr. 25, 2025.
- Fairlie R, Fossen FM, Johnsen R, et al. Were small businesses more likely to permanently close in the pandemic? Small Bus Econ (Dordr). 2023;60(4):1613-1629.
- Lavery P, Wilson N. The performance of private equity portfolio companies during the COVID-19 pandemic. Journal of Corporate Finance. 2024 Dec;89:102641.
- Collins C, Ocampo O, Mycklebust S, et al. Report: billionaire wealth vs. community health. Inequality.org, Nov. 18, 2020.
- 118 billionaires in New York see net worth jump $77.3 billion or 14.8% in first three months of COVID-19 pandemic. Americans for Tax Fairness, Jul. 1, 2020. https://americansfortaxfairness.org/wp-content/uploads/NEW-YORK-ATF-HCAN-CANY-Billionaires-Report-Release-FINAL-7-1-20.pdf
- Klebnikov S. The richest private equity billionaires on the Forbes 400 List 2021. Forbes, Oct. 5, 2021 (updated Apr. 21, 2022).
- Rao P. Ranked: top sources of billionaire wealth by industry. Visual Capitalist, Sep. 2, 2025.
- Bristow L, Greenwell M. Private equity. Health Wanted, Emory University, Rollins School of Public Health, Aug. 1, 2025.
- Schwenk K. Lawmakers aren’t disclosing their private equity millions. Jacobin, Oct. 4, 2024.
- DOJ’s dismissal of the HCR ManorCare fraud case demonstrates an underlying policy shift in the current administration’s “fight” against Medicare fraud. The Law Office of Jeffrey J. Downey, P.C., Nov. 21, 2017.
- Appelbaum E, Batt R. Private Equity Buyouts in Healthcare: Who Wins, Who Loses? Institute for New Economic Thinking, Working Paper No. 118, Mar. 15, 2020. https://www.ineteconomics.org/uploads/papers/WP_118-Appelbaum-and-Batt-2-rb-Clean.pdf
- Jones KB. How private equity and the financialization of health services can undermine access to sexual and reproductive care. Center for American Progress, Oct. 30, 2025.
- PESP private equity hospital tracker. Private Equity Stakeholder Project, April 2025. https://pestakeholder.org/private-equity-hospital-tracker/
- Nielsen E. Most ED visits happen at corporate-owned facilities. MedPage Today, Aug. 8, 2025.
- Cai AG, Jarou ZJ, Janke AT, et al. Emergency physician employer market share and concentration by ownership type. Ann Emerg Med. 2026 Jan;87(1):50-55.
- Abraham Zadeh A. Private equity and reproductive medicine: “fertile breeding ground” – a physician’s perspective. Reprod Biol Endocrinol. 2025 Aug 1;23(1):113. Erratum in: Reprod Biol Endocrinol. 2026 Feb 17;24(1):26.
- Leitner R. Private equity healthcare acquisitions – December 2025. Private Equity Stakeholder Project, Jan. 28, 2026.
- Dabos V. Private equity moves into clinical trials. Private Equity Stakeholder Project, Nov. 24, 2025.
- Siliezar J. Private equity firms acquired more than 500 autism centers in past decade, study shows. Brown University School of Public Health, Jan. 7, 2026.
- Why private equity is betting big on revenue cycle management companies in 2026. I-conic Solutions, n.d. https://i-conicsolutions.com/why-private-equity-is-betting-big-on-revenue-cycle-management-companies/
- Fenne M. Private equity’s revenue cycle: creating and collecting U.S. medical debt. Private Equity Stakeholder Project, Sep. 12, 2024.
- Webster JR. Private equity and the ravaging of United States healthcare. Mo Med. 2025 Jan-Feb;122(1):7-10.
- Kannan S, Bruch JD, Zubizarreta JR, et al. Hospital staffing and patient outcomes after private equity acquisition. Ann Intern Med. 2025 Nov;178(11):1529-1538.
- Leitner R. Profiting on all sides: private equity and the No Surprises Act. Private Equity Stakeholder Project, Nov. 5, 2025.
- How many IVF babies are born in the US? USAFacts, updated Aug. 4, 2025. https://usafacts.org/articles/how-many-ivf-babies-are-born-in-the-us/
- Ke J, Chen J, Chun E, et al. Trends in private equity affiliations with fertility clinics in the US. JAMA. 2026 Feb 17;335(7):630-632.
- Kastiel K, Nili Y. The Rise of Private Equity Continuation Funds. Chicago: Stigler Center for the Study of the Economy and the State, University of Chicago Booth School of Business, New Working Paper Series No. #340, January 2024.
- Democratizing access to alternative assets for 401(k) investors. The White House, Aug. 7, 2025. https://www.whitehouse.gov/presidential-actions/2025/08/democratizing-access-to-alternative-assets-for-401k-investors/
- Neff J. State treasurer sings a new tune on private equity. Willamette Week, Nov. 3, 2025.
- Kaufman A. How to stay out of the emergency department. Wise Traditions. Summer 2024;25(2):32-43. https://www.westonaprice.org/health-topics/when-should-you-not-go-to-the-emergency-room/


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