When private capital becomes the private government of health

The Guardian reports that a watchdog group has raised an alarm about the proliferating joint ventures between private equity firms and nonprofit healthcare organizations, warning of risks to patients and calling for greater government oversight. I was not alive to witness the particular mechanisms of modern finance, and I will not pretend otherwise. But the shape of this problem — private capital massing into an institution so large and so essential that it sets the terms of life for ordinary citizens — is exactly the shape I spent a public career resisting.

I distrusted the Bank of the United States not because banking is wicked, but because a single private institution commanding the financial sinews of a republic becomes, in time, a private legislature. It issues its own edicts; it makes its own sovereigns. Whatever I said of Hamilton's Bank, I say now of any entity that quietly absorbs control over what a citizen cannot live without. Healthcare is not a luxury good. It is, in the most literal sense, the precondition of every other liberty. A person who cannot be treated when ill, or who is driven into poverty by the terms of that treatment, is not the free citizen on whom a republic depends.

The watchdog's concern, as The Guardian frames it, centers on arrangements between private equity and nonprofit institutions — arrangements that may blend the tax-favored standing of public charity with the profit imperatives of private capital. This is precisely the kind of opacity that republics must resist. When the legal form says "nonprofit" and the economic reality says "extraction," the citizen is being deceived twice: once at the bedside, and once in the public record.

I am wary of reflexive calls for federal expansion. The concentration of regulatory power in a single national authority carries its own dangers, and I have never been shy about saying so. But concentrated private power is not the cure for concentrated public power; it is merely the same disease wearing a different coat. Where a market has grown so consolidated that patients have no meaningful exit — no competing provider, no alternative — the republican remedy is transparency, accountability, and the restoration of genuine competition. If law and oversight are required to achieve that, then law and oversight are what the public interest demands.

The deeper question the watchdog raises is one of accountability: to whom does this accumulation of power answer? A king answers — in theory, at last resort — to the law of nations and the sword of his subjects. An elected government answers to the ballot. But a private equity firm that controls a regional hospital network answers chiefly to its limited partners, most of whose names the public never learns. Quis custodiet ipsos custodes? — who watches the watchmen? — is not merely a legal puzzle. It is the central republican question, and the answer, in a self-governing society, must always be: the public, through its chosen institutions.

The citizens of this Republic should take this report not as a technical matter for specialists, but as a civic alarm. The accumulation of essential services under private control, shielded from public scrutiny and answerable to distant investors rather than to local communities, is the modern form of the old monopoly problem. I labored to keep power dispersed and visible. That labor belongs to every generation that inherits this Republic — not as a nostalgic exercise, but as the price of remaining free.