Dustin Gentry, MD, FAAFP

This completely ignores the legislative handcuffs placed on doctors. You ask why independent physicians don't 'scale' to access the same funding mechanisms hospitals use. The answer is simple: it’s illegal. Between the ACA's ban on Physician-Owned Hospitals (POH) and the Stark Law, doctors are expressly barred from scaling. If they try to build their own facilities—the ORs and imaging suites you mention—they are literally cut off from the Medicare/Medicaid markets or buried in compliance costs. They also don't have access to the tax-free municipal bonds hospitals use for cheap capital. There’s nothing 'special' about HCA or PE-backed groups. The only thing 'special' about non-profit systems is that they can grow at scale without paying taxes and self-refer across their entire network—something the law calls 'criminal' if a small group of doctors tries to do it with a local ASC. Independent doctors 'ration' Medicaid because they are structurally excluded from the revenue streams and 'State Directed Payments' that hospital lobbyists have secured for themselves. Look at the double standard: When a physician-led facility like Doctors Hospital at Renaissance in McAllen serves a massive Medicaid population, they get labeled 'greedy' by Atul Gawande and the Obama admin. But when a giant 'non-profit' system throttles Medicaid appointments, consolidates to jack up prices, and guts the local economy, we’re told they’re doing 'charitable work.' Finally, let's talk about the GME 'subsidy.' Hospitals get a massive ROI on resident labor. When UNM’s neurosurgery program lost its 10 residents, they had to hire 23 APPs just to cover the volume. Residents 'pay' for their education with 80+ hour weeks at sub-market rates. The hospital isn’t gifting an education, it’s performing labor arbitrage on the most highly skilled workers in the country. Doctors aren't 'choosing' to be passive beneficiaries. They’ve been legally sequestered from the capital and scale required to compete