Private Equity’s Grip on U.S. Reproductive Care: Rising Costs, Risks & Health Threats

The expansion of private equity investment into reproductive, maternal, and hospital‐based care in the U.S. presents a complex picture. Based on recent evidence, certain patterns are now well supported, while key unknowns and strategic risks persist.

What is known:

• Prevalence: PE has taken ownership or affiliation in a large number of reproductive health providers—OB-GYN practices, fertility clinics, maternity services—and as of 2024, engagement in health care reached $104 billion in deals in that year alone [1]. In fertility care, only ~4% of clinics were affiliated with PE in 2013, but by 2023 that had increased to 32%, and these PE-affiliated clinics now perform over half of all IVF cycles in the country [2].
• Patient outcomes: Peer-reviewed studies indicate measurable deterioration in quality and safety after PE hospital acquisitions. For example, ED mortality rates for Medicare patients in hospitals acquired by PE rose by ~13% relative to matched hospitals—translating to about seven more deaths per 10,000 ED visits [4][6]. Hospitals also saw larger increases in hospital-acquired conditions like infections and falls after PE acquisition [5]. Staffing and salary costs in critical care settings were sharply cut [4][5].
• Access, equity, and cost: There is consistent evidence that PE ownership contributes to rising costs for patients and payers, because of both increased charges and focusing on higher-margin services [1]. Marginalized populations—low-income, rural, or predominately Medicaid patient populations—appear disproportionately affected through facility closures (including maternity units), avoidance of low-reimbursement patients (e.g., fewer Medicaid childbirths), and medical debt exacerbation via aggressive financial practices [1][7][8].

What is less certain or contested:

• Quality and patient satisfaction outside ED/ICU/maternal settings: While fertility care shows massive PE involvement, studies yet to clearly demonstrate whether on average these clinics under PE achieve lower or higher patient satisfaction or clinical outcomes than non-PE clinics [2].
• Heterogeneity across PE firms: PE firms differ in strategy, geography, existing infrastructure, and duration of ownership. Not all follow identical cost-cutting practices; some make investments in modernization or capacity, especially in under-served or rural settings—though evidence is sparse [1][2][3].
• Long-term versus short-term trade-offs: Many PE model critiques focus on short-to-medium‐term harms (3-7 years post-acquisition), but longer-term outcomes—including whether efficiency gains or reinvestment offset earlier harms—are not yet well documented.

Strategic implications:

• Regulatory risk: Many PE health care transactions fall below federal antitrust thresholds and avoid review; state oversight and transparency requirements are inconsistent. This creates risks for both communities and investors as public backlash grows. The passage of laws like Massachusetts’s H.B. 5159 in 2025 indicates potential regulatory tightening [1].
• Reputation and trust: Negative outcomes (greater mortality, poor safety, facility closures) may reduce public trust in both PE-owned entities and hospitals broadly, particularly when communities feel underserved.
• Investor exposure: Facilities under PE control may face financial risk (bankruptcies, closures) when cost structure, debt load, or regulatory environment shifts, as seen with Prospect Medical Holdings’ bankruptcy and subsequent hospital closures [1].
• Equity in access: Closures of maternity wards, and the creation or persistence of maternity care deserts, raise strategic concerns for public health, especially in rural or under-resourced areas. Ensuring equitable access will become more challenging without deliberate policy design.

Open questions:

• What are the long-term clinical outcomes at PE-affiliated fertility clinics—success rates, adverse outcomes, cost per cycle, and patient experiences—compared to non-PE models?
• How do PE strategies vary by region, population served, and type of facility (for-profit hospital, nonprofit hospital acquisition, rural vs urban clinics)? What best practices mitigate risks?
• How will ongoing legal, public policy, and regulatory changes (e.g., lower antitrust thresholds, ownership transparency laws, oversight of medical debt practices) affect future PE investment behavior and health care market structure?
• What are the implications for insurance markets, especially Medicaid and Medicare reimbursement rates, when PE ownership leads to higher charges and possibly changes in case mix?