We agree with Hughes’ objectives of ensuring that profit-seeking behavior should not affect patient care and resident training, pay, and wellbeing, but we disagree with his conclusions.

Hughes’ concern between “for-profit training sites” and resident training stems from research showing that pediatrics residents affiliated with for-profit hospitals have lower board pass rates than those in nonprofit hospitals. If we dismiss the plausible explanation that the caliber of trainees in for-profit hospitals differs from trainees in nonprofit hospitals (which are among the most prestigious training programs), we hypothesize that lower pass rates are a result of for-profit hospitals overburdening residents by hiring fewer support staff and overemphasizing volume due to fee-for-service reimbursement. Unlike for-profit hospitals, value-based care practices have a hybrid or fully capitated reimbursement model that de-emphasizes service output and allows for ample support staff along with higher physician compensation.

Hughes notes that training residents in for-profit environments risks producing physicians who normalize the prioritization of profit and entrenched inequities, ultimately resulting in burnout and moral injury. We agree with this risk but argue that profit-seeking behavior is not limited to profit status. Similar to for-profit hospital systems, nonprofit hospital systems—which manage most residency training programs—in recent years have also consolidated with the goal of maximizing market share, resulting in higher prices for patients, and are largely governed by finance and business executives without a background in healthcare.1 Research also finds that nonprofit hospitals spend less on charity care than for-profit hospitals.2 Linking profit status with trainee wellbeing ignores the financialization of healthcare that overlies tax-based distinctions.

Hughes points to concerning data showing the potential patient harm of private equity–acquired hospitals and America’s lagging healthcare outcomes with high healthcare costs. We are similarly concerned with the role of private equity in healthcare but have yet to see data showing that venture-backed primary care practices similarly result in worse healthcare outcomes. Entirely dismissing the role of private actors is premature and could hinder care delivery innovations that may improve healthcare outcomes and reduce costs. Finally, to suggest that profit status is behind America’s lagging healthcare outcomes and high costs is to ignore leading arguments for this phenomenon. Compared to other countries, the US does not invest enough, particularly in its youth, in social services that affect health.3 And, the US comparatively has higher healthcare prices, prices set by both for-profit and nonprofit entities.4