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The report documents a significant increase in private equity (PE) and venture capital (VC) ownership within the U.S. PACE sector, noting that 15% of all programs now have such backing. It highlights the risks of leveraged buyouts and debt-driven strategies, using InnovAge as a case study to illustrate how aggressive growth and investor payouts can lead to financial instability and regulatory sanctions for care deficiencies. The document also examines the use of federal Opportunity Zone tax incentives to attract healthcare investment and calls for stronger oversight to prevent extractive financial practices in publicly funded elder care.

The Private Equity Stakeholder Project (PESP) supports Massachusetts Senate Bill 868, which aims to prevent healthcare provider financial distress by prohibiting excessive leverage, debt-funded dividends, and certain real estate transactions. PESP argues that private equity ownership in the US healthcare sector has led to increased consolidation, service cuts, and high bankruptcy rates, citing the 2024 bankruptcy of Steward Health Care as a primary example of the risks posed to Massachusetts patients and workers.

The report analyzes the incursion of private equity into private duty nursing (PDN), a critical service for medically complex individuals. It argues that the private equity business model—characterized by leveraged buyouts, roll-up strategies, and high debt—diverts Medicaid funds away from direct patient care to service debt and generate investor returns. Through case studies of Team Select Home Care and Aveanna Healthcare, the document illustrates how these financial pressures lead to staffing shortages, low wages, and compromised patient safety. It highlights the 'preferred payer' strategy used by Aveanna to deprioritize patients with lower-reimbursing payers and notes industry opposition to the CMS 80/20 pass-through rule. The report concludes with policy recommendations including antitrust enforcement, limits on healthcare debt, and the expansion of paid family caregiver programs.

The report estimates that air pollution from a subset of private equity-backed fossil fuel infrastructure in the U.S. causes between $11.3 billion and $15.1 billion in annual health costs. Using the EPA's COBRA tool, the analysis finds these facilities are responsible for approximately 1,000 premature deaths and 1,500 emergency room visits each year. The document argues that private equity firms must disclose their fossil fuel exposure and health impacts, cease investments in fossil fuel expansion by 2030, and integrate environmental justice into their operations.

The document details the expansion of private equity ownership in Michigan's housing market, specifically across manufactured home communities, apartment complexes, and student housing. It highlights a pattern of aggressive rent increases, hidden fees, and poor maintenance, while noting that state and university funds have invested billions into the firms responsible. For example, Blackstone increased average rents at its five Michigan student housing properties by 26% over three years, and Yes! Communities owns 64 parks with approximately 20,900 lots in the state.

The report details how private equity-owned VRS providers, Sorenson Communications and ZP Better Together, maintain unsafe working conditions that lead to interpreter burnout and a national shortage, negatively impacting service quality for Deaf consumers despite increased federal funding from the FCC.

The report examines how private equity firms use 'energy transition funds' to invest in 'false solutions'—technologies that are unproven, promote continued fossil fuel use, or lack accountability. It analyzes six specific industries: carbon capture, carbon trading, gas certification, hydrogen, biomass, and renewable natural gas. Through case studies of firms like BlackRock (GIP), Warburg Pincus, Quantum Capital Group, and Apollo, the report demonstrates a gap between sustainability claims and actual portfolio holdings, which remain heavily invested in fossil fuels. It concludes by providing due diligence resources for institutional investors to mitigate climate-related financial risks.

The report argues that the Opportunity Zone program, created by the 2017 Tax Cuts and Jobs Act, serves as a subsidy for private equity firms rather than a tool for community redevelopment. PESP identified $16.2 billion raised for Qualified Opportunity Funds (QOFs) by approximately 200 firms, with Bridge Investment Group Holdings, CIM Group, and Griffin Capital Company among the top beneficiaries. The document details how firms profit via capital gains tax deferrals and annual management fees, often ranging from 1.25% to 2%. Case studies in Los Angeles, Atlanta, and Arizona suggest the program encourages the development of luxury housing and the displacement of low-income residents through 'substantial improvement' requirements that necessitate evictions. The report also highlights political ties between major QOF investors and the Trump administration, and criticizes the lack of federal reporting requirements to track the program's actual impact on poverty.

The report argues that outsourcing critical school functions to private equity-backed firms prioritizes short-term profit over student wellbeing and worker stability, leading to lower service quality, increased staff turnover, and risks to student data privacy.

The report details a crisis of occupational health among ASL interpreters at the two dominant US Video Relay Service (VRS) providers, Sorenson Communications and ZP Better Together. Drawing on academic research and interviews, it finds that intense call volumes, insufficient breaks, and a lack of ergonomic support lead to high rates of cumulative motion injury and psychological distress. These conditions, exacerbated by private equity ownership, drive experienced interpreters to leave the field, thereby reducing the quality of service for Deaf users. The document recommends that the FCC and VRS providers engage with unions and researchers to redesign job roles and increase break times.

Private equity firms control nearly 9% of Michigan's private sector workforce, with investments often linked to public pension funds like the State of Michigan Investment Board. The document details how this ownership model has contributed to bankruptcies in the automotive, retail, and hospitality sectors, as well as labor disputes and service reductions in healthcare and waste management. Specific examples include the bankruptcy of Joann and IAC Group, and child labor allegations at Hearthside Food Solutions.

The report examines the 'Gulch' redevelopment project in downtown Atlanta, where the city provided significant tax breaks to the LA-based private equity firm CIM Group. It highlights that CIM Group reneged on its affordable housing commitments in October 2024, opting instead to pay an $8 million fee that advocates claim was based on outdated figures. The text frames this as part of a broader pattern of private equity infiltration in Atlanta's housing market and calls for greater city official accountability in vetting corporate partners.

The Private Equity Stakeholder Project (PESP) testified in support of Maine's LD 985 (SP 416), arguing that a moratorium on private equity ownership of hospitals is necessary to protect health systems from extractive investment practices. PESP highlights that private equity has invested over $1 trillion in US healthcare over the last decade, leading to horizontal consolidation across various medical specialties. The organization claims these practices include looting safety net hospitals, stripping real estate, and cutting less profitable services. Furthermore, PESP notes a high correlation between private equity ownership and healthcare bankruptcies, stating that 21% of healthcare bankruptcies in 2024 involved private equity-owned companies.

The Private Equity Detention and Surveillance Tracker details the involvement of private equity firms in the US mass incarceration system, covering facility management, healthcare, food services, telecommunications, and surveillance tools. It highlights how profit motives lead to cost-cutting in critical services, high markups on basic necessities, and the deployment of controversial surveillance technologies.

The report examines the 'Centennial Yards' (formerly the Gulch) redevelopment project in Atlanta, where the City provided nearly $2 billion in tax breaks to the LA-based private equity firm CIM Group. It highlights CIM's decision in October 2024 to renege on affordable housing promises by paying an $8.5 million 'in-lieu' fee, which critics argue is based on outdated 2017 data. The document further details CIM's controversial track record in other cities, including allegations of predatory behavior at Southern Towers in Alexandria, Virginia, and driving gentrification in the West Adams neighborhood of Los Angeles.

The report argues that the private equity business model, characterized by high debt and a focus on short-term returns, is incompatible with the goals of value-based care (VBC). It details how three VBC companies—CareMax, Cano Health, and Clinical Care Medical Centers (CCMC)—filed for Chapter 11 bankruptcy in 2024 due to unsustainable debt levels. The document highlights that these companies served vulnerable dual-eligible Medicare and Medicaid populations and that their failures accelerated healthcare consolidation, as assets were bought by vertically integrated insurers like Humana. It concludes with policy recommendations to limit debt in leveraged buyouts and increase antitrust enforcement.

The Private Equity Stakeholder Project (PESP) testifies in support of Oregon SB 951, arguing that private equity firms use physician management companies (PMCs) to bypass laws prohibiting the corporate practice of medicine. Citing various studies, PESP claims that private equity involvement in physician practices leads to increased healthcare costs for patients and dangerous market consolidation. The document highlights that in some metropolitan statistical areas, a single private equity firm controls over 50% of the physician practice market, and argues that limiting PMC control by non-physicians is necessary to protect clinical decision-making and competition.

The Private Equity Stakeholder Project (PESP) urges the Wisconsin Joint Finance Committee to adopt bill 25-1647, which would grant the Department of Health Services (DHS) power to review and approve material transactions in the health sector. PESP argues that private equity's debt-heavy business model—characterized by leveraged buyouts, sale-leasebacks, and dividend recapitalizations—leads to higher costs, reduced staffing, and increased bankruptcy risks for healthcare providers. The testimony highlights that in 2024, 21% of healthcare bankruptcies involved private equity-owned companies, and 88% of the largest bankruptcies (liabilities over $500 million) had a history of private equity ownership. PESP supports the bill's expansive definition of 'material change transactions' to include joint ventures and sale-leasebacks, aiming to prevent the 'looting' of safety net hospitals and protect patient care quality.

The document argues that private equity firms continue to acquire US nursing homes despite industry claims to the contrary, with ownership estimates ranging from 5% to 13%. It highlights how profit-driven practices, high debt, and complex ownership structures lead to bankruptcies and degraded care, citing specific cases like LaVie Care Centers and Goldner Capital Management. The report notes that while the Biden administration increased scrutiny, the Trump administration's focus on deregulation shifts the burden of protecting patients and workers to state legislatures.

The Private Equity Stakeholder Project argues against the University of California (UC) potentially reversing its 2020 decision to divest from fossil fuels. The letter asserts that fossil fuel investments are financially risky, citing the underperformance of fossil-fuel-heavy portfolios and the volatility of the LNG market. It further highlights the material threats of climate change to California, including astronomical wildfire costs, and warns that demand forecasts for data center power may be overstated, potentially misleading investors.