What started as a Christian work of mercy has morphed into a $31 billion-a-year industry that’s attracting fraudsters and private-equity profit hunters. As legalized assisted suicide gains a foothold in the U.S., some pro-life advocates fear worse problems lie in store.

….Recent news reports about rampant fraud have cast hospice in a different light. In June, for example, federal authorities charged the operator of multiple Los Angeles hospice businesses, along with a group of alleged accomplices, with a $27-million fraud scheme that involved stealing the identities of dead people and billing the government for phony healthcare services, using the proceeds to pay for luxury items including lease payments on a Rolls-Royce Phantom sedan that costs more than $500,000.

“Can you imagine anything more low than to pretend you’re taking care of dying people when you’re not?” said Wesley J. Smith, chair and senior fellow at the Center on Human Exceptionalism….

“I’m a big supporter of good hospice care,” Smith said. “But I’m worried about the direction hospice is going.”

Smith isn’t alone, and it isn’t fraud that worries him most. With physician-assisted suicide becoming legalized in a growing number of U.S. states, pro-life hospice advocates fear some hospice operators, focused more on the bottom line rather than ethics, will present it as simply another end-of-life option for vulnerable patients and their families.

Medicare helped expand access to hospice by creating a reimbursement system in which providers receive daily payment for each day a patient remains enrolled, regardless of the amount of care provided.

Hospice demand has grown alongside the nation’s aging population and rising chronic illnesses such as dementia, cancer and cardiovascular disease. Baby boomers make up about 20% of the U.S. population — roughly 73 million Americans. According to the Brookings Institution, the nation’s population aged 80 and older is projected to nearly double from 14.7 million in 2025 to 29.4 million by 2045, increasing demand for long-term care services, including hospice.

Those demographic factors have transformed the hospice landscape. According to the University of Pennsylvania’s Leonard Davis Institute of Health Economics, the number of Medicare hospice users grew from 500,000 in 2000 to 1.8 million today, while annual Medicare spending on hospice increased from $3 billion to $23 billion during the same period.

The ownership structure of hospice providers changed alongside that growth. In 2000, about one-third of hospice agencies were nonprofit organizations, according to Penn. Data from the March 2026 Medicare Payment Advisory Commission report to Congress shows that, today, more than 80% of all U.S. hospice agencies operate as for-profit organizations. Research from the National Center for Biotechnology Information found that private-equity ownership of hospices also tripled between 2011 and 2019.

Private-equity-owned hospice agencies are operated by investment firms rather than nonprofits or independent owners. Supporters argue these models can expand access, while critics question whether financial incentives align with hospice’s patient-centered mission. Penn LDI found that nonprofit hospice agencies generate yearly profit margins of roughly 5%-6%, compared with about 18%-22% among for-profit private-equity or publicly owned agencies.

National hospice data does not categorize providers by religious affiliation, but Catholic hospices represent only a small share of the overall field. Based on CMS ownership data, an estimated 100-200 Catholic hospice providers operate in the United States, representing roughly 2%-3% of all hospice providers.

Dr. Ira Byock, a physician and longtime leader in hospice and palliative care, said the expansion of hospice remains one of the field’s greatest achievements, allowing millions more Americans to receive end-of-life care outside of hospitals. His concern, however, is that increasing commercialization has changed the priorities of some providers.

But he said the landscape began changing in the early 2000s, when some large hospice companies became publicly traded and new management structures placed greater emphasis on financial performance.

“After that we watched the hospice quality spiral down and the attitudes of the new management focus on finances,” Byock said.

“I am not against for-profit hospice care,” he noted. “I’m an American and a capitalist. I think there is a place for for-profit hospice care, but those programs must succeed by delivering consistently high-quality care and, unfortunately, that’s not what we’ve seen.”

He pointed to staffing pressures as one example, telling the Register that “it’s not uncommon these days, particularly in corporate hospice programs, for hospice physicians to be responsible for 150, 200 or even more patients at a time.” That, he said, is “dangerous” when a well-trained physician should be caring for around 70 patients at a time.

As hospice has grown into a larger and more complex industry, concerns about financial incentives have been accompanied by reports of more serious abuses. A ProPublica report documented numerous examples of alleged misconduct, including providers accused of enrolling patients who did not meet hospice eligibility requirements, using stolen identities to bill Medicare and creating financial incentives tied to patient enrollment.

California is home to some 2,200 hospice providers, nearly 40% of the national title, with the lion’s share based in the Los Angeles area. Between 2010 and 2023, the number of hospice companies in Los Angeles County spiked 1,500%, with a corresponding rise in suspected fraud, according to a report by the state auditor.

A recent CBS News investigation found that 700 of the roughly 1,800 hospices in LA County trigger multiple red flags for fraud as defined by the state.

The recent federal investigations, Byock said, have brought renewed attention to warnings that some within the hospice field had raised for years.

“Some of us in the field who have been close to this have been seeing this happening over the years and have been trying to get attention from the Department of Justice and Medicare,” Byock said….

Catholic leaders point to developments outside the United States as another reason for concern. Joseph Meaney, senior fellow at The National Catholic Bioethics Center, which provides ethical guidance on healthcare issues from a Catholic perspective, said Catholics should pay particular attention to Canada, where Medical Assistance in Dying (MAID) was legalized nationwide in 2016.

The debate has become especially visible in British Columbia, where Catholic healthcare institutions have faced questions over whether they can remain MAID-free while participating in the public health system….

“Thankfully the U.S. is not Canada,” Meaney said, “but I’m fearful because what’s happening there sort of gives you an impression of where things are headed here in the States….”

From the National Catholic Register