Opinion | Universities Are Prioritizing Their Health Systems Over Teaching. That’s Killing Academic Freedom.

Higher education has had a historically bad year. 

In June, the Supreme Court imposed constitutional restraints on how universities select its own students. Throughout the summer, Republican Florida Gov. Ron DeSantis trumpeted his bullying of higher education in the state, making it a centerpiece of his presidential campaign. And most recently, university presidents were humiliated during a congressional testimony on antisemitism on campus. One central lesson emerging at year’s end is that, more than ever, we in higher education need our university leaders to be bold and articulate defenders of academic freedom. Yet this is precisely what they have not been able to do.

Before we blame the individuals on center stage, however, we should look at the structural causes that brought us to this moment. A big reason for our disenchantment is that the job of a university president no longer prioritizes being a pioneering thought leader, but instead requires the skills of a savvy lobbyist. For most large universities, administrators’ attention has increasingly focused on outside funding and large revenue generators and away from student instruction and traditional scholarship.

One significant reason — one that has been wholly unappreciated but is growing in importance — is the role many universities play in our nation’s health sector. Universities with health systems are better understood as health systems with universities. As such, they are highly dependent on the graces and whims of policymakers, and their leaders are structurally restrained from asserting independence against, or challenging the wrongheaded politics of, elected leaders. In the end, academic freedom is the big loser.

Window into the Politics of Higher Education

It is not just Desantis, the Supreme Court and Congress. Many state legislatures have targeted higher education to advance their political objectives, and my home state of North Carolina offers a vivid microcosm of what might be called the new politics of higher education.

This legislative term, the state’s General Assembly advanced a number of bills this year that targeted academic ventures on the state’s University of North Carolina flagship campus, including a bill that would eliminate tenure, an effort to prescribe how instructors are to teach American history, and a budgetary intervention aimed to promote certain political ideologies.

The UNC faculty protested vocally, as nearly 700 signed a letter decrying the state’s recent actions “violate the principles of academic freedom and shared governance that undergird higher education in N.C. and the U.S.” UNC administrators, however, have not protested. Instead, UNC leaders aggressively sought special favors for its health system. The crown prize was the North Carolina Senate vote, 48-0, to grant the UNC Health system immunity from federal antitrust laws (after public scrutiny, the measure did not pass the state House).

We should be clear: health policy experts — including researchers at UNC’s renowned Gillings School of Global Public Health — agree that this is a horrendous policy move. The federal antitrust laws, designed to prevent monopolies and preserve competition, are gravely needed in the health sector (in the Senate’s limited debate, this much was conceded), and voluminous research has shown that hospital monopolies severely raise health care costs while reducing quality.

The mystery is not why the state considered implementing such unwise policy, since legislatures routinely extend special privileges to favored institutions. The real curiosity is why, with its academic integrity threatened and its independence on the line, UNC invested its limited political capital to ask for such a naked political favor.

The University-turned-Health System Finances

One answer — albeit a distressing one — is that UNC, like many large universities, is really a hospital system with a university appendage. UNC Health has a budget that is about $2.2 billion more than the entirety of UNC’s flagship campus in Chapel Hill ($3.5 billion vs $5.5 billion). This is also true for North Carolina’s private universities that operate health systems, like Duke University, whose health system has a budget $1.1 billion larger than the remainder of the university ($4.5 billion vs $3.4 billion). Moreover, both health systems are growing faster than the rest of both campuses.

These facts are important because the financial health of hospitals is highly dependent on political decisions. For example, the North Carolina General Assembly’s legislative session this year included debates over Medicaid expansion, which would infuse enormous sums of additional dollars into the state’s health sector, and “certificate of need” rules that would govern whether current hospitals could prevent competition from new entrants. The legislature — like all other state legislatures — also routinely makes decisions on insurance eligibility, the array of services that medical professionals may offer (so called scope-of-practice rules) and the tax-exempt status of many health care facilities.

So, perhaps it is not surprising that UNC leaders prioritized legislation that enhanced the financial security of its hospital system rather than measures that would protect its Chapel Hill faculty. And perhaps it is not surprising the University of Pennsylvania, MIT and Harvard — each of which rely heavily on government, foundation and industry funding (UPenn’s health system has a budget that is more than twice the university’s) — might seek presidents who exhibit the cautious effectiveness of corporate leaders, who can assure cooperation with policymakers and compromise with ideologues, rather than visionaries who inspire resoluteness and can mount an aggressive defense against Rep Elise Stefanik (R-N.Y.).

Florida and the Future of Higher Education

Of course, this is not a happy story. If the recent UNC experience is a reflection of what many large universities have become — institutions that are hamstrung in defending academic freedom and scholarly inquiry — Florida shows how universities can fall prey to genuinely malicious attacks from ambitious politicians.

DeSantis’ scorched earth approach to higher education might be one such campaign. It certainly has produced some permanent changes to higher education. One is the dismantling of the New College, the eclectic public liberal arts college in Sarasota, where DeSantis appointees fired the president, defunded departments and caused 40 percent of the faculty to leave. Another is at the University of Florida’s flagship campus in Gainesville, where — while the history department subsists on a $4 million budget — the Republican Legislature authorized $10 million in annual funds to build a center dedicated to address “cancel culture and uniformity.”

It is not a surprise that these efforts have triggered sharp criticism from faculty from both state universities. The legislative intrusions have led to an exodus of faculty at the University of Florida. University leaders, in contrast, have been largely compliant with their legislatures’ moves. This could simply reflect the reality that the president was appointed by and reports directly to the governor’s political overseers (“University presidents are not supposed to be puppets, but this is Florida,” said one UF faculty member). But there has been little resistance from academic administrators across the state’s large universities, including from the private University of Miami. And it is worth noting that both the University of Florida and the University of Miami both operate health systems that approximate or exceed the size of their flagship campuses.

This might also explain why the UF president, while receiving criticism for being absent from campus (“Missing! Have you seen this man?” a poster read with the president’s picture), nonetheless made a pilgrimage to Pensacola Beach, about 350 miles from campus, to meet the chair of Florida’s Senate Appropriations Committee.

Given the general acquiescence among Florida’s academic administrators, the resistance from the New College community is remarkable. At a trustees meeting in August, students, faculty, staff and alumni challenged the DeSantis proposals, and a coalition of former New College leaders have formed an alternative New College designed to protect academic freedom with online educational offerings (in an especially spiteful twist, DeSantis appointees threatened to sue the Alt New College for trademark infringement, forcing it to change its name from Alt New College to AltLiberlArts). Of course, the New College, a liberal arts institution with no hospital or medical school, had a total budget that was less than 3 percent of UF Health’s alone. It is the exception that proves the rule.

If Florida and North Carolina offer a window into the political economy of higher education, then it doesn’t matter who is appointed presidents of large universities — the political vise is inescapable. Even after President Liz Magill’s resignation from the University of Pennsylvania, the state Legislature voted against an appropriation for the university’s veterinary school to protest the school’s actions in the wake of the Israel-Hamas war.

The long-term consequences are grave. If university leaders cannot speak for and defend academics because they are overwhelmed by the economic realities of running a hospital, and if the university’s research arm and scholarly community are quieted or ignored by its industrial arm, we get bad public policy, demoralized scholars and unhealthy learning environments for all. Worse, failing to preserve the integrity of academic inquiry — the curiosity, scientific rigor and intellectual freedom that made American universities the envy of the world — degenerates what fuels our economy and inspires our imagination.

This past month and this past year have made us crave forceful leadership in higher education, but recovering what we’re losing will require more than just new appointees.