In 2025, Sam Hazen’s total compensation as CEO of HCA Healthcare rose by $2.7 million, according to a proxy statement the company filed with the Securities and Exchange Commission in March 2026. That same year, nurses at an HCA hospital in Riverside, California, were still fighting in federal court over a $6 million arbitration penalty their union was hit with after striking over staffing levels.
Both of those facts are true. Only one of them made headlines.
The Raise That Explains the Whole Industry
HCA Healthcare is the largest for-profit hospital operator in the country, running roughly 190 hospitals across 20 states and the United Kingdom. In 2025, it posted $75.6 billion in revenue and $6.8 billion in net income, up from $70.6 billion in revenue and $5.8 billion in net income the year before. By any normal measure, that is a company having a very good year.
Hazen’s pay reflects it. In 2024, his total compensation came to $23,799,137, according to the company’s own disclosures filed with the Securities and Exchange Commission. The 2026 proxy statement shows that figure climbed by another $2.7 million in 2025, putting his total package at roughly $26.5 million. For context, HCA’s median employee earned $60,820 in 2024, which puts the CEO-to-median-worker pay ratio at 391 to 1. A year earlier, it was 356 to 1. The gap is not narrowing. It is accelerating.
None of this is hidden. It is sitting in plain text in a document filed with federal regulators, the same regulators whose disclosure rules exist so that shareholders, and the public, can see exactly how a company decides who gets paid what, and why.
Twenty-Seven Years of the Same Fight
Here is the thing nurses will tell you: if you ask them why this number makes them so angry. It is not new.
In 1999, California became the first and still only state to pass a law setting legally enforceable nurse-to-patient ratios, after the California Nurses Association spent nearly a decade lobbying for it. The law took full effect on January 1, 2004. A widely cited 2010 University of Pennsylvania study found that if New Jersey and Pennsylvania hospitals matched California’s ratio of one nurse to five patients on surgical units, those states would see measurably fewer patient deaths.
Twenty-two years after California’s ratios became enforceable, no other state has matched them. At the federal level, the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act has been reintroduced in Congress again in the current session, this time as H.R. 3415, with companion legislation from Senators Alex Padilla and Jeff Merkley. It would require hospitals to submit staffing plans that meet minimum nurse-to-patient ratios by unit, and it would direct Medicare to adjust hospital payments to help cover the cost. Versions of this bill have come and gone for decades. None has become law.
So when nurses say they have been asking for this for twenty years, that is not rhetorical inflation. It is a documented legislative record.
What “Chronic Understaffing” Looks Like on the Floor
The $6 million arbitration penalty did not come from nowhere. In July 2020, healthcare workers at HCA’s Riverside Community Hospital in California, represented by SEIU 121RN, went on strike. HCA argued the strike violated the terms of the union contract because striking workers had also raised public concerns about personal protective equipment during the pandemic. An arbitrator sided with HCA and awarded the company $6 million. A federal district court later upheld that the nurses had been within their rights to strike over chronic understaffing, even as it left the underlying penalty in place. The union has called the ruling an attempt to silence frontline workers from speaking publicly about conditions inside HCA hospitals.
This is not an isolated dispute in one state. In June 2024, nurses at HCA Florida Osceola Hospital in Kissimmee organized around the same core issue, short staffing, as part of a national day of action led by National Nurses United. Their new three-year contract ultimately included an average 15 percent wage increase and a pilot break relief program, concessions that do not happen unless workers spend months building public pressure for them.
And in Los Angeles, a family sued West Hills Hospital, an HCA-owned facility, over injuries they say a relative suffered after he could not get timely nursing care. The lawsuit landed in the same window as a three-day strike by SEIU RN Local 121 nurses protesting unsafe staffing at three Southern California HCA hospitals, including West Hills. The family’s attorney has said they do not blame the nurses on shift. They blame the staffing levels under which those nurses were forced to work under.
The Argument Hospitals Actually Make
To be fair to the other side of this, because a one-sided story is not journalism, hospital executives are not simply twirling mustaches when they resist mandated ratios.
Labor costs are the single largest line item in any hospital budget, and they have been rising fast. According to Kaufman Hall’s National Hospital Flash Report, hospital labor and expense costs per calendar day grew 5 percent from 2024 to 2025, and 12 percent since 2022. Rural and community hospitals, operating on thin margins to begin with, say a hard numerical ratio applied uniformly could force them to either hire staff they cannot find in tight labor markets or cut services entirely. The industry’s preferred alternative is staffing based on patient acuity, meaning flexible levels that shift depending on how sick the patients on a given unit actually are that day, rather than a fixed number written into law.
There is also a genuine workforce shortage layered underneath all of this. Healthcare employers across the country have spent the past two years raising wages just to keep nurses from leaving, with dozens of hospital systems announcing pay increases through 2026. If hospitals are already struggling to fill shifts at current ratios, the industry argument goes, mandating lower ratios everywhere does not create more nurses. It just creates more unfilled positions on paper.
It is a coherent argument. It is also one that sits uneasily next to a $2.7 million raise for the person at the top of a company that, by its own SEC filings, is more profitable than it has been in years.
The Debt Trap Underneath the Staffing Crisis
While the staffing fight played out on picket lines, a quieter version of the same power imbalance was working its way through state courts. In July 2025, California Attorney General Rob Bonta announced a settlement with HCA Healthcare and its staffing subsidiary, Health Trust Workforce Solutions, over a program called StaRN, Specialty Training Apprenticeship for Registered Nurses. According to the California Department of Justice’s announcement of the settlement, HCA required newly hired nurses to repay the cost of mandatory training if they left, or were terminated, before completing two years of employment.
The investigation, run jointly with attorneys general in Nevada and Colorado, found this violated state labor and consumer protection laws as well as federal consumer financial protection rules. By November 2025, HCA had agreed to cancel the outstanding training debts, refund nurses who had already paid, and pay $2.9 million in penalties across the three states.
Strip away the legal language, and the mechanism is simple. A nurse who wants to leave a unit because it is dangerously understaffed has to weigh that decision against a bill for their own training. For two years, that debt functioned as a tether. It is the kind of leverage that does not show up in a staffing ratio debate, but it shapes who feels free to speak up and who stays quiet, the same dynamic at work when a payday-style lending model gets dressed up as a routine service fee somewhere else in the economy.
Where Nurse-to-Patient Staffing Ratios Stand Now
As of 2026, the legal landscape on nurse-to-patient staffing ratios looks almost identical to how it looked a decade ago. California remains the only state with an enforceable law. The federal bill sits in committee, as previous versions have for years. What has changed is the financial backdrop against which that stalemate continues.
HCA’s profitability is not an outlier in American healthcare. It sits inside a much larger pattern, one where corporate consolidation has quietly bought up doctors, vets, and dentists and changed how each of them operates. It also echoes a wage story playing out across the broader labor market, where the wage behind one of the country’s most common jobs has not moved since 1991, even as corporate profits at the top of those same industries climb.
None of this means hospital executives are solely responsible for a staffing crisis with roots in nursing school capacity, pandemic burnout, and an aging population that needs more care than the system was built for. But it does mean that when hospital trade groups argue they cannot afford mandated ratios, that argument has to be weighed against what the same companies can, and do, afford to pay the people at the very top.
The Number That Doesn’t Move
Sam Hazen’s raise last year was $2.7 million. By itself, that number is unremarkable in corporate America, a rounding error for a company that made $6.8 billion.
But put it next to the other number. Twenty-seven years since California first wrote nurse-to-patient ratios into law. Twenty-two years since those ratios actually took effect. Zero other states have followed. A federal version of the same idea has been introduced, debated, and shelved across multiple sessions of Congress, including the one sitting right now.
One number moved by $2.7 million in a single year. The other number has not moved at all.
