What Remains Open

The most consequential open question in the funding paradox chapter concerns the relationship between Providence's funding strategy and its governance independence. Every form of capital carries governance implications. Patient endowment capital gives governance influence to endowment managers. Cooperative ownership gives governance influence to member-owners. Community bonds give governance influence to bond holders. State capital gives governance influence to state actors. The question is not which form of capital avoids governance influence — none do — but which forms of governance influence are compatible with Providence's constitutional requirements.

A second open question concerns scale. The funding structures identified in this chapter as most compatible with Providence's constitutional requirements — patient endowment, cooperative ownership, community bonds — have been successfully deployed at relatively modest scale. Whether they can be deployed at the scale Providence will eventually require, and what happens to their constitutional compatibility at that scale, is an empirical question that the historical record does not yet answer.