Yet unlike a public corporation, the nonprofit entity answers to no shareholders, enjoys broad tax exemptions, and derives much of its revenue from taxpayer-supported healthcare programs.

AltaMed also reported $1.66 billion in assets and its revenues exceeded expenses by $68.4 million. It operates more than 70 clinics, employs roughly 5,000 people, and serves more than 700,000 patients throughout Southern California, making it one of the nation's largest federally qualified health center (FQHC) systems.

But AltaMed's extraordinary growth raises another question that extends far beyond Southern California: What happens when a nonprofit grows into a multibillion-dollar enterprise while retaining the governance structure of a traditional charity?

That question has become increasingly relevant as individual nonprofit hospital systems, universities, and other charitable organizations now control hundreds of billions of dollars in assets while benefiting from tax exemptions, government reimbursements, tax-deductible donations, and public financing. Their primary accountability mechanism is a board of directors charged with ensuring that charitable resources remain devoted to public benefit rather than private profits.

Since 2001, AltaMed has paid more than $32 million in compensation to its CEO, Castulo de la Rocha, his wife Zoila Escobar, and one of their sons - which is significantly higher than most of its peer FQHCs. For instance, the chief executives of Family Health Centers of San Diego, Family HealthCare Network, and Comprehensive Community Health Centers each earned substantially less than de la Rocha in 2024 despite overseeing similarly large healthcare organizations.

Following scrutiny of excessive executive pay more than a decade ago, AltaMed adopted a split-dollar life insurance loan program designed to help retain selected executives. The program has provided substantial loans to a small group of senior leaders to finance life insurance policies. Split-dollar arrangements are technically legal, although federal officials have cautioned that similar structures have been used improperly in certain tax-avoidance schemes.

Executive compensation is only one measure of nonprofit governance. Equally important is how charitable organizations deploy their resources and whether those expenditures advance the mission for which they receive tax-exempt status.