Commonfund, in partnership with the Council on Foundations, recently released the 2025 Council on Foundations–Commonfund Study of Investment of Endowments for Private and Community Foundations (CCSF, or the “Study”). The annual Study examines investment performance, governance and management practices at hundreds of private and community foundation endowments over the 2025 calendar year.
As we did last year, we took a closer look at results from the health conversion foundations that participated in the Study. This year that group grew to 26 institutions, from 23 in 2024, and we compare them against 171 total private foundation respondents (up from 154 last year). Because the respondent pool shifts somewhat from year to year, the year-over-year comparisons below should be read as directional trends across the two cohorts rather than a change measured on the same set of institutions.
What are health conversion foundations? Health conversion foundations, sometimes called health legacy foundations, are philanthropic organizations typically formed when a nonprofit hospital, health system or health plan is sold or converted to for-profit status. Their mission is generally to carry the charitable value of that original institution forward, often through grantmaking focused on health equity, access to care and the broader social determinants of health. Learn more about these foundations.
Health conversion foundations reported $4.7 billion in total endowment assets in this year’s Study, up from $4.1 billion in 2024, against $96.7 billion for total private foundation respondents in 2025. The median endowment value for health conversion foundations was $129.7 million in 2025, down from $149.3 million in 2024, compared with $189.1 million for total private foundations this year (down from $197.5 million last year). By size, 2 of the 26 health conversion foundations in this year’s Study reported total assets over $500 million, 14 reported assets between $101 million and $500 million, and 10 reported assets under $101 million.
The top-line results
Performance
Returns were positive across every time horizon in this year’s Study, and materially stronger than the year before, for both groups. Health conversion foundations reported a 14.4 percent average 1-year return, up sharply from 10.4 percent in 2024, and now modestly ahead of the 14.1 percent posted by total private foundations (up from 10.3 percent). Three-year average returns jumped to 12.5 percent for health conversion foundations and 12.4 percent for total private foundations — a sharp rebound from 3.2 and 3.1 percent, respectively, in last year’s Study, as a weak year rolled out of the trailing window. Five-year returns were roughly steady at 7.9 percent for health conversion foundations (7.4 percent in 2024) and 8.0 percent for total private foundations (7.8 percent in 2024).
Longer-term returns tell a more mixed story. Health conversion foundations reported an 8.5 percent 10-year annualized return, up from 7.2 percent last year but still trailing the 9.0 percent posted by total private foundations. Health conversion foundations reported a 20-year return for the first time this year, at 6.0 percent, trailing the 7.2 percent reported by total private foundations.
| Health Conversion Foundations 2024 | Health Conversion Foundations 2025 | Total Private Foundations 2024 | Total Private Foundations 2025 | |
| 1-Year | 10.4 | 14.4 | 10.3 | 14.1 |
| 3-Year | 3.2 | 12.5 | 3.1 | 12.4 |
| 5-Year | 7.4 | 7.9 | 7.8 | 8.0 |
| 10-Year | 7.2 | 8.5 | 7.3 | 9.0 |
| 15-Year | 7.4 | ** | 7.5 | 8.1 |
| 20-Year | ** | 6.0 | 6.4 | 7.2 |
** sample size insufficient to report
Asset allocation
The asset allocations of health conversion foundations continue to differ meaningfully from those of the broader group of private foundations. The group carries a larger allocation to U.S. equities than total private foundations (33.7 percent vs. 24.9 percent in 2025). The group also carries a materially larger allocation to fixed income (15.4 percent vs. 10.3 percent) and non-U.S. equities (20.8 percent vs. 16.3 percent) than total private foundations this year, continuing a pattern of being overweight both asset classes relative to the broader group.
The offsetting difference remains a lighter allocation to alternative strategies: 27.8 percent for health conversion foundations versus 45.8 percent for total private foundations in 2025 — a gap of roughly 18 percentage points, slightly wider than the 20-point gap reported in 2024 (25 percent vs. 45 percent). Within alternatives, private equity remained the largest single sleeve for health conversion foundations in both years, at 8.9 percent in 2025 (8 percent in 2024), followed by marketable alternatives at 6.6 percent (7 percent in 2024). The clearest contrast with total private foundations is venture capital: total private foundations allocate 13.6 percent of their book to venture capital in 2025, versus just 2.1 percent for health conversion foundations.
Spending
Health conversion foundations reported an average stated policy spend rate of 5.2 percent in 2025, up slightly from 5.1 percent in 2024, and in line with the 5.2 percent reported by total private foundations in both years. The two groups differ, however, in how they arrive at that rate, and those differences shifted somewhat year over year. Meeting the IRS minimum of 5 percent spend remains the most common approach for both groups, but usage declined for both: 54 percent of health conversion foundations used it in 2025, down from 61 percent in 2024, and 61 percent of total private foundations this year. Using a percentage of a moving average, by contrast, grew more common among health conversion foundations — 38 percent in 2025, up from 30 percent in 2024 — even as it became somewhat less common among total private foundations (33 percent, down from 36 percent). (Multiple responses were allowed.)
Responsible investing practices
Adoption of responsible investment practices continued to grow for health conversion foundations, and at a faster pace than for the broader group. In 2024, both health conversion foundations and private foundations overall reported that 26 percent required or permitted investments ranking high on ESG criteria. In this year’s Study, that figure rose to 31 percent for health conversion foundations, while total private foundations reported 28 percent. A similar pattern shows up in manager diversity and mission screening: in 2025, 27 percent exclude or screen out investments inconsistent with the institution’s mission and 31 percent seek to include investments with diverse managers (both up from 22 percent), compared with 25 percent and 20 percent, respectively, for total private foundations. Health conversion foundations also reported that 35 percent allocate a portion of the endowment to investments that further the institution’s mission, versus 29 percent for total private foundations.
This year’s results show health conversion foundations as an increasingly distinct cohort within the broader Study. Slight differences in returns and asset allocation— with a lighter alternatives and a heavier public-markets tilt for health conversion foundations — have persisted and modestly widened across both Studies, while responsible-investing adoption has grown faster among health conversion foundations than among their peers. The most useful way to read this data isn’t to match any single figure, but to use it to consider your own foundation’s practices — and we encourage you to read the full Study to evaluate your performance and positioning against your benchmark or peers.
Source: 2025 and 2024 Council on Foundations–Commonfund Study of Investment of Endowments for Private and Community Foundations. Asset allocation figures are dollar-weighted.
