Even though last year saw “notable improvement” in the median financial performance of nonprofit hospitals and health systems, the largest nonprofit health systems by revenue continued to struggle. Nonprofits comprise eight of the ten largest health systems, and four of those eight—Advocate Health, Ascension, Providence, and UPMC—lost money on operations (although UPMC’s losses stem from its insurance services, which were hit by high volumes and pharmacy costs). Meanwhile, Kaiser Permanente, by far the largest health system due to its insurance offerings and now Risant Health, barely broke even. Two systems, HCA Healthcare and Tenet, stand out among the rest as the only for-profit systems on the list and the only systems posting double-digit operating margins. It’s not a shock that for-profit systems, which are obliged to maximize shareholder profit, have the healthiest operating margins, but the gap between them and the nonprofits is remarkable. Nonprofits and for-profits alike have faced rising expenses and revenue pressures, but the for-profits have proven nimbler in their responses to these challenges. In our next edition, we’ll dig into HCA and Tenet’s financial reports to illustrate how and why.