now look at EBITDA, a common metric representing cash flow. look at EBITDA / revenue, ie cash profit margin. this is around 20%, which is massive. this profitability is around the level of big tech and big pharma. however, most hospitals in the US have almost no profit. the profitability of large hospital companies is mostly due to their bargaining power. in fact, a decade ago, big hospital systems were some of the best private equity / LBO investments, bc they were massively profitabel, stable businesses that could take on a lot of debt. and this is before the ACA

before the ACA, this was even worse, especially for smaller hospitals. see [1], financial statements for Community Health Systems, a massive (but smaller than HCA) public hospital company, from 2009. for some hospitals this figure was 30% or higher

the problem is that not all hospitals are equal. the companies i mentioned are some of the biggest, most powerful hospital companies. however, many hospitals are completely different (often independent urban hospitals), and just bleed money. sometimes its because they have more under/uninsured pts, sometimes its because their contracted rates are lower, sometiems its bc they dont have enough commercial pts (instead having more medicare / medicaid). so a blanket law making hospitals eat more costs would just help the rich get richer and kill the little guys

i worked in investment banking and these big hospital systems were some of our best clients. a business that can write of 10-30% of its revenue as bad debt and still generate 20-25% profit margins is an incredible borrower, and we'd underwrite multi billion dollar bond issuances for these companies, so they could issue dividends to shareholders, and because they were so profitable they could afford tons of high yield debt without breaking a sweat

[0] https://www.sec.gov/Archives/edgar/data/860730/0001193125180...

[1] https://www.sec.gov/Archives/edgar/data/1108109/000095012310...