The report, authored by Dr. Dan Greenstein, highlights that 39 systems are struggling with a toxic combination of declining enrollment and shrinking operating margins. These factors serve as primary indicators of structural decline. While many leaders assume that size or historical funding serves as a buffer against instability, the data suggests otherwise. High-performing systems distinguish themselves through their capacity to identify emerging risks early and execute strategic shifts before their financial options narrow.

According to the findings, the primary barrier for struggling institutions is not a lack of legal authority to reform, but a deficit in operational capacity and integrated data. Simply cutting costs rarely reverses a downward trajectory; sustainable recovery requires a focus on rebuilding enrollment demand and aligning academic credentials with workforce needs. Systems that prioritize stabilizing internal operations before attempting broader structural transformations show the highest rates of long-term success.