Why it matters: Hospitals say they're having trouble staying afloat because insurance programs, namely Medicare and Medicaid, aren't paying them enough. But while their margins on patient care are slim, they've more than made up for it on Wall Street. 
 
 The nation's largest not-for-profit hospital systems reaped more than $21 billion last year from their Wall Street investments, mergers and other investment options, according to an Axios analysis of financial documents. 
 
 The analysis: We looked at the financial documents of 84 of the biggest, most dominant not-for-profit hospital systems in the country. They don't all operate on the same fiscal year, so we looked at their latest annual filings. These systems collected $535.5 billion of annual revenue — a big piece of the entire health care system. 
 
 Data: Axios review of health system financial documents; Chart: Chris Canipe and Andrew Witherspoon / Axios 
 
 What we found: Cumulatively, these hospital systems made $14.4 billion in profit last year from caring for patients, for an operating profit margin of 2.7%. Add in Wall Street investments, stocks, bonds, credit default swaps and accounting gains from mergers and acquisitions, though, and their surpluses rose to $35.7 billion, or a 6.7% total profit margin — more than double the year before. 
 
 Those margins aren't gigantic. But modest margins on a large amount of revenue still equal a large amount of profit. 
 
 Many of these systems operate their own health insurance arms. Their financial status varied from extremely healthy (like Kaiser Permanente) to red ink (Partners HealthCare). 
 
 Many academic systems, including Northwestern Memorial HealthCare in Chicago and University of Colorado Health, registered some of highest margins and surpluses. 
 
 The bottom line: Top tax-exempt hospital systems are quite profitable. They are raking in cash from Wall Street, as well as from their rush to merge and acquire competing hospitals and systems. Researchers say all that consolidation often has led to higher prices and higher insurance premiums — and usually does not lower costs, contrary to hospitals' marketing pitches. 
 
 "We don't have anything close to what most people would see as a functioning, competitive market in hospital care," says Alan Sager, a health policy professor at Boston University who reviewed the analysis. "Hospitals may do well because they got dominant or because they were lucky in some of their investments." 
 
 The American Hospital Association responded to the analysis with a statement saying hospitals are benefiting from the booming stock market, and they "need a positive margin to keep pace with advances in medicine and increasing health care needs." The lobbying group also faulted Medicaid and Medicare for paying "less than the cost of care." 
 
 The AHA also said investment income gets reinvested. However, money often goes toward projects that boost revenue. 
 
 A caveat: The analysis highlights the wealthiest hospital systems in the country. But there are many hospitals — smaller, rural facilities and publicly owned hospitals — that are struggling more because of dwindling payments, fewer patients and an inability to compete against larger, better-funded systems when negotiating payment rates with commercial insurers. 
 
 "Some systems are doing really well in this country. That doesn't mean all systems and all facilities are doing well," says Gary Young, a health policy professor at Northeastern University. 
 
 Get smart: Large not-for-profit hospital systems now resemble and act like Fortune 500 companies instead of the charities they were often built as. They consequently hold immense financial and political power. ||||| poster="http://v.politico.com/images/1155968404/201705/2924/1155968404_5453533342001_5453523512001-vs.jpg?pubId=1155968404" true Trump's communications director is out as larger shakeup looms Mike Dubke, who was on the job a little over three months, resigned May 18. 
 
 Mike Dubke, President Donald Trump’s communications director, has resigned as Trump considers a larger personnel shakeup to confront the growing scandals weighing down his administration. 
 
 The veteran GOP strategist privately announced his resignation in a meeting with the president on May 18, and Trump accepted immediately, Dubke said in an interview. He added that he offered to stay through Trump’s first foreign trip to ensure there was a smooth transition as he exited. 
 
 Story Continued Below 
 
 Dubke, who spoke with POLITICO as he drove into the White House early Tuesday morning, said he expects to go back to Black Rock Group, his communications and public affairs firm. A White House official said press secretary Sean Spicer will return to his dual role as communications director until everything is sorted out. Axios first reported that Dubke was leaving. 
 
 “The reasons for my departure are personal, but it has been my great honor to serve President Trump and this administration,” Dubke emailed friends Tuesday morning. “It has also been my distinct pleasure to work side-by-side, day-by-day with the staff of the communications and press departments. This White House is filled with some of the finest and hardest working men and women in the American Government.” 
 
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 Chief of staff Reince Priebus thanked Dubke for his service in a statement Tuesday. “Mike will assist with the transition and be a strong advocate for the President and the President's policies moving forward,” Priebus said. 
 
 Dubke’s exit comes as Trump considers larger staff changes as he tries to contain the deepening scandals related to ties between Russia and his campaign. 
 
 Trump returned to Washington this weekend facing not only congressional probes but the investigation by special counsel Robert Mueller into possible collusion between Trump’s associates and Russia as the Kremlin allegedly tried to tip the election Trump’s way. Trump, whose tweets were largely restrained while he was abroad, returned to form Tuesday morning, writing that Germany has a “MASSIVE trade deficit” with the U.S. and pays “FAR LESS than they should on NATO & military.” 
 
 “Very bad for U.S.,” he said. “This will change.” 
 
 In subsequent tweets, Trump claimed Russian officials are laughing at America and “how a lame excuse for why the Dems lost the election has taken over the Fake News.” He also recommended that the Senate do away with the legislative filibuster to advance health care legislation and approve tax cuts. Republicans, however, are already pursuing both issues with a budget procedure known as reconciliation that allows them to advance the measures with a simple majority. 
 
 The president rounded out his spree with retweets of his Memorial Day crowd size and an anonymously sourced Fox News report that says his son-in-law, Jared Kushner, didn’t suggest a Russian communications channel when he met with the Russian ambassador in December. 
 
 Beyond Dubke, Spicer, the press secretary, is expected to take on a reduced public role, though he is conducting the briefing later on Tuesday. Dubke, who was only on the job for a little over three months, had generally been seen as a Spicer ally in the White House. 
 
 Trump has also been in talks with former campaign aides Corey Lewandowski and David Bossie about taking on more formal roles, possibly in a crisis management function. Trump met with Lewandowski and Bossie in the White House on Monday, and the discussion centered on what role they could play, said one person briefed on the matter. 
 
 Trump is also said to have become more frustrated with Kushner, a top adviser who has become the subject of damaging reports alleging that he tried to set up secret communications with the Russians during the transition and failed to disclose multiple meetings with Russian officials. 
 
 However, it’s not clear that Trump would remove a family member, and Kushner’s lawyer said he is willing to cooperate with the various investigations into the matter. 
 
 White House counselor Kellyanne Conway on Tuesday tried to downplay the idea of a staff shake-up and said Dubke has been professional about his departure. 
 
 “He has expressed his desire to leave the White House and made very clear that he would see through the president’s international trip and come to work every day and work hard even through that trip,” Conway told "Fox & Friends." 
 
 In a notoriously leak-prone White House, Dubke told POLITICO he was surprised that the news of his planned departure took 12 days to leak out. 
 
 A longtime Republican operative and establishment stalwart, Dubke never fit into a White House consumed by chaos. Some questioned why he and not a Trump loyalist was tapped for the communications director job. After being selected for the post, he began telling people in the administration that he never produced TV ads targeting Trump during the 2016 campaign — a move that was designed to reassure loyalists in the White House, but one that left some rankled. 
 
 There was also some awkwardness to Dubke’s role: internally, it was made clear he was subordinate to the press secretary, Spicer — an unusual set-up. Dubke also came under fire after POLITICO reported last month that the president didn’t have a foreign policy doctrine. 
 
 Trump told friends in recent weeks that he was unhappy with Dubke — and that he wondered why he never seemed to get positive press anymore. 
 
 As the president dwells on the scandals, the embattled communications wing has emerged as the center of possible change in the White House. It is seen as increasingly likely that Lewandowski and Bossie will take on some functions, though it remains unclear whether they will join the White House or work for Trump as outside advocates. Both have complex business dealings that would need to be untangled should they enter the administration in an official capacity. 
 
 The two fit the mold of what Trump is looking for. Both have reputations as cutthroat, hard-charging operatives, and both worked on Trump’s presidential campaign in senior roles. Lewandowski, however, was pushed out as campaign manager after a power struggle with campaign chairman Paul Manafort. And there are questions about how effective Lewandowski would be in a crisis management role, given how he has clashed with top Trump aides including Priebus and Kushner. 
 
 In recent days, the president has told aides he misses being around some of those who worked for him during the campaign and has talked about bringing the crew back together. 
 
 Other changes could also be in the works: While Spicer is likely to remain in the White House, Conway, a frequent Trump on-air surrogate, could take on a broader role. 
 
 Nolan D. McCaskill contributed to this report.
– Rumors of major restructuring of White House staff have been circulating in recent days, and on Tuesday the first shoe may have dropped in the form of Mike Dubke, President Trump's communications director. Axios reports that Dubke offered Trump his resignation on May 18, though he offered to stay on at least until the president's overseas trip had wrapped up. A senior administration official notes Dubke is leaving on friendly footing, and he's still reporting for work—in fact, Politico nabbed him for an interview as he was driving into the White House on Tuesday. It's not clear yet when his last day will be, though he plans to return to the Black Rock Group communications firm once he exits the White House. "The reasons for my departure are personal, but it has been my great honor to serve President Trump and this administration," Dubke said in a Tuesday morning email. Dubke told Politico he was shocked it took nearly two weeks for news of his resignation to get out. Axios notes Dubke's sayonara is just the "start of a wave of changes." Sean Spicer is expected to take on a downplayed role, though it's unclear where the fates of Steve Bannon, Reince Priebus, and Trump son-in-law Jared Kushner lie. Axios reports Trump is rumored to be considering bringing on "killers," including GOP lobbyist David Urban and former campaign aides David Bossie and Corey Lewandowski, the latter being one who "experience suggests … will not only indulge Trump's most combative instincts, but goad them." In other anticipated changes, an official says Trump plans on serving more often as the White House's spokesperson. "He says things exactly the way he wants them to be said," the official notes.