As a not-for-profit, Private entity, Ballad Health seeks to be socially responsible and to consistently meet the needs of the Appalachian Highlands. Ballad Health (A3 stable) will continue to demonstrate its ability to operate effectively under state-imposed regulations following the 2018 merger of two formerly competing and like- sized health systems. We expect Ballad to continue to generate synergies through integration and consolidation while remaining compliant with the rate regulations of the Terms of Certification of the Certificate of Public Advantage (COPA) in Tennessee and Cooperative Agreement (CA) in Virginia. Ballad weathered the first two years of the pandemic with very solid operating cash flow (OCF) margins through fiscal 2022. Fiscal 2023 appears to be back in line with historical margins after a first quarter downturn attributed to volume softness and labor costs. The ability to sustain solid OCF margins will depend on expense management due to limited volume growth opportunities in an aging service area and competitive labor market.