No Margin, No Mission: Persisting Lessons from Sister Irene Kraus
- FrontRunnerHC
- 2 hours ago
- 5 min read
"No margin, no mission"
Federally Qualified Health Center (FQHC) and Community Health Centers often reference the adage: “No margin, no mission.”
It’s popular (perhaps overused), but a nevertheless profound component behind what makes these places tick. It’s genuine, and it’s a reminder of the reason so many people choose to work in this arena – to help others who need support. It’s the mission part that makes a difference.
In a given moment, an FQHC employee may be in contact with any variety of unhoused, or nearly unhoused patients potentially struggling with disease, addiction, or a lack of basic necessities. Patients often have no insurance or means of payment. English may not be their first language, making communication and detailed paperwork an additional challenge. It takes a significant amount of time to verify insurance eligibility and patient demographics (address, name changes). And all of this is impossible to manage without dedicated employees and funding, the margin part.
It makes sense, but where did the adage come from? Did a particular person or group coin it? And what is it about the phrase that causes it to sustain conversations today?
The woman behind the words: Sister Irene Kraus
The person credited with first coining the phrase, “No margin, no mission,” is Sister Irene Kraus.
Kraus was born in Philadelphia on July 25, 1924. At the age of 17, Kraus joined the Daughters of Charity of St. Vincent de Paul congregation. She worked as an elementary and high school teacher before shifting to nursing in 1952, where she was placed in hospitals throughout the Northeast and Midwest, including Connecticut, Michigan, Maine, New York, and Massachusetts.
From there, her resume is packed with high-ranking credentials ranging from the first female chair of the American Hospital Association to President or Chair of countless councils, conferences, and societies, including the President of the Daughters of Charity National Health System (now part of Ascension Healthcare).
Sister Irene’s extensive background in education and nursing offers a clue into the origin of her now well-known phrase. It’s no wonder she came to believe that mission-driven care and disciplined financial stewardship were not opposed but interdependent. Healthcare's Evolving Mission
To understand why the phrase mattered, we have to imagine the hospital/health system environment in the late 1960s through the 1980s. Nonprofit and faith-based hospitals were under increasing financial pressure: mounting regulation, rising staff and technology costs, the growth of for-profit hospital chains, and shifting payment models.
“Sister Irene believed that strong fiscal management, not just charity, is what hospitals needed to fulfill their mission. ‘In the United States in this day and age,’ she would say, ‘the way to do it is to run institutions that are financially solid.’” Becker's Hospital Review
Viewed this way, the phrase becomes a practical ethic: if you want to serve your community, especially vulnerable populations, you must ensure the enterprise can keep going.
How the phrase found its way into community health
Although the phrase originated in a hospital/health-system context, it has traveled well into the world of community health centers, FQHCs, and mission-driven clinics. Why? Because the underlying challenge is similar: how to serve underserved populations, deliver high-quality care, and remain sustainable.
In the FQHC world, where reimbursement is often lower, the payer mix is more challenging, and grants and subsidies only go so far, the principle of “margin supporting mission” is highly relevant.
When FQHC leaders say “no margin, no mission,” what they’re really acknowledging is: without financial viability, we can’t expand hours, invest in care coordination, hire needed staff, or keep up with regulatory and technology demands.
What “margin” really means in modern community health
Here’s where we shift from the slogan to the substance: margin doesn’t mean margin in the sense of “profits distributed to shareholders.” For community health centers, margin can mean something like: excess cash flow or resource-flexibility that allows investment in mission-critical services and supports.
Examples of what margin enables:
Opening a weekend clinic or evening care hours
Hiring a behavioral health coordinator or social services lead
Upgrading an EHR or eligibility system to reduce claims denials
Offering sliding-scale or free services that aren’t fully reimbursable
Engaging in proactive outreach and community partnerships that extend reach
Margin provides a beat to examine the whole patient. Health, yes, but also housing or electric assistance, nutrition, and wellness. It opens doors to have the real impact that mission demands. In this sense, margin is mission in motion: it’s the financial cushion that lets a center go beyond “just surviving” to thriving.
The financial reality FQHCs face today
These margin pressures are anything but theoretical. Some contemporary stress points include:
Potential impact from the US Administration’s One Big Beautiful Bill creates significant uncertainty, but promises some level of financial setbacks
Medicaid redetermination: As coverage churn increases, so does uncertainty in cost-savings.
Lower reimbursement: Primary care, preventive services and behavioral health often pay less than specialty or hospital services.
Staffing and workforce shortages: recruiting, onboarding, and retaining care coordinators, behavioral health professionals, and community health workers is expensive. In 2024, over 70% of FQHCs reported shortages due to turnover and staffing gaps.
Claim denials after care. Data inaccuracy, mismatched, or unavailable paperwork causes workforce strain and an inability to properly predict margin.
The technology and regulatory burden: EHR upgrades, fluctuating compliance measures, prior-authorizations, and telehealth infrastructure create additional challenges.
The phrase “no margin, no mission” acknowledges that these are not optional niceties; they are material to fulfilling the mission.
Lessons from Sister Irene for today’s community health leaders
If you look at Sister Irene’s leadership through a contemporary lens, several lessons stand out:
Courage: she named the financial realities not as something that dampened mission, but as something mission-leaders must master.
Stewardship: seeing resources (people, facilities, finances) as tools of service, not ends in themselves.
Vision: she understood that mission-organizations can’t outsource financial discipline; it must be baked into the culture.
For community health center leaders, clinical leaders, and board members, the takeaway is: the tension between margin and mission isn’t a moral dilemma, it’s a strategic one. And addressing it thoughtfully is a leadership mandate. In the end, the phrase “No margin, no mission” is not cynical. It is, in fact, deeply compassionate. It says: if you care about serving people, you must also care about how your organization is built, financed and managed.
For the FQHC sector, this means operational excellence and mission-centricity go hand in hand. It means that the systems, the billing and eligibility workflows, the partnerships and data foundations, are not peripheral, they are essential to fulfilling care objectives.
As community health leaders look ahead toward greater value-based care, more integrated services, and larger roles in population health, they carry forward the spirit of Sister Irene’s insight. Because when your organization has margin, your mission has momentum.
How FrontRunnerHC Supports FQHC Missions and Margins
FQHCs and community health centers need more time to focus on whole-patient care.
To help solve the margin problem, FrontRunnerHC leverages its athenahealth native platform to:
Automate real-time payer data
Stay ahead of redetermination and keep visits billable
Improve data accuracy for clean claims and fast payments
Verify coverage, income & FPL, and discover overlooked insurance before care begins
Identify eligibility: Medicaid, Medicare, and additional state assistance (housing, wellness, nutrition)
FrontRunnerHC eliminates the drudgery of time-consuming paperwork and empowers community health teams to serve, not chase claims. This reduces employee churn while enhancing the patient’s experience. More time for mission-focused care.
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Discover how FrontRunnerHC helps improve these FQHC patient workflows with fast, accurate data, automated state assistance discoverability, and complete athenahealth integration. Learn more.