In this study, the operating performances of not-for-profit community hospitals are compared among groups partitioned by bond ratings, level of debt insurance coverage, and number of bond rating services. The analysis indicates that the performances of hospitals with full debt insurance coverage resulting in AAA ratings are significantly lower than those of hospitals with partial debt insurance and with AA ratings or better. Indeed, the hospitals with full debt insurance resemble those with partial insurance that are rated BBB to A. These findings have implications for managerial action choices. Hospitals seeking external funding to improve their operating performance may consider the costs and benefits of full insurance coverage.