FIFA Is a Nonprofit. It Is Not Naïve: What the World Cup can teach healthcare about the money required to keep a mission alive.
I once made a room uncomfortable by saying that a nonprofit is not the same as a charity.
I did not mean that mission did not matter. I meant the opposite: a mission that refuses to understand money eventually hands control to people who do.
Nonprofit is a legal and tax status. It tells us, in broad terms, that no shareholders are taking the remaining surplus home as dividends. It does not mean there is no revenue. No payroll. No debt. No reserve. No capital plan. No bad quarter. No hard decision.
It does not mean innocence, which is why the World Cup is worth watching with a hospital leader’s eye.
FIFA is a nonprofit association. It is also one of the most formidable commercial machines in the world. This summer, it is running a tournament across three countries, featuring 48 teams and 104 matches. It sells broadcast rights, sponsorships, hospitality, licensing, data, tickets, merchandise, and the scarce privilege of being associated with the largest sporting event on earth.
Football begins with a ball and a patch of grass. The World Cup does not.
FIFA’s revised revenue target for the 2023–26 cycle is $13 billion. That number sounds almost absurd until you put it alongside institutions that healthcare professionals know.
Texas Children’s reported roughly $6.2 billion in annual operating revenue in fiscal year 2024. NYU Langone, where I spent much of my academic career, reported $15.4 billion in revenue for fiscal year 2025.
All three are nonprofits.
All three operate at a scale that demands adult financial management.
The comparison is not perfect. FIFA sells a global spectacle. Hospitals are paid to care for sick people, train clinicians, conduct research, support communities, and maintain the capacity to respond when things go wrong. But the arithmetic makes one point unavoidable: mission-led institutions do not survive on sentiment.
They survive because someone builds the financial structure beneath the sentiment.
FIFA has expanded the World Cup from 32 teams to 48, from 64 matches to 104, and from a tournament that once dominated one month every four years into a year-round commercial platform. That expansion irritates people for good reason. Players worry about the schedule. Fans resent ticket prices. Host cities bear the costs. Critics see an institution that keeps finding new ways to monetize the game. None of those criticisms is frivolous.
But football did not become global because people loved it. People have loved football for more than a century.
Football became global because someone paid for the dull, expensive work: pitches, lighting, coaches, referees, youth leagues, women’s competitions, travel, medical support, training centers, technical staff, and the administrators who keep a federation running after the television cameras leave.
Romance fills stadiums, but it does not maintain them.
FIFA understands this. The World Cup is its commercial engine, and that engine funds football beyond the countries with major domestic leagues, major television markets, and major sponsors. Through its Forward program, FIFA has made funds available for facilities, technical centers, domestic competitions, coaching education, referee development, women’s football, youth pathways, and the basic operations of member associations that could not sustain these activities on their own.
Some of those projects are large, but many are not.
A pitch in a small federation. A coach-education program. Travel for a women’s team that otherwise would not compete. A modest national training center that gives talented players a place to train instead of another reason to quit.
That is where the money matters. It is also where the story becomes uncomfortable. Money on this scale creates capacity, but it also creates temptation.
FIFA’s revenue and reinvestment do not make it clean. No serious account of the organization can avoid the corruption cases that exploded into public view in 2015 or the criminal prosecutions that followed. The allegations involved bribery, commercial rights, racketeering, fraud, and money laundering. FIFA has also faced sustained criticism over governance, ticket access, human rights, executive power, and the political incentives created when those receiving distributed funds also elect those controlling the institution.
These are not side issues; they are the point. Revenue does not prove virtue. A nonprofit label does not cleanse an organization. Money, power, prestige, and weak controls create a dangerous mix in football, medicine, universities, charities, governments, and professional societies alike.
The question is not whether an institution makes money. Of course it should. The real question is what happens next: how the money was earned, who controls it, who audits it, what is disclosed, who benefits, what happens when someone abuses the system, and whether the organization can show what its surplus actually built.
Those are governance questions. They matter more than the tax status. I learned the healthcare version of this lesson slowly, and not always comfortably.
Physicians are trained to view money as slightly contaminating. We are taught to care about patients, outcomes, ethics, equity, science, and service. We should. Those are the reasons most of us entered medicine. But many doctors absorb a second lesson without anyone saying it aloud: that financial fluency somehow compromises the mission.
I believe that is wrong. The controversial lesson is this: financial illiteracy is not moral cleanliness. It is abdication.
A physician who refuses to understand margin, payer mix, capital allocation, philanthropy, or the economics of a service line does not protect patients from finance. He simply gives more power to people who may understand the spreadsheet better and the patient less.
I saw this clearly in my time at NYU. Our pediatric orthopedic division grew. More patients came. Referring doctors trusted us. The clinical work improved. Education improved. Research improved. By every measure that mattered to the people in the room with us, the division was succeeding.
But in a large academic health system, success exists at different scales.
A child with a complex hip problem may be the most important patient in the world to that family. A pediatric orthopedic program may be clinically excellent. It may still be a small financial signal inside an enterprise driven by cancer, transplant, adult reconstruction, imaging, cardiovascular care, neuroscience, and a thousand other demands on capital.
That did not diminish our work; it clarified the map.
Clinical importance and financial weight are not always aligned. A physician leader who understands that can make a better case for the program: not just that it is good, but why it deserves investment; what it enables; what it protects; what it will cost if it is allowed to drift.
That is a more difficult argument than “this is the right thing to do.” It is also the argument that institutions act on.
At Texas Children’s, as in every large nonprofit hospital system, the mission is real. So is the financial burden required to sustain it. Operating rooms need equipment. Nurses need to be recruited and retained. Data systems need to function. Fellows need teaching time. Research needs coordinators. Families with difficult diagnoses need someone to help them navigate care rather than being handed a phone number and a follow-up date.
None of that happens because the mission statement is inspiring. It happens because someone paid for it. And when margin disappears, the first losses are often invisible.
It is the nurse navigator who catches a missed preoperative test before a family arrives at the hospital. It is the person who calls after surgery and learns that a wound looks wrong. It is the research coordinator who turns 300 cases into a usable database, then a paper, and eventually evidence that helps the next 3,000 patients. It is the fellow who carries a program’s technical standards into the next hospital, or the quality analyst who spots a complication pattern before it becomes a scandal.
These are not administrative luxuries. They are the scaffolding. A hospital can cut them, and the spreadsheet will often show a saving. The patient sees the bill later.
Bad profit is real. It should be called out without hesitation. It is unnecessary surgery driven by good reimbursement. It is a hospital chasing volume without measuring outcomes. It is a company burying bad data. It is a service line built around what pays best, while the community’s real needs go unanswered.
That is not mission.
But no margin is a different failure.
No margin means the program runs on goodwill until goodwill runs out. It means the next idea must be built in someone’s spare time, which is usually another way of saying it never gets built properly. It means that when a key person leaves, equipment breaks, reimbursement changes, or demand suddenly rises, the organization has nothing left to absorb the shock.
Bad profit exploits. No margin abandons.
One takes too much. The other stops building.
Neither should be defended.
This is the argument behind my forthcoming book, Mission Requires Margin. Margin is not the mission. It is not proof of virtue, nor is it permission to treat patients as customers with diagnoses. It is fuel.
A well-run nonprofit should generate revenue ethically, retain enough margin to remain resilient, and reinvest that margin in the work the market alone will not fund well: access, teaching, research, quality, care coordination, workforce stability, and the programs that matter deeply, even when they do not produce the strongest immediate return.
That is cross-subsidy. It is not an accounting trick. It is a statement of values.
A profitable surgical service can support a pediatric program. A donor’s unrestricted gift can fund the coordinator’s role, even though no one will name a building after it. A hospital reserve can protect a mission-critical service during a difficult year. A successful World Cup can fund a training center, a girls’ competition, or a national pathway in a country where commercial football cannot yet pay for itself.
The decisions must be deliberate.
That is the standard I would apply to FIFA, to Texas Children’s, to NYU Langone, to any children’s hospital, to any university, and to any nonprofit that claims to exist for more than its own survival.
The test is not whether the institution makes money. It is whether it earns that money honestly, governs it properly, and can explain who gains when the surplus appears, and what disappears when it does not. Then look at what the institution built.
The World Cup is on our screens because FIFA learned to sell football to the world. It has made serious mistakes. It deserves scrutiny and strong governance. It deserves critics who understand that a game belonging to everyone can still be captured by those closest to the revenue. But the answer is not to pretend that football could spread globally without an engine.
Nor can healthcare. Mission needs more than good intentions. It needs cash, controls, and the discipline to put both back to work. That is not a retreat from mission.
It is the price of keeping it alive.