Hospitals in New York State are by far the nation's weakest financially - so weak that nearly half of them have a hard time raising the money needed to invest in renovated wards, new ambulances and improved computer systems, according to a national analysis released last week.

Dividing all hospitals into three categories by their ability to raise cash, the report says that in 2001, 43 percent of New York's hospitals fell into the bottom group, with "limited access to capital," compared with 19 percent nationally. The report, by the Healthcare Financial Management Association, a national health industry group, and GE Healthcare Financial Services, with research from PricewaterhouseCoopers, says that the top group, with "broad access" to money for capital projects, included 36 percent of hospitals nationwide, but just 8 percent of those in New York. In both groups, New York ranked last among the states.

Hospitals' ability to raise money outside of day-to-day operations - through philanthropy, for example, or selling bonds or real estate - has suffered lately. The report says the amount they raised fell from $51.4 billion nationally in 2001 to $36.5 billion in 2002, and the true drop was even greater, because a large part of last year's figure represents refinancing of old debt.

But the decline, and the financial troubles underlying it, have not been evenly spread. The report says that over the last several years, hospitals in the top category slipped only slightly by most financial measures, while those in the bottom group - and, by extension, many New York hospitals - lost ground at a much faster pace.

The report cites "a widening gap between the haves and the have-nots, " with New York accounting for a disproportionate share of the have-nots. New Jersey's hospitals fared a bit below the nation's as a whole in 2001, the report says, and Connecticut's did substantially better.

"The industry is strangulated if it's denied access to capital," a problem that "has been a real worry of mine for some time," said Kenneth E. Raske, president of the Greater New York Hospital Association, the main trade group in the metropolitan area.

When hospitals have trouble borrowing or raising money, he said, it means they are slower to make the improvements that they finance over several years rather than paying cash: building new buildings or refurbishing old ones, buying or leasing expensive machinery like CAT scans, or upgrading the computers that handle everything from pharmacy orders to patient billing. Patient care suffers, he said, and so does the hospitals' financial performance.

The number of hospitals nationwide in the "limited access" category rose sharply, from 11 percent in 1997 to 19 percent in 2001. While the report did not name specific hospitals, the troubles of New York hospitals are plain to see in just this year's events. Several hospitals around the state, including the Caledonian campus of Brooklyn Hospital Center and St. Agnes Hospital in White Plains, have closed or their closings have been announced. And the closing of St. Clare's Hospital in Manhattan was averted by takeovers by larger hospitals. And some hospitals, like St. Vincent Catholic Medical Centers, have struggled to cut tens of millions of dollars from their budgets, while others have closed outpatient clinics.

Hospitals around the country have been squeezed by insurance companies' and government health programs' efforts to cut costs, and a sharp decline in charitable fund-raising since the recession two years ago. New York City's hospitals have been especially hard hit by the drop in philanthropy, as well as shrinking federal support for teaching hospitals, a large uninsured population and the aftereffects of the World Trade Center attack. The report shows a sharp rise in hospitals' selling their real estate holdings.

Critics, including Wall Street analysts, politicans and scholarly researchers, have argued over the years that the city has more hospitals than it can support and that they are inefficient, and that a little winnowing might be a healthy thing.

The report shows that hospitals that were in the worst condition in 1997 have also suffered most since then - their patient volumes have shrunk most, their debt payments have grown most and their operating profit and loss picture has soured most.

From 1997 to 2001, operating margins at hospitals with good access to capital slipped only slightly, to an average of 4.7 percent from 5.2 percent over expenses. But those in the fast-growing "limited access" group had sharper losses, to 7.3 percent from 1.5 percent.