This could be the best of years, it could be the worst, but Grady hospital's budget will still be written in red ink.

Despite changes occurring at Grady Memorial Hospital, the hospital's finance chief projected Tuesday that the struggling facility will run a deficit of $20 million to $43 million this year.

At the high end, that loss in a $618 million budget nearly matches last year's shortage and ranks among the largest in the hospital's history.

Grady officials are quick to say that while the hospital is turning around, the major challenges — rising health care costs, dwindling government aid and old equipment — remain.

Grady's outlook for this year was battered when anticipated support from state and local governments didn't materialize. The Legislature failed to provide a dedicated long term source for statewide trauma care.

But Grady is expected to benefit from a one-year infusion of $58 million for statewide trauma care, which could provide the hospital with as much as $25 million. That could reduce the 2008 deficit to about $20 million, giving Grady its best financial picture in years.

In addition, the shift of hospital control to a nonprofit corporation, expected to be final next month, will draw millions more in private donations.

"I think we're doing better," Grady chief financial officer Michael Ayres said in an interview with the Atlanta Journal-Constitution. Still, "We have huge concerns ...

"Can it all go to hell in a handbasket? Sure."

Ayres said three to four years may pass before the hospital can even break even.

"It's not just tied to Grady fixing itself, it's how society choses to provide health care," he said.

As early as next month, the hospital anticipates its first of four annual gifts of $50 million from the Woodruff Foundation.

In addition, Ayres said, the hospital expects to save $50 million this year through greater efficiencies and higher revenues from implementing recommendations from an outside consultant firm.

Consequently, Ayres said, hospital officials are no longer talking about the prospect of cutting staff this year or closing Grady, one of the nation's largest charity care hospitals and the primary trauma center for the most serious injuries in metro Atlanta.

Tom Bell, a member of the new Grady nonprofit corporation, said he forsees great things for Grady, but that the turnaround will take time.

"You have to order the equipment, install it, train the people," said Bell, who is head of Cousins Properties. "I think there's great hope inside of the hospital, and outside in the community."

This year has marked some of the biggest events in the history of the 116-year-old medical facility, both good and bad. The transfer of hospital control is expected to revitalize both the community's faith and financial support for Grady, including campaigns that have pledged some $300 million over five years.

But most of that philanthropic money will be restricted to capital needs of equipment and facilities. Grady, having neglected these needs for years, has a wish list of about $600 million.

More pressing are the operational needs for staff, services and programs. Despite assurances from state leaders, the Legislature failed to approve long term funding for statewide trauma care, which would have provided about $30 million for Grady.

Meanwhile, Fulton and DeKalb counties, struggling with their own budget problems, provided Grady with about $25 million less than their total allocation last year.