Health Care Equipment

Overweight While the latest ISM manufacturing survey made for grim reading, there is a corner of the manufacturing landscape that excels when overall manufacturing is in retreat: health care equipment (HCE) makers (second panel, ISM shown inverted). This defensive health care sub-group is firing on all cylinders. Not only is medical equipment industrial production going against the grain and climbing at a healthy clip, but also the industry’s new orders-to-inventories ratio is in its third consecutive year of a sling shot recovery. Moreover, HCE pricing power is expanding smartly at a time when our overall corporate pricing power proxy is contracting. All of this suggests that the earnings-driven vault to all-time relative performance highs has staying power. A Healthy Start A Healthy Start Bottom Line: We reiterate our recent boost to an overweight stance in the S&P health care equipment index. The ticker symbols for the stocks in the index are: BLBG: S5HCEP – ABT, MDT, DHR, BDX, SYK, ISRG, BSX, BAX, EW, ZBH, IDXX, RMD, TFX, HOLX, ABMD, VAR.

Overweight As a follow up to yesterday’s Insight Report where we highlighted our sanguine view on the S&P health care equipment index, a structural EM macroeconomic trend further reiterates our constructive view on the U.S. health care equipment providers. Aging population, one of the major factors that has been driving the explosion of health care spending in DM for the past 20 years, is now rapidly impacting EM. According to the UN, the share of the population aged 65 and older in EM countries will rise from roughly 7% this year to 16% by 2060, while population growth slows to below the replacement rate (see chart). Meanwhile, IMF data shows that EM health care spending is approximately 5% of GDP, whereas it stands in excess of 14% in DM. U.S. health care equipment providers are the first in line to benefit from the upcoming increase in health care spending in EM. Indeed, U.S. companies are often the only source of equipment for hospitals/clinics globally given their status of technological leaders. Bottom Line: Long-term EM demographic trends as well as the short-term “fear selling” discussed in Monday’s Special Report create an exploitable trading opportunity in the S&P health care equipment index. The ticker symbols for the stocks in the S&P health care equipment index are: BLBG: S5HCEP – ABT, MDT, DHR, BDX, SYK, ISRG, BSX, BAX, EW, ZBH, IDXX, RMD, TFX, HOLX, ABMD, VAR. Chart 1

Overweight This past Monday we co-authored a Special Report with our sister Geopolitical Strategy service gauging the odds of “Medicare For All” becoming law. Our analysis showed that the odds of universal health care legislation being enacted in the U.S. by 2022 are about 10%-15%. As a result, we were compelled to boost the S&P health care index to overweight as fear selling created an exploitable trading opportunity in this defensive sector. We are executing this upgrade by lifting the S&P health care equipment index to overweight (as a reminder we have been overweight the S&P managed health care index since April 15, 2019). This move is not contingent upon earnings outperformance. Rather, it is a combination of overwrought investors creating a buying opportunity, along with health care’s historic outperformance at the end of the business cycle. Our prior research shows that health care stocks have been the top performer in the last equity market surge to take place between the peak of the ISM manufacturing composite index and the beginning of the subsequent recession (see chart). Bottom Line: Lift the S&P health care equipment index to overweight. This move also lifts the overall health care index to an above benchmark allocation. Please see this Monday’s Special Report for additional details. Health Care Is A Resilient Late Cycle Performer Health Care Is A Resilient Late Cycle Performer

Highlights The odds of universal health care legislation being enacted in the U.S. by 2022 are about 10%-15%. Former Vice President Joe Biden is the most likely Democratic candidate in 2020, but the alternative is most likely a progressive candidate seeking universal health care. Trump is slightly favored to win in 2020, but a Trump loss is likely to translate into full Democratic control of the U.S. government, making ambitious legislation more likely to pass Congress. An overweight portfolio allocation in the S&P health care index is a sensible and defensive move. Fear selling in health care stocks could easily return but would create an exploitable trading opportunity at this late stage of the cycle. We are executing the upgrade of the S&P health care index via an upgrade of the S&P health care equipment index, which has seen a material valuation de-rating at the same time as profits are expanding, to overweight. Feature Will The Democrats Win? Can They Pass Universal Health Care? “Medicare for All,” or government-led universal health care in the United States, is less likely to become the law of the land by 2022 than the market expects. We put the probability at around 10%-15%. Here’s why. The industry faces only two certainties: Americans are getting older and the federal government is increasing its involvement. The former is a secular driver for health care demand. The latter is an inference drawn from the fact that the Republican Party failed to repeal the Affordable Care Act, or Obamacare, even when it had full control of government. It is very unlikely that the Republicans will get another chance at repeal. It is also very unlikely that the public will tolerate the current status quo forever. The result is that the U.S. will eventually end up with a restored Obamacare or an altogether new system with a greater government role. The Republican failure to repeal was not idiosyncratic – it was not based on the fact that the late Senator John McCain, who cast the decisive vote on July 27, 2017, had been diagnosed with brain cancer earlier that year. Rather, it was structural – the repeal failed because (1) it is always extremely difficult to remove an entitlement once it has been given to voters and (2) a slim majority of Americans approved of Obamacare – and still do (Chart 1). Chart 1 Republicans went on to dismantle aspects of Obamacare, including the problematic “individual mandate.” But they did so without replacing it. The result was a severe electoral defeat in the 2018 midterm elections, despite a huge drop in the unemployment rate (Chart 2) – which matters directly in a country where 49% get their health insurance through their employer. Health care was the single most important issue driving people to vote against the ruling party in November 2018, judging by both pre-election polls and exit polls (Charts 3 & 4). Chart 2Low Unemployment Has Not Solved Health Care Woes Low Unemployment Has Not Solved Health Care Woes Low Unemployment Has Not Solved Health Care Woes Chart 3 Chart 4 The need for reform is manifest. It is widely known that the U.S. spends more than other countries on health care (Chart 5) and yet achieves worse results: preventable mortality is higher than in other countries that spend less (Chart 6). Democrats have tried to overhaul the system since 1993. Even President Trump is seeking to cap prescription drug prices and maintain the Obamacare requirement that health care insurers accept customers with “pre-existing conditions.” Chart 5 Chart 6 Uncertainty has risen since the Republicans’ midterm defeat, which increases, or is seen as increasing, the odds of a Democratic victory in 2020. Such a victory would mark the third time in 12 years that American policy would witness a 180-degree reversal – and it would have a major impact on the health sector (Chart 7). Chart 7The Sector's Response To Major Political Events The Sector's Response To Major Political Events The Sector's Response To Major Political Events In truth Trump is still favored to win in 2020, on the back of the incumbent advantage – as long as the economy holds up. But with a chronically weak approval rating, and narrow 2016 margins of victory and the aforementioned midterm losses in key swing states, his odds of reelection are probably not much better than 55%. Meanwhile the Democrats are swinging to the left and may not settle simply for restoring Obamacare. Left-wing or “progressive” candidates for the Democratic nomination are polling in line with traditional center-left candidates (Chart 8), which is highly unusual (even compared with the 2007-08 race). Candidates are crowding onto the democratic socialist bandwagon in the wake of Bernie Sanders’s formidable challenge to Hillary Clinton and her subsequent loss to Trump. Chart 8 Could a progressive candidate win the nomination? Certainly. Former Vice President Joe Biden leads the pack at this early stage in the nomination process. He would seek to restore and build upon Obamacare. The second-ranked candidate is Sanders, whose initial proposal to create Medicare for All has transformed the national debate. Following Sanders are Senators Kamala Harris, who co-sponsored the latest version of the bill with Sanders, and Elizabeth Warren, an outspoken progressive who is also in favor of universal health care (Chart 9). Chart 9 Sanders does have a path to winning the nomination, as the leading progressive candidate at a time when the party is becoming more progressive. He performs better than Biden in head-to-head polls against Trump in the key battleground states (Chart 10). Strategic voters will have trouble convincing fellow Democrats that they should not vote for him because he is unelectable: he has a clear electoral path to the White House via Michigan, Pennsylvania, and Wisconsin, where he performed well in 2016 and polls well today. If Sanders has a chance, then Medicare for All has a chance. Chart 10 Because it is extremely difficult to unseat an incumbent president, a victory over Trump in 2020 is only likely to occur if there is a surge in voter turnout and Democratic Party support among (1) blue-collar workers who abandoned the Democrats for Trump in 2016, or (2) young voters, women, or minorities. Any such surge would also enable the Democrats to defend their senate seats while picking up Arizona, Colorado, and Maine, which are statewide elections that will be affected by the headline presidential race. And if the Democrats win 50 seats, they would get a majority in the senate, as the vice president would break any tie. With a majority, Senate Democrats could use the “nuclear option” to bypass the filibuster and drive through their priority legislation.1 This would set a new precedent with far-reaching consequences. But recent majority leaders have already begun eroding the filibuster and there is no hard constraint preventing a ruling party from removing it entirely. It is perfectly possible, and all the more likely if the nation sweeps a progressive candidate to power in a wave of enthusiasm for dramatic changes like universal health care. In other words, any victory against Trump is likely to entail full Democratic control of government. In this scenario, Democrats would have a very good chance of passing a major piece of legislation. Hence, if a progressive wins the nomination, and makes Medicare for All the policy priority, there is at least a 50/50 chance it will pass, probably more like 60%. The catch is that a progressive may not win the nomination. There is not decisive evidence that Americans really want Medicare for All. First, Americans tend to view their own health costs as “reasonable” (Chart 11). They are not, as a whole, clamoring for a single-payer system. Chart 11 Second, while Americans say they support Medicare for All, that support evaporates when they learn about the various policies that it would necessitate, such as eliminating private health insurance and raising taxes (Chart 12). Chart 12 Third, most Democrats are closer to Biden’s position than Sanders’s – they want to fix Obamacare rather than revolutionize the system (Chart 13). Chart 13 Fourth, Colorado tried to pass its own version of Medicare for All on the state level in 2016. The bill’s advocates were handed a 79% defeat by voters. Colorado is a swing state so it is not an irrelevant experiment. Fifth, independents are not shifting to the left in a way that would validate the sharp leftward shift within the Democratic Party (Chart 14). Nominating Sanders or another progressive is more likely to lead to a loss in the general election than it is to ensure that universal health care gets passed.   Chart 14Independents Not Swinging Dramatically To The Left Independents Not Swinging Dramatically To The Left Independents Not Swinging Dramatically To The Left A simple back-of-the-envelope exercise suggests that odds of universal health care by 2022 are about 10%-15%. Nevertheless, we attempt a conservative, back-of-the-envelope method for estimating the probability of passage. It runs like this: There is a 50% chance a progressive wins the Democratic nomination. We assume that if Biden wins it is because Democratic voters prefer a restitution of Obamacare. There is a 45% chance that Trump loses the presidential election. We assume that for the Democrats to unseat an incumbent is difficult enough that they will also win the Senate. Under these circumstances, there is a 50%-60% chance that universal health care legislation passes – even though it will be very difficult to get it over the line. (Note that the ACA passed very narrowly at a time when the Democrats had a huge tailwind due to voters’ disenchantment after the global financial crisis). With these assumptions, the conditional probability of passage is around 13.5% (0.5 x 0.45 x 0.6 = 0.135) These odds can be moderated by boosting Trump to a 69% chance of reelection (the historical average for sitting presidents), which brings down the odds of ultimate passage to 9%. Note, however, that the bond market is pricing a 27% probability of a recession 12 months from now (Chart 15). If there is a recession, then President Trump is virtually assured to lose reelection and the Democratic victor will have a strong tailwind of public support. This will increase the chance that universal health care passes to 80%. (We still assume in this case that Biden would stick with Obamacare as he would not be committed to Medicare for All and it is not an economic stimulus package). The conditional probability would become 0.5 x 0.27 x 0.8 = 11%. Chart 15Probability Of Recession Is Rising NY Fed's Yield Curve Model Suggests That The Probability Of A Recession Is Still Quite Low Probability Of Recession Is Rising NY Fed's Yield Curve Model Suggests That The Probability Of A Recession Is Still Quite Low Probability Of Recession Is Rising NY Fed's Yield Curve Model Suggests That The Probability Of A Recession Is Still Quite Low In other words, whether we upgrade Trump’s chances of winning or we upgrade the chances of a recession that kicks him out of office, the odds are roughly the same at 9%-11%. And they could be a bit higher at 14%. Medicare for All has a chance of becoming law, although it is not all that great. Bottom Line: With fairly conservative assumptions the odds range from 10%-15%. that the U.S. could legislate a sweeping overhaul of the health care system and new social entitlement by 2022. This is a serious risk to the industry. Health care equities have recovered the losses suffered since Sanders’s latest push for Medicare for All, which means that it is not pricing in a high probability of passage at present. Additional policy-related selloffs are likely between now and the spring of 2020, if and when the odds increase of Sanders (or another progressive) winning the Democratic nomination. Buy Into Health Care Weakness Regardless of the likelihood of passage, the faintest hint of the winds of change has brought about significant price changes in the relevant equities. In the lead up to the 2016 U.S. presidential election, Hillary Clinton, a health care reformer (though importantly NOT a Medicare for All advocate) was polling well ahead of Donald Trump. Health care stocks underperformed the broad market in anticipation of potential reforms resulting from a Clinton win (Chart 16). Two years after Donald Trump’s election, both S&P health care equipment and S&P managed health care have significantly outperformed with the effect most dramatic in the former. Chart 17 shows the reverse picture: a “blue wave” in the 2018 midterm elections was swiftly followed by the zenith for health care stocks as the market digested the implications of a Democratic House and the resulting higher probability of a similar sweep in 2020 in the Senate and executive branch. Chart 16Election Fear Creates Buying Opportunities... Election Fear Creates Buying Opportunities... Election Fear Creates Buying Opportunities... Chart 17...And History Appears To Be Repeating Itself ...And History Appears To Be Repeating Itself ...And History Appears To Be Repeating Itself Furthermore, our prior research shows that S&P health care has been the top performer in the last equity market surge to take place between the peak of the ISM manufacturing composite index and the beginning of the subsequent recession.2 This research was confirmed in a report last month analyzing sector returns after a Fed loosening cycle begins. The S&P health care index has historically outperformed from six months before a rate cut all the way to two years after easing policy.3#fn_3 As a reminder, the market has now priced in two rate cuts over the next year. We recommend an overweight position for the broad S&P 500 health care index as well as for health care equipment. BCA’s U.S. Equity Strategy has already moved to an overweight recommendation on the S&P managed health care index, a move that has netted our portfolio 12.4% of alpha. Today U.S. Equity Strategy is raising our recommendations on both the S&P health care equipment and, more importantly, the broad S&P health care index from neutral to overweight. Further, considering U.S. Equity Strategy’s recent portfolio changes, namely moving the S&P materials index to neutral, this upgrade of S&P health care to overweight moves our cyclicals vs. defensives style preference from overweight cyclicals to neutral. This move to the sidelines on the cyclical/defensive portfolio bent has netted modest gains of 2% since its October 2, 2017 inception. Equipping The World’s Hospitals Our upgrade of S&P health care equipment to overweight is not contingent upon earnings outperformance. Rather, it is a combination of overwrought investors having created a buying opportunity, combined with health care’s historic outperformance at the end of the business cycle. Nevertheless, an examination of the sector’s macro environment is revealing. The health care equipment index has recently completed an inventory clear-out cycle, as evidenced both by a slingshot rebound in the shipments-to-inventories ratio (second panel, Chart 18) and a recovery in industry pricing power (bottom panel, Chart 18). This is remarkable in the context of the deceleration in equipment fixed-investment growth that the industry has faced since reaching decade-highs in 2017 (third panel, Chart 18). The upshot is that steady pricing and resilient volume growth should deliver positive top-line growth. The margin picture has also dramatically improved: industrial production has been surging for the past year while hours worked have remained tepid (second and third panels, Chart 19). The combination has driven our productivity proxy to a multi-year high where it has recently diverged from the relative stock price (bottom panel, Chart 19). Chart 18Inventories Have Cleared Inventories Have Cleared Inventories Have Cleared Chart 19Productivity Is Soaring Productivity Is Soaring Productivity Is Soaring This underpins our thesis that health care stocks in general and health care equipment stocks in particular have recently suffered based on fear, not fundamentals, amidst a stable domestic demand environment and rosy profit picture. The export channel is at least as important to the S&P health care equipment index as the domestic demand environment. In fact, roughly 60% of sector revenues are generated outside the United States. The news on this front is encouraging. Europe, the other key market for domestically-manufactured health care equipment, has lately seen a pickup in new orders and coupled with the loss of momentum in the trade-weighted U.S. dollar signal that future export growth will remain upbeat (trade-weighted U.S. dollar shown inverted and advanced, bottom panel, Chart 20). The global PMI has historically led exports. While this series has turned down, it has been diverging from export growth for the past year. We believe this is a function of the early stages of a secular trend in health care equipment: the expansion of the EM safety net with health care at its core. The same demographic trend that has been driving the explosion of health care spending in the DM for the last 20 years is rapidly impacting the EM, namely an aging population. The UN projects that the share of the population aged 65 and older in the EMs will rise from roughly 7% this year to 16% in 2060, while population growth slows to below the replacement rate, a tectonic shift in the demographic landscape (Chart 21). Meanwhile, according to IMF data, EM health care spending is approximately 5% of GDP. By contrast, the DMs stand in excess of 14%. Chart 20The Export Valve Is Wide Open The Export Valve Is Wide Open The Export Valve Is Wide Open Chart 21 A catch-up phase looms, driven by both demographics and an overall global harmonization of standard of care, resulting in a secular outperformance of internationally geared health care equipment manufacturers’ earnings. This bodes well for U.S. health care equipment providers who are the technology leaders and often the only source for equipping hospitals/clinics around the globe. Notwithstanding the bright outlook, fear selling in the S&P health care equipment index has driven a reversal in the two-year valuation rerating that the index has undergone (bottom panel, Chart 22). With the valuation retreating back to its historical range, our main concern that the index is too expensive has eroded. Further, the valuation decline is coming at a time when forward earnings growth has come out of hiding and is now slated to materially outgrow the broad market (middle panel, Chart 22). Chart 22Valuations Have Returned To Earth Valuations Have Returned To Earth Valuations Have Returned To Earth Bottom Line: Something has to give in this equation and macro tailwinds suggest that a valuation re-rating phase looms. Accordingly, we are moving to an overweight recommendation on the S&P health care equipment index. This move pushes our S&P health care index to an above benchmark allocation and also moves our cyclical vs. defensive preference back to neutral. The ticker symbols for the stocks in the S&P health care equipment index are: BLBG: S5HCEP – ABT, MDT, DHR, BDX, SYK, ISRG, BSX, BAX, EW, ZBH, IDXX, RMD, TFX, HOLX, ABMD, VAR. BCA’s Geopolitical Strategy echoes the tenor of these recommendations and is going long the S&P 500 health care index and the health care equipment index versus the broad market. A Word On Pharma Between 1980 and 2000, pharma earnings expanded at a record clip, taking sector share prices into the stratosphere (top panel, Chart 23). Since the zenith in the early 2000’s, margins have been continually under pressure as R&D costs have outpaced volume gains (second panel, Chart 23). However, earnings growth has continued mostly uninterrupted as the industry has raised drug prices. Since 2015, however, price increases have flat lined and now they move at the same pace as overall inflation, though the current convoluted system keeps pricing mostly opaque (bottom panel, Chart 23). We think this is the new normal. The thesis of this report revolves upon a blue vs. red probability outcome. However, as noted, both parties seem united in the fight against high drug costs and Republicans under President Trump are not averse to government intervention to drive down prices. As such, we expect the pharma pricing headwinds to remain a secular trend, driven by outrage from both sides of the aisle and even universal coverage is not enough to bear the pressure. Accordingly, we reiterate our underweight recommendation. Chart 23Pharma Remains Underweight Pharma Remains Underweight Pharma Remains Underweight Conclusion Universal health care will be negative for the U.S. budget deficit but positive for economic growth. As for the macroeconomic impact of universal health care, it is complex to assess because much would depend on the extent of any reduction in private health-related sectors. Almost certainly, the U.S. would adopt a parallel system where private health care remains available, but there inevitably would be some job losses in the insurance sector. And drug companies would face downward pressure on pricing. On the other hand, the marked increase in government spending would be stimulative. And we do not see future American administrations exercising a heretofore unknown fiscal discipline once such a new entitlement is established. Many families would enjoy a reduction in health care costs. Overall, it should be positive for economic growth.   Matt Gertken, Vice President Geopolitical Strategy mattg@bcaresearch.com Chris Bowes, Associate Editor U.S. Equity Strategy ChrisB@bcaresearch.com Anastasios Avgeriou, U.S. Equity Strategist anastasios@bcaresearch.com   Footnotes 1      The filibuster is a means of prolonging debate and obstructing a vote. It can be defeated if 60/100 senators vote to move to end debate (“cloture”). It effectively ensures that the three-fifths majority is the standard majority needed to pass legislation in the senate. However, it is possible for the senate majority leader, backed with a simple majority, to alter the senate rules and remove the filibuster, so legislation can be passed with a simple majority. But it would be an aggressive move and a historic precedent. 2      Please see BCA U.S. Equity Strategy Weekly Report, “Portfolio Positioning For A Late Cycle Surge” dated May 22, 2018, available at uses.bcaresearch.com. 3      Please see BCA U.S. Equity Strategy Weekly Report, “Sector Performance And Fed Loosening Cycles: A Historical Roadmap” dated May 6, 2019, available at uses.bcaresearch.com.   Current Recommendations

Neutral The S&P health care equipment (HCE) index has caught a bid recently, reflecting the sector's strong profit momentum, following nearly a decade of decline (second panel). We fear, however, that investors have become somewhat overzealous as the run up in stock prices has dramatically outpaced earnings expectations, pushing the forward price/earnings multiple to its highest level since the GFC (third panel). Such excitement, particularly when industry pricing power is lagging far behind the rest of the broad corporate sector (bottom panel) seems misplaced. Net, we continue to think the catalyst for a sustainable move higher in the index will be a recovery in pricing power and, in the absence of evidence of this, we reiterate our benchmark allocation. The ticker symbols for the stocks in this index are: BLBG: S5HCEP: MDT, ABT, DHR, BDX, SYK, ISRG, BSX, BAX, EW, ZBH, IDXX, RMB, VAR, HOLX. Too Early To Turn Bullish On Health Care Equipment Too Early To Turn Bullish On Health Care Equipment

Neutral At the beginning of the summer, we downgraded the S&P health care equipment (HCE) index to neutral for three main reasons: valuations had shot higher, demand had downshifted and pricing had cooled substantially. Relative valuations have since fallen back (top panel), but the operating environment has worsened, providing confirmation that our downgrade was well-timed. Both HCE orders and production crested in the middle of 2016 and have been falling since, production precipitously so (second panel). At the same time, medical equipment relative selling prices have been contracting (third panel), indicating the industry could be in oversupply despite slowing production. The likely result is contracting margins and valuation multiples. Still, the news is not all bad. New health care facility construction has recovered recently and investment in medical equipment may follow suit (bottom panel), potentially portending a resurgence in demand. On balance, we think it prudent to sit on the sidelines and wait for evidence of a recovery in pricing power before reentering the fray; stay neutral. The ticker symbols for the stocks in this index are: BLBG: S5HCEP: ABT, BAX, BCR, BDX, BSX, DHR, EW, HOLX, IDXX, ISRG, MDT, RMD, SYK, VAR, ZBH. Not Out Of The Woods Yet Not Out Of The Woods Yet

We are making room for the financials sector upgrade by trimming the health care sector to neutral. As discussed in recent weeks, a modest shift away from a defensive to a more balanced portfolio has been on our radar. At the beginning of the year we added the S&P health care equipment (HCE) index to our high-conviction overweight list for three main reasons: valuations had undershot owing to health care reform uncertainty, domestic sales were set to improve and leading indicators of foreign sourced revenue also painted a rosy picture. But some of these forces are losing their potency. The most troubling aspect has been a downturn in leading indicators of domestic demand growth. New health care facility construction has dropped sharply, warning that investment in medical equipment may soon follow suit (second panel). Consumer outlays at hospitals have nosedived on a growth rate basis. This suggests that the growth in patient visits has dried up, and may be a warning that medical equipment new order growth will also decelerate (third panel). Moreover, as outlined in recent Weekly Reports, the broad corporate sector has regained pricing power, but medical equipment suppliers have lagged (bottom panel). The implication is that our confidence in a further valuation re-rating has been dented. Take profits and downgrade to neutral, and please see yesterday's Weekly Report for more details. This brings our overall health care sector weighting to neutral. Take Profits In Health Care Equipment Take Profits In Health Care Equipment

Highlights Portfolio Strategy Upgrade the financials sector to overweight. This year's consolidation phase is drawing to a close as inflation expectations stabilize. Lift the S&P banks index to overweight. Leading indicators of credit creation are signaling a reacceleration as the year progresses. Trim the S&P health care sector to neutral via profit-taking in medical equipment stocks. Recent Changes S&P Financials - Upgrade to overweight from neutral. S&P Banks Index - Upgrade to overweight from underweight. S&P Health Care - Downgrade to neutral. S&P Health Care Equipment - Downgrade to neutral. Table 1 Girding For A Breakout? Girding For A Breakout? Feature Chart 1Yields Are Not Yet Restrictive Yields Are Not Yet Restrictive Yields Are Not Yet Restrictive The S&P 500 is challenging the top end of its range. A playable breakout looks increasingly probable, albeit the exact timing is difficult. First quarter profit results have been strong, corporate guidance has been solid and monetary conditions are unlikely to become tight enough in the short run to dent renewed profit optimism. The latest string of economic disappointments is seen as providing the Fed with ample leeway, and investors are willing to overlook ongoing sluggishness because earnings are outperforming the economy via margin expansion. As discussed in detail in recent weeks, earnings growth is supported by a broad-based recovery in sales and pricing power. Top-line growth is critical to sustaining the overall equity market overshoot given sky-high valuations. Indeed, the appeal of equities stems from their attractiveness relative to other asset classes rather than in absolute terms. History shows that an asset preference shift can take time to play out, and push valuations higher than seems justified on fundamentals alone as long as recession is not an imminent risk. The Treasury market can provide clues as to when vulnerabilities will intensify. According to BCA's Treasury Bond Valuation Model, yields usually need to be at least one standard deviation above normal before stocks, and the economy, are at risk of a major downturn (Chart 1). At those turning points, inflation concerns are typically running hot, forcing the Fed to tighten enough to slow growth and undermine economic activity. This simple rule of thumb warned of the most recent stock market peaks, as well as equity slumps in the early-1990s, 1987, and the early-1980s, and supported bond vs. equity outperformance. Recently, the 10-year Treasury yield has returned to fair value, and the U.S. dollar has come off the boil. The implication is that there is no monetary roadblock to halt the upward momentum in equities at the moment. There is ample room for yields to rise before becoming restrictive, especially if the primary driver is the real component. In this light, we will continue with our program of transitioning to a more balanced equity portfolio from its previous defensive tilt. This week we downgrade a defensive sector to neutral and redeploy capital into the financials sector. Upgrade The Financials Sector... The financials sector has given back roughly 50% of its post-election surge this year. The main culprits have been a calming in Fed interest rate hike expectations, a flattening yield curve and softening inflation expectations. Moribund credit creation has also created earnings uncertainty (Chart 2). Nevertheless, the corrective phase appears to be drawing to a close, because financials sector profits are increasingly likely to surpass those of the overall corporate sector going forward. Traditionally, the financials sector benefited from a strong U.S. dollar. A strong dollar exerted downward pressure on interest rates, which spurred domestic economic strength, loan demand and a steepening yield curve. However, since the GFC, the opposite has been true. Zero interest rates and intense deflationary risks were exacerbated by U.S. dollar appreciation, as the corporate sector and commodities suffered. In other words, with the economy operating on a knife's edge between deflation and inflation, a strong currency weighed heavily on financial shares. Thus, the hiatus in the U.S. dollar bull market is a significant positive catalyst, if it arrests the decline in inflation expectations. The yield curve is making an effort to stabilize, suggesting that the risks of falling back close to the deflationary precipice are low. There are already signs of a positive reversal in euro area financials, which had led the U.S. financial sector on the way down after peaking late last year (Chart 2). The euro area has been in a deleveraging phase with acute deflationary risks, underscoring that the signal from share price stabilization in this region is worth noting. The key to a sustained recovery in sector profits is economic reacceleration. Corporate sector profits are healing as a consequence of the pickup in global final demand and the peak in the U.S. dollar, which should ensure that labor market slack does not imminently build. That is necessary to sustain credit quality and generate faster credit demand, and can be illustrated through the positive correlation between the output gap and relative share price performance (Chart 3), at least until the gap grows too large to generate inflationary pressures and by extension, tight monetary policy. Chart 2Earnings Uncertainty... Earnings Uncertainty... Earnings Uncertainty... Chart 3...But A Narrowing Output Gap... ...But A Narrowing Output Gap... ...But A Narrowing Output Gap... Leading economic indicators are consistent with erring on the side of optimism (Chart 4). Our proxy for the supply/demand balance for C&I loans confirms a positive bias for future loan growth (Chart 4). The upturn in the financial sector sales/employment ratio is encouraging (Chart 4). Productivity improvement has begun prior to a reacceleration in loan creation, suggesting that additional upside looms as balance sheets expand. Any unlocking of the regulatory shackles would be a bonus. Strength in our Financials Cyclical Macro Indicator confirms that profits should best those of the overall corporate sector. The financial sector is contributing more to overall GDP growth than it did even during the credit binge/housing bubble (Chart 5), despite the headwind of ultralow interest rates. Chart 4...And Leading Indicators ##br##Are Positive Offsets ...And Leading Indicators Are Positive Offsets ...And Leading Indicators Are Positive Offsets Chart 5Market Cap ##br##Gains Loom Market Cap Gains Loom Market Cap Gains Loom Even though financials represent an ever increasing share of the broad economy, the sector still garners less than its historic median market cap weight (Chart 5). The upshot is that if the economy stays resilient, the correction in relative share price performance should fully reverse, and we recommend further upgrading allocations to overweight via the heavyweight bank group. ...And Bank On Faster Growth Bank profit growth is supported by three main pillars: the quantity, price and quality of credit. All three are set to improve. While seven out of eight lending categories are experiencing a negative credit impulse, forward looking indicators are sending a more positive message. Business and consumer confidence have skyrocketed (Chart 6). If the revival in animal spirits lifts real economic activity later this year, capital demands could finally break out of their slump and reinvigorate moribund loan growth (Chart 6). Importantly, our U.S. Capital Spending Indicator (CSI) snapped back into positive territory. This primarily reflects both the firming in the ISM manufacturing survey and tightness in the labor market. Credit growth has not yet troughed, but should recover in the second half of the year based on our CSI's reading (Chart 6, top panel). Other leading indicators are heralding a pickup in credit demand. A steepening yield curve and the soaring ISM new orders index have an excellent track record in leading the Fed's Senior Loan Officer Survey for overall credit demand (Chart 6). Solid house price inflation and a tight labor market should ensure that consumer credit growth also firms (Chart 7), pointing to the potential for a broad-based bank balance sheet expansion. Overall household leverage has fallen back to 2003 levels and the household debt-service ratio is at multi-decade lows. Chart 6A Turning Point For Loans... A Turning Point For Loans… A Turning Point For Loans… Chart 7...As Demand Recovers …As Demand Recovers …As Demand Recovers Bank deposits are still growing, outpacing nominal GDP by 200bps, and the sector is extremely well capitalized. The loan-to-deposit ratio remains low by historical standards (Chart 8). Bank holdings of risk free securities comprise about 15% of the sector's assets, well above the historic average (Chart 8). The upshot is that there is plenty of firepower to crank up credit creation. True, a rundown in Treasury holdings would result in mark-to-market losses, but banks are well positioned to navigate through rising interest rates. According to the FDIC, net interest income as a share of total revenue has climbed steadily at commercial banks with assets greater than $1bn (Chart 9). Thus, if a better economy and rising inflation materialize in the back half of the year, then higher interest rates will boost profitability (Chart 9). Chart 8Banks Have Dry Powder Banks Have Dry Powder Banks Have Dry Powder Chart 9A Durable NIM Expansion A Durable NIM Expansion A Durable NIM Expansion Table 2 shows a sample of the four largest U.S. banks' earnings sensitivity to interest rate changes. Banks profit from overall rising interest rates in two ways: reinvesting at higher yields and assets repricing at a faster pace than deposits. Table 2Top Four Banks' Interest Rate Sensitivities Girding For A Breakout? Girding For A Breakout? Thus, a steepening yield curve would signal that bank profit estimates should experience a re-rating, provided the yield lift at the long end of the curve was gradual and did not choke off growth via a sudden spike (Chart 9). In terms of credit quality, non-performing loans and charge-offs are sinking from already low levels. It would take a significant deterioration in the labor market to warn that credit quality was about to become a profit drag (Chart 10). Chart 10Credit Quality Is Not An Issue, For Now Credit Quality Is Not An Issue, For Now Credit Quality Is Not An Issue, For Now Importantly, the reserve coverage ratio has climbed to near 100%, as non-current loans have fallen faster than banks have released reserves. Historically, credit quality improvement has been positively correlated with rising valuations (Chart 10). This message is corroborated by return on equity (ROE). Bank ROE has recouped most of the losses since the GFC on the back of recovering productivity gains. However, valuations do not yet reflect the ROE improvement. History shows that after a financial crisis, it can take a prolonged period of improved ROE before investors reward the sector with a valuation expansion, as occurred in the early-1990s (Chart 7, bottom panel). Bottom Line: Boost the S&P financials sector to overweight from neutral. Lift the S&P banks index to overweight. The ticker symbols for the stocks in the S&P banks index are: BLBG: S5BANKX - WFC, JPM, BAC, C, USB, PNC, BBT, STI, MTB, FITB, CFG, RF, KEY, HBAN, CMA, ZION, PBCT. Take Health Care Equipment Down A Notch We are making room for the financials sector upgrade by trimming the health care sector to neutral. As discussed in recent weeks, a modest shift away from a defensive to a more balanced portfolio has been on our radar and the surge in equities over the past week suggests that the consolidation phase is now ending in a bullish fashion, as expected. At the beginning of the year we added the S&P health care equipment (HCE) index to our high-conviction overweight list for three main reasons: valuations had undershot owing to health care reform uncertainty, domestic sales were set to improve and leading indicators of foreign sourced revenue also painted a rosy picture. What has changed? Relative share prices have undergone a V-shaped snapback, all of which can be attributed to a valuation expansion. A flurry of recent M&A activity has also buoyed relative valuations, as takeover premiums have been significant. Relative performance is now at a natural spot to expect a breather. On the operating front, a number of positive profit drivers are still intact. The industry's shipments-to-inventories ratio remains at multi-decade highs and the backlog of medical equipment orders is robust (top and bottom panels, Chart 11). HCE exports are primed to accelerate in the coming months likely irrespective of the U.S. dollar's move. In particular, Europe matters most to S&P HCE constituents, as roughly half of international sales originate in the old continent. Forward-looking indicators of European demand are upbeat, especially with the surge in German medical equipment orders (Chart 11). However, domestic sales indicators have downshifted. New health care facility construction has dropped sharply, warning that investment in medical equipment may soon follow suit (Chart 12, second panel). Consumables demand growth may also take a breather. Consumer outlays at hospitals have nosedived on a growth rate basis. This suggests that the growth in patient visits has dried up, and may be a warning that medical equipment new order growth will also decelerate (Chart 12). Moreover, as outlined in recent Weekly Reports, the broad corporate sector has regained pricing power, but medical equipment suppliers have lagged. Chart 12 shows that relative selling prices are contracting at an accelerating pace. This is significant, as deflation concerns could undermine revenues, and halt the valuation expansion. If domestic medical equipment demand cools, then it will sustain downward pressure on industry activity (Chart 13). Already, medical equipment industrial production (IP) has collapsed, in marked contrast with the expansion in overall IP. Chart 11Export Prospects Are Positive... Export Prospects Are Positive... Export Prospects Are Positive... Chart 12...But Domestic Blues... ...But Domestic Blues... ...But Domestic Blues... Chart 13...Will Weigh On Activity ...Will Weigh On Activity ...Will Weigh On Activity Worrisomely, the HCE new orders-to-inventories ratio has also lost steam, warning that a recovery in future production growth may not be imminent. The implication is that productivity gains are petering out, denting our confidence in a further valuation re-rating. Bottom Line: Downgrade the S&P health care equipment index and remove it from the high-conviction overweight list for an 9% gain. This also pushes the broad health care index to neutral. The ticker symbols for the stocks in this index are: BLBG: S5HCEP: MDT, ABT, DHR, SYK, BDX, BSX, ISRG, BAX, ZBH, EW, BCR, IDXX, HOLX, VAR. Current Recommendations Current Trades Size And Style Views Favor small over large caps and stay neutral growth over value.