Health Care Facilities

Highlights Upgrade The Health Care Sector To An Overweight: Expressed through an overweight position in Health Care Equipment and Services, and an equal weight position in Pharmaceuticals and Biotech The Sector Faces A Few Tailwinds: Recovery of delayed elective procedures and hospital visits will accelerate health care sector sales and profit growth into the balance of the year Aging baby boomers and longer life expectancy will further boost health care spending The Democratic Party’s “blue wave” victory in 2020 has had little effect on health care policy, as the Biden administration has sidelined the party’s most ambitious proposals to deal with the pandemic. This is hardly a tailwind, but the political backdrop for the sector is better than was initially expected There Are Also Headwinds: Reducing or capping drug prices is a bipartisan interest, and may result in imports, price regulation, or inflation indexing, further increasing price pressures The Biden administration’s anti-trust stance may preclude mergers that allow medtech companies to acquire new technology and help hospitals realize economies of scale and preserve razor thin margins Patent expiration for blockbuster drugs is expected to peak in 2023, reducing overall drug spending by $160 billion from 2019 to 2023, and further increasing price pressure from the generic drug manufacturers Overweight Health Care: This as a defensive sector, which will fare well during the slowdown stage of the business cycle. Its performance will also be aided by post-Covid-19 tailwinds. The sector is cheap, and profitability is improving (Chart 1, top panel). Overweight Health Care Equipment And Service Providers: We prefer this industry group to Pharmaceuticals and Biotech, as it faces less intense price pressures, does not face bipartisan political scrutiny, is more profitable, and enjoys resilient profit margins (Chart 1, second panel). Equal Weight Pharma: This industry faces many challenges, such as upcoming patent cliff and generic competition, political and regulatory uncertainty, and declining profitability, which explains the significant valuation discount but makes it risky (Chart 1, bottom panel). Feature In conjunction with our colleagues from the US Political Strategy Team (USPS), today we publish a “deep dive” report on the US Health Care sector. The sector faces significant long-term political and regulatory headwinds, and understanding the political landscape is necessary to making the right investment decisions. The Health Care sector consists of two industry groups: Pharmaceuticals and Biotech, and Health Care Equipment and Services. In this report, we will assess the overall attractiveness of the sector in terms of its investment characteristics, as well as its outlook in the context of the current macroeconomic backdrop and potential political developments. Further, we will drill down into each industry group to provide more granular investment recommendations. We upgrade the Health Care sector to an overweight, expressed through an overweight position in Health Care Equipment and Services, and an equal weight position in Pharmaceuticals and Biotech. Chart 1Fundamentals Are Improving Fundamentals Are Improving Fundamentals Are Improving Recent Performance Being a defensive sector, Health Care outperformed the S&P 500 by about 12% in the midst of the pandemic, only to lag the market during the recovery rally (Chart 2). Chart 2Health Care Outperformed During The Lockdowns, But Lagged In A Recovery Rally Health Care Outperformed During The Lockdowns, But Lagged In A Recovery Rally Health Care Outperformed During The Lockdowns, But Lagged In A Recovery Rally Chart 3Health Care Sector Breakdown By Key Segment Checking The Pulse: Deep Dive Into The Health Care Sector Checking The Pulse: Deep Dive Into The Health Care Sector Health Care Sector Overview Health Care sector is very important to the US economy. After all, the US commands the highest health care spending in the world – 17% of GDP, $500B in sales annually. The sector constitutes about 13% of the S&P 500 index by market capitalization and is split equally between Pharmaceuticals and Biotech, and Health Care Equipment and Services, which itself consists of Health Care Providers and Equipment Manufacturers (Chart 3). Health Care Providers is a category which includes major hospitals, health insurers, and pharmacy chains, is the largest segment of the sector, and contributes 49% of the sector revenue. However, this is an industry under a significant price pressure from well-organized buyers such as private and government health insurance and has EBIT margins of only 8%. Pharma and Biotech is the second largest segment and delivers 33.5% of the sector revenue. This industry group faces its own unique challenges, such as patent expirations, politics, and competition from generic drug manufacturers. Yet, thanks to limited time patent protection, this industry manages to achieve EBIT margins of 12.2%. Health Care Equipment and Services is the smallest, contributing only 17% of all sector revenue, but it is the most promising and profitable segment, with EBIT margins circa 20%. The medical devices industry was able to preserve some its pricing power. Health Care Sector Tailwinds Recovery of Delayed Procedures And Hospital Visits Continues While health care earnings were relatively resilient throughout 2020, growth will accelerate into the balance of the year thanks to the recovery of delayed elective procedures and hospital visits following the easing of lockdown measures. These procedures are not only most lucrative for hospitals, but also increase demand for prescription drugs and translate into profits for medtech. Moreover, there is still a significant backlog of delayed procedures to work through. According to CFRA, medical utilization will not only recover, but will also increase by about 3% over a 2019 base by the year-end. Aging Baby Boomers Will Further Accelerate Health Care Spending Global demographic trends bode well for long-term health care spending: The share of the world’s population aged 65 years or over increased to 9.3% in 2020. People live longer thanks to medical innovations and increases in per-capita spending on health care. Longer life expectancy contributes to the rising incidence of chronic diseases, increases in spending on prescription drugs, medical facilities, and services. It also helps that in the developed world, and in the US in particular, baby boomers are the most affluent demographic group. The M&A Environment Has Been Hot M&A activity is booming for Health Care Equipment and Services. Medical equipment companies continue to seek to increase their exposure to nascent technologies with significant growth potential, while hospital chains consolidate to realize economies of scale and increased influence over suppliers and customers. However, as for pharma, many companies already carry high levels of debt, which precludes significant M&A activity. Blue Wave Has Had Little Effect On Health Care Policy (So Far) In principle, the blue wave was perceived as unfavorable to the Health Care sector, but in practice, so far, its effect has been neutral. The narrow margins in the House (4 seats) and Senate (0 seats, de facto 1 seat) reduce the effectiveness of the blue wave. Moreover President Biden has sidelined the party’s interests on health care for the time being. He did not include a public health insurance option in his American Families Plan, nor did he push for Medicare to take an active role in negotiating drug prices. He even sidelined the Democrats’ plan to expand the eligibility age for Medicare. Of course, he is still formally committed to these policies, and he will try to revisit health care in 2022. But by then it will be campaign season for the 2022 midterms and the odds of getting significant legislation passed will fall sharply. Of course, the current White House health care policy is hardly a tailwind. It is still conceivable (albeit low odds) that House Speaker Nancy Pelosi could convince the Senate leadership to insert the party’s more ambitious aims into the American Families Plan as the final draft of this fall’s budget reconciliation bill is prepared. Plus the Department of Health and Human Services will unveil a slew of new rules and regulations as the administration tries to compensate for the lack of bold initiatives. But on the margin the political backdrop for the sector is less negative than initially expected. Health Care Sector Headwinds While the sector enjoys these tailwinds, there are a few dark clouds gathering on the horizon, creating a lot of uncertainty and a more challenging policy backdrop. Reducing Or Capping Drug Prices Is A Bipartisan Issue Reducing or capping the price of drugs is one of the few bipartisan legislative priorities. Trump focused on this issue as well as Biden, which shows it is a vote getter as both parties are courting older voters. Executive orders are pushing key federal agencies to promote generics and biosimilars to reduce name-brand drug prices. Some of the ideas being circulated are: Allow drug imports from Canada and other countries (a big legal battle looms but the initiative is bipartisan and popular). Negotiate drug prices over Medicare with pharmaceuticals instead of having the companies freely set the prices. Limit high-launch prices of novel specialty drugs. (The administration is still formally committed to this.) Link drug price increases to inflation or an International Pricing Index. (Likely to occur at some point.) Having said that, while the situation remains fluid, so far health care and drug prices have not been a priority for Biden. A single lost vote in the Senate could derail his signature American Jobs and Families Plan reconciliation bill. Therefore he wants the bill to focus on $200 billion in subsidies for the existing Affordable Care Act. He does not want to add new controversial measures and revive the Obama administration’s bruising political battles over government involvement in health care. He also does not want to take any actions seen as punitive for the industries that cared for people during the pandemic and invented the vaccines. Biden Administration Anti-Trust Stance Biden’s administration is positioning itself to be very forward on anti-trust issues, which is a big change from the previous administration. Executive Order 14036 on anti-trust and competition takes aim at hospital consolidation, which is said to cause a low supply of health care and higher prices. Indeed, hospitals have been gobbling up smaller providers for over a decade to prop up their razor thin margins. Other M&As across the sector have occurred, like drug retailers buying insurers. The order also says that health insurers need to standardize the options they provide – limiting company flexibility and straight-jacketing pricing schemes. This policy development has a caveat, which may mitigate some of the clauses. The executive order does not involve concrete action that would stop this process. But it does exhort the Department of Health and Human Services and the Federal Trade Commission to develop new rules. Note that there are legislative constraints to muscular anti-trust enforcement, namely that new interpretations of anti-trust are unlikely to pass judiciary review. Therefore, there is a need for new legislation to overrule the judiciary/courts. But, as mentioned, Biden is not willing to risk his larger legislative priorities and hardly any big bills will pass in 2022. This means that the primary risk for now comes from agency rule-making, or new executive orders. Hence there is a shift in executive approach to these issues that will create a lot of uncertainty and put downward pressure on the performance of the sector. This risk could grow later, after the market prices in the positive news that Biden has not prioritized bold legislation in this sector. Patent Cliff Patent cliff is one of the key headwinds the pharmaceutical industry is facing: patent expiration for blockbuster drugs with global revenues exceeding $1B, is expected to peak in 2023. According to IQVIA, the decrease in spending on branded medicines is expected to reduce overall drug spending by $160 billion from 2019 to 2023. Macroeconomic Backdrop Is Favorable To The Health Care Sector Growth Is Slowing: Defensives Rule The business cycle has shifted into a slowdown stage. The earnings cycle has also peaked (Chart 4). We have written about this over the past few weeks, and by now it is baked into the market consensus. To position for a slowdown, we recommended rotation to Growth in the beginning of June. Defensive sectors like Health Care also thrive when growth rolls over. In fact, according to our analysis (Chart 5), Health Care and its constituent Industry Groups tend to do even better than Growth style during a slowdown. Chart 4Earnings Have Rolled Over Earnings Have Rolled Over Earnings Have Rolled Over Chart 5Health Care Outperforms During The Slowdown Stage Of The Business Cycle... Checking The Pulse: Deep Dive Into The Health Care Sector Checking The Pulse: Deep Dive Into The Health Care Sector Health Care is also a sector that benefits from rate stabilization, as it can be characterized as a “stable, quality growth”, as much of its cash flow growth extends far into the future (Chart 6). Chart 6...And When Rates Are Falling Checking The Pulse: Deep Dive Into The Health Care Sector Checking The Pulse: Deep Dive Into The Health Care Sector Health Care Is A Domestic Industry Health Care is a relatively domestically focused industry, as it derives about 39% of its sales from outside the US – compared with 42% for the S&P 500, and 58% for the Technology sector. As a result, investors perceive Health Care to be a safe haven in times of appreciating USD, as its earnings are more insulated from currency moves. As a result, Health Care relative returns are positively correlated with the DXY (Chart 7). The dollar has been appreciating since the beginning of June, which bodes well for the outperformance of the sector (Chart 8). Chart 7Health Care Is Domestically Focused And Is Insulated From An Appreciating Dollar Checking The Pulse: Deep Dive Into The Health Care Sector Checking The Pulse: Deep Dive Into The Health Care Sector Chart 8Positive Correlation With The Dollar Positive Correlation With The Dollar Positive Correlation With The Dollar Fundamentals Sector Is Cheap The Health Care sector is inexpensive and is trading with an about 20% discount to the S&P 500, both on a trailing and forward basis. According to the BCA Valuation Indicator, it’s trading 2 std below its long-term average (Chart 9). Within the sector, Pharma and Biotech is the cheapest industry group and its valuation discount is dictated by its unique challenges (Table 1). Chart 9Unloved & Undervalued? Unloved & Undervalued? Unloved & Undervalued? Table 1Summary Of Valuations And Growth Expectations Checking The Pulse: Deep Dive Into The Health Care Sector Checking The Pulse: Deep Dive Into The Health Care Sector Earnings Growth Expectations Are Stable For Health Care Valuation discount may be explained by the fact that sector earnings growth expectations for the next 12 months are about half of those for the broad index, i.e., 10% vs 20% (Table 1). For Q2-21, analysts expect YoY growth of 36% for the sector and 68% for the S&P 500. However, this earnings differential is misleading as Health Care earnings were resilient throughout the pandemic, while the cyclical components of the S&P 500 have collapsed. Thus, differences in expectation are mostly due to the 2020 base effect. Indexing 12 months forward EPS to one in July 2019, we see that Health Care earnings have been stable, and now exceed the level of S&P 500 earnings (Chart 10). Chart 10Health Care Earnings Are Resilient Checking The Pulse: Deep Dive Into The Health Care Sector Checking The Pulse: Deep Dive Into The Health Care Sector Margins Are Under Pressure While immediate earnings growth expectations look good, the degree to which the sector is losing pricing power is a source for concern (Chart 11). Health Care sector margins have been eroding for years now (Chart 12). Pricing pressure is a perennial concern for the sector as third-party payers, including the government and private health insurance chains seek to reduce the mounting costs of health care in the US. Chart 11Pricing Power Is Fading Pricing Power Is Fading Pricing Power Is Fading Chart 12Margins Have Been Eroding For Years Margins Have Been Eroding For Years Margins Have Been Eroding For Years Medicare and Medicaid have recently become a larger proportion of revenues for health care facilities, which is unfavorable for these companies because government health programs tend to have lower reimbursement rates than private sector payers. In turn, large hospital chains put price pressure on drug manufacturers and medical equipment suppliers. Lastly, Pharma faces competition from the generic drug manufacturers with which they have little product differentiation. R&D And Capex Are Rebounding During the pandemic, aiming to preserve cash in their war chests, companies in the sector have reduced their investments into R&D and Capex. More recently, both Capex and R&D have rebounded, cutting into margins. Indeed, the Health Care sector, especially pharma and medtech, is held hostage to R&D and Capex. EvaluatePharma estimates that large investments, typically around $4 billion in R&D, are required for pharma companies before any new products could be approved to be marketed. R&D is the “backbone” of novel drugs, and thus, the extent of R&D spending serves as an important metric to show a company’s commitment to finding new drugs. Medtech is held to similar demands as companies spend more and more to research and develop innovative new products, which are also subject to FDA approval. The only silver lining is that some analysts forecast that increased use of big data analytics or artificial intelligence to enhance processes has the potential to reduce growth in R&D and Capex (Chart 13 & Chart 14). Chart 13Capex Picked Up... Capex Picked Up... Capex Picked Up... Chart 14...So Did R&D ...So Did R&D ...So Did R&D Technicals Suggest Healthcare Is Oversold According to the BCA Technical Indicator, the Health Care sector is significantly oversold. This is a contrarian indicator, and positioning suggests that the sector is ripe for a rebound (Chart 15). Cash Yield Is Expected To Pick Up Last but not least, Health Care is one of the highest cash yielding sectors in the S&P 500. In Q1-21 the sector paid shareholders around $20B, the third highest payout in the index behind Financials and Tech. Cash yield is currently around 3% and the sector is in a strong position to ramp up payouts as its cash flows rebound. Chart 15A Good Entry Point A Good Entry Point A Good Entry Point Pharmaceuticals And Biotech Faces Many Challenges Pharmaceuticals is one of the most challenging businesses to be in: not only does R&D takes years, and thousands, if not millions, of chemical compounds tested, but also there is absolutely no guarantee of success. And each promising compound has to go through rounds of arduous FDA trials to get approval for a new drug. The price of the new drug is protected for ten to twenty years, after which the original manufacturers face competition from generic drug manufacturers. Generics already account for the majority of drug spending around the world. Many traditional manufacturers have entered the generic drug manufacturing business: if you can’t beat them, join them! As such, the covid-19 vaccine rollout was the biggest catalyst for pharma sales this cycle with millions of people still awaiting their first shot in both developed and emerging countries. Given the steady drip of news about emerging virus variants, we can assume that the pandemic-driven demand for pharma products is here to stay. However, there is a caveat to the story. A number of pharma producers, such as AstraZeneca and Johnson & Johnson, pledged to supply vaccines not for profit, which is also evident in the data. Chart 16& Chart 17 show that while pharma sales took off during the pandemic, both EBIT and margins contracted. Chart 16Vaccines Boost Sales... Vaccines Boost Sales... Vaccines Boost Sales... Chart 17...But Not Profits ...But Not Profits ...But Not Profits Of course, decline in profits and margins was transitory since the pandemic also reduced hospital visits for non-Covid patients as well as delayed other procedures like non-urgent surgeries that both require drug usage. As demand for these two categories that positively contribute to profits and margins is starting to bounce back, we expect bottom-line growth numbers to recover for pharma stocks. However, we are more concerned about a longer-term trend in Pharma margins: here we see the effect of patent cliff, the ubiquitous shift to generics, and price pressures from insurers and hospital chains. The political backdrop exacerbates the situation: reducing or capping the price of drugs is one of the few bipartisan priorities, which creates a lot of uncertainty for the industry, and could be a drag on margins for years to come. This poisoned chalice that the industry is facing explains why Pharma trades with a 34% discount to the S&P 500 PE NTM, and 17% discount to Health Care (14.3x, 21.6x and 17.3x respectively). This is the largest discount in the past 25 years. This valuation discount is likely to close – after all, there is a price for everything. However, for now we remain cautious about the prospects for Pharma and Biotech, especially in the context of political uncertainty. Health Care Equipment And Services Is Thriving Increases in hospital visits and resumption of elective medical procedures is great news both for the medical service providers and for medical equipment manufacturing. With 56% of Americans age 12 or older vaccinated, medical utilization is swiftly recovering. Chart 18 shows that sales for the industry group have surged by nearly 20% from the darkest days of the pandemic. This industry group was also able to manage costs during the downturn and exited the pandemic with higher margins. Also, unlike Pharma and Biotech, this industry group is not experiencing a long-term margin erosion trend. Pricing pressures for this industry group are less severe than for Pharma. Competition in certain product categories is often limited to several key players due to various challenges, such as regulation, product liability, and substantial R&D and Capex outlays required to enter the industry. As such, sales growth translates into income growth (Chart 19), and the industry group is able to maintain its margins. Chart 18Equipment Manufacturers Are Thriving Equipment Manufacturers Are Thriving Equipment Manufacturers Are Thriving Chart 19Strong Earnings All-around Strong Earnings All-around Strong Earnings All-around Further, political pressures on the industry group appear less severe than those on Pharma and Biotech. True, Democrats are inclined to tax devices and impose price caps, but their initiatives to expand health care access increase overall demand for equipment and services. Another sign, that the current administration focus is not on equipment and services, is that President Biden temporarily exempted medical tech from his “right to repair” executive order, which prevents manufacturers from restricting the right of third parties to repair their devices. While it is a small issue, it signals that Biden is not aggressive on this industry thus far. Overall, we believe that Health Care Equipment And Services is attractive, and it is less affected by some of the negative trends in the sector, but benefits from reopening and demographic tailwinds. Investment Implications Upgrade Health Care Sector - Overweight Health care sector earnings are aided by a number of secular and structural tailwinds: Recovery in hospital visits and volume of elective procedures which also translates into pickup in the use of health care equipment and drugs A large and affluent cohort of aging baby boomers who enjoy a longer life expectancy, but also will spend more on medical procedures and prescription drugs Political backdrop is less negative than expected – and longer-term political risks will likely be stalled for campaigning in 2022 US growth rolling over is also favoring Health Care as a defensive sector that tends to outperform during period of economic slowdown. Further, this sector is cheap and stable earnings growth looks favorable compared to the broad market. Pharmaceuticals And Biotech Industry Group – Equal Weight Like the rest of the sector, this industry group is enjoying post-covid-19 recovery tailwinds. Sales growth has stabilized, but profit margins are perennially depressed. We do believe that over the short term both profits and margins may rebound. However, we are concerned about structural headwinds: political backdrop is unfavorable and will add to the price pressures traditional pharma is facing from generic competition, exacerbated by an upcoming patent cliff. Health Care Equipment and Service Providers – Overweight Like Pharma, this industry group benefits from a resurgence of hospital visits and an increase in the volume of medical procedures. However, it faces much fewer headwinds: the Biden administration has not made the regulation of hospital and medical equipment manufacturers as one of its legislative priorities. This industry group also faces fewer pricing pressures than Pharma. Health Care Equipment and Service Providers is trading with a slight discount to a broad market, while its profitability and margins are expected to pick up significantly. Bottom Line: Overweight Health Care, which is a defensive sector and will fare well in the slowdown stage of the business cycle. Its performance will also be aided by post-covid-19 tailwinds such as resumption in the delayed elective procedures, a significant demand for health care from aging baby boomers, and benign political backdrop. Within the sector we favor Health Care Equipment and Service Providers over Pharmaceuticals and Biotech, as this industry group faces less intense price pressures, is more profitable, and enjoys resilient profit margins, and is currently is flying under “regulatory radar”. Pharma not only suffers from upcoming patent cliff and generic competition, but also faces potential regulatory pressures: these headwinds have affected its long-term profitability and weigh on its performance and valuations.   Irene Tunkel Chief Strategist, US Equity Strategy irene.tunkel@bcaresearch.com Matt Gertken Vice President Geopolitical Strategy mattg@bcaresearch.com     Recommended Allocation Checking The Pulse: Deep Dive Into The Health Care Sector Checking The Pulse: Deep Dive Into The Health Care Sector Footnotes  

Hospitals Are Facing Margin Pressure Hospitals Are Facing Margin Pressure   Neutral The S&P health care facilities index was an exceptionally solid performer last year as investors sought safe harbor from the headwinds to global trade in wholly domestic stocks. This outperformance belied some deeper issues on the operating front. Hospitals’ pricing power is currently accelerating at the slowest rate since the GFC, which bodes ill for revenue growth (second panel). Tack on spiking labor costs (third panel) and the EPS growth prospects of this defensive sector appear at serious risk. However, there are a number of potential offsets to this weak picture. The first is the much lower write-offs that hospitals can expect given the generationally low unemployment rate. A second lies in declining hospital construction (bottom panel) which could serve to both bolster free cash flow despite weakening operating earnings as well as reverse the fall in pricing power if supply is constrained. Regardless of the operating picture, the S&P health care facilities index is unlikely to move dramatically in either direction without a resolution to the current trade war, either positive or negative. Net, we reiterate our neutral stance on the S&P health care facilities index. The ticker symbols for the stocks in this index are: BLBG: S5HCFA - UHS, HCA.

Neutral As a wholly domestic industry, the S&P health care facilities index is well insulated from trade tremors that have been shaking the broad market this year. It is thus understandable that the index has been rallying in 2018. Still, as a particularly labor-intensive industry, rising wages pose a significant risk. On that front, investors have reason to be wary; the employment cost index for hospitals has jumped dramatically in its most recent reading, rising faster than at any point since the financial crisis, now keeping pace with overall payrolls (second panel). Further, job openings are soaring, having doubled in the last five years (third panel) which suggests hospital employment costs have much further to rise. Still, the picture is not all bad. Other input costs, such as the cost of medical equipment and supplies, have fallen steeply and now hover close to the deflation line (bottom panel). This could be enough to sustain margins, everything else being equal. Net, we reiterate our neutral stance on the S&P health care facilities index. The ticker symbols for the stocks in this index are: BLBG: S5HCFA - UHS, HCA. A Mixed Cost Picture For Health Care Facilities A Mixed Cost Picture For Health Care Facilities

We bought the S&P health care facilities index last December after a steep post-election sell-off created a valuation and technical undershoot relative to the fundamental outlook. The doomsday concern was that President Trump would tear up the Affordable Care Act (ACA), potentially leaving millions without insurance: treating the uninsured is the bane of any hospital's existence. The index has outperformed by 12% since then, encouraged by a jump in analyst net profit revisions following upbeat profit results and guidance from industry heavyweights such as HCA Holdings, and a realization that any ACA action is likely to be more of a rework than a total rebuild. Our conviction level has decreased a notch. Our concern is primarily revenue based, rather than fear that provisions for doubtful accounts will suddenly deteriorate as a consequence of treating uninsured patients. Instead, the main push from the surge in the insured population and increase in procedures on the back of rising consumer confidence/job security is likely to peter out. Consumer spending on hospitals has already rolled over decisively on a growth rate basis, and is contracting compared with total consumer spending. The same is true of spending on physician visits. Fewer doctor visits mean a reduction in procedures performed at hospitals. Health care is a labor-intensive industry. Health care facilities staff up when they get busy and prune when capacity utilization slips. As such, slowing growth in hospital employment reinforces that patient volume growth is likely to ebb. In fact, the contraction in hospital hours worked signals the same ahead for hospital sales. Bottom Line: Downgrade the S&P 1500 health care facilities index to neutral, locking in a 12% profit since inception in December 2016. Please see yesterday's Weekly Report for additional details. Book Profits In Health Care Facilities Book Profits In Health Care Facilities

Highlights Portfolio Strategy A relapse in the global financials sector threatens to spill into U.S. financials as credit growth sinks. Bank equities are the most vulnerable to such a phase, given their reliance on rising interest rate expectations rather than increased lending. Take profits in the S&P health care facilities index and downgrade to neutral. Recent Changes S&P Health Care Facilities - Take profits of 12% and downgrade to neutral. Table 1Sector Performance Returns (%) As Good As It Gets? As Good As It Gets? Feature Momentum continues to trump all else, with the equity market surging to new all-time highs last week. However, in the background, the Fed is becoming steadily more hawkish, and the odds of a March rate hike have risen substantially. This should be cause for some trepidation. Chart 1Multiples Are Headed##br## Lower As The Fed Hikes Multiples Are Headed Lower As The Fed Hikes Multiples Are Headed Lower As The Fed Hikes The market advance since November has been supported primarily by valuation expansion, along with some improvement in corporate profits. The forward P/E has climbed to 18, its highest level in well over a decade. The scope for further expansion is limited. Importantly, if a transition to an earnings-led rally is in the offing, Fed funds expectations likely need to be ratcheted higher. Chart 1 shows that valuation multiples contract during Fed tightening cycles, using cycle-on-cycle analysis. Thus, the valuation expansion is inconsistent with a significant upgrade in the economic and profit outlook, particularly with return on equity so weak (Chart 1). In other words, the economy has good momentum, but that is not translating one for one to the corporate sector. Keep in mind that even a small two P/E multiple point decline requires 11% earnings growth for the market just to hold its ground. That is a tall order given the squeeze on profit margins from labor cost inflation and a strong U.S. dollar. Ironically, high multiples would be more durable if economic data softened enough for the Fed to hold its fire. Against this background, it is not surprising that a stealthy flight to safety has developed, although it is not uniform across asset classes. For instance, gold has outperformed most major currencies (note we recently upgraded the gold shares group as a portfolio hedge); global government yields have eased back while sovereign bond spreads have widened (Chart 2). In the U.S., the economically-sensitive transport group has rolled over in line with the yield curve narrowing (Chart 2), the equity SKEW index remains historically elevated, and a defensive vs. cyclical portfolio bias has outperformed handily since early December (Chart 2, bottom panel), on broad-based non-cyclical sector participation. These shifts, on the margin, signal that some investors are bracing for a bout of volatility. On the flipside, U.S. junk bond spreads have narrowed back to 2014 lows, and emerging market corporate bond spreads are testing similarly tight levels. The global purchasing manager survey recorded yet another monthly gain (Chart 3). Chart 2Contrarian##br##Alert... Contrarian Alert... Contrarian Alert... Chart 3... Defensives Can Outperform##br## When Growth Is Good ... Defensives Can Outperform When Growth Is Good ... Defensives Can Outperform When Growth Is Good Ergo, a systemic economic threat is not the main obstacle to further asset price appreciation. Rather, it is that expectations in some assets and sectors have become divorced from reality. Indeed, we have noted for the last two months the disturbing downtrend in bank credit growth and the unprecedented gap between strong 'soft' and pedestrian 'hard' economic data. Mixed economic and financial market messages suggest that any equity turbulence may be marked by a mostly rotational correction rather than a savage drawdown in the broad averages. Still, the latter cannot be ruled out given the high degree of complacency and buoyant profit and economic expectations. It is notable that defensive equities embarked on a massive outperformance phase when both U.S. and EM bond spreads were just as low as they are currently, i.e. they hit 'as good as it gets' levels (Chart 3). Any widening in corporate bond spreads would tighten financial conditions, spurring a slowdown in growth down the road. In sum, the odds of an equity market sweet spot extension beyond the very near run have diminished as a consequence of ongoing strong economic data, which reflects the easing in financial conditions a year ago. In terms of positioning portfolios, there is still a mismatch between developed and developing markets, as measured by the relative ISM indexes (Chart 3, fourth panel). The upshot is that defensives will continue to generate much more cash than their cyclical counterparts (Chart 3, bottom panel), supporting the nascent relative share price recovery. The financial sector could also be due for a correction. Financials And Banks: Where To Next? The global financials sector has cheered the firming in leading economic indicators and back up in bond yields since last autumn, but that celebration is likely drawing to a close. Euro area financials have rolled over, in line with renewed weakness in German government bond yields (Chart 4). Continued slippage in global yields could cap U.S. yields, thereby flattening the yield curve (Chart 5). U.S. financials are much more expensive than their euro area counterparts (Chart 5, bottom panel), suggesting heightened vulnerability. Chart 4Are EMU Financials ##br##Sending A Warning Signal? Are EMU Financials Sending A Warning Signal? Are EMU Financials Sending A Warning Signal? Chart 5Watch The##br## Yield Curve Watch The Yield Curve Watch The Yield Curve In our view, the S&P bank index contains the most downside vulnerability, in relative performance terms, of all the financial sector sub-components, especially if regulatory reform disappoints and/or is slow to evolve. True, as outlined in a Special Report published on October 3, 2016, interest rate expectations have a checkered history of predicting bank stock relative performance. When they do drive bank stocks, it is typically because most other profit drivers are lacking, as is currently the case (Chart 5, top panel). This cycle, interest rate spreads have been unduly suppressed by the zero lower bound. Under normal circumstances, when short-term interest rates are well above zero lower bound, banks can target a spread between rates on assets and liabilities. But when the fed funds rate is at zero, the spread is compressed, because banks generally cannot charge customers a penalty implied by negative interest rates on deposits (at least in the U.S.). As the Fed pushes interest rates back upward, banks may be able to return their spreads to their target levels, by raising deposit rates more slowly than loan rates. However, this dynamic has been fully priced in over the last few months and the risk is that higher net interest margins will not offset the lack of credit creation and/or that Fed funds rate expectations will level off if economic data start to disappoint. After all, Chart 6 shows that net interest margins can both widen and narrow when the Fed is hiking interest rates. Moreover, the yield curve is narrowing, after peaking two months ago. If rising fed interest rate expectations are the primary factor driving bank stock performance, then it follows that market expectations must continue to price in a much more hawkish rate environment in order to extend any rally in bank share prices. However, the global credit impulse is still negative, albeit less so, reflecting capital constraints and deleveraging. The Bank of International Settlements global credit impulse indicator has been an excellent leading indicator of relative bank profitability, and it is premature to expect earnings outperformance (Chart 7). U.S. credit data are also inconsistent with a major upshift in Fed funds interest rate expectations. Total loan growth is contracting, led by commercial & industrial loans (Chart 8). Commercial real estate loan growth has also turned lower. Chart 6Net Interest Margins And The Fed Net Interest Margins And The Fed Net Interest Margins And The Fed Chart 7Don't Chase Without Profit Support Don't Chase Without Profit Support Don't Chase Without Profit Support Chart 8Shrinking Balance Sheets Shrinking Balance Sheets Shrinking Balance Sheets The most recent Fed Senior Loan Officer Survey showed that banks are tightening lending standards in most categories, with the exception of mortgages (Chart 9). The number of banks reporting increased loan demand has also softened. Since the credit crisis, banks have shifted their balance sheet exposure toward businesses and away from consumers and residential mortgages, underscoring that a decent housing market is unlikely to provide an offset to lackluster corporate credit demand. Only mortgages have experienced an uptick in loan demand and availability of funds (Chart 9). This credit backdrop is not conducive to a much more aggressive Fed, reinforcing that it would be dangerous to discount a sustained and meaningful uptrend in net interest margins. To further confound the bank stock reward/risk profile, bank employment continues to rise steadily (Chart 10), even though balance sheet expansion is no longer a sure thing. We have shown in past Reports that bank stocks have almost always underperformed when bank employment is rising. Chart 9Credit Standars Are Tightening Credit Standars Are Tightening Credit Standars Are Tightening Chart 10Sagging Productivity Sagging Productivity Sagging Productivity The current combination of fading credit creation and rising employment has done a number on our bank productivity proxy. The latter is now contracting on a rate of change basis, warning that the expansion in bank stock valuations is due for a squeeze (Chart 10). Bottom Line: The run in bank stocks over the past few months is on the cusp of a reversal, based on the leading message from the euro area, sinking productivity and punk credit demand. Our financial sector preference remains skewed toward areas not dependent on credit creation, such as asset managers. Book Profits In Health Care Facilities We bought the S&P health care facilities index last December after a steep post-election sell-off created a valuation and technical undershoot relative to the fundamental outlook. The doomsday concern was that President Trump would tear up the Affordable Care Act (ACA), potentially leaving millions without insurance: treating the uninsured is the bane of any hospital's existence. At the time of purchase, the 52-week rate of change was diverging positively from the share price ratio after hitting deeply oversold levels, often a harbinger of a playable rally (Chart 11). That was particularly true given an historically high short position. The index has outperformed by 12% since then, encouraged by a jump in analyst net profit revisions following upbeat profit results and guidance from industry heavyweights such as HCA Holdings (Chart 11), and a realization that any ACA action is likely to be more of a rework than a total rebuild. Valuations remain appealing, but a technical breakout above key resistance levels requires increased confidence in the durability of profit outperformance. Is such a phase forthcoming? Our conviction level has decreased a notch. Our concern is primarily revenue based, rather than fear that provisions for doubtful accounts will suddenly deteriorate as a consequence of treating uninsured patients. Instead, the main push from the surge in the insured population and increase in procedures on the back of rising consumer confidence/job security is likely to peter out. Consumer spending on hospitals has already rolled over decisively on a growth rate basis (Chart 12, third panel), and is contracting compared with total consumer spending. The same is true of spending on physician visits. Fewer doctor visits mean a reduction in procedures performed at hospitals. Chart 11Hitting Resistance Hitting Resistance Hitting Resistance Chart 12Top-Line Trouble Ahead? Top-Line Trouble Ahead? Top-Line Trouble Ahead? Health care is a labor-intensive industry. Health care facilities staff up when they get busy and prune when capacity utilization slips. As such, slowing growth in hospital employment reinforces that patient volume growth is likely to ebb (Chart 12). In fact, the contraction in hospital hours worked signals the same ahead for hospital sales (Chart 12, bottom panel). The good news is that labor costs remain in check, as measured by the employment cost index for hospitals (Chart 13). Other input costs, such as the cost of medical equipment and supplies, have perked up (Chart 13), which may require increased pricing power in order to sustain profit margins. However, the revenue trends noted above suggest that hospitals may not experience a sufficient rise in patient volumes to the extent that restores pricing power to a more solid footing. Chart 14 shows that the consumer price index for hospitals is losing momentum relative to overall inflation. Durable outperformance phases require accelerating relative pricing power, in addition to a cooling in overall economic growth, as proxied by the ISM manufacturing index (see shading, Chart 14). Those conditions provide a durable competitive profit advantage. Chart 13A Mixed Picture For Costs A Mixed Picture For Costs A Mixed Picture For Costs Chart 14Shaky Long-Term Support Shaky Long-Term Support Shaky Long-Term Support Chart 15Macro Headwinds Macro Headwinds Macro Headwinds In addition, the ideal macro conditions for hospital stocks exist when consumer spending on overall health care services is accelerating relative to total spending. That implies that the providers of health care services have an advantage over those that pay for them, such as insurers. Total medical care spending is steadily decelerating (Chart 15), underscoring that investors are better off targeting investments in other parts of the sector. In sum, the forces required to sustain the oversold rally in the S&P 1500 health care facilities index are losing clout, so we recommend booking profits. Bottom Line: Downgrade the S&P 1500 health care facilities index to neutral, locking in a 12% profit since inception in December 2016. Current Recommendations Current Trades Size And Style Views Favor small over large caps. Favor growth over value (downgrade alert).

We recommend buying into health care facilities share price weakness. It would take massive earnings downgrades to validate the pessimism embedded in current valuations. Given that this group is traditionally a strong U.S. dollar winner, there is scope for a playable relative performance rally in the coming six months if the newfound profit margin preservation mindset leaks through into earnings results. Hospital cost inflation is beginning to recede, led by drug costs. Physician services costs and inflation in other medical supplies is also subsiding. Health care facilities have also reduced capital spending in a bid to protect profit margins. Construction data show that hospitals have eased back on the throttle significantly. There has been a sharp reduction in headcount growth and decline in total wage inflation. Labor cost control provides another positive profit margin support, over and above the fillip from the reacceleration in hospital pricing power. Consumers are allocating an increasing portion of their spending to hospitals, which provides confidence that pricing power gains will stick. The bottom line is that health care facilities shares are undershooting and a contrarian bet has an appealing reward/risk tradeoff. The ticker symbols for the stocks in this index are: BLBG: S15HCFA - HCA, UHS, WOOF, HLS, LPNT, SEM, SCAI, THC, ENSG, USPH, KND, CYH, QHC. bca.uses_in_2016_12_20_002_c1 bca.uses_in_2016_12_20_002_c1

Highlights BCA's U.S. Equity Strategy team would like to wish our clients a healthy, happy and prosperous New Year. Portfolio Strategy The growth vs. value style bias is due for a bounce, but beyond the near run, the outlook has become more balanced. Stick with a small vs. large cap bias for the time being, but get ready to book profits if domestic wage inflation continues to accelerate. Buy into the health care facilities sell-off. Value is surfacing as profit margin pressures subside. Recent Changes S&P 1500 Health Care Facilities - Boost to overweight today. Downgrade Alert Growth vs. Value - Downgrade alert. Table 1Sector Performance Returns (%) Contrarian Alert: Reflation Is Reversing Contrarian Alert: Reflation Is Reversing Feature Stocks look poised to maintain their momentum-fueled march higher into yearend, seemingly impervious to potential profit backlash from tightening monetary conditions, a more hawkish Fed and/or overheating sentiment. Sellers are holding back in anticipation of lower tax rates next year. In fact, our Composite Sentiment Gauge has surged to extremely bullish levels (Chart 1). This gauge comprises surveys of traders, individuals and investment professional sentiment. Overtly bullish readings have been a reliable contrary indication of building tactical risks, although not foolproof. The broad market has returned nearly 80%, excluding dividends, since the beginning of 2012, and over 5% since election night in November. Lately, earnings expectations have increased their contribution to the market's return, but the vast majority of the gains over the last five years can be explained by multiple expansion. Soaring median industry price/sales ratios are consistent with lopsidedly optimistic sentiment (Chart 1). Now that the Fed has signaled its intention to steadily raise interest rates in 2017, a critical question is whether profits can take over the reins from liquidity as the main market driver, at least partially validating the valuation increase? On this front, our confidence level is low. Profit margins are steadily narrowing. Our profit margin proxy is not signaling any imminent relief (Chart 2). With labor costs rising, faster sales are needed to halt the squeeze. But U.S. dollar appreciation is a significant headwind to top-line performance, given that 45% of sales come from abroad. As hedges fall off, the impact on 2017 revenue will become increasingly meaningful. Corporate debt levels are disturbingly high, in absolute terms and as a share of GDP (Chart 2, bottom panel). If borrowing costs continue to climb, then it will be hard for companies to turn expansionist, potentially offsetting any benefit from a reduced tax rate. Against this backdrop, it is difficult to envision a robust rebound in corporate profits. Our confidence level would be higher if monetary conditions were still reflationary. Instead, our Reflation Gauge (RG), a combination of oil prices, Treasury yields and the U.S. dollar, has plummeted at its fastest rate ever (Chart 3)! The speed and ferociousness of the plunge underscores the economic need for a massive and imminent fiscal offset. Chart 1Sentiment Is Overheating Sentiment Is Overheating Sentiment Is Overheating Chart 2Stiff Headwinds For The Corporate Sector Stiff Headwinds For The Corporate Sector Stiff Headwinds For The Corporate Sector Chart 3Reflation Is Dead Reflation Is Dead Reflation Is Dead The RG leads both equity sentiment and the U.S. Economic Surprise Index (ESI, Chart 3). If economic activity begins to disappoint in the coming months, i.e. before any meaningful fiscal stimulus arrives, there is a window of risk for the equity market because valuations will narrow as optimism fades, especially in those sectors that have gone vertical since the U.S. election. Keep in mind, last week we showed that typical Fed tightening cycles augur well for non-cyclical sector relative performance on a 12 and 24 month horizon. Surprisingly, financials and utilities have also managed to at least keep pace with the broad market, with cyclical sectors lagging behind overall market returns. The bottom line is that a number of objective indicators are signaling that the post-election rally will hit turbulence, perhaps in the first quarter of the New Year. Investors would be well served from a cyclical perspective to take advantage of value creation in defensive sectors while reaping any windfalls received in deep cyclical sectors. Will Growth Vs. Value Recover? The sudden surge in the financials and industrials sector has caused a sharp correction in the growth vs. value (G/V) share price ratio. The scope of the move has been both powerful and unnerving, catching many off guard, including us. Is this the start of a value renaissance after nearly eight years of growth stock dominance? History shows that sustained rotations into the value complex require validation from strengthening global economic growth. We have shown in previous research that G/V share price momentum is negatively correlated with the growth in durable goods orders, house prices and profits, i.e. when these variables accelerate, growth underperforms value. By virtue of the improvement in our global PMI composite (Chart 4), it would be easy to conclude that value stocks are coming back in vogue. Financials, energy and industrials account for over 50% of the value composite. These sectors only comprise roughly 15% of the growth benchmark. In addition, the technology sector weighs in at one third of the growth index, while representing only 8% of the value cohort. In addition, consumer discretionary and health care also represent about the same weight as technology in the growth composite, but only contribute about half that in the value index. It is no wonder that rising bond yields and hopes for a fiscal stimulus bonanza have triggered such a violent G/V reaction. While we are sympathetic to this view, extrapolating the last six weeks to continue over the next six months is dangerous. Much of the Treasury yield advance has been driven by inflation expectations. Global real yields are up, but not by as much as share prices have discounted (Chart 5). That is not surprising, as the soaring U.S. dollar is a deflationary force, and heralds a sharp rebound in the G/V ratio (Chart 5, top panel). Chart 4A Vicious Correction... A Vicious Correction... A Vicious Correction... Chart 5... That May Soon Reverse ... That May Soon Reverse ... That May Soon Reverse U.S. currency strength will make it difficult for developing economies to service large foreign debt obligations and could drain domestic liquidity if they are forced to sell foreign exchange reserves to defend their currencies. It is notable that EM capital spending is virtually nil in real terms, and their share prices are underperforming the global benchmark by a wide margin (Chart 5). Our Global Economic Diffusion Index has crested (Chart 5, shown inverted), perhaps picking up emerging market sluggishness. Unless the U.S. dollar begins to weaken, it is premature to forecast robust economic growth in the coming quarters, thereby raising some skepticism about the durability of the value stock rebound. The objective message from our Cyclical Macro Indicators for the growth vs. value style is slowly shifting from bullish to neutral, and the pricing power advantage no longer exists (Chart 6). However, the latter is an unwinding of the rate of change shock in the commodity complex rather than renewed demand-driven pricing power gains in the deep cyclical space. From a longer-term perspective, growth stocks should stay well supported by the increase in long-term earnings growth expectations (Chart 7). When the latter are rising, growth stocks tend to enjoy multiple expansion relative to value shares. Moreover, if equity volatility perks up on uncertainty over the path and pace of future fiscal policy and a more hawkish Fed, then growth stocks should receive another source of natural support. The VIX and G/V indices tend to correlate positively over time (Chart 7). Chart 6Mixed Signals Mixed Signals Mixed Signals Chart 7Structural Supports Structural Supports Structural Supports In sum, choosing value over growth is not a slam dunk, nor is forecasting a recovery to new highs in the G/V ratio given the large sector weightings discrepancies. Rather, a reflex rally in the G/V ratio is probable as post-election financials/industrials sector enthusiasm wanes, with a lateral move thereafter. Bottom Line: We will likely recommend moving to a neutral style bias over the coming weeks/months from our current growth vs. value stance, but expect to do so from a position of strength. A Revival In Small Business Animal Spirits? A broad-based and powerful rotation into small caps has occurred, as all the major small cap sectors have surged relative to their large cap counterparts (Chart 8), flattering our current stance. Small caps fit nicely into one of our overriding longer-term themes, namely favoring domestic over global industries. Small companies are typically domestically-geared regardless of geography, underscoring that if anti-globalization trends pick up steam, this theme could gain traction around the world. The potential for U.S. corporate tax cuts has provided another source of domestic company enthusiasm, because multinationals already have low effective tax rates. However, these developments are not assured, details remain scant, and chasing small cap relative performance on that basis alone could be a mistake from a tactical perspective. We have noted that we would recommend profit taking if evidence of a reversal in the small vs. large cap profit outlook materialized. Recent labor market and pricing power data are slightly worrying. The NFIB survey of the small business sector showed that planned labor compensation is still diverging markedly from the overall employment cost index (Chart 9, second panel). While reported price changes have also nudged higher, the discrepancy in labor cost gauges may be signaling that the massive profit margin gap between small and large companies will not be quick to close (Chart 9, bottom panel). Still, the overall NFIB survey was strong, and suggests that animal spirits in the small business sector may finally be reawakening (Chart 10, second panel). The latter may reflect an easing in worries about government red tape, excessive bureaucracy and health care costs. Chart 8Broad-based Small Cap Outperformance Broad-based Small Cap Outperformance Broad-based Small Cap Outperformance Chart 9Yellow Flag For Margins Yellow Flag For Margins Yellow Flag For Margins Chart 10Overbought, But Not Overvalued Overbought, But Not Overvalued Overbought, But Not Overvalued These sentiment shifts may allow extremely overbought technical conditions for the relative share price ratio to persist for a while longer (Chart 10, middle panel), particularly if the Trump honeymoon phase for the overall market lasts until early in the New Year. Importantly, there is no meaningful valuation roadblock at the moment (Chart 10). From a longer-term perspective, however, it is notable that the share price ratio is trading well above one standard deviation from its mean. Such a stretched technical level warns against getting too comfortable with small caps. In fact, the share price ratio is tracing out a pattern similar to the early-1980s (Chart 11), when it enjoyed a brief run to new highs in 1983 on the back of similar aspirations of meaningful fiscal thrust and as the U.S. dollar sprang higher. However, that surge was short-lived and in hindsight, was a blow-off top that marked the beginning of a massive underperformance phase. Chart 11The Big Picture The Big Picture The Big Picture Bottom Line: Stick with a small/large cap bias for now, but get ready to take profits if the relative profit margin outlook does not soon improve. Buy Into Health Care Facilities Weakness Rapid sub-surface market gyrations are creating attractive value in a number of areas, particularly in the defensive health care sector. In particular, we downshifted our view on the S&P health care facilities index at mid-year, because consumer spending on health care was decelerating, which favored moving into equities that paid for medical services (managed care) vs. those that provided them. While that trend remains intact, health care facilities stocks appear to be discounting an extreme scenario. The current concern is that the Affordable Care Act (ACA) will be repealed, leaving hospitals to foot the bill for uninsured patients. While such a scenario would potentially reverse the decline in the provision for doubtful accounts (PDA, Chart 12), a major profit margin support, the ACA is more likely to be reworked than repealed especially in the absence of a replacement plan. Importantly, there are other offsets. PDA follows the unemployment rate, which is signaling that the former will decline further. Hospital cost inflation is beginning to recede, led by drug costs (Chart 12). Physician services costs and inflation in other medical supplies is also subsiding. Health care facilities have also reduced capital spending in a bid to protect profit margins. Construction data show that hospitals have eased back on the throttle significantly (Chart 13). A shift to a profit margin preservation mentality is confirmed by the sharp reduction in headcount growth and decline in total wage inflation (Chart 13). Labor cost control provides another positive profit margin support, over and above the fillip from the reacceleration in hospital pricing power (Chart 13). Consumers are allocating an increasing portion of their spending to hospitals, which provides confidence that pricing power gains will stick. It would take massive earnings downgrades to validate the pessimism embedded in current valuations (Chart 14). Technical conditions argue that the sell-off is overshooting. The share price ratio has made new lows, but cyclical momentum is diverging positively. Given that this group is traditionally a strong U.S. dollar winner (Chart 14, top panel), there is scope for a playable relative performance rally in the coming six months. Chart 12Hospital Costs Are Easing... Hospital Costs Are Easing... Hospital Costs Are Easing... Chart 13... While Sales Improve ... While Sales Improve ... While Sales Improve Chart 14Dirt Cheap Dirt Cheap Dirt Cheap Bottom Line: Augment the S&P 1500 health care facilities index (BLBG: S15HCFA - HCA, UHS, WOOF, HLS, LPNT, SEM, SCAI, THC, ENSG, USPH, KND, CYH, QHC) to overweight. Current Recommendations Current Trades Size And Style Views Favor small over large caps. Favor growth over value (downgrade alert).

We downshifted our view on the S&P health care facilities index at mid-year, because consumer spending on health care was decelerating, which favored moving into equities that paid for medical services (managed care) vs. those that provided them. While this trend remains intact, health care facilities stocks appear to be discounting an extreme scenario. The current concern is that the Affordable Care Act (ACA) will be repealed, leaving hospitals to foot the bill for uninsured patients. While such a scenario would potentially reverse the decline in the provision for doubtful accounts (PDA), a major profit margin support, the ACA is more likely to be reworked than repealed especially in the absence of a replacement plan. Importantly, there are other offsets. PDA follows the unemployment rate, which is signaling that the former will decline further. Hospital cost inflation is beginning to recede, led by drug costs. It would take massive earnings downgrades to validate the pessimism embedded in current valuations. We will look to buy this group opportunistically in the coming months. bca.uses_in_2016_12_08_002_c1 bca.uses_in_2016_12_08_002_c1

The combination of biotech stabilization and a health care facilities plateau argues for profit taking in our long/short trade between the two groups. We had exploited the valuation mismatch because hospital profit prospects were far superior to those of the biotech group, especially within the context of a soaring U.S. dollar. Now that the primary upward thrust in the currency has played out, the revenue playing field will shift to a more neutral setting, on the margin. Indeed, while hospital spending is still growing much faster than pharmaceutical exports, a proxy for relative top-line trends, pricing power has not followed suit. Against a backdrop of soaring hospital wage bills, especially relative to pharmaceutical wages, we are closing this pair trade for a profit of 10%. The ticker symbols for the stocks in both indexes are: BLBG: S15HCFA - HCA, UHS, WOOF, AMSG, LPNT, THC, CYH, SCAI, SEM, KND, ENSG, USPH, QHC and BLBG: S5BIOT - AMGN, GILD, ABBV, CELG, BIIB, REGN, ALXN, VRTX. bca.uses_in_2016_06_28_003_c1 bca.uses_in_2016_06_28_003_c1

Health care facilities equities may become the odd man out in the overall health care sector bull market. While we are not concerned that hospitals will see a drop off in activity levels, slowing revenue growth may constrain incremental valuation expansion. Hospital procedures are labor-intensive, underscoring that business models are not scalable. Hospitals have hired at the most aggressive pace in the entire history of the BLS data. Other costs are also inflating. Hospitals are one of the largest buying groups for pharmaceuticals, and the relentless advance in drug prices is profit margin sapping. The producer price indexes for physician services and medical equipment, while still low in absolute terms, are beginning to accelerate. These forces will limit earnings growth potential, especially given that they appear to have been strong enough to offset the benefit from falling bad debt expenses and low capital spending. If operating margins and ROE cannot expand in the current environment, both are unlikely to improve much if overall employment growth continues to cool, as we expect, causing a second derivative slowdown in bad debt recoveries and surgical procedures. Downshift to neutral. The ticker symbols for the stocks in this index are: BLBG: S15HCFA - HCA, UHS, WOOF, AMSG, LPNT, THC, CYH, SCAI, SEM, KND, ENSG, USPH, QHC. bca.uses_in_2016_06_28_002_c1 bca.uses_in_2016_06_28_002_c1