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In separate calls Jan. 4 with subscribers, and both maintained a gloomy outlook for the not-for-profit hospital sector in 2024. S&P reported the highest proportion of negative outlooks in a decade, affecting 24% of the sector. This pessimism was underscored by 51 credit rating downgrades in 2023, the most significant in five years. Fitch reported a credit downgrade-to-upgrade ratio of 3:1 —alarmingly close to the ratio seen during the 2008 financial crisis — calling it a “make or break” year and highlighting the sector's struggles, particularly among smaller hospitals with annual revenues under $500 million. Factors contributing to these negative outlooks included escalating labor costs, low reimbursement rates and slow recovery of cash flow.