CHICAGO - Despite remaining largely insulated from the turmoil in the capital markets so far, the years-long strong operating performance across the nonprofit health care sector could be headed for a decline in 2009, particularly among smaller, lower-rated credits, Fitch Ratings analysts said in a report on median ratios on the industry released yesterday.

The industry turned in a stable performance in 2007, though the overall picture is mixed, with a host of negative fiscal pressures such as bad debt and increasing competition waiting in the wings.

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