As a gauge of distress in the health-care sector has soared, at least 30 hospitals entered bankruptcy in 2019, according to data compiled by Bloomberg. They range from Hahnemann University Hospital in downtown Philadelphia to De Queen Medical Center in rural Sevier County, Arkansas and Americore Health LLC, a company built on preserving rural hospitals.

There’s more distress to come. Already this week, the bankrupt owner of St. Vincent Medical Center in Los Angeles said it plans to shut the facility after a failed sale attempt.

The pressures on the sector are as tangled as the health-care system itself.

Americans are fleeing rural areas in favor of urban centers, reducing the demand for hospital services in already struggling communities. In both cities and towns, many hospitals that care for impoverished citizens often rely heavily on government payments that reimburse less than private insurers and may fail to cover rising costs.

The American Hospital Association, an industry group, calculated that payments from Medicare and Medicaid, the federal programs for the elderly and poor, lagged costs by $76.6 billion in 2018. Hospitals are also losing key income as more profitable procedures move to lower-cost outpatient centers.

If that weren’t enough, with both Republicans and Democrats making a political football out of health care ahead of the 2020 presidential election, significant policy change could be near.

“How are you supposed to craft a business plan if you don’t know if you’re going to have an America with Medicare for all, or a complete repeal of the Affordable Care Act, or a million options in the middle?” said Sam Maizel, a partner with the Dentons US law firm who focuses on health-care restructuring. “If you knew Elizabeth Warren was going to get elected, you’d be writing a very different business plan.”

Even before the election, the current system is being challenged, according to Georgetown University health-care policy professor Edwin Park. The Trump administration is trying to tighten eligibility rules for Medicaid, while a rule proposed late last year could also cut billions of dollars in supplemental payments to hospitals, he said. In a closely watched case, a district judge in Fort Worth, Texas is weighing whether Obamacare can survive after an appeals court ruled that its broad mandate requiring people to have health insurance was unconstitutional.

The usual playbook for managing distress doesn’t readily apply. Shutting down a hospital isn’t the same as boarding up a storefront. Hospitals are not only major employers, their closures often leave the most vulnerable patients bereft. Bankruptcy judges tend to push back on approving hospital closings in ways they wouldn’t for a retailer, said Andrew Sherman, head of restructuring at law firm Sills Cummis & Gross.

In May, a 25-bed hospital in Sevier County, Arkansas shut down after sliding into such financial disrepair that a receiver was appointed, local newspaper The De Queen Bee reported. For many of the county’s 17,000 residents, the hospital’s emergency room provided the only such services within an hour’s drive, court papers show. In suburban Chicago, Westlake Hospital was losing more than $1 million a month before it commenced a liquidation bankruptcy in August, sapping that community of about 550 jobs and 230 hospital beds.

“In a typical restructuring you’re dealing with widgets,” Sherman said. “In a health-care restructuring you’re dealing with people’s lives.”

In many rural areas, the population just isn’t large enough to justify keeping the lights on, according to Bloomberg Intelligence analyst Mike Holland. Morgan Stanley analysts led by Vikram Malhotra in 2018 found that 8% of U.S. hospitals were at risk of closing and another 10% were considered weak. AHA statistics released Tuesday show the number of U.S. hospitals fell by 64 to 6,146 in 2018, the most recent year available.

There’s little reason to believe the situation has improved. The Polsinelli TrBK Health Care Services Distress Index, which tracks bankruptcy filings in the health-care sector, had nearly quadrupled as of the third quarter. The index uses 2010 as its benchmark year.

“Most of the cases we see, you’re struggling to survive on a cash basis to try to get to a sale process,” Sherman said. “People need to understand that these hospitals will continue to falter. Communities are going to have to inject more money if they want to maintain health care.”

Some of the more recent closings are the result of large health systems weeding out weaker facilities. That’s the case with hospitals run by Community Health Systems Inc. and its spin-off, Quorum Health Corp.

Quorum’s revenues have been falling since it separated from Community Health in 2016. After bleak third-quarter results, the company said it would ask lenders to modify its debt agreements and reiterated a warning that it may not be able to stay afloat. Its shares and bonds plunged in the aftermath.

Late last year, KKR & Co. offered to take the company private at $1 a share in a deal that may help it refinance and stave off deeper distress.

Community Health, meanwhile, has piled up about $5 billion in losses in recent years as it labors under more than $13.5 billion in debt. A concentration of rural hospitals dependent on Medicare and Medicaid hurts Community Health, BI’s Holland said. Expanded insurance coverage under the 2010 Affordable Care Act, or Obamacare, also means more people are getting care earlier and not ending up in the company’s hospitals, he said, or are being directed to lower-cost outpatient facilities.

“It’s a problem now for hospitals to have sufficient inpatient revenues,” said Eileen Appelbaum, co-director of the Center for Economic and Policy Research.

A representative for Community Health said in a statement that factors including its recent refinancing, asset sales and a program to increase margins have positioned the company to continue to improve its operating performance.

A representative from Quorum didn’t respond to a request seeking comment, while KKR declined to comment.

While rural hospitals are most at risk of failing, the controversial shutdown of Philadelphia’s Hahnemann University Hospital could invite more disruption in urban centers, Appelbaum said.

Private-equity investor Joel Freedman bought Hahnemann in early 2018, but failed to revitalize the money-losing hospital and shut it after a trip through bankruptcy. Excluded from the filing, however, was its prime real estate in the heart of the city, which was separated into another entity.

Freedman didn’t respond to requests for comment.

Despite the successful 2006 acquisition of HCA Healthcare Inc. by a consortium that included Bain Capital LP and KKR, private equity has found it isn’t easy to make money running hospitals, Appelbaum said. The Hahnemann case may provide a new template, she said, calling the transaction “proof of concept” that if a hospital isn’t profitable, you can shutter it and sell the real estate.

“Hahnemann is a safety-net hospital in a gentrifying area,” Appelbaum said. “Probably every major city in America has safety-net hospitals in gentrifying areas, where the real estate is so much more valuable than the hospital to the private-equity company.”

UTCC will also lower export growth forecast from 1.8 per cent for 2020, he added.

The drought is expected to cause an economic contraction of 0.03 per cent, totalling Bt8 billion to Bt10 billion.

An escalation of the US-Iran conflict could spike crude price to between US$75-80 per barrel from around US$65 per barrel, he said. A price hike of Bt1 per litre in all fuel types would mean that Thai consumers will have to shoulder an additional living cost of Bt2.1 billion monthly.

Regarding the strengthening baht, he said its appropriate value should be Bt31 per US dollar.

On January 7, Ghanyapad Tantipipatpong, chairwoman of Thai National Shippers’ Council said the council expected zero or a 1 per cent growth in Thai exports this year from 2019.

The forecast was based on the assumption of the average baht value at Bt30.5 per US dollar. The baht was at Bt30.17 per US dollar as of January 6.

If the Thai currency strengthens beyond that level, exports this year may contract by 5 per cent, she said.

For just the second time in history, women outnumbered men as the majority of the U.S. paid workforce, buoyed by fast job growth in healthcare and education over the past year, as well as the ongoing tight-labor market.

At first glance, the shift is tiny and easy to miss: Women worked 50.04 percent of payroll jobs in December, up from 49.99 percent the prior month. But the figure reflects a larger, ongoing trend. Of the 145,000 jobs picked up in December throughout the economy, women won most of them – 139,000, according to Labor Department data.

“Why is today a milestone? It’s a milestone because it’s really heralding the future and not just telling us where we are today,” said Betsey Stevenson, a professor of public policy and economics at the University of Michigan and an Obama administration economic adviser.

Indeed, women’s share of the workforce has been growing steadily for the past few years. Zooming out, looking at all workers, including farm workers and those self-employed, men still outnumber women. But women have been joining the workforce at a faster pace than men since 2018. Economists say this narrowing in the gender gap comes as women have been getting college degrees in larger numbers than men, which has radiated out to the job market as they reach higher ranks in the office.

“As women get into more senior positions, it creates more space to hire more women and brings more equality into management decisions,” Stevenson said. “It’s one of those things that’s self-reinforcing and keeps on going.”

Industries that have long attracted larger numbers of women, like education and healthcare, are growing at a much faster pace than male-dominated industries like manufacturing and construction. At the same time, with the unemployment rate hovering at a 50-year-low, just 3.5 percent, all workers have more leverage than ever to to negotiate their own work schedules and salaries, which is often a top priority for parents.

The first time the share of women in the workforce crossed over 50 percent was back in early 2010 in the aftermath of the Great Recession, which was a time of tremendous volatility in the labor market. Men were losing jobs at a much greater pace, as industries like manufacturing and construction struggled. That left more women working while men hoped to return.

Now, there’s a more permanent dynamic in play. Women are dominating sectors that are growing the fastest. Health care in particular was one of a few sectors that added more jobs in 2019 than 2018, Stevenson said. Also, jobs in education and health services outnumber jobs in male-dominated goods production sectors; mining, construction, transportation and warehousing saw a slow down in hiring last year. And women still dominate service sector jobs, which is 84 percent of non-farm payroll jobs in the country.

A big difference between now and ten 10 years ago is that women today are getting a boost from technology that has opened the door to jobs that used to be considered men-only. Julia Pollak, labor economist at ZipRecruiter, pointed to transportation jobs: For decades, cab drivers were almost exclusively male. But apps and other platforms help bring women into the driver’s seat.

“Women who might have felt less safe as taxi drivers before, waiting around for some man to wave them down, now have the protection of an app where people can be identified if something goes wrong,” Pollak said.

Plus telecommuting and parental leave policies are becoming more common in the private sector, as employees are competing to hire and keep talent in this hot jobs market.

Stacey Ferguson, 42, worked in corporate law and government for 10 years before she left to start her own digital marketing company in 2012. A year and a half ago, she took a marketing job that allowed her to work remotely full-time. Ferguson, who has three kids and lives in suburban Maryland, said her entire team works out of the office, which helps cement a culture where “everyone is in the same boat.”

That’s a stark shift from her time practicing law which wasn’t as family friendly, she said. Plus, cultural norms around working from home have drastically changed over the years.

“The biggest thing is the mindset,” Ferguson said. “Trying to work remotely ten years ago was received very differently than it is now…There’s just a general loosening of the typical corporate guidelines and restrictions.”

Liz Cook just nabbed a full-time job in November, working as a data analyst for The Mom Project, which helps women workers find jobs. Cook left her job as a prosecutor in 2011 to spend more time with her children. And until recently, she’d had trouble getting back into the workforce with the gap on her resume, despite having a law degree.

“Perhaps [employers] are more willing to overlook gaps in resumes, or there’s a cultural shift and they’re more willing to bring moms or women in,” said, Cook, 36, who needed to return to work to pay off student loans.

The data on women in the workforce was tucked into an otherwise steady jobs report, as the unemployment rate remained at a strong 3.5 percent, unchanged from November and at a 50-year low. The Department of Labor data showed gains in retail and health care, while mining jobs slipped. Manufacturing jobs, which analysts have been closely monitoring during Trump’s protracted trade war, changed little in December.

The December jobs report continued a 10-year streak of strong labor market growth since the Great Recession. President Trump’s Director of the National Economic Council touted the continued strong jobs numbers, acknowledging the growth of women in the workforce.

“This stuff will translate in the election, I’m surprised the Democrats are so pessimistic painting a picture of a deep recession,” Kudlow said in an interview. “The key point here is 3.5 percent unemployment continues, and that is a very low number historically and shows you still have a healthy economy and healthy job market.”

Average hourly earnings rose by a mere 0.1 percent in December, meaning over the past year, wage growth is at 2.9 percent.

Economists say wages are not growing as fast as they should be, especially for those who aren’t seeing a boost from state and local minimum wage increases. Many businesses are still pulling back on investment and say Trump’s truce with China does little to assuage their anxiety. Plus, Democratic leaders and presidential hopefuls caution that Trump’s economic and trade agenda could eventually stymie the growth.

Diane Swonk, chief economist for the accounting firm Grant Thornton, said the disappointing wage growth reflects “an economy where you can get a job, but it’s harder to get a raise.” Swonk said it’s possible wage growth figures for the start of 2020 could be ever harsher because wages for 2019 peaked in February.

Analysts have also been concerned about transportation and warehousing, with transportation in particular affected by the economy’s manufacturing slowdown. But those numbers didn’t change all that much.

Average monthly jobs gains for all of last year were 176,000, compared to 223,000 in 2018. But Mark Hamrick, senior economic analyst for Bankrate, said the decrease shouldn’t come as a surprise. December’s figures didn’t reveal “anything that rocked our world,” he said.

“Expansions don’t last forever, and this one probably is getting a little long-toothed, but it’s not on life support,” Hamrick said.

Analysts predicted around 150,000 new jobs for the month and forecast a steady unemployment rate of 3.5 percent. Those estimates were significantly less than the 256,000 jobs added in November, although those figures also accounted for thousands of General Motors workers who returned to the workforce after a lengthy strike.

The jobs figures come as President Trump touts the economy’s strength as one of his administration’s top achievements. In 2019, the unemployment rate in particular hit lows not seen 50 years. The Dow Jones industrial average has gained about 45 percent since Trump took office, and fears of a recession have largely faded. The Federal Reserve cut interest rates three times last year, helping to sustain an 11-year-old economic expansion. And last month, the United States and China reached a “phase one” trade deal that is set to be signed on Jan. 15.

The S&P 500 dropped for the first time in three days after hiring data fell short of estimates and wage growth was the weakest in more than a year. The benchmark still notched a weekly advance as the situation in the Middle East held a tenuous calm. Boeing Corp. slumped, helping to pull down the Dow Jones Industrial Average.

Treasuries pushed higher as the wage figures erased any inflation worries. Futures traders maintained the amount of easing they expect from the Federal Reserve.

The jobs data ultimately did little to alter investor views on the strength of the economy or the Fed’s next step. With stocks near all-time highs, markets continue to look past the flare-up in tensions with Iran and focus on the potential for a pickup in global economic growth.

“This is the opposite of a game-changer. It’s very consistent with everyone’s views going into this report, the Fed stays on hold and the economy is slowing down,” said Nela Richardson, an investment strategist at Edward Jones. “We’re consistent on the overall view the Fed stays pat on short-term rates this year. If anything, this report tilts the Fed a little bit towards being more accommodative, not less.”

Elsewhere, European shares rose, while bonds in the region advanced. Gold gained, while West Texas oil dropped below $60 a barrel.

These are moves in major markets:

Stocks

–The S&P 500 Index fell 0.3% as of 4 p.m. New York time.

–The Dow Jones Industrial Average dropped 0.5%.

–The Stoxx Europe 600 index fell 0.1%.

–Germany’s DAX index gained 0.3%.

Currencies

–The Bloomberg Dollar Spot index fell 0.1%.

–The British pound dropped 0.1% at $1.3059.

–The euro rose 0.1% at $1.1112.

–The Japanese yen was little changed at 109.50 per dollar.

Bonds

–The yield on 10-year Treasuries fell three basis points to 1.82%.

–Britain’s 10-year yield fell five basis points to 0.773%.

–Germany’s 10-year yield declined two basis points to -0.198%.

Commodities

–West Texas Intermediate crude dropped 0.9% to $59.05 a barrel.

–Gold rose rose 0.4% at $1,560.30 an ounce.