In a series of recent reports, the three major credit ratings agencies -- Fitch, Moody's, and Standard & Poor's -- have maintained negative outlooks for the not-for-profit healthcare sector, while identifying new issues emerging from the economic downturn. In its 2009 Nonprofit Hospitals and Health Care Systems Outlook, Fitch Ratings says the combined effects of significant liquidity declines, increasing uncompensated care, and higher capital costs are adversely affecting many hospitals' credit profiles. Moody's Investors Service reported that an acceleration of ratings downgrades has already begun. An unprecedented 27 downgrades to four upgrades in the fourth quarter of 2008 resulted in 2-to-1 downgrade-to-upgrade ratio for the year. Standard & Poor's has focused on long-term funding shortage risks for pension plans.