Pharmaceuticals

Neutral – Downgrade Alert Sticking to the spirit of covering defensive sectors in this week’s US Equity Sector Insights, today we turn our attention to a major player by market cap weight in the healthcare sector – the S&P pharmaceuticals index. High odds of a Biden victory weigh heavily on this sector’s prospects as we outlined in the recent joined Special Report with our sister Geopolitical Strategy service (please see “Health Care Stands To Lose The Most From A Blue Sweep” section of the report). Simultaneously, the Fed’s almost overnight drop in the fed funds rate to zero in March, coupled with investors’ further rotation out of defensive and into cyclical stocks on the back of the reopening of the economy, further dampen the allure of Big Pharma (middle & bottom panels). The only reason keeping us from downgrading the sector is a potential spike in relative share prices due to a vaccine or other virus-related news. But our sense is that most of the good news is already priced in. Bottom Line: We are neutral the S&P pharmaceuticals index, but getting ready to pull the trigger on our downgrade alert and trim exposure to below benchmark. Stay tuned. The ticker symbols for the stocks in this index are: BLBG: S5PHAR – JNJ, PFE, MRK, LLY, BMY, ZTS, CTLT, MYL, PRGO.  

Neutral – Downgrade Alert There is trouble brewing for the S&P pharmaceuticals index as President Trump recently signed four executive orders geared toward lowering drug pricing for Americans. Trump is not the only one who is ready to fight Big Pharma. In recent research we also highlighted that Biden will be tough on pharma, especially on the industry’s pricing power. The implication is that irrespective of who the next President is, the S&P pharmaceuticals index will come under intense scrutiny. Consequently, we find the relative 4% year-over-year sales growth estimates overly optimistic (third panel). The sell-side community is also forecasting even more impressive relative EPS growth over the next 12 months. This is a tall order as double digit relative profit growth typically marks a peak in relative share price performance (second panel). Nevertheless there is a significant offset to the grim pharma selling price backdrop: compelling valuations. The forward P/E is trading at a nearly 40% discount to the broad market a multi decade low, even piercing through the GFC lows (bottom panel). Bottom Line: We remain neutral the S&P pharmaceuticals index, but it is now on our downgrade watch list.  

Special Report

Highlights We reiterate our longstanding overweight on healthcare equities for the next 12 months and possibly beyond. The macro environment, as well as underlying demand factors, will continue to drive the sector’s outperformance. Within healthcare equities, we favor biotechnology and healthcare technology over pharmaceuticals. Healthcare corporate bonds, however, are not especially attractive, and therefore warrant no more than a neutral position. Feature Chart 1Healthcare Has Outperformed Over The Past Decade... Over the past decade, global health care stocks have been clear outperformers, alongside information technology and consumer discretionary stocks, rising by almost 50% relative to the broad market (Chart 1). Not only have they benefited from increased demand from an aging population in developed economies and a growing middle class in emerging markets, they have also provided a downside cushion during recessions and bear markets, given their defensive, non- cyclical nature. The COVID-19 pandemic leads us to reiterate our longstanding overweight position on global healthcare equities over the next 12 months and possibly beyond. Favorable tailwinds will continue to drive healthcare outperformance. It is likely that government spending on healthcare will increase over the coming years. Innovative solutions in healthcare technology (healthtech), as well as increased overall research and development (R&D), the shift to value-based healthcare delivery, the focus on preventive medicine, and a low risk of substantial regulatory change and reform (at least in the US, assuming former Vice President Biden is elected president this November) should continue to support the sector’s outperformance. In this Special Report, we analyze whether our long-term overweight position on healthcare equities remains valid. In a later section, we also review healthcare-related investments in bonds and private equity. Why We Like Healthcare BCA Research’s Global Asset Allocation (GAA) service has been positive on global healthcare stocks for over five years. The main reason is that we see demand for healthcare services continuing to rise, as life expectancy increases, populations age – people over 65 will comprise 25% of the developed world’s population by 2040, up from 15% in 2020 – and the middle class in emerging economies becomes richer (Charts 2&3). As people live longer, healthcare spending should rise since, after the age of 65 (retirement), it tends to squeeze out discretionary spending (Chart 4). Chart 2...As The Global Population Grew Older... Chart 3...And Richer       Healthcare spending everywhere represents a large proportion of GDP, but the percentage varies considerably between countries. In the US for example, healthcare spending comprises 16.9% of GDP, higher than in other advanced economies, where it averages 9.9%, and substantially higher than in emerging economies (average 6.5% of GDP) (Chart 5). It is likely that these figures will increase over the next few years. Chart 4Healthcare Expenditure Dominates Late-Life Spending Chart 5Spending On Healthcare Will Rise   A strong case can be made for serious outbreaks of infectious diseases becoming more common, and therefore governments will have to increase their readiness. The number of countries experiencing a significant outbreak has almost doubled over the past decade, after being on a declining trend during the prior 15 years (Chart 6). The World Health Organization (WHO) warns that, while pandemics are rare, highly disruptive regional and local outbreaks are becoming more frequent and causing more economic damage.1 The non-cyclical nature of healthcare demand makes the industry less vulnerable to economic downturns. In times of below-trend growth, investors rush into defensive-growth stocks. Over the past two recessions, the drawdown of healthcare equities was, respectively, 20% and 27% less than the broad market. Chart 6Number Of Countries Experiencing Serious Outbreak Of Infectious Disease Chart 7The Defensive Side Of Healthcare   However, the sector is not totally cyclically insensitive, given its capital intensity and reliance on debt. In the US, healthcare sector debt amounts to almost $500 billion (Chart 7). This also leaves it vulnerable to rising interest rates. Nevertheless, the current macro outlook should keep a lid on interest rates for some time. The healthcare industry has lagged in digitalization (Chart 8). This offers wide-ranging opportunities for the sector, particularly in healthtech, biotechnology, and pharmaceuticals. Innovative solutions in robotics, artificial intelligence (AI), and genomics will drive the industry in the years to come. Digitalization will accelerate productivity and improve profitability. Chart 8The Healthcare Sector Is Way Behind In Digitalization Lastly, valuations for healthcare equities in most countries remain attractive, close to their long-run averages. The only exceptions are the UK and Japan, which are two standard deviations above the historical mean relative to their respective markets (Chart 9). The Future Of Healthcare Every crisis provides insights into what went wrong, what needs to be changed, and what areas should be explored. The COVID-19 pandemic is no exception. The pandemic has highlighted supply-chain fragilities, particularly a shortage of some healthcare equipment and drugs, the production of which is outsourced. In the US, for example, according to the Food and Drug Administration (FDA), over 70% of facilities producing essential medicines for the US are located abroad (Chart 10). Chart 9Valuations Remain Reasonable Chart 10Supply Chain Fragilities   Some argue that reshoring healthcare production is essential. Joe Biden, favored to be the next US president, has highlighted this in his plan to rebuild US supply chains.2 This could, however, lead to higher healthcare costs. This would either require increased government spending to subsidize medical expenses, or lead to fewer people being able to afford adequate healthcare. This effect would be pronounced in economies where a large percentage of the population is uninsured, around 10% in the US, and much more so in some emerging economies where healthcare quality is poor. This might be less of a risk for pharmaceutical and biotechnology companies, where the largest cost of bringing a new drug to market is R&D and marketing, rather than manufacturing. In the first months of the outbreak, resources such as ventilators, hospital and ICU beds, and basic personal protective equipment (PPE) quickly became scarce. Inventories of such items and overall hospital capacity will need to increase. This will entail massive investments to boost the public healthcare infrastructure and increase the number of healthcare workers. Chart 11COVID-19 Unveiled Poor Health Standards... The pandemic also underlined weaknesses in social and health standards. The excessive number of deaths from COVID-19 in nursing homes in some developed economies emphasizes the need for investment in this area. For example in Quebec, Canada, a staggering 80% of the province’s deaths occurred in nursing homes and senior residences (both public and private), illustrating the mismanagement and lack of funding (Chart 11). Most notably, care homes run for profit (approximately 70% of the total in the US) have seen almost four times as many COVID-19 infections as those not. The quality ratings of for-profit nursing homes, as measured by the Centers for Medicare and Medicaid Services (CMS), are much lower on average than those of non-profit or government-run facilities (Chart 12). This could imply the mass nationalization of nursing homes. However, this is unlikely. A better option would be to impose higher standards on privately run homes, reducing the sector to a smaller number of high-quality providers. Chart 12...In Most For-Profit Nursing Homes Chart 13The Evolution Of Genome Sequencing Is Illustrated In The Price More positively, there remains a large gap to be filled by a new era of technology-driven, integrated, and online healthcare. Investments in biotechnology – particularly related to genetic information – are also likely to increase, as DNA sequencing becomes cheaper (Chart 13). The way patients interact with physicians will also change. The American Medical Association (AMA) surveyed more than 1000 physicians on the use of digital tools in their practices. Reliance on digital tools for monitoring and clinical support has increased significantly over the past three years. The largest jump however was in the number of practices using telemedicine and virtual visits (Chart 14). Chart 14The Transition To A Digital-Driven Healthcare Model “Contact tracing” is a term that has been widely used during the coronavirus outbreak. The ability to track those infected and monitor their interactions to limit the spread of the virus is seen as a crucial step to mitigate further contagion. This would help not only to eradicate the virus, but might be developed into a long-lasting technology. Similar to how security screening equipment was developed after 9/11, there should be investment opportunities in the medical-screening segment. Breaking Down Healthcare Equities It is important to note that not all healthcare equities are equal: Different regions and industries have performed differently. In this report, we distinguish between the industry groups and subgroups, based on the GICS Level 2 and Level 3 classifications. We also look at the nine largest regions in the MSCI indexes to see if certain regions provide more favorable opportunities. Healthcare equities are broken down into two industry groups, which in turn break down into six industries: Healthcare equipment & services Healthcare equipment & supplies Healthcare providers & services Healthcare technology Pharmaceuticals, biotechnology & life sciences Pharmaceuticals Biotechnology Life sciences tools & services In Table 1, we drill down the constituent weights of the MSCI healthcare indexes. This allows us not only to analyze the size of the sector and its parts, but also to gain multiple insights. For example, a bet on Swiss healthcare stocks is essentially a bet on pharmaceuticals, given the greater-than-80% weighting of that industry. Exposure to the overall Danish equity index is by default a play on healthcare stocks, since they comprise almost 60% of the index. Table 1Global Healthcare Weights Chart 15Healthcare Has Outperformed Broad Indices Globally... As noted earlier, global healthcare stocks have outperformed the broad index by almost 50% over the past decade. This is true across all regions. However, several distinctions can be made. US, Swiss, and Danish healthcare equities have outperformed the global healthcare benchmark over the past decade, but their counterparts in the euro area, UK, and Japan have lagged (Chart 15). On a risk-adjusted basis, Danish healthcare equities have been the best performer with a Sharpe-ratio of 0.84 and an annualized return of 18% since 2000 (Table 2).   Table 2...However Not All Healthcare Stocks Are Alike Investment Opportunities Chart 16Within Healthcare Equities, Favor Biotechnology and Healthcare Technology... Viewing healthcare as a set of separate segments, rather than as a single industry, highlights pockets of opportunity.  A selective approach might be preferable for asset allocators in the coming years. As discussed in The Future Of Healthcare section, the sector is likely to shift to a model that relies more on technology, is data-driven, and harnesses the power of digitization, robotics, and AI. The patient will be at the center of the new healthcare model.  We divide our overview of investment opportunities into three categories: equities, corporate bonds, and private investments. Equities: Based on our view of the future of healthcare and the structure of the GICS equity classifications, we favor biotechnology and healthcare technology, and would have only a benchmark allocation to pharmaceuticals. There are insights to be drawn from the fundamentals, historical performance, and valuation metrics. Historically, pharmaceutical equities stand out as the worst performers within the sector. Over the past decade, they have underperformed the global healthcare benchmark by 20%, whereas biotechnology and healthcare technology stocks have outperformed by 59% and 127%, respectively (Chart 16). The outperformance of biotechnology has predominantly been earnings-driven, whereas pharmaceuticals’ and healthcare technology stock prices appear to be detached from earnings (Chart 17). It is worth nothing that despite the fact that valuations for those industries appear expensive relative to the broad market, we remain positive on their outlook. As we drill deeper into Level 3 industries, the small number of constituents within the index makes relying on valuations challenging (Chart 18). Chart 17..Despite A Detachment From Earnings... Chart 18...And Elevated Valuations   Chart 19No Attractive Opportunities Within Healthcare Corporate Bonds Corporate Bonds: Within the corporate bond universe, we favor those that qualify for central banks’ purchase programs: Investment-grade bonds and the highest tranche of high-yield. BCA Research’s US fixed-income strategists have an overweight recommendation on US healthcare corporate bonds, though their recommendations are based on a six-to-12 month investment horizon rather than the longer perspective that we are taking in this report.3 Both healthcare and pharmaceuticals bonds, similar to their equity counterparts, trade defensively, outperforming the broad corporate index when spreads widen and underperforming as they tighten (Chart 19). This applies to both investment-grade and high-yield bonds. The credit risk measure favored by our US bond strategists is the duration-times-spread (DTS) ratio. This measure confirms the sector’s defensive nature: A value below 1 implies credit risk lower than the market. However, the recent uptick in the DTS ratio of healthcare investment-grade bonds shows the sector has become riskier and as such may trade more cyclically in the short term. Nevertheless, the macro environment should remain favorable. Pricing power is still strong, with medical care services rising by almost 6.0%, and drug prices rising by 1.4% on a year-over-year basis, outpacing overall consumer prices (Chart 20). Neither segment within the investment-grade space offers an attractive spread advantage over the broad index. However, the risk outlook for healthcare remains better than that for pharmaceuticals, particularly related to political risk (as discussed later in the Risks section). Private Investments: Venture-capital investments in healthtech reached a quarterly record high of $8.2 billion in Q1 2020. The recent pandemic is likely only to push this trend higher. Moreover, large private-equity investments in recent years have been targeted at biopharma.4 According to Bain & Company, global biopharma private-equity deals where value was disclosed, reached $40.7 billion in 2019, up from $16.5 billion the prior year.5  The number of biotech firms going public is also trending up, despite slipping to 48 in 2019 from 58 in 2018 (Chart 21). To date (as of early June), 21 out of 43 US IPOs this year are healthcare-related. Chart 20Pricing Power Remains Favorable Chart 21More Biotech IPOs Are Coming To Market   Additionally, M&A activity has been increasing, particularly within the biotechnology segment, although the economic shutdown has slowed the deal flow recently. The number of M&A deals peaked in March 2020, when the average premium is 45% (Chart 22). The long-term rising trend is likely to persist. Over the next year, firms with drugs or vaccines related to COVID-19 would be clear targets for acquisitions and should outperform. Over the long term, we also expect to see some industry consolidation. Risks We see the following as the biggest risks to our overall positive outlook for healthcare investments: Quicker-Than-Expected Economic Growth Rebound: As we highlighted, the healthcare sector is defensive – outperforming the broad market during recessions and economic slowdowns. However, if growth rebounds more quickly, driven by further fiscal and monetary stimulus, the upside for healthcare performance could be challenged. Political Risk: Joe Biden might swing to the left in the run-up to the US presidential election to bring on board supporters of Elizabeth Warren and Bernie Sanders. Nevertheless, we see that particular risk for healthcare as relatively small (Chart 23). Biden’s approach is to restore and expand Obamacare (the Affordable Care Act, or ACA), shifting some of the burden of healthcare spending from individuals to the government. Overall, this should be positive for healthcare spending, particularly for insurers and healthcare providers. However, pharmaceutical companies may face headwinds if the administration imposes price caps on drug prices. Chart 22Secondary Market Activity Is Also Strong Chart 23Political Risk Has Waned As Biden's Chances Of Election Have Increased Chart 24Reliance On Inorganic Growth Might Prove Unsustainable Lack Of Innovation: Over the past two decades, the healthcare sector has shifted to relying on inorganic growth, driven by takeovers, rather than on research and development. Capital expenditure as a percentage of sales by both pharmaceutical and biotechnology firms fell sharply in the 2000s and has stagnated around 2% and 4%, respectively since (Chart 24). Only A Few Make It: While more IPOs in the healthcare sector is a sign of improving innovation, it is worth noting that only a few newly listed companies are successful. Over the past decade, only 3% of the 349 biotech IPOs had positive earnings at the time of their IPO. This nevertheless is a consequence of the nature of the industry: Companies tend to list while they await a big breakthrough in product development or regulatory approval. Conclusion We continue to recommend investors hold an above-benchmark allocation to healthcare-related investments on a long-term basis. Aging populations, the need to improve the quality of global healthcare, a likely increase in government spending, the shift to digitalized healthcare, and demand which is non-cyclical all support this stance. Healthcare equities in general, and particularly biotechnology and healthcare technology, should perform well over the coming years. For investors with global mandates, allocations to US, Swiss, and Danish healthcare equities should outperform those in the euro area, Japan, and the UK. Corporate bonds do not offer any advantage over the broad corporate US bond index. Political risks for the US healthcare sector should be limited even if the Democrats win the White House. However, the risk is highest for pharmaceuticals, in the event where the government imposes price caps.   Amr Hanafy Senior Analyst amrh@bcaresearch.com   Footnotes 1  "World Economic Forum, Outbreak Readiness and Business Impact, Protecting Lives and Livelihoods across the Global Economy," January 2019. 2  For more info please see Joe Biden https://joebiden.com/supplychains/ 3  Please see US Bond Strategy, "Assessing Healthcare & Pharma Bonds In A Pandemic," dated June 9, 2020.available at usbs.bcaresarch.com. 4  Biotech refers to manufactured products that rely on using living systems and organisms. The biopharma industry is backed by biotechnology, the science, which allows products to be manufactured biologically. 5  Bain & Company, Global Healthcare Private Equity and Corporate M&A Report 2020.

Highlights China and India periodically fight each other on their fuzzy Himalayan border with zero market consequences. A major conflict is possible in the current environment – but it would present a buying opportunity. Chinese escalation with India would not have a negative impact on global trade and economy, unlike escalation with the US or its East Asian allies. If China gets into a major conflict with India, it is less likely to stage major military actions in the South China Sea or Taiwan Strait. It would reduce much more significant geopolitical risks. Go strategically long Indian pharmaceuticals. Feature India and China have engaged in their first deadly military clash since 1967. An Indian colonel and at least 20 troops died in fighting on June 15 in the Galwan Valley, Ladakh, where territorial disputes have heated up over the past month.At least 50 Chinese troops are estimated dead.1 Chart 1Regional Equities May Not Shrug Off War In Himalayas ... At First It was a minor incident. No shots were fired. Combatants used stones and knives and threw each other off cliffs. However, the occasion of the battle was a negotiation to de-escalate tensions, and talks have gone on since June 3. So that bodes ill. Prime Minister Narendra Modi’s government has not responded but China’s foreign ministry is making conciliatory remarks. Normally India-China border clashes occur during the summer, when weather permits, and do not last long and do not impact the rest of the world, either politically or financially. However, the structural and cyclical drivers of the conflict suggest it could escalate over the summer. A major escalation between nuclear powers is unlikely but could conceivably cause volatility in global financial markets. Global equity investors are focused on other things (COVID-19, global stimulus), but recent volatility suggests that Chinese, Indian, and Pakistani bourses could be vulnerable to any major military escalation (Chart 1). However, a Himalayan-inspired selloff would be short-lived and would present a buying opportunity. India-China tensions are far less relevant to global financial markets than China’s disputes with the United States in East Asia. If the US uses India as a pretext for tougher actions on China, then that is a different story. But it is unlikely for reasons explained below. Our base case strategic assessment of India remains the same: Chinese expansionism will pressure India to speed up economic development to gain greater influence in South Asia. India will also pursue better trade and defense relations with the United States and its allies in East Asia and the Pacific. We are tactically cautious on global equities, but strategically we expect equities to beat bonds and cyclicals to beat defensives. Selloffs stemming from Himalayan conflict will create buying opportunities for emerging market equities, especially India. The Drivers Of The Ladakh Skirmish India and China have a 2,170-mile border in the Himalayan mountains that is disputed in India’s northwest (Aksai Chin) and northeast (Sikkim; Arunachal Pradesh). These border disputes have simmered for decades and occasionally flare into violent incidents, usually meaningless. An India-China border war could occur, but is unlikely. Today’s clashes are mostly taking place in eastern Ladakh, as with disputes in 2013-14. Minor incidents have also occurred in India’s northeast (Naku La, Sikkim). These may be unrelated, but they may also suggest a broad India-China border conflict is in the works (Map 1). Map 1India And China Often Fight Over Undefined Himalayan Border When Ice Melts There is always a local spark for clashes along the Line of Actual Control. These tend to be triggered by infrastructure construction or military patrols that cross the countries’ various border claims. Typically China triggers the incident as it is always pouring more money and concrete into new structures to solidify its territorial claims, whereas India’s resources are more limited. However, in recent years India has grown more capable. Both sides may also be surging infrastructure spending amid the recession (Chart 2). Chart 2China No Longer Alone In Nation-Building In Himalayas Chart 3China's Slower Growth Jeopardizes Communist Party Legitimacy In the current dispute both sides claim the other broke the peace. Indian builders supposedly violated China’s space while working on the Darbuk-Shayok-DBO road which connects to an airfield near Galwan Valley, the site of the clash. But the Indian side argues that Chinese military forces have ventured several miles from their usual outposts and amassed major forces on their side suggesting they are preparing for a bigger effort to expand their control of territory. 2 We may never know who “started” it. There is no clear border and even the Line of Actual Control is hard to define.3 Investors should not confuse the proximate cause of this conflict for the underlying cause. There are structural and cyclical factors at work on both sides: 1. China’s declining domestic stability and rising international assertiveness. The crises of 2008, 2015, 2018-19, and 2020 have caused a hard break in China’s economic model. Slower trend growth jeopardizes the Communist Party’s long-term monopoly on power (Chart 3). The Xi Jinping administration has responded to each crisis by tightening the party’s grip and reasserting central Beijing control. This is true at home, in peripheral territories like Xinjiang and Hong Kong, and abroad, as in the South China Sea and the Belt and Road Initiative. Territorial disputes have flared up across China’s borders. India is no exception, with incidents in 2013, 2014, 2017, and now 2020 marking the change (Table 1). Table 1China’s Territorial Assertiveness Triggers Clashes With India The China-Pakistan Economic Corridor strengthens the alliance between these two countries and deepens India’s insecurities. India perceives China’s Belt and Road Initiative as a threat of economic and eventually military encirclement. In 2017, the Doklam dispute between China, Bhutan, and India – which lasted over two months – served to distract the Chinese populace from a major increase in US pressure on China’s periphery. That was President Trump’s “fire and fury” campaign to intimidate North Korea into entering nuclear negotiations (Chart 4). In 2020, China faces its first recessionary environment since the mid-1970s as well as rocky relations with the United States over trade, technology, Hong Kong, North Korea again, and possibly even the Taiwan Strait. It is a convenient time to turn the public’s attention to the Himalayas. Chart 4China's Last Dispute With India Occurred During US-North Korea Tensions 2. India’s emerging national consensus and international coming-of-age. India’s rise as a global power has accelerated since the Great Recession, especially after oil prices fell in 2014. Prime Minister Modi has won two smashing general elections with single-party majorities, in 2014 and 2019. His movement also maintains the upper hand in state legislatures, which is important given that India’s weak federal government cannot simply force structural reforms onto the country (Map 2). Modi’s electoral success reflects a deeper national consensus on the need for stronger central leadership, faster economic development, deeper international trade and investment ties, and pro-efficiency reforms such as the creation of a single market. The policy retreat from globalization benefits insular and service-oriented economies like India at the expense of mercantilist trading powers such as China. America’s pivot to Asia and “Indo-Pacific” strategy create a chance for India to attract investment as multinational corporations diversify away from China (Chart 5). Map 2Modi’s Political Capital At State-Level Chart 5India Attracts Investment As Supply Chains Diversify From China Chart 6US And India Fiscal Stimulus Enable Supply Chain Shift Out Of China In August 2019, after Modi’s big election victory, he launched an ambitious agenda of state-building. He converted the autonomous region of Jammu and Kashmir into two union territories under New Delhi: Jammu and Kashmir, and Ladakh. This change of status quo angered China and Pakistan, which felt their own territory threatened. Chinese territorial pressure could be retribution for these administrative reforms. China and Pakistan will also want to undermine Modi’s party in upcoming elections for the state assembly of Jammu and Kashmir. China’s territorial encroachments reflect its desire to gain control of the entire Aksai Chin plateau. India does not want China to gain such a strategic advantage at the head of the Indus River and valley. The global pandemic and recession reinforced these structural and cyclical trends by pushing both India and China to use nationalist devices to divert their populations from domestic ills. The use of fiscal stimulus across the world enables leaders to pursue risky strategic policies (Chart 6). There is also a tactical issue: India took over the chairmanship of the World Health Assembly in May, while the US is lobbying on behalf of Taiwan’s long desire to be represented in the World Health Organization in the wake of COVID-19. China is resisting this call and could be using Ladakh as a pressure tactic.4 How Far Will Sino-Indian Conflict Escalate? Reports suggest that India and China have reinforced troops in and near Ladakh and have brought more firepower and airpower into range.5 Some of this activity, on both sides, consists of seasonal military drills. So it is not certain that a build-up is occurring. China is less constrained and more capable of escalation than India. If China continues pressing its territorial advance, or if India tries to reclaim territory or take other territory in compensation, then the fight will expand. The conflict is taking place in rocky recesses at a far remove from the rest of the world, so there is a temptation to believe that any escalation can be controlled.6 This may be false and lead to tit-for-tat escalation. Table 2Military Balance: India Versus China In Himalayas Which side faces greater constraints? China is least constrained and most capable of escalation. Over the short run, China can utilize improved military command and capabilities in the area and can control the media and political response at home. Besting India would demonstrate that all Asian territorial claimants should defer to China. However, over the long run, aggression would cement the balance-of-power alliance between the US and India. India is more constrained than China, less capable of escalation: Modi has considerable political capital, but his conventional military advantage in this area is eroding and China has the higher ground from which to stage attacks (Table 2). India’s loss in the 1962 Himalayan war with China was a national humiliation. A repeat of such an event could destroy much of Modi’s mystique as a strongman leader and national savior. In the worst-case scenario, China would demonstrate superior military capability while the US and its allies would remain utterly aloof, leaving India looking both weak and isolated. Therefore India will engage in tit-for-tat military response while seeking diplomatic de-escalation. The US lacks interest in the dispute: Trump has already offered to mediate, presumably to demonstrate his deal-making skills again before the election. But the US does not have a compelling interest in this dispute and India does not want US mediation. If Trump takes punitive measures against China it will be for other reasons. Serious punitive measures require the stock market and economy to relapse, since at the moment Trump’s average approval rating is 43% and he hopes financial and economic gains will help him recover (Diagram 1). Diagram 1Odds President Trump Will Hike Tariffs On China Before US Election The above points suggest that China can afford to escalate if it wants to show India and the rest of Asia that the US is toothless and that China’s territorial claims in Asia should not be opposed. Since COVID-19, China has been aggressive in the South China Sea and Taiwan Strait, despite the fact that these areas bring economic risks. The Himalayas do not. The implication is that China’s risk appetite is large, particularly in territorial disputes, and driven by social and economic pressure at home. Investment Takeaways Because India and China (and Pakistan) have nuclear arms, and because the US could get involved, it is possible that a major escalation could occur and cause volatility in global financial markets. But it would not last long and no parties will use nuclear arms over Himalayan territorial disputes. A major conflict that results in a Chinese victory would subtract from Prime Minister Modi’s political capital and hence weigh on Indian equities, which have broken down badly since COVID-19 (Chart 7). The reason is that strong political support for Modi would enable India to continue making structural economic reforms that increase productivity. Chart 7Indian Equities Underperforming Since COVID-19 Chart 8India’s Path To Regional Primacy Lies Through Economic Opening And Reform In the long run, a major conflict, especially a humiliating defeat, would accelerate India’s attempts to improve national economic prowess for the sake of strategic security. Since India cannot achieve its strategic objective of primacy in South Asia merely through military power, it will need to do so through a stronger economic pull (Chart 8). This is an impetus for structural economic reform even beyond Modi. Hence our secularly bullish outlook on India. Indian pharmaceutical equities offer an investment opportunity (Chart 9). In an attempt to address land acquisition, which is one of the biggest constraints faced by companies looking to invest in India, New Delhi has announced that it is developing an area the size of Luxembourg to attract businesses moving out of China. The government reached out to over 1,000 US companies in April with incentives for them to move their facilities to India, with a focus on industries in which India has a comparative advantage, such as medical equipment suppliers, food processing units, textiles, leather, and auto part makers. Chart 9US And Indian Stimulus Policies Will Boost Investment In Indian Pharma While India is not as economically competitive as China, it could be attractive for non-strategic industries that would not want to relocate to the US but are looking to reduce uncertainty from US-China tensions. The next round of US fiscal stimulus is also likely to contain significant provisions that will incentivize companies to relocate from China, particularly in the medical and health care sector. For global investors, while a major Sino-Indian escalation could lead to short-term volatility, it would ultimately be a positive development if Beijing vented its nationalism on a strip of earth that is not globally relevant, rather than on the seas, which are highly relevant. Conflict between the US and China in East Asia is a far greater risk than Sino-Indian conflict. Indeed Chinese and American actions over the Taiwan Strait, North Korea, or the South and East China Seas are still far more likely than Sino-Indian tensions to affect global trade and stability and financial markets this year. The US could impose sanctions on Chinese tech and trade, a military incident could occur in the Taiwan Strait, North Korea could provoke US President Donald Trump into a new round of “fire and fury” that triggers a showdown with China, or the US and China could fight a naval skirmish in the South or East China Sea. None of these options is low probability, especially surrounding the US election. Over the short run, global investors should prepare for greater equity volatility, primarily because of hiccups in delivering new stimulus in the US, EU, and China, plus US domestic political risks and US-China-Asia strategic tensions. Stay long JPY-USD. Over the long run, a global growth rebound driven by massive global fiscal and monetary stimulus will drive the US dollar to weaken, global equities to outperform bonds, and cyclicals to outperform defensives. We remain long China-sensitive plays as well as infrastructure, cyber-security, and defense stocks. Strategically, go long Indian pharmaceuticals relative to the emerging market benchmark.   Matt Gertken Vice President Geopolitical Strategist mattg@bcaresearch.com Footnotes 1 The Guardian, "Soldiers fell to their deaths as India and China’s troops fought with rocks," June 17, 2020. 2 See Ashley J. Tellis, "Hustling in the Himalayas: The Sino-Indian Border Confrontation," Carnegie Endowment for International Peace, June 4, 2020. See also Mohan Guruswamy, "India-China Border Dispute: Is A Give And Take Possible Now?" South Asia Monitor, June 3, 2020. 3 The Treaty of Tingmosgang (1684) only specifies one checkpost, at the Lhari Stream near Demchok, leaving everything else to disputed Indian and Chinese claims. See Alexander Davis and Ruth Gamble, "The local cost of rising India-China tensions," June 1, 2020. 4 See Nayanima Basu, "India Isn’t Worried About Tension With China, Unlikely To Give In To US Pressure On Taiwan," May 13, 2020. 5 See Ren Feng and He Penglei, "PLA Xizang Military Command holds coordinated exercise in plateau region," China Military Online, June 15, 2020. See also "空降兵某旅积极探索远程兵力投送新模式 空地同步 奔赴高原". 6 The reason escalation is normally limited is because of the extreme difficulty of operating extended military operations and resupply at 13,000-feet altitude. Both sides have the ability to surge reinforcements and equalize the contest. The cost and difficulty of retaking lost territory is often prohibitive. And while India’s conventional military power may overbalance China in this region, China has the uphill advantage and has made leaps and bounds in operational capabilities in recent decades. In short, escalation is normally controllable. See Aidan Milliff, "Tension High, Altitude Higher: Logistical And Physiological Constraints On The Indo-Chinese Border," War On The Rocks, June 8, 2020.

Highlights Duration: Investors should keep portfolio duration close to benchmark, but continue to hold yield curve steepeners (on both the nominal and real yield curves) as well as overweight TIPS positions versus nominal Treasuries. These tactical trades will profit from higher Treasury yields in the near-term. Healthcare: We recommend an overweight allocation to investment grade Healthcare bonds relative to the overall investment grade corporate index. But we also recommend an underweight allocation to high-yield Healthcare relative to the high-yield corporate index.  Pharmaceuticals: Investors should underweight Pharmaceutical bonds in both the investment grade and high-yield credit universes. How Much Higher For Bond Yields? Two weeks ago, we warned that bonds would struggle in the near-term as the re-opening of the US economy led to an improvement in economic data.1 However, we definitely didn’t anticipate the magnitude of the positive data surprise that has occurred since then. The US Economic Surprise Index was -55 one week ago and today it sits at +66 (Chart 1)! The bulk of that jump occurred after Friday’s employment report revealed that 2.5 million jobs were added in May when Bloomberg’s consensus estimate had called for a contraction of 7.5 million. Against this back-drop, it shouldn’t be too surprising that bond yields jumped sharply. The 30-year Treasury yield rose 27 bps last week to 1.68% and the 10-year yield rose 26 bps to 0.91% (Chart 2). The 2-year yield rose a more modest 6 bps to 0.22%, as the Fed maintains its tight grip on the front-end of the curve. Chart 1Back In Business Chart 2Yields Have Room To Move Higher For investors, the first relevant question is: How high can yields go? Our view is that if last week does indeed represent the cyclical economic trough, then forward rates at the long-end of the curve will revert to levels consistent with market expectations for the long-run neutral fed funds rate. The median estimate of that rate from the New York Fed’s most recent Survey of Market Participants is 2%, but with an unusually wide interquartile range of 1.3% to 2.5% (Chart 2, bottom panel). At the very least, we’d expect the 10-year and 30-year Treasury yields to re-test their respective 200-day moving averages of 1.38% and 1.91%, respectively. However, we are not ready to declare last week the economic trough for three reasons: First, we cannot rule out a re-acceleration in the number of confirmed COVID cases as the economy re-opens. This could lead to the re-imposition of lockdown measures come fall. Second, last week’s positive economic data might cause some members of Congress to question the need for further fiscal stimulus. This would be a mistake. In last week’s report we showed that fiscal measures have done a good job propping up household income so far, but these measures are temporary and will need to be renewed.2  Even after last week’s large drop, the unemployment rate is still 3.3% above its Great Recession peak (Chart 1, bottom panel). This is by no means a fully healed economy that can withstand policymakers taking their feet off the gas. Even after last week’s large drop, the unemployment rate is still 3.3% above its Great Recession peak. Finally, US political risks are heightened with anti-police protests occurring daily in most major cities. Added to that, President Trump is now the underdog heading into November’s election and he will need to develop a reelection bid that doesn’t hinge on the economy. Our geopolitical strategists think a doubling down on “America First” foreign and trade policies makes the most sense.3 A significant move in that direction would certainly send a flight to quality into US bonds. Investment Strategy As we advised two weeks ago, nimble investors should tactically reduce duration as yields still have more upside in the next month or two. However, we are not yet sufficiently confident in the sustainability of the economic rebound to recommend reducing portfolio duration on a 6-12 month horizon. Rather, we continue to recommend keeping portfolio duration close to benchmark while holding several less risky positions that will profit from higher yields. Specifically, investors should hold duration-neutral curve steepeners along the nominal Treasury curve. We advise going long the 5-year note and short a 2/10 barbell.4 We also like holding TIPS over nominal Treasuries and positioning for a steeper real Treasury curve.5 In terms of spread product, we also recommend staying the course. This entails overweighting corporate bonds rated Ba and higher, Aaa consumer ABS, Aaa CMBS (both agency and non-agency) and municipal bonds, while avoiding corporate bonds rated B and below and residential mortgage-backed securities. Appendix A at the end of this report shows how these positions have performed since the March 23 peak in spreads. The remainder of this report focuses on the Healthcare and Pharmaceutical sectors of both the investment grade and high-yield corporate bond markets. Investment Grade Healthcare & Pharma Risk Profile When assessing the risk profiles for investment grade-rated Healthcare and Pharmaceutical bonds, we first consider the credit rating distributions of both sectors relative to the overall Bloomberg Barclays corporate index (Chart 3). Chart 3Investment Grade Credit Rating Distribution* Immediately, we see that the Healthcare sector has a lower credit rating than the benchmark: 71% of the Healthcare index is rated Baa, compared to 48% for the corporate index. Meanwhile, the Pharmaceuticals sector has slightly higher credit quality than the corporate benchmark: 12% of the Pharmaceuticals index is rated Aa or Aaa, compared to 8% for the corporate index. Credit rating alone suggests that Healthcare should trade cyclically relative to the corporate index. That is, it should outperform during periods of spread tightening and underperform during periods of spread widening. However, this turns out to not be the case. Chart 4 shows that healthcare has outperformed the corporate benchmark during each of the last five major bouts of spread widening and underperformed during periods of spread tightening. Clearly, despite its low credit rating, Healthcare trades like a defensive corporate bond sector. Healthcare’s historically defensive nature is confirmed by its duration-times-spread (DTS) ratio, which has tended to be below 1.0 (Chart 4, top panel).6 Though recently, the DTS ratio climbed above 1.0 due to a lengthening of the sector’s duration (Chart 4, bottom panel). This suggests that Healthcare, while historically defensive, might trade more cyclically during the next 12 months. Neither the Healthcare nor Pharmaceuticals sectors offer a spread advantage over the corporate index. Pharmaceuticals, on the other hand, are a much more cut and dry defensive sector (Chart 5). The DTS ratio is almost always below 1.0 and the sector has a strong track record of outperforming the corporate index during periods of spread widening (Chart 5, panels 2 & 3) Chart 4IG Healthcare Risk Profile Chart 5IG Pharma Risk Profile   Valuation Turning to valuation, we find that neither sector offers a spread advantage compared to the corporate index or its comparable credit tier (Table 1). This is true whether we look at the raw option-adjusted spread or if we control for duration differences by looking at the 12-month breakeven spread.7  It is interesting to note that the Healthcare index offers a spread advantage compared to the A-rated corporate index. On the one hand, this is not surprising because the Healthcare index carries an average Baa rating. On the other hand, we have seen that Healthcare tends to trade more defensively than its average credit rating implies. This arguably makes its spread advantage over A-rated debt somewhat compelling. Table 1IG Healthcare & Pharma Valuation Balance Sheet Health Both the Healthcare and Pharmaceuticals sectors loaded up on debt during the last recovery. The amount of Healthcare debt in the corporate index grew 8.8 times since 2010. Meanwhile, total debt in the corporate index grew 2.4 times. The result is that Healthcare’s weight in the corporate index increased from 1.1% in 2010 to 4.3% today (Chart 6). The Pharma sector also increased its debt load at a faster pace than the overall corporate universe since 2010 (3.2 times versus 2.4 times), but the boom in Pharma debt has been much milder than in Healthcare. The weight of Pharmaceuticals in the corporate index increased from 4.1% in 2010 to 5.5% today (Chart 7). Chart 6IG Healthcare Debt Growth Chart 7IG Pharma Debt Growth Despite rapid debt growth during the past few years, credit quality in both the Healthcare and Pharma sectors appears quite solid. Appendix B lists the issuers in the Healthcare index, grouping them by credit tier and indicating whether they carry a positive, stable or negative ratings outlook from Moody’s. Of the 56 issuers in the Healthcare index, only six currently have a negative ratings outlook. The two largest issuers in the Healthcare index are Cigna and CVS Health. Both carry Baa ratings, but Moody’s just confirmed Cigna’s ratings outlook at stable in mid-May. CVS Health, on the other hand, has carried a negative ratings outlook since 2018. Appendix C lists issuers in the Pharmaceuticals index. Of the 17 issuers, only four carry a negative ratings outlook. None of the Baa-rated Pharmaceutical issuers currently has a negative ratings outlook. The two biggest issuers in the index are Bristol-Myers Squibb and Abbvie. Bristol-Myers Squibb is A-rated with a negative outlook, while Abbvie is Baa-rated with a stable outlook. Macro Considerations In a typical demand-driven recession, consumers tend to prioritize healthcare spending while they cut back on more discretionary outlays. This dynamic is probably what causes healthcare bonds to trade defensively relative to the overall corporate index. However, the unique nature of the COVID recession has thrown this traditional pattern into reverse. Consumer spending on health care services is down 40% since February while overall consumer spending is 19% lower (Chart 8). Oddly, healthcare bonds shrugged off this year’s massive drop in spending and continued to behave defensively – outperforming the corporate index when spreads widened and underperforming since the March 23 peak in spreads. Despite the plunge in spending, pricing power in the health care industry remains strong. Health care services prices continue to accelerate even as overall inflation has dropped sharply (Chart 8, bottom panel). Unlike healthcare, pharmaceutical spending has held firm during the past couple of months (Chart 9). Consumer spending on pharmaceuticals is only down 4% since February, while overall consumer spending is down 19%. But despite firm spending, medicinal drug prices have decelerated in concert with the overall headline CPI (Chart 9, bottom panel). Chart 8Healthcare Demand & Pricing Power Chart 9Pharmaceutical Demand & Pricing Power Investment Conclusions Putting everything together, we are inclined to recommend an underweight allocation to Pharmaceuticals and an overweight allocation to investment grade Healthcare. Pharmaceuticals are simply too expensive and too defensive for the current environment. Given our positive outlook on investment grade corporate bonds, we should target cyclical sectors with elevated spreads that have more room to compress. Healthcare is slightly more interesting. It has behaved like a typical defensive sector so far this year, but there are some indications that it is becoming more cyclical. The DTS ratio recently shot above 1.0 and consumer spending on healthcare services is poised for a rapid snapback. In terms of valuation, healthcare is expensive relative to other Baa-rated bonds but cheap versus the A-rated universe. This would seem to make healthcare a good risk-adjusted bet. Even if the sector continues to behave defensively, its spread advantage over A-rated bonds makes it an attractively priced defensive sector. High-Yield Healthcare & Pharma Risk Profile Considering the risk profile of high-yield Healthcare and Pharmaceuticals, we first notice that both sectors have significantly lower credit ratings than the overall junk index (Chart 10). Ba-rated credits account for 29% and 24% of the Healthcare and Pharma indexes, respectively, compared to 54% for the High-Yield index as a whole. Chart 10High-Yield Credit Rating Distribution* The fact that significant portions of the Healthcare and Pharmaceutical indexes are rated B and lower immediately raises alarm bells. This is because we do not expect that many B-rated or lower issuers will be able to take advantage of the Fed’s Main Street Lending Program. This lack of Fed support for the lower-rated junk tiers has led us to recommend underweighting junk bonds rated B & below.8 High-yield Healthcare and Pharmaceuticals sectors have significantly lower credit ratings than the overall junk index. Interestingly, despite low credit ratings, a look at both sectors’ DTS ratios and historical excess returns reveals that they tend to trade defensively relative to the high-yield benchmark index. Healthcare outperformed the high-yield index by 473 bps from the beginning of the year until the March 23 peak in spreads and has underperformed the index by 123 bps since (Chart 11). Similarly, Pharmaceuticals outperformed the junk index by 670 bps from the beginning of the year until March 23 and have since underperformed by 136 bps (Chart 12). Chart 11HY Healthcare Risk Profile Chart 12HY Pharma Risk Profile Valuation Turning to spreads, we would characterize both high-yield Healthcare and Pharmaceuticals as expensive (Table 2). Despite both sectors carrying average credit ratings of B, they offer spreads that are below both the overall junk index average and the average for other B-rated credits. Tight option-adjusted spreads are at least partially attributable to low average duration for both sectors. If we adjust for duration differences by looking at 12-month breakeven spreads, we see that Pharmaceuticals look somewhat cheap versus other B-rated credits while Healthcare remains expensive. Table 2HY Healthcare & Pharma Valuation Balance Sheet Health Healthcare debt has grown less quickly than overall high-yield index debt since 2010 (Chart 13). Healthcare debt has grown 1.7 times since 2010 while the overall index has grown 1.8 times. This has caused Healthcare’s weight in the index to fall from 6.2% to 5.7%. In contrast, the high-yield Pharmaceuticals sector has grown rapidly during the past decade (Chart 14). Pharma debt has increased 10.3 times since 2010 compared to 1.8 times for the overall index. This has brought the sector’s weight in the index up to 2.3% from 0.4% Chart 13HY Healthcare Debt Growth Chart 14HY Pharma Debt Growth Looking beyond debt growth, in the current environment we are mostly concerned with the number of issuers in each index that will be able to access Fed support through the Main Street Lending facilities. In this regard, neither sector fares particularly well. Appendix D lists all high-yield Healthcare issuers along with their ratings outlooks, number of employees, 2019 revenues and total debt-to-EBITDA ratios. To qualify for the Fed’s Main Street Lending facilities, issuers must have either less than 15000 employees or less than $5 billion in 2019 revenues. Additionally, they must be able to keep their Debt-to-EBITDA ratios below 6.0. We estimate that all but three of the Ba-rated Healthcare issuers are eligible for the Main Street program, but only one of the B-rated issuers is eligible. High-yield Pharmaceuticals issuers are listed in Appendix E. Here, we once again find that only one of the B-rated issuers is likely to qualify for the Main Street lending facilities. Of the two Ba-rated issuers, one is likely to qualify. The other is Bausch Health, a Canadian firm that is by far the largest issuer in the Pharma index. It would need to turn to the Canadian authorities for help in an emergency lending situation. Investment Conclusions We recommend underweight allocations to both the high-yield Healthcare and Pharmaceuticals sectors. In the current environment we prefer to focus our high-yield credit exposure on the Ba-rated credit tier where issuers are more likely to have access to Fed support. The large concentration of B-rated and lower issuers in both the Healthcare and Pharma sectors, along with their generally expensive valuations, makes us wary about both sectors. Appendix A: Buy What The Fed Is Buying The Fed rolled out a number of aggressive lending facilities on March 23. These facilities focused on different specific sectors of the US bond market. The fact that the Fed has decided to support some parts of the market and not others has caused some traditional bond market correlations to break down. It has also led us to adopt of a strategy of “Buy What The Fed Is Buying”. That is, we favor those sectors that offer attractive spreads and that benefit from Fed support. The below Table tracks the performance of different bond sectors since the March 23 announcement. We will use this to monitor bond market correlations and evaluate our strategy’s success. Table 3Performance Since March 23 Announcement Of Emergency Fed Facilities Appendix B Table 4Investment Grade Healthcare Issuers Appendix C Table 5Investment Grade Pharmaceuticals Issuers Appendix D Table 6High-Yield Healthcare Issuers Appendix E Table 7High-Yield Pharmaceuticals Issuers   Ryan Swift US Bond Strategist rswift@bcaresearch.com Footnotes 1 Please see US Bond Strategy Weekly Report, “Bonds Vulnerable As North America Re-Opens”, dated May 26, 2020, available at usbs.bcaresearch.com 2 Please see US Bond Strategy Portfolio Allocation Summary, “Filling The Income Gap”, dated June 2, 2020, available at usbs.bcaresearch.com 3 Please see Geopolitical Strategy Weekly Report, “Spheres Of Influence (GeoRisk Update)”, dated May 29, 2020, available at gps.bcaresearch.com 4 For more details on this recommended yield curve position please see US Bond Strategy Weekly Report, “Life At The Zero Bound”, dated March 24, 2020, available at usbs.bcaresearch.com 5 For more details on these recommendations please see US Bond Strategy Weekly Report, “Negative Oil, The Zero Lower Bound And The Fisher Equation”, dated April 28, 2020, available at usbs.bcaresearch.com 6 Duration-Times-Spread (DTS) is a simple measure that is highly correlated with excess return volatility for corporate bonds. The DTS ratio is the ratio of a sector’s DTS to that of the benchmark index. It can be thought of like the beta of a stock. A DTS ratio above 1.0 signals that the sector is cyclical (or “high beta”), a DTS ratio below 1.0 signals that the sector is defensive or (“low beta”). For more details on the DTS measure please see: Arik Ben Dor, Lev Dynkin, Jay Hyman, Patrick Houweling, Erik van Leeuwen & Olaf Penninga, “DTS (Duration-Times-Spread)”, Journal of Portfolio Management 33(2), January 2007. 7 The 12-month breakeven spread represents the spread widening that must occur for a sector to underperform a duration-matched position in Treasury securities during the next 12 months. It can be proxied by option-adjusted spread divided by duration. 8 For more details please see US Investment Strategy/US Bond Strategy Special Report, “Alphabet Soup: A Summary Of The Fed’s Anti-Virus Measures”, dated April 14, 2020, available at usbs.bcaresearch.com Fixed Income Sector Performance Recommended Portfolio Specification

Special Report

Highlights Global shortages of medical equipment – including medicines – are frontloaded until emergency production kicks in. As the crisis abates, political recriminations between the US and China will surge. The US will seek to minimize medical supply exposure to China going forward, a boon for India and Mexico. China has escaped the COVID-19 crisis with minimal impact on food supply. Pork prices are surging due to African Swine Flu, but meat is a luxury. Still, the “Misery Index” is spiking and this will increase social instability. Food insecurity, inflation, and large current account deficits suggest that emerging market currencies will remain under pressure. Turkey and South Africa stand to suffer while we remain overweight Malaysia. Feature Chart 1Collapse In Economic Activity With a third of the world population under some form of lockdown, general activity in the world’s manufacturing powerhouses has collapsed (Chart 1). The breakdown is a double whammy on market fundamentals. On the supply side, government-mandated containment efforts force workers in non-essential services to stay home while, on the demand side, households confined to their homes are unable to spend. Acute demand for medical supplies is causing shortages, while supply disruptions threaten states that lack food security. While global monetary and fiscal stimulus will soften the blow (Chart 2), the economic shock is estimated to be a 2% contraction in real GDP for every month of strict isolation. If measures are extended beyond April, markets will sell and new stimulus will be applied. Already the US Congress is negotiating the $1-$2 trillion infrastructure package that we discussed in our March 4 report, and cash handouts will be ongoing. When the dust settles the political fallout will be massive. Authoritarian states like China and especially Iran will face greater challenges maintaining domestic stability. Democracies like Italy and the US, which lead the COVID-19 case count, are the most likely to experience a change in leadership (Chart 3). Initially the ruling parties of the democracies are receiving a bump in opinion polling, but this will fade as households will be worse off and will likely vent their grievances at the ballot box. Until a vaccine or treatment is discovered, medical equipment and social distancing are the only weapons against the pandemic. National production is (rightly) being redirected from clothing and cars to masks and ventilators to meet the spike in demand. Will the supply shock cause shortages in food and medicine – essential goods for humankind? In this report we address the impact of COVID-19 on global supply security and assess the market implications. Medical Equipment Shortages Will Spur Protectionism Policymakers are fighting today’s crisis with the tools of the 2008 crisis, but a lasting rebound in financial markets will depend on surmounting the pandemic, which is prerequisite to economic recovery (Table 1). As the US faces the peak of its COVID-19 outbreak, public health officials and doctors are raising the alarm on the shortage of medical supplies. A recent US Conference of Mayors survey reveals that out of the 38% of mayors who say they have received supplies from their state, 84.6% say they are inadequate (Chart 4). Italy serves as a warning: A reported 8% of the COVID-19 cases there are doctors and health professionals, often treating patients without gloves or with compromised protective gear. These workers are irreplaceable and when they succumb the virus cannot be contained. In the US, doctors and nurses are re-using masks and sometimes treating patients behind a mere curtain, highlighting the supply shortage. While the shortages are mainly driven by a surge in demand from both medical institutions and households, they also come from the supply side, particularly China. Factory closures and transportation disruptions in China earlier this year, coupled with Beijing’s government-mandated export curbs, reduced Chinese exports, a major source of US and global supplies (Chart 5). Other countries have imposed restrictions on exports of products used in combating the spread of COVID-19. Following export restrictions by the French, German, and Czech governments in early March, the European Commission intervened on March 15 to ensure intra-EU trade. It also restricted exports of protective medical gear outside of the EU. At least 54 nations have imposed new export restrictions on medical supplies since the beginning of the year.1 Both European and Chinese measures will reduce supplies in the US, the top destination for most of these halted exports (Chart 6). Thus it is no wonder that the Trump administration has rushed to cut import duties and boost domestic production. The administration has released strategic stockpiles and cut tariffs on Chinese medical equipment used to treat COVID-19. With the whole nation mobilized, supply kinks should improve greatly in April. After a debacle in rolling out test kits (Chart 7), the US is rapidly increasing its testing capabilities to manage the crisis, with over a million tests completed as of the end of March (Chart 8). Meanwhile a coalition of companies is taking shape to make face masks. The president has invoked the defense production act to force companies to make ventilators. However, with the pandemic peaking in the US, the hardest-hit regions will continue experiencing shortages in the near term. Shortages are prompting public outcry against the US government for its failure to anticipate and redress supply chain vulnerabilities that were well known and warned against. A report in The New York Times tells how Mike Bowen, owner of Texas-based mask-maker Prestige Ameritech, has advised the past three presidents about the danger in the fact that the US imports 95% of its surgical masks. “Aside from sitting in front of the White House and lighting myself on fire, I feel like I’ve done everything I can,” he said. He is currently inundated with emergency orders from US hospitals. The same report tells of a company called Strong Manufacturers in North Carolina that had to cut production of masks because it depends on raw materials from Wuhan, China, where the virus originated.2 The Trump administration will suffer the initial public uproar, but the US government will also seek to reduce import dependency going forward, and it will likely deflect some of the blame by focusing on the supply risks posed by China. Beijing, for its part, is launching a propaganda campaign against the US to distract from its own failures at home (some officials have even blamed the US for the virus). Meanwhile it is cranking up production and shipping medical supplies to crisis hit areas like Italy to try to repair its global image after having given rise to the virus. In addition, the city of Shenzhen is sending 1.2 million N95 masks to the US on the New England Patriots’ team plane. Even Russia is sending small donations. But these moves work to propagandistic efforts in these countries and will ultimately shame the Americans into taking measures to improve self-sufficiency. Bottom Line: The most important supply shortage amid the global pandemic is that of medical equipment. While these shortages will abate sooner rather than later, the supply chain vulnerabilities they have exposed will trigger new policies of supply redundancy and import substitution. The US in particular will seek to reduce dependency on China. That COVID-19 is aggravating rather than reducing tensions between these states, despite China’s role as a key supplier in a time of need, highlights the secular nature of their rising tensions. The US-China Drug War Shortages of pharmaceuticals are also occurring, despite the fact that the primary pandemic response is necessarily “non-pharmaceutical” (e.g. social distancing). The US Food and Drug Administration (FDA) announced the first COVID-19 related drug shortage in the US on February 27. While the specific drug was not disclosed, the announcement notes that “the shortage is due to an issue with manufacturing of an active pharmaceutical ingredient used in the drug.”3 The FDA is monitoring 20 other (non-critical) drugs potentially at risk of shortages because the sole source is China. The global spread of the pandemic will increase these shortages. On March 3 India announced export restrictions on 26 drugs, including paracetamol and several antibiotics, due to supply disruptions caused by the Chinese shutdown. While Chinese economic activity has since picked up, India is now among the string of countries under a nationwide lockdown. Similar measures enforced across Europe will also hamper the production and transportation of these goods. The implication is that even if Chinese drugs return to market, supplies further down the chain and from alternative suppliers will take a hit. The risk that this will evolve into a drug shortage depends on the intensity of the outbreak. Drug companies generally hold 3-6 months’ worth of inventories. Consequently, while inventories are likely to draw as supplies are disrupted, consumers may not experience an outright shortage immediately. In the US, as with equipment and protective gear, the government’s strategic stockpile will buffer against shortfalls in supplies of critical drugs. COVID-19 is aggravating rather than reducing US-China tensions. Nevertheless the supply chain is getting caught up in the larger US-China strategic conflict. Even before the pandemic, the US-China trade war brought attention to the US’s vulnerabilities to China’s drug exports. This dispute is not limited to illicit drugs, as with China’s production of the opioid fentanyl, but also extends to mainstream medicines, as highlighted in the selection of public statements shown in Table 2. How much does the US rely on China for medicine? According to FDA data, just over half of manufacturing facilities producing regulated drugs in finished dosage form for the US market are located abroad, with China’s share at 7% (Chart 9).4 The figures are higher for manufacturing facilities producing active pharmaceutical ingredients, though still not alarming – 72% of the facilities are located abroad, with 13% in China. Of course, high-level data understate China’s influence. The complex nature of global drug supply chains means that the source of finished dosage forms masks dependencies and dominance higher up the supply chain (Figure 1). For instance, active pharmaceutical ingredients produced in Chinese facilities are used as intermediate goods by finished dosage facilities in India as well as China. The FDA reports that Indian finished dosage facilities rely on China for three-quarters of the active ingredients in their generic drug formulations, which are then exported to the US and the rest of the world. Any supply disruption in China – or any other major drug producer – will lead to shortages further down the supply chain. Chinese influence becomes more apparent when the sample is restricted to generic prescription drugs. These are especially relevant because nearly 70% of Americans are on at least one prescription drug, of which more than 90% are dispensed in the generic form. In this case, 87% of ingredient manufacturers and 60% of finished dosage manufacturers are located outside the US, with 17% of ingredient facilities and 8% of dosage facilities in China (Chart 10). Of all the facilities that manufacture active ingredients that are listed on the World Health Organization’s Essential Medicines List – a compilation of drugs that are considered critical to the health system – 71% are located aboard with 15% located in China (Chart 11). Moreover, manufacturers are relatively inflexible when adapting to market conditions and shortages. Drug manufacturing facilities generally operate at above 80% of their capacity and are thus left with little immediate capacity to ramp up production in reaction to shortages elsewhere. In addition, manufacturers face challenges in changing ingredient suppliers – there is no centralized source of information on them, and additional FDA approvals are required. The US will look to reduce its dependency on China for its drug supplies regardless of 2020 election outcome. China also has overwhelming dominance in specific categories. The Council on Foreign Relations reports that China makes up 97% of the US antibiotics market.5 Other common drugs that are highly dependent on China for supplies include ibuprofen, acetaminophen, hydrocortisone, penicillin, and heparin (Chart 12). Taking it all together, US vulnerability can be overstated. Consider the following: Of the 370 drugs on the Essential Medicines List that are marketed in the US, only three are produced solely in China. None of these three are used to treat top ten causes of death in the United States. Import substitution is uneconomical. Foreign companies, especially Chinese companies, are attractive due to their lower costs and lax regulations. While China’s influence extends higher up the supply chain, this is true for US markets as well as other consumer markets. While China can cut off the US from the finished dosages it supplies, it cannot do the same for the ingredients that are used by facilities in other countries and eventually make their way to the US in finished dosage form. Americans are demanding that drug prices be reduced and an obvious solution is looser controls on imports. The recent activation of the Defense Production Act shows that the US can take action to boost domestic production in emergencies. Nevertheless, China is growing conspicuous to the American public due to general trade tensions and COVID-19. As it moves up the value chain, it also threatens increasing competition for the US and its allies. Hence the US government will have a strategic reason to cap China’s influence that is also supported by corporate interests and popular opinion. This will lead to tense trade negotiations with China and meanwhile the US will seek alternative suppliers. China will not want to lose market share or leverage over the United States, so it may offer trade concessions at some point to keep the US engaged. Ultimately, however, strategic tensions will catalyze US policy moves to reduce the cost differential with China and promote its rivals. Pressure on China over its currency, regulatory standards, and scientific-technological acquisition will continue regardless of which party wins the White House in 2020. The Democrats would increase focus on China’s transparency and adherence to international standards, including labor and environmental standards. Both Republicans and Democrats will try to boost trade with allies. The key beneficiaries will be India, Southeast Asia, and the Americas. Taiwan’s importance will grow as a middle-man, but so will its vulnerability to strategic tensions. Bottom Line: The US and the rest of the world are suffering shortfalls of equipment necessary to combat COVID-19. There is also a risk of drug shortages stemming from supply disruptions and emergency protectionist policies. These shortages look to be manageable, but they have exposed national vulnerabilities that will be reduced in future via interventionist trade policies. While the US and Europe will ultimately manage the outbreak, the political fallout will be immense. The US will look to reduce its dependency on China. This will increase investment in non-China producers of active pharmaceutical ingredients, such as India and Mexico. The US tactics against China will vary according to the election result, but the strategic direction of diversifying away from China is clear and will have popular impetus in the wake of COVID-19. Food Security In addition to the challenges posed by COVID-19 on medical supplies, food – another essential good – also faces risk of shortages. China is a case in point. Food prices there were on the rise well before the COVID-19 outbreak, averaging 17.3% in the final quarter of 2019. However inflation was limited to pork and its substitutes – beef, lamb and poultry – and reflected a reduction in pork supplies on the back of the African Swine Flu outbreak. While year-on-year increases in the prices of pork and beef averaged 102.8% and 21.0%, respectively, grain, fresh vegetable, and fresh fruit prices averaged 0.6%, 1.5%, and -5.0% in Q42019 (Chart 13). Chart 13Chinese Inflation Has (Thus far) Been Contained To Pork Chart 14China's Misery Index Is Spiking - A Political Liability However China’s COVID-19 containment measures had a more broad-based impact on food supplies, threatening to push up China’s Misery Index (Chart 14). Travel restrictions, roadblocks, quarantined farm laborers, and risk-averse truck drivers introduced challenges not only in ensuring supplies were delivered to consumers, but also to daily farm activity and planting. The absence of farm inputs needed for planting such as seeds and fertilizer, and animal feed for livestock, was especially damaging in regions hardest hit by the pandemic. Livestock farmers already struggling with swine flu-related reductions in herd sizes were forced to prematurely cull starving animals, cutting the stock of chicken and hogs. Now as the country transitions out of its COVID-19 containment phase and moves toward normalizing activity (Chart 15), food security is top of the mind. Authorities are emphasizing the need to ensure sufficient food supplies and adopt policies to encourage production.6 This is especially important for crops due to be planted in the spring. Delayed or reduced plantings would weight on the quality and quantity of the crops, pushing prices up. With food estimated to account for 19.9% of China’s CPI basket – 12.8% of which goes towards pork (Chart 16) – a prolonged food shortage, or a full-blown food crisis, would be extremely damaging to Chinese families and their pocketbooks. However, apart from soybeans and to a lesser extent livestock, China’s inventories are well stocked (Chart 17) and are significantly higher than levels amid the 2006-2008 and 2010-2012 food crises. Inventories have been built up specifically to provide ammunition precisely in times of crisis. Corn and rice stocks are capable of covering consumption for nearly three quarters of a year, and wheat stocks exceeding a year’s worth of consumption. Thus, while not completely immune, China today is better able to weather a supply shock. Moreover, with the exception of soybeans, China is not overly dependent on imports for agricultural supplies (Chart 18).   As the COVID-19 epicenter shifts to the US and Europe, farmers there are beginning to face the same challenges. Reports of delays in the arrival of shipments of inputs such as fertilizer and seeds have prompted American farmers to prepare for the worst and order these goods ahead of time. While these proactive measures will help reduce risks to supply, farmers in Europe and parts of the US who typically rely on migrant laborers will need to search for alternative laborers as the planting season nears. Just last week France’s agriculture minister asked hairdressers, waiters, florists, and others that find themselves unemployed to take up work in farms to ensure food security. As countries become increasingly aware of the risks to food supplies, some have already introduced protectionist measures, especially in the former Soviet Union: The Russian agriculture ministry proposed setting up a quota for Russian grain exports and has already announced that it is suspending exports of processed grains from March 20 for 10 days. Kazakhstan suspended exports of several agricultural goods including wheat flour and sugar until at least April 15. On March 27, Ukraine’s economy ministry announced that it was monitoring wheat export and would take measures necessary to ensure domestic supplies are adequate. Vietnam temporarily suspended rice contracts until March 28 as it checked if it had sufficient domestic supplies. The challenge is that, unlike China, inventories in the rest of the world are not any higher than during the previous food crisis and do not provide much of a buffer against supply shortfalls (Chart 19). Higher food prices would be especially painful to lower income countries where food makes up a larger share of household spending (Chart 20). In addition to using their strategic food stockpiles, governments will attempt to mitigate the impact of higher food prices by implementing a slew of policies: Trade policies: Producing countries will want to protect domestic supplies by restricting exports – either through complete bans or export quotas. Importing countries will attempt to reduce the burden of higher prices on consumers by cutting tariffs on the affected goods. Consumer-oriented policies: Importing countries will provide direct support to consumers in the form of food subsidies, social safety nets, tax reductions, and price controls. Producer-oriented policies: Governments will provide support to farmers to encourage greater production using measures such as input subsidies, producer price support, or tax exemptions on goods used in production. While these policies will help alleviate the pressure on consumers, they also result in greater government expenditures and lower revenues. Thus, subsidizing the import bill of a food price shock can weigh on public finances, debt levels, and FX reserves. Currencies already facing pressure due to the recessionary environment, such as Turkey, South Africa and Chile will come under even greater downward pressure. Food inventories ex-China are insufficient to protect against supply shortages. Bottom Line: COVID-19’s logistical disruptions are challenging farm output. This is especially true when transporting goods and individuals across borders rather than within countries. This will be especially challenging for food importing countries, as some producers have already started erecting protectionist measures and this will result in an added burden on government budgets that are already extended in efforts to contain the economic repercussions of the pandemic. Investment Implications Chart 21Ag Prices Inversely Correlated With USD China will continue trying to maximize its market share and move up the value chain in drug production. At the same time, the US is likely to diversify away from China and try to cap China’s market share. This will result in tense trade negotiations regardless of the outcome of the US election. The COVID-19 experience with medical shortages and newfound public awareness of potential medical supply chain vulnerabilities means that another round of the trade war is likely. Stay long USD-CNY. Regarding agriculture, demand for agricultural commodities is relatively inelastic. This inelasticity should prevent a complete collapse in prices even amid a weak demand environment. Thus given the risk on supplies, prices face upward pressure. However, not all crops are facing these same market dynamics. While wheat and rice prices have started to move in line with the dynamics described above, soybeans and to a greater extent corn prices have not reacted as such (Chart 21). In the case of soybeans, we expect demand to be relatively muted. China accounts for a third of the world’s soybean consumption. 80% of Chinese soybeans are crushed to produce meal to feed China’s massive pork industry. However, the 21% y/y decline in pork output in 2019 on the back of the African Swine Flu outbreak will weigh on demand and mute upward pressures on supplies. Demand for corn will also likely come in weak. The COVID-19 containment measures and the resulting halt in economic activity reduce demand for gasoline and, as a consequence, reduce demand for corn-based ethanol, which is blended with gasoline. In addition to the above fundamentals, ag prices have been weighed down by a strong USD which makes ex-US exporters relatively better off, incentivizing them to raise exports and increase global supplies. A weaker USD – which we do not see in the near term – would help support ag prices. It is worth noting that if there is broad enforcement of protectionist measures, then producers will not be able to benefit from a stronger dollar. In that case we may witness a breakdown in the relationship between ag prices and the dollar. In light of these supply/demand dynamics, we expect rice and wheat prices to be well supported going forward and to outperform corn and soybeans.   Roukaya Ibrahim Editor/Strategist Geopolitical Strategy RoukayaI@bcaresearch.com   Matt Gertken Vice President Geopolitical Strategist mattg@bcaresearch.com   Footnotes 1 See "Tackling COVID-19 Together: The Trade Policy Dimension," Global Trade Alert, University of St. Gallen, Switzerland, March 23, 2020. 2 See Rachel Abrams et al, "Governments and Companies Race to Make Masks Vital to Virus Fight," The New York Times, March 21, 2020. 3 The announcement also notes that there are other alternatives that can be used by patients. See "Coronavirus (COVID-19) Supply Chain Update," US FDA, February 27, 2020. 4 All regulated drugs include prescription (brand and generic), over the counter, and compounded drugs. 5 Please see Huang, Yanzhong, "The Coronavirus Outbreak Could Disrupt The US Drug Supply," Council on Foreign Relations, March 5, 2020. 6 The central government ordered local authorities to allow animal feed to pass through checkpoints amid the lockdowns. In addition, Beijing has relaxed import restrictions by lifting a ban on US poultry products and announcing that importers could apply for waivers on goods tariffed during the trade war such as pork and soybeans. The lifting of these restrictions also serves to help China meet its phase one trade deal commitments. Please see "Coronavirus hits China’s farms and food supply chain, with further spike in meat prices ahead," South China Morning Post, dated February 21, 2020.

Underweight While Johnson & Johnson’s (JNJ) recent earnings release was in line with expectations, one phrase caught our attention: “Our robust growth can be attributed to volume, not price” - JNJ CEO Alex Gorsky. We agree with Alex Gorsky that industry pricing dynamics are disappointing to say the least, and will remain a headwind for the foreseeable future (third panel). Meanwhile, on the volume front industry level data reveals that retail sales have “caught the flu” and are infecting relative share prices (second panel). Adding insult to injury, the capex cycle has clearly turned for the worse underscoring that the path of least resistance remains to the downside for Big Pharma. Bottom Line: We remain underweight the S&P pharmaceuticals index. The ticker symbols for the stocks in this index are: BLBG: S5PHAR – JNJ, PFE, MRK, LLY, BMY, ZTS, AGN, MYL, PRGO.  

Special Report

Highlights The odds of universal health care legislation being enacted in the U.S. by 2022 are about 10%-15%. Former Vice President Joe Biden is the most likely Democratic candidate in 2020, but the alternative is most likely a progressive candidate seeking universal health care. Trump is slightly favored to win in 2020, but a Trump loss is likely to translate into full Democratic control of the U.S. government, making ambitious legislation more likely to pass Congress. An overweight portfolio allocation in the S&P health care index is a sensible and defensive move. Fear selling in health care stocks could easily return but would create an exploitable trading opportunity at this late stage of the cycle. We are executing the upgrade of the S&P health care index via an upgrade of the S&P health care equipment index, which has seen a material valuation de-rating at the same time as profits are expanding, to overweight. Feature Will The Democrats Win? Can They Pass Universal Health Care? “Medicare for All,” or government-led universal health care in the United States, is less likely to become the law of the land by 2022 than the market expects. We put the probability at around 10%-15%. Here’s why. The industry faces only two certainties: Americans are getting older and the federal government is increasing its involvement. The former is a secular driver for health care demand. The latter is an inference drawn from the fact that the Republican Party failed to repeal the Affordable Care Act, or Obamacare, even when it had full control of government. It is very unlikely that the Republicans will get another chance at repeal. It is also very unlikely that the public will tolerate the current status quo forever. The result is that the U.S. will eventually end up with a restored Obamacare or an altogether new system with a greater government role. The Republican failure to repeal was not idiosyncratic – it was not based on the fact that the late Senator John McCain, who cast the decisive vote on July 27, 2017, had been diagnosed with brain cancer earlier that year. Rather, it was structural – the repeal failed because (1) it is always extremely difficult to remove an entitlement once it has been given to voters and (2) a slim majority of Americans approved of Obamacare – and still do (Chart 1). Republicans went on to dismantle aspects of Obamacare, including the problematic “individual mandate.” But they did so without replacing it. The result was a severe electoral defeat in the 2018 midterm elections, despite a huge drop in the unemployment rate (Chart 2) – which matters directly in a country where 49% get their health insurance through their employer. Health care was the single most important issue driving people to vote against the ruling party in November 2018, judging by both pre-election polls and exit polls (Charts 3 & 4). Chart 2Low Unemployment Has Not Solved Health Care Woes The need for reform is manifest. It is widely known that the U.S. spends more than other countries on health care (Chart 5) and yet achieves worse results: preventable mortality is higher than in other countries that spend less (Chart 6). Democrats have tried to overhaul the system since 1993. Even President Trump is seeking to cap prescription drug prices and maintain the Obamacare requirement that health care insurers accept customers with “pre-existing conditions.” Uncertainty has risen since the Republicans’ midterm defeat, which increases, or is seen as increasing, the odds of a Democratic victory in 2020. Such a victory would mark the third time in 12 years that American policy would witness a 180-degree reversal – and it would have a major impact on the health sector (Chart 7). Chart 7The Sector's Response To Major Political Events In truth Trump is still favored to win in 2020, on the back of the incumbent advantage – as long as the economy holds up. But with a chronically weak approval rating, and narrow 2016 margins of victory and the aforementioned midterm losses in key swing states, his odds of reelection are probably not much better than 55%. Meanwhile the Democrats are swinging to the left and may not settle simply for restoring Obamacare. Left-wing or “progressive” candidates for the Democratic nomination are polling in line with traditional center-left candidates (Chart 8), which is highly unusual (even compared with the 2007-08 race). Candidates are crowding onto the democratic socialist bandwagon in the wake of Bernie Sanders’s formidable challenge to Hillary Clinton and her subsequent loss to Trump. Could a progressive candidate win the nomination? Certainly. Former Vice President Joe Biden leads the pack at this early stage in the nomination process. He would seek to restore and build upon Obamacare. The second-ranked candidate is Sanders, whose initial proposal to create Medicare for All has transformed the national debate. Following Sanders are Senators Kamala Harris, who co-sponsored the latest version of the bill with Sanders, and Elizabeth Warren, an outspoken progressive who is also in favor of universal health care (Chart 9). Sanders does have a path to winning the nomination, as the leading progressive candidate at a time when the party is becoming more progressive. He performs better than Biden in head-to-head polls against Trump in the key battleground states (Chart 10). Strategic voters will have trouble convincing fellow Democrats that they should not vote for him because he is unelectable: he has a clear electoral path to the White House via Michigan, Pennsylvania, and Wisconsin, where he performed well in 2016 and polls well today. If Sanders has a chance, then Medicare for All has a chance. Because it is extremely difficult to unseat an incumbent president, a victory over Trump in 2020 is only likely to occur if there is a surge in voter turnout and Democratic Party support among (1) blue-collar workers who abandoned the Democrats for Trump in 2016, or (2) young voters, women, or minorities. Any such surge would also enable the Democrats to defend their senate seats while picking up Arizona, Colorado, and Maine, which are statewide elections that will be affected by the headline presidential race. And if the Democrats win 50 seats, they would get a majority in the senate, as the vice president would break any tie. With a majority, Senate Democrats could use the “nuclear option” to bypass the filibuster and drive through their priority legislation.1 This would set a new precedent with far-reaching consequences. But recent majority leaders have already begun eroding the filibuster and there is no hard constraint preventing a ruling party from removing it entirely. It is perfectly possible, and all the more likely if the nation sweeps a progressive candidate to power in a wave of enthusiasm for dramatic changes like universal health care. In other words, any victory against Trump is likely to entail full Democratic control of government. In this scenario, Democrats would have a very good chance of passing a major piece of legislation. Hence, if a progressive wins the nomination, and makes Medicare for All the policy priority, there is at least a 50/50 chance it will pass, probably more like 60%. The catch is that a progressive may not win the nomination. There is not decisive evidence that Americans really want Medicare for All. First, Americans tend to view their own health costs as “reasonable” (Chart 11). They are not, as a whole, clamoring for a single-payer system. Second, while Americans say they support Medicare for All, that support evaporates when they learn about the various policies that it would necessitate, such as eliminating private health insurance and raising taxes (Chart 12). Third, most Democrats are closer to Biden’s position than Sanders’s – they want to fix Obamacare rather than revolutionize the system (Chart 13). Fourth, Colorado tried to pass its own version of Medicare for All on the state level in 2016. The bill’s advocates were handed a 79% defeat by voters. Colorado is a swing state so it is not an irrelevant experiment. Fifth, independents are not shifting to the left in a way that would validate the sharp leftward shift within the Democratic Party (Chart 14). Nominating Sanders or another progressive is more likely to lead to a loss in the general election than it is to ensure that universal health care gets passed.   Chart 14Independents Not Swinging Dramatically To The Left A simple back-of-the-envelope exercise suggests that odds of universal health care by 2022 are about 10%-15%. Nevertheless, we attempt a conservative, back-of-the-envelope method for estimating the probability of passage. It runs like this: There is a 50% chance a progressive wins the Democratic nomination. We assume that if Biden wins it is because Democratic voters prefer a restitution of Obamacare. There is a 45% chance that Trump loses the presidential election. We assume that for the Democrats to unseat an incumbent is difficult enough that they will also win the Senate. Under these circumstances, there is a 50%-60% chance that universal health care legislation passes – even though it will be very difficult to get it over the line. (Note that the ACA passed very narrowly at a time when the Democrats had a huge tailwind due to voters’ disenchantment after the global financial crisis). With these assumptions, the conditional probability of passage is around 13.5% (0.5 x 0.45 x 0.6 = 0.135) These odds can be moderated by boosting Trump to a 69% chance of reelection (the historical average for sitting presidents), which brings down the odds of ultimate passage to 9%. Note, however, that the bond market is pricing a 27% probability of a recession 12 months from now (Chart 15). If there is a recession, then President Trump is virtually assured to lose reelection and the Democratic victor will have a strong tailwind of public support. This will increase the chance that universal health care passes to 80%. (We still assume in this case that Biden would stick with Obamacare as he would not be committed to Medicare for All and it is not an economic stimulus package). The conditional probability would become 0.5 x 0.27 x 0.8 = 11%. Chart 15Probability Of Recession Is Rising NY Fed's Yield Curve Model Suggests That The Probability Of A Recession Is Still Quite Low In other words, whether we upgrade Trump’s chances of winning or we upgrade the chances of a recession that kicks him out of office, the odds are roughly the same at 9%-11%. And they could be a bit higher at 14%. Medicare for All has a chance of becoming law, although it is not all that great. Bottom Line: With fairly conservative assumptions the odds range from 10%-15%. that the U.S. could legislate a sweeping overhaul of the health care system and new social entitlement by 2022. This is a serious risk to the industry. Health care equities have recovered the losses suffered since Sanders’s latest push for Medicare for All, which means that it is not pricing in a high probability of passage at present. Additional policy-related selloffs are likely between now and the spring of 2020, if and when the odds increase of Sanders (or another progressive) winning the Democratic nomination. Buy Into Health Care Weakness Regardless of the likelihood of passage, the faintest hint of the winds of change has brought about significant price changes in the relevant equities. In the lead up to the 2016 U.S. presidential election, Hillary Clinton, a health care reformer (though importantly NOT a Medicare for All advocate) was polling well ahead of Donald Trump. Health care stocks underperformed the broad market in anticipation of potential reforms resulting from a Clinton win (Chart 16). Two years after Donald Trump’s election, both S&P health care equipment and S&P managed health care have significantly outperformed with the effect most dramatic in the former. Chart 17 shows the reverse picture: a “blue wave” in the 2018 midterm elections was swiftly followed by the zenith for health care stocks as the market digested the implications of a Democratic House and the resulting higher probability of a similar sweep in 2020 in the Senate and executive branch. Chart 16Election Fear Creates Buying Opportunities... Chart 17...And History Appears To Be Repeating Itself Furthermore, our prior research shows that S&P health care has been the top performer in the last equity market surge to take place between the peak of the ISM manufacturing composite index and the beginning of the subsequent recession.2 This research was confirmed in a report last month analyzing sector returns after a Fed loosening cycle begins. The S&P health care index has historically outperformed from six months before a rate cut all the way to two years after easing policy.3#fn_3 As a reminder, the market has now priced in two rate cuts over the next year. We recommend an overweight position for the broad S&P 500 health care index as well as for health care equipment. BCA’s U.S. Equity Strategy has already moved to an overweight recommendation on the S&P managed health care index, a move that has netted our portfolio 12.4% of alpha. Today U.S. Equity Strategy is raising our recommendations on both the S&P health care equipment and, more importantly, the broad S&P health care index from neutral to overweight. Further, considering U.S. Equity Strategy’s recent portfolio changes, namely moving the S&P materials index to neutral, this upgrade of S&P health care to overweight moves our cyclicals vs. defensives style preference from overweight cyclicals to neutral. This move to the sidelines on the cyclical/defensive portfolio bent has netted modest gains of 2% since its October 2, 2017 inception. Equipping The World’s Hospitals Our upgrade of S&P health care equipment to overweight is not contingent upon earnings outperformance. Rather, it is a combination of overwrought investors having created a buying opportunity, combined with health care’s historic outperformance at the end of the business cycle. Nevertheless, an examination of the sector’s macro environment is revealing. The health care equipment index has recently completed an inventory clear-out cycle, as evidenced both by a slingshot rebound in the shipments-to-inventories ratio (second panel, Chart 18) and a recovery in industry pricing power (bottom panel, Chart 18). This is remarkable in the context of the deceleration in equipment fixed-investment growth that the industry has faced since reaching decade-highs in 2017 (third panel, Chart 18). The upshot is that steady pricing and resilient volume growth should deliver positive top-line growth. The margin picture has also dramatically improved: industrial production has been surging for the past year while hours worked have remained tepid (second and third panels, Chart 19). The combination has driven our productivity proxy to a multi-year high where it has recently diverged from the relative stock price (bottom panel, Chart 19). Chart 18Inventories Have Cleared Chart 19Productivity Is Soaring This underpins our thesis that health care stocks in general and health care equipment stocks in particular have recently suffered based on fear, not fundamentals, amidst a stable domestic demand environment and rosy profit picture. The export channel is at least as important to the S&P health care equipment index as the domestic demand environment. In fact, roughly 60% of sector revenues are generated outside the United States. The news on this front is encouraging. Europe, the other key market for domestically-manufactured health care equipment, has lately seen a pickup in new orders and coupled with the loss of momentum in the trade-weighted U.S. dollar signal that future export growth will remain upbeat (trade-weighted U.S. dollar shown inverted and advanced, bottom panel, Chart 20). The global PMI has historically led exports. While this series has turned down, it has been diverging from export growth for the past year. We believe this is a function of the early stages of a secular trend in health care equipment: the expansion of the EM safety net with health care at its core. The same demographic trend that has been driving the explosion of health care spending in the DM for the last 20 years is rapidly impacting the EM, namely an aging population. The UN projects that the share of the population aged 65 and older in the EMs will rise from roughly 7% this year to 16% in 2060, while population growth slows to below the replacement rate, a tectonic shift in the demographic landscape (Chart 21). Meanwhile, according to IMF data, EM health care spending is approximately 5% of GDP. By contrast, the DMs stand in excess of 14%. Chart 20The Export Valve Is Wide Open A catch-up phase looms, driven by both demographics and an overall global harmonization of standard of care, resulting in a secular outperformance of internationally geared health care equipment manufacturers’ earnings. This bodes well for U.S. health care equipment providers who are the technology leaders and often the only source for equipping hospitals/clinics around the globe. Notwithstanding the bright outlook, fear selling in the S&P health care equipment index has driven a reversal in the two-year valuation rerating that the index has undergone (bottom panel, Chart 22). With the valuation retreating back to its historical range, our main concern that the index is too expensive has eroded. Further, the valuation decline is coming at a time when forward earnings growth has come out of hiding and is now slated to materially outgrow the broad market (middle panel, Chart 22). Chart 22Valuations Have Returned To Earth Bottom Line: Something has to give in this equation and macro tailwinds suggest that a valuation re-rating phase looms. Accordingly, we are moving to an overweight recommendation on the S&P health care equipment index. This move pushes our S&P health care index to an above benchmark allocation and also moves our cyclical vs. defensive preference back to neutral. The ticker symbols for the stocks in the S&P health care equipment index are: BLBG: S5HCEP – ABT, MDT, DHR, BDX, SYK, ISRG, BSX, BAX, EW, ZBH, IDXX, RMD, TFX, HOLX, ABMD, VAR. BCA’s Geopolitical Strategy echoes the tenor of these recommendations and is going long the S&P 500 health care index and the health care equipment index versus the broad market. A Word On Pharma Between 1980 and 2000, pharma earnings expanded at a record clip, taking sector share prices into the stratosphere (top panel, Chart 23). Since the zenith in the early 2000’s, margins have been continually under pressure as R&D costs have outpaced volume gains (second panel, Chart 23). However, earnings growth has continued mostly uninterrupted as the industry has raised drug prices. Since 2015, however, price increases have flat lined and now they move at the same pace as overall inflation, though the current convoluted system keeps pricing mostly opaque (bottom panel, Chart 23). We think this is the new normal. The thesis of this report revolves upon a blue vs. red probability outcome. However, as noted, both parties seem united in the fight against high drug costs and Republicans under President Trump are not averse to government intervention to drive down prices. As such, we expect the pharma pricing headwinds to remain a secular trend, driven by outrage from both sides of the aisle and even universal coverage is not enough to bear the pressure. Accordingly, we reiterate our underweight recommendation. Chart 23Pharma Remains Underweight Conclusion Universal health care will be negative for the U.S. budget deficit but positive for economic growth. As for the macroeconomic impact of universal health care, it is complex to assess because much would depend on the extent of any reduction in private health-related sectors. Almost certainly, the U.S. would adopt a parallel system where private health care remains available, but there inevitably would be some job losses in the insurance sector. And drug companies would face downward pressure on pricing. On the other hand, the marked increase in government spending would be stimulative. And we do not see future American administrations exercising a heretofore unknown fiscal discipline once such a new entitlement is established. Many families would enjoy a reduction in health care costs. Overall, it should be positive for economic growth.   Matt Gertken, Vice President Geopolitical Strategy mattg@bcaresearch.com Chris Bowes, Associate Editor U.S. Equity Strategy ChrisB@bcaresearch.com Anastasios Avgeriou, U.S. Equity Strategist anastasios@bcaresearch.com   Footnotes 1      The filibuster is a means of prolonging debate and obstructing a vote. It can be defeated if 60/100 senators vote to move to end debate (“cloture”). It effectively ensures that the three-fifths majority is the standard majority needed to pass legislation in the senate. However, it is possible for the senate majority leader, backed with a simple majority, to alter the senate rules and remove the filibuster, so legislation can be passed with a simple majority. But it would be an aggressive move and a historic precedent. 2      Please see BCA U.S. Equity Strategy Weekly Report, “Portfolio Positioning For A Late Cycle Surge” dated May 22, 2018, available at uses.bcaresearch.com. 3      Please see BCA U.S. Equity Strategy Weekly Report, “Sector Performance And Fed Loosening Cycles: A Historical Roadmap” dated May 6, 2019, available at uses.bcaresearch.com.   Current Recommendations

Underweight In last month’s downgrade of the S&P pharma index to underweight, we highlighted that headwinds to drug prices would weigh on the sector’s earnings profile.1 This week’s CPI report confirmed this negative pricing view with prescription drugs falling into outright deflation; in fact industry pricing power is falling at its fastest rate in more than 15 years (second panel). Despite collapsing prices, pharma inventories have continued to climb which indicates that prices may have to fall further to clear out excess supply (third panel). The upshot is that, though they still trail the broad market by a wide margin, the recent uptick in both short- and long-term relative earnings estimates may be premature (bottom panel). Bottom Line: An increasingly difficult pricing environment means more downside lies in store for S&P pharma earnings estimates and, consequently, share prices; stay underweight. The ticker symbols for the stocks in this index are: BLBG: S5PHAR – JNJ, PFE, MRK, LLY, BMY, ZTS, AGN, MYL, NKTR, PRGO. Deflating Drug Prices Bode Ill For Pharma Profits   1      Please see BCA U.S. Equity Strategy Weekly Report, “ Reflating Away” dated February 19, 2019, available at uses.bcaresearch.com.