S&P Global Ratings revised its outlook to negative from stable and affirmed its ?A+? long-term and underlying (SPUR) ratings on various series of tax-exempt and taxable debt issued for or by Novant Health . We also affirmed our ?A+/A-1? dual rating on the North Carolina Medical Care Commission 's series 2004A and 2004B variable-rate demand bonds (VRDBs) issued for Novant Health. Lastly, we affirmed our ?A-1? short-term rating on Novant Health?s series A taxable commercial paper (CP) program backed by the system?s self-liquidity. The negative outlook reflects our view that Novant Health retains limited balance sheet flexibility at the rating given its elevated debt and liability load, which would further increase upon consideration of an expected energy-as-a-service agreement. We believe
