The Hospital sector ended 2019 with 80 transactions in the United States reaching the definitive agreement stage or closing. All told, 99 hospital deals are on the books for the year, which is a 25% increase over 2018’s 79 hospital deals.

For the fourth quarter of 2019, 23 transactions reached the definitive agreement stage or closing. That was a 21% decline from the third quarter’s 29 deals, but a 10% gain over the same quarter in 2018.

What’s ahead for the Hospital sector in 2020? More of the same, meaning that consolidation among strong regional health systems will continue the trend that began a few years ago. Small standalone hospitals will still push to join a larger organization for the needed scale and clinical collaborations. And REITs will be rolling up more sales as organizations look to cut capital costs.

The sector’s not off to a flying start, however. Four transactions have closed or entered due diligence in the first few weeks of 2020, compared with January 2019, when 12 deals were announced in the entire month. Only eight of those transactions were U.S.-based, however.

All four transactions this month are U.S.-based and all involve not-for-profit targets. They also involve mergers that cross state lines, and therefore may not draw as much attention from the Federal Trade Commission and the Department of Justice. The largest is Michigan-based Beaumont Health System‘s merger with Summa Health (four hospitals, 1,300 beds) in Akron, Ohio. The deal includes Summa’s health insurance operation.

Advocate Aurora, which has headquarters outside Chicago and in Milwaukee, divested two hospitals in Illinois: Advocate BroMenn Medical Center (206 licensed beds) in Normal and Advocate Eureka Hospital, a critical access hospital (25 beds) in Eureka, and their affiliated sites in central Illinois. Not-for-profit Carle, based in Urbana, is assuming corporate membership of the two organizations.

Finally, two small stand-alones found larger partners. Granite Falls Hospital, a 25-bed critical access hospital in Minnesota, joined Avera Health in Sioux Falls, South Dakota. And the 96-bed Union Hospital of Cecil County (Maryland) became part of ChristianaCare Health System in neighboring New Castle County, Delaware.

A lot could “go wrong” for this sector in the months ahead, of course. The U.S. Supreme Court is being urged by hospitals, insurers and trade associations such as America’s Health Insurance Plans to grant an expedited hearing on the constitutionality of the Affordable Care Act. A Texas appeals court turned the case back to the lower court judge who ruled the ACA was unconstitutional without the individual mandate (which was stripped out as part of the Republicans’ 2017 corporate tax overhaul).

If the Court doesn’t take up the case in this term, the ACA’s fate will remain undecided until after the national elections in November. That leaves millions of Americans unsure about healthcare coverage and could leave hospitals on the hook for uncompensated care. We’ll see you at the end of the first quarter.