The health system owns and operates nine hospitals, several outpatient centers, a health plan in partnership with Aetna and a joint venture hospital, Moody's said. It holds about $1.6 billion in outstanding debt. Allina Health will likely have difficulty deleveraging from a 2021 debt increase, thanks to sector and regional operating challenges and investment losses, the report said. That means a weak 2022 performance and prolonged deleveraging. "[Despite improvement initiatives], cash measures will likely remain solid but below previously forecasted levels as well as Aa-rated peers," Moody's said. The health system may need to sustain improvements in operating cash flow margins and lower debt to cash flow to see further credit upgrades. Allina Health's total operating revenue for fiscal 2021 was more than $4.8 billion.