In the fourth quarter of 2023, overall Chapter 11 distress rose sharply on both a quarterly and year-over-year basis, continuing its upward trend while remaining below historical benchmark levels. Real estate distress increased for a fourth consecutive quarter and was significantly higher than a year earlier, though it continued to track well below long-term norms. Health care services distress surged to another record high, extending an unprecedented period of sector-specific distress even as the share of health care filings declined modestly.