Can Medtronic PLC (NYSE:MDT) get its stock back in rhythm? Up until mid-2015, Medtronic stock was a star performer. It doubled from 2013 up to that point. Since then, Medtronic has seriously underperformed. MDT stock has spent the last three years in a tight trading range between $70 and $90 per share, while the rest of the market has launched further upward.

What’s gone wrong for Medtronic? Uncertainty about health care reform continues to be a major obstacle. Medtronic’s reliance on U.S. sales adds to that worry. The stock also looks a little on the expensive side, and the debtload remains high. On the plus side, the company has strong opportunities to grow overseas, and its dividend track record is highly appealing.

Here’s a closer look:

Medtronic Stock Cons

Health Care Uncertainty: Medtronic, more than most other large health care companies, relies on the U.S. market for the lion’s share of its revenues. That puts it, more than the rest, in an uncertain place going forward.

It’s simply impossible to forecast accurately where American health care will go following the 2020 election. Trump campaigned on a serious overhaul of Obamacare. Little has actually happened on this front, however, since he took office. On the left, many folks, led by Sen. Bernie Sanders, suggested that Obamacare wasn’t a liberal enough approach to health care.

In five or 10 years, will the U.S. have a more market-based system? Will it be single-payer by then? It’s hard to see the nearly 50/50 split of Medicare/Medicaid and private payer holding up. And whatever way things go, Medtronic faces downside risk if reimbursements are decreased. The U.S. pays far more than other developed markets for health care as a percentage of gross domestic product without achieving superior health care outcomes. As a result, expect fat profits for medical device-makers to slip in coming years.

More Expensive Than Johnson & Johnson: One of Medtronic’s main rivals is Johnson & Johnson (NYSE:JNJ). Normally, JNJ stock tends to attract a premium valuation, since it is the gold standard of diversified health care companies.

Now, however, Medtronic stock, at 16.6x forward earnings, is more expensive. J&J stock is at 14.4x, making it look cheap both compared to its historical median and the market as a whole. Consider that J&J is the safer company as well, and the match-up tilts further in its favor. J&J has the rarest of all, the triple A credit rating, while Medtronic is in the single A range. That’s not bad, but it’s not top-notch either. On top of that, J&J stock currently pays a higher yield than MDT — see below for more on the dividend.

Levered-Up Balance Sheet: The Covidien deal described in the pros below brought a ton of growth potential to Medtronic. But it also left the company saddled with a large debtload.

As of the most recent quarter, Medtronic now carries almost $29 billion in near-term and long-term debt. That’s a manageable sum for a company with a $120 billion market cap. But it’s still a lot, representing six years of Medtronic’s income.

And at this point, management doesn’t seem in a rush to pare back its leverage. Since the Covidien deal closed, Medtronic has continued to buy back stock at a decent clip and it put through more large dividend increases. Even with its balance sheet at a weak point, the company is upping its dividend payout ratio. This could work out well for shareholders, but the operating risk here has increased notably.

Medtronic Stock Pros

International Opportunity: Medtronic finds itself in a fairly unusual position. Despite dominating its core cardiac care market in the U.S. (50% market share), it gets very little overseas revenue.

It’s also important to remember that Medtronic’s CEO, Omar Ishrak, has a good pedigree. In his previous job, he was in charge of the GE Healthcare arm of General Electric Company (NYSE:GE). During his time there, he led the highly successfully push by GE Healthcare into China. With so little international revenues, Ishrak could power Medtronic stock higher with a similar emerging markets build-out.

Dividend Aristocrat: When you bring up health care and dividends, you’ll inevitably hear about Johnson & Johnson. J&J has distinguished itself by raising its dividend for more than 50 years in a row. But don’t sleep on Medtronic stock either.

Medtronic has a dividend growth streak of its own, currently sitting at 40 years and counting. MDT stock’s 2.2% current dividend yield is far from the flashiest available today. But when that dividend increases every year, often dramatically, the income adds up. Medtronic’s dividend has grown at a 12% compounded rate over the past 10 years, and the quarterly payment has doubled since 2012.

Covidien Benefits: Medtronic made a major move in 2014. It announced a $43 billion acquisition of Covidien. The deal subsequently closed in 2015. It was a gigantic partnership within the medical device industry, moving Medtronic from fourth place to second place in market share, as the combined entity overtook General Electric and Siemens AG (ADR)  (OTCMKTS:SIEGY). It trails only rival Johnson & Johnson now.

In particular, Medtronic greatly widened its product platform. Traditionally, the company has focused on devices for treating chronic diseases. Covidien brings many more hospital-related products to Medtronic. That will allow for great cross-selling in that category which Medtronic previously had little influence in. On top of that, Medtronic has moved into managing operating rooms and catheterization labs. That should lead to another stream of high margin recurring revenue.

Medtronic Stock Verdict

Medtronic stock hasn’t performed well over the past three years. Unfortunately, there’s no clear sign that its under-performance is about to end. Compared to rivals such as Johnson & Johnson, MDT stock seems fully valued at today’s price.

The company certainly has plenty of opportunities to grow, particularly internationally. But for now, the main appeal is its consistent dividend record. And even that is less valuable in light of its larger debtload.

For now, MDT stock is a skip.

At the time of this writing, the author owned JNJ stock. He had no positions in the other aforementioned securities. You can reach him on Twitter at @irbezek.