HCA Healthcare has adjusted its earnings outlook for 2026 after reporting a significant rise in the number of uninsured patients, driven largely by an unfavorable shift in payer mix.
Uninsured volume spikes amid ACA coverage lapse
CEO Sam Hazen said the increase in uninsured volume during the second quarter was higher than expected. Most of the hike came from patients who lost coverage on the Affordable Care Act health insurance exchanges but failed to secure other forms of insurance.
“We expected some of these patients to shift to other forms of coverage, but this did not happen,” Hazen said. “Instead, these patients migrated almost one-for-one to uninsured.”
The attrition is linked to the expiration of enhanced premium tax credits at the end of 2025. Hazen noted that the company advocated for extending these credits throughout the year, but the benefits lapsed as planned. The result was a wave of people who lost coverage and continued to rely on emergency care from hospitals.
HCA CFO Mike Marks confirmed that ER visits increased by 3.6% in the second quarter. He noted that the migration to uninsured status accounts for approximately 80% of the system’s uninsured volume growth.
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Financial impact and revised estimates
Officials now estimate that almost all individuals leaving the exchanges are becoming uninsured, a shift from the original assumption of 80% to 85%. Marks said the system also failed to see the decline in utilization it had anticipated from newly uninsured patients.
The unfavorable payer mix shift has reduced adjusted earnings by approximately $400 million. This includes an additional $75 million related to the first quarter’s exchange impact. Hazen identified the payer mix change as the primary source of financial pressure, alongside a decline in elective surgery demand.
Second-quarter data showed admissions rose 2.5%, while inpatient and outpatient surgeries dropped 2.3% and 3.4% respectively. Despite the volume shifts, emergency inpatient surgery volumes—accounting for about two-thirds of total cases—increased compared to the previous year.
Revenue climbed 8.7% to $20.2 billion, and net income attributable to the company grew 2.8% to $1.7 billion. The Nashville-based for-profit system also saw positive factors, including a $400 million benefit from Medicaid Supplemental Payment Programs and improved expense results.
The company has approved more than $7 billion in capital expenditures slated to come online over the next three years. With 189 hospitals and roughly 2,600 ambulatory sites across 19 states and the United Kingdom, the system’s infrastructure relies on this capital to maintain capacity for the influx of uninsured patients.