HCA Warns That Lost Health Coverage Is Increasing Pressure on Hospitals
HCA Healthcare has lowered its 2026 earnings outlook after finding that patients leaving Affordable Care Act insurance plans were becoming uninsured at a higher rate than the hospital operator expected. The company initially disclosed the change on July 14 and explained the coverage losses further during its second-quarter earnings call. Its experience offers a detailed account of how the expiration of enhanced insurance subsidies is affecting hospital finances while patients continue to need emergency treatment.
The Nashville-based company now expects diluted earnings of $28.70 to $30.50 per share for the year, compared with its previous range of $29.10 to $31.50. HCA also reduced its adjusted earnings before interest, taxes, depreciation and amortization forecast to $15.4 billion to $16.1 billion. These estimates reflect the company's own operations and assumptions, rather than a projection for every U.S. hospital.
The largest pressure came from a change in who was paying for care. HCA estimated that shifts involving health insurance exchange patients would reduce annual pretax income by $1 billion to $1.2 billion, substantially above its April estimate of $600 million to $900 million. The updated forecast signaled that coverage disruptions were proving more costly than the company had anticipated earlier in the year.
Management's explanation became more specific during the earnings call, according to Healthcare Finance News. Chief Executive Officer Sam Hazen said patients who lost exchange coverage were moving almost directly into uninsured status, with fewer obtaining another form of insurance than HCA expected. Chief Financial Officer Mike Marks said the company had originally assumed that 80% to 85% of those losing coverage would become uninsured, but the actual proportion was approaching all of them.
Hazen attributed most of the attrition to enhanced premium tax credits expiring at the end of 2025. These subsidies had made marketplace insurance more affordable, and their expiration increased the financial burden on some enrollees. Reuters reported that ACA enrollment had declined 13% in 2026, providing national context for the coverage changes HCA was observing in its facilities.
Patients continued to seek care despite losing insurance. HCA reported that emergency room visits at comparable facilities rose 3.6% in the second quarter, while admissions increased 2.5%. Marks said the company had expected lower utilization among patients becoming uninsured, but that assumption had not materialized. Continued demand meant the financial effect extended beyond a simple reduction in patient visits.
Surgical activity moved in a different direction. Same-facility inpatient surgeries declined 2.3%, and outpatient surgeries fell 3.4% compared with the second quarter of 2025. Management linked some of the weakness in elective procedures to patients previously covered through the exchanges. Healthcare Finance News reported that emergency inpatient surgery volumes nevertheless increased, illustrating the differences between scheduled care and urgent treatment.
Other developments helped offset the pressure. HCA's July 14 release identified approximately $400 million in incremental net benefits from Medicaid supplemental payment programs, primarily involving Florida, alongside improved expense trends. The company also raised its expected annual incremental benefit from those programs to $300 million to $500 million. Fierce Healthcare reported that this reversed an earlier assumption of a negative annual impact from supplemental payments.
Revenue growth continued even as the profit outlook weakened. Second-quarter revenue reached approximately $20.2 billion, an 8.7% increase, according to Healthcare Finance News. The combination of higher revenue and greater uninsured exposure shows why patient volume alone does not explain hospital earnings. Coverage status and the services delivered also influence the financial result.
HCA's next reports will show whether its revised assumptions capture the remaining effect of exchange coverage losses. The company maintained its annual capital expenditure estimate of $5 billion to $5.5 billion, excluding acquisitions, in the July preliminary update. For hospitals following the same insurance trends, the immediate question is how much ongoing care will be delivered without a payer as the year progresses.
Sources
1. "HCA Healthcare Previews Second Quarter 2026 Results," HCA Healthcare, July 14, 2026.
2. "HCA cuts profit forecast as Obamacare coverage losses drive up uninsured patients," Reuters, July 14, 2026.
3. "HCA Healthcare now expects ACA exchange impacts to exceed $1B in 2026," Fierce Healthcare, July 14, 2026.
4. "HCA now expects up to $1.2B hit from ACA headwinds," Becker's Hospital Review, July 14, 2026.
https://www.beckershospitalreview.com/finance/hca-now-expects-up-to-1-2b-hit-from-aca-headwinds/
5. "HCA adjusts earnings due to higher-than-expected number of uninsured patients," Healthcare Finance News, July 28, 2026.