HCA Healthcare reported that patients who left the Affordable Care Act (ACA) exchanges largely became uninsured, a much larger migration than the company had forecast. Executives had expected roughly 80%–85% of those patients to lose ACA coverage with the remainder obtaining other insurance. Instead, CEO Sam Hazen said on the company’s investor call that the shift occurred almost one for one to uninsured status.
That abrupt loss of coverage reduced HCA’s reimbursement and depressed demand for nonessential care. HCA estimated the coverage losses and related declines in demand trimmed approximately $400 million from its second-quarter results. The company pre-announced that policy-driven increases in uninsured patients had taken a bigger bite out of income than previously modeled.
In the quarter, HCA’s volumes for patients previously covered by the ACA fell 15% year over year, while uninsured volumes rose 15%. Hazen emphasized that the operator continues to treat these patients but that uninsured cases yield much lower payments, if any, thereby pressuring income.
HCA reported notable declines in elective and surgical volumes that executives tied in part to the loss of ACA coverage. Elective volumes were down 6% in the first half of 2026 compared with the prior year, a deterioration from the already weak elective performance in 2025. Hazen specifically cited reduced demand among patients losing ACA coverage as a substantial contributor to elective declines across both inpatient and outpatient settings.
Surgical activity in the quarter showed declines across settings: inpatient surgeries dropped 2.3% year over year, while outpatient surgeries declined 4.4%. HCA’s leadership and analysts characterized the magnitude of surgical declines as unprecedented for the company outside of the COVID-19 impacts in 2020 and 2021.
The falloff in elective and surgical procedures matters because those services typically generate higher margins than many other types of care. As patients who previously purchased coverage on the ACA exchanges became uninsured or deferred nonessential procedures, revenue and operating leverage for HCA in certain service lines weakened.
Despite the headwinds from ACA coverage losses, HCA posted second-quarter net income of $1.7 billion, up 3% year over year, on revenue of $20.2 billion, up 9% year over year, beating analyst expectations. Several factors helped offset the estimated $400 million impact from uninsured patients.
Overall volumes were up: admissions increased 2.4% year over year and emergency department visits rose 3.5%. HCA also saw growth in cardiac procedures and rehabilitation volumes. The company achieved higher revenue yields per admission, with revenue per equivalent admission up 6% and inpatient revenue per admission up 14.6% in the quarter. Those improvements in mix and pricing helped cushion the decline in ACA-related reimbursement.
HCA also benefited from higher Medicaid payments tied to state supplemental programs. CFO Mike Marks noted that add-on payments in Medicaid, mostly in Florida after CMS approved the state’s supplemental payment program in April, contributed positively to the company’s results and helped offset ACA-related losses.
HCA is not alone in experiencing financial stress from ACA enrollment declines. Other major for-profit operators reported similar pressures: Community Health Systems said ACA volatility and patients delaying nonessential care weighed on its Q2 performance, and Tenet Healthcare likewise reported plunging ACA volumes and revenues even as it outperformed expectations overall.
Industry observers linked the mass departure from ACA exchanges to the expiration of more generous federal financial assistance, which had reduced premiums for many enrollees. When those enhanced subsidies lapsed, premiums rose and millions left the exchanges, with experts and providers reporting an associated increase in the uninsured population. Hospitals face a dual challenge when coverage falls: lower demand for elective, higher-margin procedures and greater uncompensated care exposure.
Analysts who reviewed HCA’s results noted operating trends and cost control were generally solid, and that the company’s overall performance could have been worse given the policy headwinds.
HCA’s leadership emphasized the operational reality: the system continues to care for uninsured patients, but the financial strain is real. Hazen attributed part of the company’s elective volume declines to the loss of ACA-covered patients, and CFO Mike Marks highlighted supplemental Medicaid payments and other favorable volume trends that mitigated the financial hit.
The company’s prior assumption that a share of former ACA enrollees would transition to other coverage did not materialize; virtually all moved to uninsured status according to Hazen. That outcome changed the expected payer mix and pressured reimbursement in the quarter. HCA’s experience illustrates how rapid changes in the insurance landscape can directly affect hospital volumes, payer mix, and earnings, even as other service-line growth and state payment policies can partially offset those effects.
Details such as specific guidance changes or forward-looking projections beyond the second-quarter results were not reported in the source article.