HCA Healthcare, the largest for-profit health system in the United States, reported a higher-than-expected increase in uninsured patients during the second quarter of 2026, driven by an “unfavorable payer mix”, according to CEO Sam Hazen. Most of the hike in the uninsured volume was due to patients who lost coverage on the Affordable Care Act health insurance exchanges.
Individuals left the ACA but failed to get any other type of health insurance, Hazen said. “We expected some of these patients to shift to other forms of coverage, but this did not happen,” he added. “Instead, these patients migrated almost one-for-one to uninsured.”
Most of the attrition is attributable to the expiration of the enhanced premium tax credits at the end of 2025, Hazen said. Throughout 2025, HCA’s teams advocated for extending the enhanced premium tax credits for those individuals who needed it, but they expired at the end of the year.
“Unfortunately, the enhanced premium tax credits expired at the end of the year and the effects, as expected, were that many people became uninsured and still needed emergency care from hospitals,” Hazen said. ER visits increased by 3.6%, according to HCA Healthcare CFO and Executive VP Mike Marks.
The payer mix shift related to the exchanges has had an unfavorable impact on adjusted earnings of approximately $400 million, including an increase of approximately $75 million related to HCA’s previous estimate of the exchange impact during the first quarter, Marks reported. The company has revised its estimated impact to adjusted earnings based on the updated information through the first half of the year.
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“Specifically, the key change in our updated estimate is driven by our evaluation that almost all of the individuals losing coverage on the exchanges are becoming uninsured versus our original assumption of 80% to 85%,” Marks said. Despite the higher-than-expected uninsured numbers, HCA realized a revenue increase of 8.7% to $20.2 billion during the second quarter.
Net income attributable to HCA Healthcare increased 2.8% to $1.7 billion. The company also experienced positive factors including an increased benefit of $400 million from Medicaid Supplemental Payment Programs and improved expense results. HCA has approved more than $7 billion in hospital payment expenditures that should come online in the next three years.
During the second quarter, admissions increased 2.5%, inpatient surgeries were down 2.3% and outpatient surgeries were down 3.4%, according to Marks. Emergency inpatient surgery volumes, which accounted for approximately two-thirds of total inpatient cases, were up as compared to last year.
Healthcare is changing. The trend of uninsured patients may persist, potentially leading to increased financial pressure on healthcare systems like HCA. However, with its significant capital expenditures and improved expense results, HCA may be well-positioned to address these challenges.
HCA has 189 hospitals and approximately 2,600 ambulatory sites of care in 19 states and the United Kingdom. They must adapt to changing market conditions and patient needs to maintain financial stability and provide quality care to patients.