HCA Healthcare cut its 2026 earnings forecast after losing $400 million in the second quarter, mostly from patients dropping Affordable Care Act coverage. The financial setback shows how rapidly shifting insurance trends are reshaping hospital revenue streams, particularly for large for-profit systems that rely on a stable mix of insured patients to maintain profitability. The decline in ACA enrollment has reduced the number of patients with commercial insurance and increased the proportion of uninsured individuals seeking care, which often results in delayed payments or nonpayment for services rendered.
Earnings forecast slashed amid insurance losses
The for-profit hospital chain now expects net income between $6.3 billion and $6.7 billion this year, down from its earlier projection of $6.5 billion to $7 billion. The revision came 10 days before HCA’s scheduled second-quarter earnings report, unsettling investors who had anticipated a more gradual impact from the ACA market disruptions. The timing of the announcement, just ahead of the official earnings release, amplified concerns about whether other hospital operators might soon follow with similar downward adjustments.
Shares fell nearly 10% in premarket trading, pulling down stocks of other hospital operators like Community Health Systems, Tenet Healthcare, and Universal Health Services. The market reaction reflected broader anxiety about the healthcare sector’s exposure to insurance market volatility.
ACA turbulence drives uninsured patient surge
Millions of Americans left ACA plans this year after federal subsidies expired, pushing premiums higher. Many became uninsured, a shift that’s hit hospitals with lower demand for elective procedures and rising uncompensated care costs. The expiration of enhanced subsidies created an affordability crisis for individuals who could no longer justify the expense of monthly premiums. As a result, hospitals have seen a decline in scheduled surgeries and diagnostic tests, which are typically higher-margin services compared to emergency care. The uninsured patients who do seek treatment often present with more advanced conditions, increasing the complexity and cost of care while reducing reimbursement.
HCA had already warned investors it expected to lose $600 million to $900 million this year from the coverage drop. First-quarter losses reached $150 million, but the second quarter’s $400 million hit exceeded expectations. The disparity between the two quarters suggests that the ACA market contraction is intensifying, with more individuals either falling off coverage rolls or opting out of plans as premiums rise. Hospitals typically account for uncompensated care by setting aside reserves, but the rapid increase in uninsured patients has strained those provisions.
“We expected some acceleration exiting Q1, although the magnitude is a surprise,” J.P. Morgan analyst Benjamin Rossi wrote in a note Tuesday. HCA now expects up to $1.1 billion in losses from the coverage decline this year, according to Rossi. The revised estimate implies that the second half of the year may see further deterioration in payer mix, particularly if enrollment in ACA plans does not rebound during the next open enrollment period.
Related: HCA Cuts 2026 Earnings View on Insurance Losses
The company pointed to declining surgical volumes in the second quarter, which likely factored into the earnings cut. While emergency room visits and admissions have remained relatively stable, the drop in scheduled surgeries suggests that patients are either delaying care or seeking alternatives. Still, HCA expects overall second-quarter results to improve year-over-year, citing higher admissions, emergency room visits, and increased Medicaid supplemental payments from states, particularly Florida.
Revenue and income still beat expectations
HCA projects second-quarter revenue of about $20.2 billion, up from $18.6 billion last year. Net income is expected to reach just under $1.7 billion, roughly $50 million higher than the same period in 2023. Both figures would exceed Wall Street estimates, indicating that despite the ACA-related losses, the company’s core operations remain strong. The revenue growth reflects higher patient volumes in certain service lines, as well as pricing adjustments and cost-control measures.
The company plans to release official second-quarter results on July 24. The upcoming report will provide further clarity on how the ACA coverage losses are affecting specific segments of HCA’s business. Investors will also be watching for any updates on the company’s strategic response to stabilize patient volumes.
The coverage losses may not reverse quickly. If enrollment in ACA plans remains depressed, hospitals could face sustained pressure on volumes and reimbursement rates. The longer-term risk is that the decline in insured patients could lead to a structural shift in how hospitals manage their payer mix. Smaller hospital systems, which lack the scale and financial reserves of HCA, may be more vulnerable to the financial strain caused by the ACA market contraction.
For now, HCA’s admission numbers suggest demand hasn’t collapsed entirely. But the gap between insured and uninsured patients is widening, and the financial strain is showing up in the numbers faster than many expected. The company’s ability to handle this transition will depend on its capacity to adapt to a healthcare setting where patients are more likely to delay or forgo care due to cost concerns.
