HCA Healthcare (NYSE:HCA) said its second-quarter performance reflected solid demand in several service lines and 11% growth in diluted earnings per share, but the company faced increased financial pressure as patients losing health insurance exchange coverage shifted largely into the uninsured population.
Chief Executive Officer Sam Hazen said the expiration of enhanced premium tax credits at the end of 2025 led more patients to lose exchange coverage than the company had anticipated. While HCA expected some individuals to move to other coverage options, Hazen said patients instead migrated “almost one for one” to uninsured status while continuing to require hospital care.
Payer Mix Shift Drives Updated Outlook
Same-facility equivalent admissions among patients covered through health insurance exchanges declined 15% in the second quarter and year to date, according to Chief Financial Officer Mike Marks. Equivalent admissions among insured patients excluding exchange plans increased 3.2% in the second quarter, while total uninsured equivalent admissions rose 15%.
Marks said the exchange-related payer mix shift created an approximately $400 million unfavorable impact on adjusted EBITDA in the second quarter. That figure included about $75 million tied to a higher estimate of the first-quarter exchange impact.
The company now expects the full-year adjusted EBITDA impact from health insurance exchange changes to range from negative $1 billion to negative $1.2 billion. Marks said the updated outlook reflects the company’s conclusion that nearly all patients losing exchange coverage are becoming uninsured, compared with its prior assumption that 80% to 85% would do so. HCA also said its original expectation that uninsured patients would use fewer healthcare services did not materialize.
Three divisions—Gulf Coast, North Florida and South Atlantic—accounted for about half of the companywide exchange-related impact. Hazen said exchange adjusted admissions in those divisions declined between 25% and 28% in the first half.
HCA revised its full-year 2026 guidance to:
- Revenue of $77 billion to $79.5 billion.
- Adjusted EBITDA of $15.4 billion to $16.1 billion.
- Net income attributable to HCA Healthcare of $6.3 billion to $6.7 billion.
- Diluted earnings per share of $28.70 to $30.50.
Marks said the revised outlook is more consistent with HCA’s long-term adjusted EBITDA growth target of 4% to 6%, following moderation from the company’s 2025 growth rate and its initial 2026 assumptions.
Medicaid Programs Offset Pressure in the Quarter
The company recognized approximately $400 million of incremental net benefit from Medicaid supplemental payment programs during the second quarter. That included a $540 million incremental net benefit related to a recently approved Florida program covering the period from Oct. 1, 2024, through June 30, 2026, or 21 months.
The Florida benefit was partly offset by retroactive payments received in the second quarter of 2025. HCA’s annual guidance assumes a net Medicaid supplemental-payment benefit of $300 million to $500 million, but Marks said the outlook implies a $100 million to $300 million headwind in the second half because prior program approvals and retroactive payments are expected to exceed the incremental benefit from the Florida program.
Hazen described Medicaid supplemental programs as important to supporting access to care for Medicaid patients, particularly as hospitals provide more uncompensated care to uninsured patients.
Demand Growth Continues, Though Surgeries Decline
Same-facility admissions increased 2.5% in the second quarter, while equivalent admissions rose 2.7%. Emergency room visits increased 3.6%, with cardiac procedures and rehabilitation volumes also contributing to demand.
However, inpatient surgeries declined 2.3% and outpatient surgeries fell 3.4%. Hazen attributed much of the decline to reduced demand for elective procedures, including patients previously covered through exchange plans. He also cited physician feedback regarding affordability pressures affecting patients and the effect of Medicare inpatient rule changes that have shifted some cases from inpatient to outpatient settings.
Emergency inpatient surgeries, which account for about two-thirds of HCA’s inpatient surgical cases, increased 2% year over year through the first six months. By contrast, elective inpatient surgeries were down 6% this year, compared with a 2% decline in the prior year.
Despite the surgical weakness, Hazen said the company remains encouraged by demand and continues to expect long-term demand growth of 2% to 3%, supported by population growth and market trends in its communities.
Capital Investment and Cost Initiatives
HCA has approved more than $7 billion of capital spending expected to come online over the next three years. The investments include 1,000 to 1,200 additional inpatient beds, new hospitals in certain markets, and additional outpatient facilities.
Hazen said the company had approximately 42,000 beds currently in operation, up from roughly 37,000 at the end of 2018. Occupancy increased to 75% from 71% over that period. HCA also had 5% more outpatient sites of care in the second quarter than a year earlier and expects another 250 to 300 outpatient facilities in its capital or acquisition pipeline to open later this year or early next year.
The company spent $1.2 billion on capital expenditures during the quarter, repurchased $2.1 billion of shares and paid $171 million in dividends. Cash flow from operations was $2.3 billion, down 45% year over year, primarily because of the timing of Florida Medicaid supplemental-payment cash flows and the prior-year deferral of federal income tax payments.
HCA maintained its planned 2026 capital expenditure range of $5 billion to $5.5 billion and said it currently expects to complete most of its existing share-repurchase authorization, subject to market conditions and other factors.
On costs, Marks said same-facility cost per equivalent admission, including the effect of Medicaid supplemental payment programs, was essentially flat from a year earlier and improved 1.4% sequentially. He said HCA’s financial resiliency program—which includes digital transformation, global capabilities and expanded shared services—is intended to produce multiyear efficiency benefits. Professional fees remained elevated, rising about 8.5% year over year in the quarter, primarily due to anesthesia and radiology costs.
About HCA Healthcare (NYSE:HCA)
HCA Healthcare is a for‑profit operator of healthcare facilities headquartered in Nashville, Tennessee. Founded in 1968, the company owns and operates a network of hospitals and related healthcare facilities and has grown through organic expansion and acquisitions to become a large provider of inpatient and outpatient services.
The company’s core activities include the operation of acute care hospitals, freestanding surgical and emergency centers, and outpatient clinics. HCA’s services encompass inpatient care, surgical services, emergency medicine, diagnostic imaging and laboratory testing, and various outpatient and ambulatory care offerings.
