HCA Healthcare cuts 2026 outlook after $400 million payer mix hit

HCA Healthcare Inc. lowered its full-year profit outlook Tuesday after an unfavorable shift in payer mix — driven by patients losing health insurance exchange coverage — cost the hospital operator about $400 million in second-quarter income before taxes, sending shares down more than 10 percent in premarket trading.

"Our colleagues continue to manage well through the positive and negative factors that have impacted our business in the first half of the year," Chief Executive Officer Sam Hazen said in a statement. "We have adjusted our guidance to reflect these factors."

The Nashville-based company now expects 2026 earnings of $28.70 to $30.50 per diluted share, down from a prior range of $29.10 to $31.50. It narrowed its revenue forecast to $77 billion to $79.5 billion, from $76.5 billion to $80 billion previously. Adjusted EBITDA guidance was trimmed to $15.4 billion to $16.1 billion, compared with an earlier $15.55 billion to $16.45 billion.

For the second quarter, HCA posted preliminary revenue of $20.23 billion, up 8.7 percent from $18.61 billion a year earlier. Net income rose to $1.7 billion, or $7.62 a share, from $1.65 billion, or $6.83. Adjusted EBITDA came in at $4.03 billion, versus $3.85 billion in the year-ago period.

The payer mix deterioration stemmed from an increase in uninsured volume, primarily from patients who lost coverage on the health insurance exchanges after the expiration of enhanced premium tax credits at the end of 2025. The company estimated the full-year impact from exchange-related shifts at $1 billion to $1.2 billion, up sharply from an earlier estimate of $600 million to $900 million. The revision included an additional $75 million impact from the first quarter that HCA had previously underestimated.

Partially offsetting the headwind, HCA recognized about $400 million in incremental net benefit from Medicaid Supplemental Payment Programs, mainly tied to a Florida state-directed payment program approved during the quarter by the Centers for Medicare and Medicaid Services covering October 2024 through June 2026. The company revised its full-year estimate for these programs to a net benefit of $300 million to $500 million, from a prior expectation of a net cost of $50 million to $250 million.

Operating metrics showed mixed trends. Same facility admissions rose 2.5 percent and emergency room visits increased 3.6 percent, but inpatient surgeries declined 2.3 percent and outpatient surgeries fell 3.4 percent. The company maintained its capital expenditure plan of $5 billion to $5.5 billion for the year, excluding acquisitions.

The guidance cut signals that the expiration of enhanced premium tax credits — which had subsidized exchange coverage for millions of Americans — is creating a structural headwind for for-profit hospital operators. HCA's experience mirrors broader industry concerns that the uninsured rate, which fell to a record low of 7.2 percent in 2024, may be reversing course. The last time a similar coverage erosion occurred, following the 2017 tax bill that eliminated the individual mandate penalty, hospital operators saw uncompensated care costs rise for several consecutive quarters.

HCA's preliminary results also highlighted a shift in service mix, with patients opting for emergency care over elective surgeries. The 2.3 percent decline in inpatient surgeries and 3.4 percent drop in outpatient procedures suggest consumers may be deferring discretionary medical spending, a pattern that could intensify if economic uncertainty persists. The company's next earnings call is scheduled for July 24, when management is expected to provide additional detail on second-half trends.

This article is for informational purposes only and does not constitute investment advice.