HCA Healthcare Sees Solid Demand as Exchange Headwinds Pressure 2026 Outlook

Exchange-related pressure is weighing on HCA’s 2026 outlook: The expiration of enhanced tax credits is pushing some patients into uninsured status, with estimated full-year impact of $1 billion to $1.2 billion and slower elective-care utilization. State supplemental payments and underlying demand provide offsets: HCA expects a $300 million to $500 million net benefit from state programs, while insured business excluding exchange plans grew 3.2% and adjusted admissions increased 2.7% in the second quarter. HCA is pursuing long-term growth through capacity and efficiency investments: The company is expanding outpatient facilities, improving patient throughput and cost management, and maintaining a target of 4% to 6% long-term revenue growth with stable margins.

HCA Healthcare NYSE: HCA CFO Mike Marks said the hospital operator is navigating a changing policy environment in 2026 while continuing to see solid underlying demand for services outside of the health insurance exchanges. Speaking at an investor conference, Marks described the expiration of enhanced exchange tax credits as the largest near-term issue for HCA and the broader hospital sector. He said some individuals losing exchange coverage are becoming uninsured, creating pressure on payer mix and elective-care utilization.

Still, Marks said demand in HCA’s markets remains favorable. In the second quarter, insured business excluding exchange plans rose 3.2% from a year earlier. The company reported 2.5% admission growth and 2.7% adjusted-admissions growth during the period.

Based on developments during the first half of the year, HCA updated its estimated full-year exchange-related impact to between $1 billion and $1.2 billion, Marks said. He said the company based that range on its experience through the first six months and its estimates for the remainder of 2026. Marks noted that comparisons may become somewhat more favorable in the fourth quarter because exchange volumes had already begun slowing in late 2025. He said fourth-quarter 2025 exchange volumes declined by approximately 5,000 equivalent admissions from the third quarter, while the full year had recorded exchange growth of more than 10% versus 2024.

Offsetting some of the exchange headwinds, HCA expects state supplemental payments to provide a net benefit of $300 million to $500 million for the year. Marks said five states in which HCA operates were able to advance programs under grandfathering provisions in the One Big Beautiful Bill. All five have moved through approval processes, according to Marks, including Florida, Georgia, Virginia and Colorado. Marks declined to quantify the impact of Virginia’s State Directed Payment program specifically, but said HCA’s overall estimate for supplemental-payment benefits continues to include Virginia.

Marks said the primary cause of slower elective surgery volume was the migration of patients from exchange coverage to uninsured status, which can reduce access to elective care. He identified two additional factors affecting surgical trends. The ongoing phaseout of Medicare’s Inpatient-Only List is shifting some procedures to outpatient settings. Marks said orthopedics and spine procedures were particularly affected during the second year of the three-year phaseout. HCA believes some consumers may be deferring elective procedures because of economic conditions, inflation, energy co...