A wave of second-quarter 2026 earnings calls from the nation’s largest for-profit hospital operators shows a pattern of exchange patients converting almost 1-to-1 into uninsured patients as enhanced ACA marketplace subsidies expire due to HR 1.
However, inpatient and hospital-based businesses are absorbing most of the damage, while ASC and outpatient divisions keep growing.
Here are seven things to know:
1. Dallas-based Tenet Healthcare’s hospital segment absorbed a 17% year-over-year decline in exchange revenue in the second quarter, concentrated in Florida, Arizona, Michigan, South Carolina and Texas. In an earnings call, CFO Sun Park said exchange admissions fell about 13.5%, with roughly 80% to 100% of that volume converting directly into uninsured patients.
Tenet’s ASC arm, United Surgical Partners International, grew adjusted EBITDA 8.8% to 9% to $542 million in the same quarter, powered by 10% same-store growth in total joint replacements performed in ASCs.
2. Nashville, Tenn.-based HCA Healthcare, the largest U.S. hospital operator, said it lost roughly $400 million in the second quarter to the same dynamic and cut its 2026 net income guidance to $6.3 billion-$6.7 billion, down from $6.5 billion to $7 billion. In an earnings call, HCA executives said its exchange volumes fell 15% year over year, with uninsured volumes rising a corresponding 15%.
Elective inpatient surgeries slumped 6% and hospital outpatient surgery fell 3.4%, but earnings at its ASC network grew in the first half of the year.
3. Franklin, Tenn.-based Community Health Systems cut its full-year outlook after a sharper-than-expected jump in uninsured volumes in the second quarter, and is now projecting a $50 million-to-$75 million adjusted EBITDA hit from HR 1-related losses this year, up from a prior estimate of $20 million to $30 million. CHS said patients who lost exchange coverage largely still showed up for care, but as self-pay or uninsured patients, adding costs without matching revenue. Uninsured volume growth accounted for roughly half of CHS’s 2.9% adjusted admissions growth in the quarter.
4. King of Prussia, Pa.-based Universal Health Services also downgraded its 2026 earnings outlook after second-quarter results showed rising uninsured patients and softer-than-expected volumes. UHS CFO Steve Filton said in an earnings call that “virtually everyone” who lost exchange coverage in the company’s markets became an uninsured patient rather than shifting to other coverage.
5. Nonprofit systems are feeling it too. Chicago-based CommonSpirit Health, the country’s largest Catholic nonprofit system, posted a $78 million operating loss (-0.8% operating margin) for its fiscal second quarter, even while touting volume and efficiency gains, evidence the exchange disruption is hitting margins broadly, not just at investor-owned chains.
6. The scale of the problem is industrywide. Total ACA marketplace enrollment has fallen to about 23.1 million people nationally, roughly 5% below 2025, after the expiration of enhanced premium tax credits pushed average out-of-pocket premiums from $113 to $178 a month; some projections put potential enrollment losses above 9 million by 2028, absent new subsidies. Consulting firm Premier has estimated hospitals could lose $68.6 billion in revenue across 2026 and 2027 combined from rising uninsurance tied to marketplace and Medicaid changes.
7. Against that backdrop, ASCs keep standing out as the more insulated setting. ASC payer mix leans more heavily on commercial and Medicare business than hospital inpatient and exchange-dependent outpatient care, and lower fixed costs give ASCs more room to absorb volume swings. The U.S. ASC market is still projected to grow at roughly a 6.3% compound annual rate through 2030, with cardiovascular, spine and advanced orthopedic procedures cited as the biggest growth drivers for 2026.
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