For most of 2026, the read on the expiration of enhanced ACA premium tax credits has been that hospitals take the hit while ASCs, with their commercial- and Medicare-heavy payer mix, stay insulated. Third-quarter results from Nashville, Tenn.-based HCA Healthcare complicate that picture.
HCA, which operates 189 hospitals and about 2,600 ambulatory sites of care, reported Oct. 27 that a payer mix shift toward uninsured patients, primarily people who lost coverage on the health insurance exchanges, reduced its pretax income by about $400 million in the quarter. Same-facility outpatient surgery cases fell 3.7% year over year to 237,263, while inpatient surgery cases fell 1.4% and emergency room visits rose 5.1%.
Asked on the company’s earnings call how ASC volumes compared with hospital outpatient volumes, the system’s CFO broke out the numbers.
“The ASC surgery volumes were down 5.4% on surgery,” Mike Marks, CFO of HCA, said. “Overall case volumes were down about 3.7%. The primary pressure is related to the exchanges in our ASC book, very similar to the hospital side.”
“The hospital-based outpatient surgeries were down 2.9%,” Mr. Marks said.
The volume decline came with a caveat.
“I would note, however, that even in light of the volume softness there, that our overall net revenue and earnings did show some growth to prior year,” Mr. Marks said.
That distinction matters for ASCs, whose case mixes skew toward scheduled procedures that patients can delay. “Regarding surgical volumes, consistent with the second quarter, we continued to see solid growth in our emergent surgical volumes and pressure in elective,” Mr. Marks said.
Sam Hazen, CEO of HCA, addressed elective volumes in response to a separate analyst question. HCA executives refer to the health insurance exchanges as the HIX.
“When I look at our elective care, surgical care, the HIX is a very large percentage of the explanation, and it goes back to what we have been saying all of last year and all of this year,” Mr. Hazen said. “Coverage for people matters, and it creates access, affordability and elective care. It is a very fundamental element to individuals’ abilities to get the healthcare they need.”
HCA’s freestanding surgery center count also shrank over the past year. The system operated 117 freestanding outpatient surgery centers, as of Sept. 30, down from 123 a year earlier, while its freestanding endoscopy centers rose to 30 from 29. At the same time, HCA spent $942 million on acquisitions of hospitals and healthcare entities in the first nine months of 2026, up from $361 million in the same period of 2025.
The outpatient network remains central to HCA’s growth plan. In January, Mr. Hazen said the system added roughly 100 outpatient facilities in 2025 and set a target of 18 to 20 outpatient sites per hospital by 2030.
“Our approach to our networks is continuing to advance with respect to our ambulatory platform,” Mr. Hazen said. “We are up to almost 3,000 units through acquisition of urgent care, ambulatory surgery centers and other outpatient facilities that complement our hospital’s ecosystem and create for our patients a more convenient and accessible location and efficient service.”
Unlike independent and physician-owned centers, HCA’s ambulatory sites sit inside a hospital-anchored system.
“A second important initiative for us is creating patient coordination once they do hit one of our ambulatory facilities,” Mr. Hazen said. “Through patient coordination, we think we can create a better experience for the patient and ultimately integrate them into our system. If in fact they need acute care services, we’re helping them achieve that in an efficient and transparent way.”
Medicare policy is also pushing more surgery out of the inpatient setting. CMS began a three-year phaseout of the inpatient-only list in 2026, removing 285 musculoskeletal procedures in the first year.
“This first year is focused a bit more on ortho and musculoskeletal type procedures, so that is what we are seeing,” Mr. Marks said.
The phaseout also moves those cases into a different competitive landscape.
“So we are seeing some impact of the inpatient-only list,” Mr. Marks said. “I think it is fair to say that the outpatient market for surgery is a bit larger than the inpatient market for surgery. There are more competitors, and so that is a factor.”
The question for HCA is where to put its surgical capital. “We are continuing to invest in our operating rooms and our surgical platforms in the inpatient side and the hospital side for outpatient surgery and in our ASC platforms, and believe that it is a long-term important component,” Mr. Marks said. “I don’t think that anything we are seeing would say that it would drive a material change in the way we are approaching building out our networks.”
HCA also sees a potential tailwind in CMS’ proposed Medicare outpatient prospective payment system rule, which includes a budget-neutral reallocation tied to the 340B drug pricing program.
“We were pleased with the construct that is a part of the proposed rule as it relates to a budget neutral reallocation on 340B,” Mr. Marks said. “It would benefit us. We’re not sizing that publicly at this point.”
CMS typically releases final OPPS rules in November.
“I would say, we view the OPPS rule as proposed, and we’re hoping that it gets finalized here soon as a positive factor for HCA as we head into 2027,” Mr. Marks said.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
