HCA Earnings: Rise in Uninsured Patients Cost About $400 Million
HCA Healthcare, which runs 189 hospitals, says more patients arrived uninsured in the third quarter, mostly people who lost Obamacare plans, costing it about $400 million in profit before taxes. Holding everything else equal, our calculation says that profit would have grown about 15% instead of slipping 2%.
The short answer. The extra federal help with Obamacare premiums ended with 2025. HCA now says many people who dropped those plans still come to its hospitals without insurance, costing it about $400 million in the quarter. That matters well beyond HCA’s shareholders, because losing coverage did not end the need for care, and the unpaid part of that care is landing on hospitals. We add what no single release shows. Holding everything else equal, HCA’s profit before taxes would have grown about 15%. Paid exchange enrollment also fell less than nationwide in Texas and Florida, where most of its uninsured patients are.
More uninsured patients cost HCA about $400 million in the third quarter
What we calculated
- About 15%: HCA’s third quarter profit before taxes growth with its $400 million estimate added back and no other change, against the 2% decline we compute from its reported figures.
- About $352 million: the implied remainder from the rest of HCA’s business, if its uninsured estimate is treated as part of the year’s change in profit before taxes.
- About 126,000 more emergency room visits and about 9,200 fewer same-day surgeries at HCA’s same hospitals in the third quarter, subtracting the counts in its release.
- About $800 million: HCA’s second and third quarter estimates as it states them, added together; the second includes about $75 million that belongs to the first quarter.
- About 2.6 million, or 12.0%: the fall in people with paid exchange coverage from February 2025 to February 2026, from the federal monthly count.
- 10.3% and 4.3%: the same fall in Florida and in Texas.
- About 8%: the drop in HCA’s diluted share count from a year earlier, from its release tables.
- About $4.0 billion: the rise in HCA’s total debt since the end of 2025, from its balance sheet.
On this page
How many more uninsured patients is HCA seeing?
Far more than a year ago. At hospitals HCA ran in both years, uninsured admissions rose 15.5% in the first quarter of 2026 and 23.4% in the second. HCA says the rise continued in the third quarter but has not given the rate yet.
An admission is a patient formally admitted to the hospital as an inpatient, so it counts stays, not different people. HCA reports how many of those patients had no insurance, and through most of 2025 that number barely moved, according to its quarterly report for the period ended June 30. It fell 2.0% in the third quarter of 2025, then rose 7.1% in the fourth.
Then 2026 started. HCA says both jumps, in the first and second quarters, reflect the end of the enhanced premium tax credits. Those credits were the extra federal help that had lowered premiums on the exchanges, the Obamacare marketplaces, since 2021. It also names administrative reforms to the exchanges and a decline in what it calls Medicaid conversions, which we read as fewer uninsured patients being moved onto Medicaid.
Show the data
| Category | Value |
|---|---|
| Q1 2025 | -0.7% |
| Q2 2025 | 0.4% |
| Q3 2025 | -2.0% |
| Q4 2025 | 7.1% |
| Q1 2026 | 15.5% |
| Q2 2026 | 23.4% |
Uninsured patients made up about 8% of HCA’s admissions in the second quarter, up from about 7% a year earlier.
Most of them came through two states. Texas and Florida hospitals produced 73% of HCA’s uninsured admissions in that quarter, though they handled 58% of all its admissions.
The third quarter release gives no uninsured growth rate. It says the quarter again brought “a payer mix shift driven by an increase in uninsured volume, primarily due to patients who lost coverage on the health insurance exchanges.” Payer mix means who pays the bill, here a move from insurers toward patients with no coverage.
Show the data
| Quarter | Uninsured admissions, change from a year earlier | Uninsured share of all admissions |
|---|---|---|
| Q1 2025 | -0.7% | 6% |
| Q2 2025 | +0.4% | 7% |
| Q3 2025 | -2.0% | n/a |
| Q4 2025 | +7.1% | n/a |
| Q1 2026 | +15.5% | 7% |
| Q2 2026 | +23.4% | 8% |
| Q3 2026 | not yet disclosed | not yet disclosed |
Source: HCA Form 10-Q for the quarters ended March 31, 2026 and June 30, 2026. Growth rates are for hospitals HCA ran in both years (same facility); shares are HCA’s rounded percentages for all its hospitals.
How much is the loss of Obamacare coverage costing HCA?
HCA estimates about $400 million of lost profit before taxes in the third quarter. It gave a similar figure for the second quarter, part of which belonged to the first quarter.
Profit before taxes, which HCA calls income before income taxes, fell $48 million from a year earlier, to about $2.37 billion. HCA puts the cost of the shift to uninsured patients alone at about $400 million.
Show the data
| Step | Value |
|---|---|
| Q3 2025 | $2.418B |
| Uninsured estimate | -$0.400B |
| Remainder | +$0.352B |
| Q3 2026 | $2.370B |
If HCA’s estimate is treated as part of the year’s change, the rest of the business added roughly $352 million, by our subtraction. HCA gives no such breakdown itself. It does point to faster patient growth and more revenue from insured patients. It also cites better cost results and a slightly larger net benefit from Medicaid supplemental payments, which are extra state payments to hospitals.
Added together, HCA’s second and third quarter figures come to about $800 million, and about $75 million of that belongs to the first quarter. In July HCA raised its full-year assumption for this hit to $1.0 billion to $1.2 billion. The October release does not restate that range, so it does not say what is left for the fourth quarter.
A second measure points the same way. HCA’s estimated cost of uncompensated care covers free charity care, discounts for uninsured patients and bills it does not expect to collect, valued at what the care cost to provide. That cost rose 18.7% in the first quarter and 29.5% in the second. It measures something different from the $400 million estimate, so the two are not added together here.
Show the data
| Category | Value |
|---|---|
| Q3 2025 | 4.4% |
| Q4 2025 | 8.7% |
| Q1 2026 | 18.7% |
| Q2 2026 | 29.5% |
Show the data
| Estimated cost of uncompensated care | 2026 | 2025 |
|---|---|---|
| First quarter | $1.252 billion | $1.055 billion |
| Second quarter | $1.445 billion | $1.116 billion |
| First half | $2.697 billion | $2.171 billion |
Source: HCA Form 10-Q for the quarters ended March 31 and June 30, 2026. The cost is HCA’s estimate, using its ratio of patient care costs to gross charges.
Are HCA’s emergency rooms getting busier?
Yes, counting all patients. Emergency room visits rose 5.1% in the third quarter, while surgeries that send patients home the same day fell 3.7%. HCA does not say how many of those visits were uninsured.
The 5.1% rise at HCA’s same hospitals came to about 126,000 more visits than a year earlier, by our subtraction. Growth picked up through 2026. The first quarter’s low base, which HCA ties to a light respiratory season and a January winter storm, makes that climb look steeper.
Outpatient surgeries, done without admitting the patient and usually with a trip home the same day, moved the other way. The third quarter drop was about 9,200 procedures, after smaller drops in the first half.
Show the data
| Category | Emergency room visits | Outpatient (same-day) surgeries |
|---|---|---|
| Q3 2025 | 1.3% | 1.1% |
| Q4 2025 | 0.5% | -0.5% |
| Q1 2026 | 0.3% | -1.7% |
| Q2 2026 | 3.6% | -3.4% |
| Q3 2026 | 5.1% | -3.7% |
Both counts cover every patient, insured or not, and HCA does not split them by who pays. So they cannot show whether people who lost coverage swapped planned care for the emergency room. Our reading is only that the two trends fit the uninsured numbers above, since people without coverage still get sick and hurt.
HCA itself called the second quarter’s surgery decline a “service mix shift,” meaning a change in the kinds of care it sold. In its July 14 preview it said that shift hurt results “to a lesser degree” than the move to uninsured patients.
What happened to people who lost Obamacare subsidies?
Fewer of them kept paying for a plan. About 2.6 million fewer people had a paid exchange plan in February 2026 than a year before. A KFF survey found 9% of last year’s enrollees uninsured early this year.
The exchanges, also called the Affordable Care Act marketplaces, are where people without job-based coverage get their own plans, usually with some federal help. The extra help began in 2021 and was extended through 2025, as the Department of Health and Human Services’ planning office (ASPE) notes in a June 26 brief. HCA’s filings date its expiration to the end of 2025.
Sign-ups fell only a little. CMS, the agency that runs the exchanges, counted 23.1 million plan selections for 2026, against 24.3 million for 2025 in its earlier report. Picking a plan is not the same as paying for it.
The paid count dropped harder. CMS’s monthly enrollment file shows 19.2 million people with a paid, active exchange plan in February 2026, against 21.8 million in February 2025. That is a fall of 12.0%, by our calculation from the file.
Show the data
| Category | Value |
|---|---|
| United States | 12.0% |
| Florida | 10.3% |
| Texas | 4.3% |
A smaller paid count does not mean the same number of people became uninsured. In a survey fielded in February and March, the health research group KFF found 69% of 2025 exchange enrollees had re-enrolled. Another 22% had moved to other coverage, and 9% were uninsured.
The explanations differ too. ASPE attributes part of the change in enrollment to anti-fraud measures, which it describes as cutting “improper, phantom, and fraudulent participation.” HCA’s filings put its own uninsured rise down to the end of the extra credits and to the administrative changes. HCA’s patients are people who needed hospital care, so they cannot stand for every former enrollee.
Paid enrollment fell less in HCA’s two biggest states than nationwide, 10.3% in Florida and 4.3% in Texas, by our calculation from the same file. Yet those states produce most of HCA’s uninsured admissions, so the national drop alone does not explain its experience. February is the latest month in the CMS file used here.
HCA Healthcare earnings, dividend and buybacks
Sales still grew and HCA now expects to land in the upper half of its July forecast for 2026. It keeps paying a dividend and buying back a large amount of its own stock.
Revenue rose 3.6% in the third quarter; that is the money HCA took in from patients and insurers before costs. Net income attributable to HCA fell 3.9%; that is its profit after taxes and after the share owed to partners in some of its hospitals.
Earnings per share still rose 4.5%; that is the profit divided by the number of shares. The reason is the share count. Counting stock promised to employees, which is what “diluted” means, HCA had about 8% fewer shares than a year earlier, by our calculation.
HCA bought back $2.970 billion of its own stock in the quarter. It still had $4.240 billion left under the board’s approval at September 30.
The board declared a quarterly dividend of $0.78 a share, paid on December 29 to shareholders on the company’s books on December 15.
Total debt stood at about $50.5 billion at the end of September, about $4.0 billion more than at the end of 2025 by our calculation.
HCA’s forecast for 2026, which it calls guidance, puts net income at $6.3 billion to $6.7 billion. The company now expects to land in the upper half of its ranges.
| Measure | Q3 2026 | Q3 2025 |
|---|---|---|
| Revenue | $19.849 billion | $19.161 billion |
| Income before income taxes | $2.370 billion | $2.418 billion |
| Net income attributable to HCA | $1.579 billion | $1.643 billion |
| Earnings per diluted share | $7.27 | $6.96 |
| Adjusted EBITDA (HCA’s own measure of earnings before interest, taxes and some accounting charges) | $3.918 billion | $3.870 billion |
| Diluted shares used (millions) | 217.212 | 236.181 |
| Stock bought back in the quarter | $2.970 billion (7.230 million shares) | n/a |
| Total debt, September 30, 2026 | $50.493 billion | n/a |
| Cash, September 30, 2026 | $908 million | n/a |
| 2026 forecast, July 14 (upper half expected) | Revenue $77.0 to $79.5 billion; net income $6.300 to $6.700 billion; earnings per diluted share $28.70 to $30.50 | n/a |
Source: HCA third quarter 2026 release, October 27, 2026; HCA release of July 14, 2026. Total debt at December 31, 2025 was $46.492 billion (short-term borrowings and current debt plus long-term debt, our sum from the balance sheet).
| HCA estimate of the full-year 2026 exchange hit | Range |
|---|---|
| As of April 24, 2026 | $600 to $900 million |
| As of July 14, 2026 | $1.0 to $1.2 billion |
Source: HCA release of July 14, 2026, unfavorable impact on income before income taxes from payer mix shifts due to the health insurance exchanges.
Chief executive Sam Hazen pointed to “the challenges brought about by federal policy changes this year” and said “we believe HCA Healthcare is positioned to end the year positively.” Despite that pressure, HCA expects full-year results in the upper half of its July forecast. The full figures are on HCA’s financials page and its stock overview, and insurers’ side of the same shift is in our articles on UnitedHealth and Elevance Health.
Read together, HCA’s numbers suggest that for many people who dropped their plans, the hospital visits did not stop. What changed is who pays, and so far a growing share of that bill sits with the hospital.
What to watch
- HCA’s third quarter uninsured admission growth: due in its quarterly report to the SEC, the U.S. market regulator; last quarter’s came four days after the results.
- Whether HCA still assumes a $1.0 billion to $1.2 billion exchange hit for 2026: the replay of its October 27 earnings call on HCA’s investor relations site, and the same quarterly report.
- Whether other hospital chains report the same uninsured rise: Universal Health Services after the close on October 27, Community Health Systems after the close on October 28 and Tenet Healthcare before the open on October 29.
- Whether paid exchange enrollment kept falling after February: CMS’s next monthly effectuated enrollment file, for which CMS has set no date.
How we counted
The 15% figure adds HCA’s estimated $400 million third quarter impact back to its reported income before income taxes of $2.370 billion. It compares the $2.770 billion total with $2.418 billion a year earlier and assumes nothing else would have changed, which HCA does not state.
The “Remainder” bar in the waterfall chart is the reported change less HCA’s estimate: minus $48 million minus (minus $400 million) is plus $352 million. It treats HCA’s estimate as one part of the year’s change, which HCA does not itself present as a bridge.
The 126,000 and 9,200 figures subtract the same facility counts in HCA’s third quarter operating statistics. Emergency room visits were 2,585,811 against 2,459,510, and outpatient surgery cases 237,263 against 246,452.
The $800 million adds HCA’s second and third quarter estimates as it states them. The 2.6 million subtracts the February 2026 total from the February 2025 total in CMS’s monthly effectuated enrollment file, 19,169,147 against 21,776,626. The state changes use the same file’s rows for Florida and Texas. An earlier CMS report put February 2025 at 23.4 million; we compare both years from the same monthly file. The 8% share count drop compares 217.212 million shares on a diluted count with 236.181 million, and the $4.0 billion debt rise compares $50.493 billion with $46.492 billion at December 31, 2025.
Frequently asked questions
Is HCA Healthcare for profit?
Yes. HCA Healthcare is a public company whose shares trade on the New York Stock Exchange under the ticker HCA. It pays shareholders a quarterly dividend, most recently declared at $0.78 a share on October 27, 2026.
How many hospitals does HCA Healthcare have?
HCA ran 189 hospitals and about 2,600 other sites in 19 states and the United Kingdom as of September 30, 2026. The other sites include surgery centers, freestanding emergency rooms, urgent care centers and clinics.
Why did HCA’s profit fall in the third quarter?
HCA’s income before income taxes slipped to $2.370 billion from $2.418 billion, about 2% by our calculation. The company estimates that more uninsured patients, mostly people who lost exchange plans, cost it about $400 million in the quarter.
How many people lost ACA coverage in 2026?
No official count says how many lost coverage altogether. CMS’s monthly file shows about 2.6 million fewer people with a paid exchange plan in February 2026 than in February 2025, and some of them found other coverage.
What is uncompensated care at a hospital?
It is care a hospital provides and is not paid for. HCA counts free charity care, discounts it gives uninsured patients and bills it expects to go unpaid, and also reports what that care cost to provide.
Sources
- HCA Healthcare Reports Third Quarter 2026 Results (October 27, 2026)
- HCA Healthcare Previews Second Quarter 2026 Results and Revises 2026 Guidance (July 14, 2026)
- HCA Healthcare Reports Second Quarter 2026 Results (July 24, 2026)
- HCA Healthcare Reports First Quarter 2026 Results (April 24, 2026)
- HCA Healthcare Reports Fourth Quarter 2025 Results (January 27, 2026)
- HCA Healthcare Reports Third Quarter 2025 Results
- HCA Healthcare financials on StockTitan
- HCA Healthcare stock overview on StockTitan
- HCA Form 8-K, exhibit 99.1, third quarter 2026 release (October 27, 2026)
- HCA Form 10-Q, quarter ended June 30, 2026
- HCA Form 10-Q, quarter ended March 31, 2026
- HCA Form 10-Q, quarter ended September 30, 2025
- HCA Form 10-K for 2025
- CMS, Health Insurance Exchanges Monthly Effectuated Enrollment
- CMS, 2026 open enrollment press release (March 27, 2026)
- CMS, Effectuated Enrollment: Early 2025 Snapshot and Full Year 2024 Average
- HHS ASPE, ACA Exchange Enrollment in 2026 (June 26, 2026)
- KFF, Cost Concerns and Coverage Changes: A Follow-Up Survey of ACA Marketplace Enrollees (March 19, 2026)
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