Last year, as the deadline to extend tax credits for plans on the Affordable Care Act exchanges loomed, lawmakers, policy wonks and think tanks rushed to quantify how many affected enrollees would wind up uninsured after being priced out.
Half a year after the cuts went into effect, the answer from hospitals is the same: almost all of them.
While exact data on the number of uninsured patients hasn’t been quantified yet, the trend has surprised hospital executives, who said they expected more Americans to choose cheaper health plans with higher out-of-pocket costs or switch to other forms of insurance after ACA cuts last year caused many premiums to skyrocket.
Instead, most of those who dropped their ACA plans seem to be forgoing insurance entirely, several for-profit hospital operators said on second quarter earnings calls.
“It felt like virtually everyone who lost their exchange coverage became an uninsured patient,” Universal Health Services’ CFO Steve Filton said.
The growing number of uninsured patients is starting to ding hospital companies’ finances, as they’re forced to absorb uncompensated care costs and more patients avoid elective surgeries, an important linchpin for hospitals’ revenue. It’s also the first warning sign of the ACA subsidy expiration’s impact on the broader economy.
Most of the major for-profit hospital operators, including HCA Healthcare, Community Health Systems and Universal Health Services said they expect to lose more money this year after the amount of uninsured patients increases.
Dallas-based Tenet Healthcare was the sole outlier in the quarter, after executives said the company controlled costs enough to mitigate additional headwinds from the exchanges.
HCA, the largest for-profit hospital operator in the country, made the rare move to preview its financial results to investors early as the expected hit to its income this year grew past $1 billion. HCA’s executive team said its patients who lost ACA coverage are going uninsured almost on a 1 to 1 basis.
Executives at CHS, which owns or leases 60 hospitals and more than 800 care sites across 12 states, said the amount of uninsured patients had risen by roughly 20% compared with 2025, and accelerated more rapidly in the second quarter compared with the first.
The rising uninsured population could hit hospitals hard, as many of their margins are still softer following the coronavirus pandemic, according to Erik Swanson, a managing director at consultancy Kaufman Hall.
A higher number of uninsured patients becomes “very costly” for hospitals, Swanson said, as more patients are unable to pay for services and get sicker.
“Not only are [uninsured patients] not reimbursing, but in many instances, the acuity is higher, and what they need to care for these patients actually costs quite a bit more,” Swanson said. “It's sort of a double-edged sword there.”
There’s “little chance” that a large number of those uninsured patients will regain ACA exchange coverage or find employer-sponsored insurance, which will continue to impact profitability, said Ryan Langston, a director and senior analyst at TD Cowen, in a statement to Healthcare Dive. (TD Cowen disclosed that the firm or its affiliates receives compensation from HCA Healthcare.)
Nearly 3 million less people are enrolled in ACA plans this year, according to federal data from June. The Trump administration attributed most of those cuts to fraud prevention efforts. A March survey from research firm KFF found that 1 in 10 enrollees who had a marketplace plan in 2025 say they’re uninsured.
Still, the cost of uninsured and underinsured patients rose for the major for-profit operators in the second quarter.
Charity care patients and those without insurance cost Tenet $167 million in the second quarter, a more than 14% increase compared to the prior year, according to securities filings. And the cost of total uncompensated care for HCA Healthcare was $1.45 billion, a 29% increase year over year.
Hospitals are attempting to mitigate the impact of the rising uninsured rate by controlling costs, a longstanding priority in the industry as hospitals attempt to resuscitate flagging margins. They will also look toward patient support to assist finding insurance coverage, including Medicaid, for patients, Langston said.
Hospitals that struggle with staffing are trying to deploy labor more efficiently by using predictive analytics to anticipate volumes or using larger employee float pools, Swanson said. On the non-labor side, many hospitals are trying to drive down drug and supply spending, he said.
Going forward, hospitals and industry watchers will keep their eye on metrics like bad debt or unpaid balances that hospitals expected to recover from patients, and the amount that operators spend on charity care, Swanson said.
