U.S. hospitals are now treating fewer patients with health insurance purchased through an ACA exchange. Hospitals are also seeing more uninsured patients and patients with skimpy commercial coverage.
The patients with high-deductible commercial coverage seem to be waiting until later in the year, when they have met their deductibles, to have elective surgical procedures.
Executives from the hospitals told securities analysts about the impact of exchange system shrinkage and increased commercial plan cost-sharing during conference calls their companies held to go over earnings for the second quarter.
The companies streamed the analyst calls live and have posted recordings in the investor relations sections on their websites.
What it means: Hospital executives have a strong interest in negotiating for what they see as sustainable network contract rates, and talk about deferred elective procedures could be a sign that lack of preventive care and routine sick care will lead to an increase in the number of employer plan participants who end up with serious, preventable conditions.
The ACA exchange system shift: Hospital executives were expecting ACA exchange plan patient volume to drop.
Congress decided against renewing a temporary premium subsidy boost that had been provided in response to the COVID-19 pandemic.
The number of patients who kept their exchange plan coverage was in line with or higher than what the big hospital companies had expected, but Samuel Hazen, the chief executive officer of HCA Healthcare, said HCA was surprised about how little increases in enrollment in Medicaid, employer plan coverage and other forms of coverage have offset the decreases in exchange plan enrollment.
The numbers: At HCA Healthcare, the number of admissions for people covered by ACA exchange plans fell 15%, and the drop was steeper in Florida.
At Tenet Healthcare, the number of exchange admissions fell only 13.5%. Exchange patient revenue fell 17%. Revenue fell more than enrollment because many of the people who still have exchange plan coverage have skimpier benefits and higher deductibles. For Tenet, the big, exchange-related patient volume hits caused the biggest problems in Arizona, Florida, Michigan, South Carolina and Texas.
At Community Health Systems, the total number of admissions, adjusted for various variables, was 2.9% higher in the second quarter of this year than in the second quarter of 2025. “Approximately half of the growth in adjusted admissions during the second quarter was from uninsured patients,” according to Jason Johnson, Community Health Systems’ chief financial officer.
Kevin Hammons, Community Health Systems’ chief executive officer, said the value of uncompensated care at Community Health Systems as a percentage of revenue increased to 6.1% in the latest quarter, from 5% in the year-earlier quarter.
The impact on care: Hammons noted that the biggest decline in surgery volume at his company’s hospitals has been for elective procedures, and especially for orthopedic procedures.
“So, your hip and knee and shoulder replacements,” Hammons said. “Those are typically procedures that people can delay or at least defer for periods of time, get a cortisone shot, maybe continue to try to manage the pain through rehab.”
Hammons said similar forces seem to be affecting the number of heart surgeries performed.
“Intuitively, those seem less elective, but they really are more elective,” Hammons said. “As people defer visits to their cardiologists and defer some of their screenings, oftentimes, those procedures also get deferred.”
The decline appears to be similar to the decline that occurred during the COVID-19 pandemic, Hammons said.
The emergency room: The hospital executives talked about early signs that lack of coverage and fear of high out-of-pocket costs are causing people to wait until they have serious, potentially costly problems to get care.
At Community Health Systems, “we’re not seeing a decline in the emergency room,” Hammons said.
At HCA, overall inpatient surgeries were down 2.3%, and outpatient surgeries were down 3.4, according to Mike Marks, HCA’s chief financial officer. But HCA’s emergency room visit volume increased by 3.6%, and the number of inpatient cases coming in from HCA’s emergency rooms increased 2%.
Similarly, Tenet has seen strong emergency department volume and an increase in the number of inpatient surgery cases coming in through Tenet emergency rooms.