The ACA hospital cliff
Enhanced subsidies expired and premiums more than doubled. HCA’s 10-Q has uninsured admissions up 23 percent and no surgery rebound in the guide. The House passed an extension that is not law.
The extra help on Affordable Care Act premiums expired at the end of 2025. For subsidized enrollees, the average annual payment more than doubled — from about $888 to about $1,904, a 114 percent jump.
That help was the enhanced APTC, the premium tax credit that made marketplace coverage affordable. Net of the remaining subsidy, monthly payments rose from $113 to $178, up 58 percent. The share of enrollees receiving a credit fell from 92 percent to 87 percent — the first decline in uptake since 2020. The Congressional Budget Office projected about 2.2 million people lose coverage entirely in 2026.
Average subsidized premium, annual
KFF figures. Net-of-subsidy monthly payments rose 58 percent, from $113 to $178.
Healthier people leave first. Insurers have already added about a four-point morbidity adjustment because the remaining pool is sicker. Preliminary 2027 filings show a median 14 percent increase in the benchmark premium — 77 insurers across 16 states and the District, ranging from 1 to 52 percent. That is the start of an adverse-selection spiral, not the end of one.
What the hospitals printed
HCA, the largest for-profit hospital chain, cut 2026 guidance. The ACA-coverage decline, as recovered from a search snippet, could cost up to $1.1 billion this year, with about a $400 million pre-tax hit in the second quarter. Same-facility inpatient surgeries were down 2.3 percent from a year earlier; outpatient surgeries were down 3.4 percent. An HCA executive separately blamed dented outpatient volumes on the “ACA exchange exodus.” Tenet, Universal Health Services, and Community Health Systems sold off with it.
The second-quarter 10-Q then printed the mix the snippet could not. Uninsured admissions were up 23.4 percent. Uncompensated-care cost came in at $1.445 billion against $1.116 billion. Those are filing numbers. They are not the same as the $1.1 billion coverage-hit figure.
Our guidance for the balance of the year does not consider a rebound in surgery.
Hazen, 9 September 2026
Hospitals had left the back half as a tell. Hazen answered it. In the same account, patients migrated almost one for one to uninsured. Third-quarter 2026 is still unprinted. A snapback has not shown up in what has been filed. Deferral is an air pocket. Permanent uninsured attrition is a downgrade. The second-half test is still open. It is no longer a blank.
Intuitive Surgical, which makes the da Vinci robot, is the medtech echo. US procedure growth slowed to 12 percent in the second quarter, from 14 percent in the first, concentrated in cases that can wait. Management said “changes in patient coverage and premium dynamics may be affecting when patients seek care.” The chief financial officer also hedged: there is “likely some impact from ACA, but also the law of large numbers.” The company held full-year guidance at the midpoint.