The warning signs were visible for months.
Enhanced ACA premium tax credits expired at the end of 2025, and insurers are pulling back from the ACA marketplace while enrollment composition shifts toward high-deductible bronze plans. Now, the knock-on effects of these moves are beginning to emerge as leaders from the largest for-profit health systems elaborated on first-quarter results.
Nashville, Tenn.-based HCA Healthcare reported a 15% decline in exchange equivalent admissions in the first quarter while Dallas-based Tenet Healthcare saw exchange revenues fall roughly 9% to 10% year over year.
King of Prussia, Pa.-based Universal Health Services estimated a $15 million pretax hit in the quarter alone, with CFO Steve Filton warning the impact would “get larger as the year goes on … and that impact largely is reflected in higher bad debt and uncompensated care.”
Franklin, Tenn.-based Community Health Systems flagged the exchange environment as a meaningful headwind but said material effects are not expected until the second or third quarter.
All four systems held their full-year guidance, though none sounded particularly confident in doing so.
“The complexity of the exchanges is significant,” HCA CFO Mike Marks said April 24 during the company’s first-quarter earnings call. “The exchange environment remains dynamic and has not fully settled.”
The turbulence reflects a broader structural unraveling of the ACA marketplace that is accelerating this year and as major payers pull back coverage, shrink service areas or exit the ACA entirely amid mounting financial losses.
Total exchange enrollment has dropped to 23.1 million — a 5% decrease from 2025 — as the expiration of enhanced premium subsidies pushed average out-of-pocket premiums from $113 to $178 per month, according to CMS. The premium shock drove a dramatic shift in plan selection: Bronze enrollment surged 26% nationally, rising from 30% to 40% of total ACA enrollment, even as overall enrollment declined.
Hospital leaders are not just absorbing a financial hit from the exchange contraction. They are trying to manage it in real time, with incomplete data, moving targets and no clear sense of where the floor is.
The most direct impact is the shift from insured to uninsured volume.
In the first quarter, HCA reported a 16% increase in uninsured equivalent admissions compared to the fourth quarter, with more than half of that growth attributable to patients moving off exchange plans.
HCA said patients who lose or drop exchange coverage do not disappear from hospitals; they show up as uninsured, leading to care that is significantly harder to collect on.
“We see a lower collection rate on patient balances from the exchange plans as compared to traditional managed care patients, and this shift will have an impact on patient collections on care,” Mr. Marks said. “But from a context standpoint, I do not think that the impact of the shift and the growth in patient amounts due is going to be overly material, given the relatively minor portion of our patient cash collections that relate to exchange patients.”
The grace period dynamic compounds the accounting challenge.
Under ACA rules, patients receiving premium assistance have a 90-day grace period after missing a payment, but the payer is only required to cover care during the first month. For the remaining two months, executives said hospitals are left to estimate which patients will ultimately lose coverage and reserve accordingly.
“We generally do not have reliable third-party visibility at the time of service as to whether a premium has been paid,” Mr. Marks said. “Our work was to first look at every patient that came in with exchange and try our best to understand whether or not they had attrition during the quarter, at which point we recognize that revenue impact during the quarter, or make an estimate of those that we believe will lose and come out of their grace period with attrition — where we will not get paid and we will know that in second quarter and beyond.”
Tenet CFO Sun Park described a similar approach.
“Through Conifer, [we] pay very close attention patient by patient, if we can, on exchange coverage status, premium payment status and all those details,” Mr. Park said. “We will review this as the year develops and we get more data, but I think we are very appropriately reserved on our overall patient population, including exchanges. That speaks to the numbers that we shared in Q1, where admissions were down about 9% if you do the algebra. Revenues from exchanges are down probably 9% to 10% as well, so it is sort of one to one. We are in a very reasonable situation there, and we will continue to observe this as we go.”
Beyond volume, the shift toward bronze plans is creating a secondary pressure on collections even among patients who remain insured.
HCA noted a “bit of a shift from silver to bronze in the patient selection of metal tier” among its exchange patients, and flagged that benefit designs within silver plans are also carrying higher patient cost-sharing in 2026, according to Mr. Marks.
“All this is leading us to conclude that we are seeing a growth in patient amounts due on the exchanges,” he said.
CHS CEO Kevin Hammons told investors the company had “taken into consideration the additional risk of collectibility of copays and deductibles in that amount and have adjusted accordingly.”
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