Executives leading the largest for-profit health systems — Tenet Healthcare, HCA Healthcare, Community Health Systems and Universal Health Services — addressed upcoming federal policy risks tied to Medicaid and ACA subsidies during their third-quarter earnings calls.
The prospect of reduced Medicaid supplemental payments and the uncertain future of enhanced ACA premium tax credits has put policymakers and providers alike on edge. While the outlook remains unsettled, each system offered early views on how they are preparing.
HCA Healthcare
Nashville, Tenn.-based HCA raised its full-year 2025 guidance, partially due to favorable supplemental Medicaid payments, but emphasized that new approvals still pending with CMS were not yet reflected in projections.
Executives highlighted three states with applications under review: Florida, Georgia and Virginia.
“We do not expect that CMS will be approving these additional grandfathering programs during the shutdown.,” HCA CFO Mike Marks said. “We have reports that indicate, though, that the reviews between CMS and these states are active, and those reviews continue during the shutdown. We are … not going to size those potential applications until they get approved.”
HCA CEO Sam Hazen also advocated for extending enhanced ACA subsidies.
“We continue to advocate strongly for the extension of this program for the 24 million Americans who depend on it for health insurance coverage,” Mr. Hazen said. “Today, we believe there is greater recognition by legislators of the negative impact this issue will have on families, small businesses, and individuals than earlier in the year. At this point, however, we still do not know how this policy will play out.”
Community Health Systems
Franklin, Tenn.-based CHS similarly noted the role of supplemental Medicaid payments in supporting its third-quarter revenue per admission growth.
“About a third of that 5.6% improvement in same-store net revenue per [adjusted admissions] is a result of the Tennessee and New Mexico state-directed payment programs that were approved in the second quarter,” Chief Accounting Officer and Interim CFO Jason Johnson said. “The rest of the improvement is payer mix related, and there is some offset. We did have a little bit lower acuity.”
CHS executives also cited uncertainty around other pending state-level programs.
“There’s a couple other state-directed payment programs out there in Georgia, Florida, Indiana … which we can’t quantify at this point, but that should be incrementally positive for us,” President and Interim CEO Kevin Hammons said. “We’re continuing to make some growth investments.”
Tenet Healthcare
Dallas-based Tenet remains exposed to changes in ACA exchange dynamics through its Conifer Health Solutions business and self-pay populations, though direct commentary on federal cuts was more muted than at HCA or CHS.
CEO Saum Sutaria, MD, emphasized that Tenet’s government relations team continues to be very active and we’re monitoring all of these policies very closely.
“We’re not planning, nor are we saying that we expect the [ACA subsidies] to expire at this stage. Much of what we’re hearing is that it may take time, but a compromise will be achieved from our intelligence coming from Washington,” Dr. Sutaria said. “We are patiently waiting to see what happens there.”
Dr. Sutaria added that Conifer Health Solutions — Tenet’s revenue cycle subsidiary — could play a key role in helping patients navigate coverage changes if ACA exchange enrollment timelines shift. He explained that while Conifer has long supported Medicaid redeterminations and coverage transitions, it may be even more valuable if exchange enrollments are delayed or extended due to policy compromises in Washington.
“We have invested in the right capacity and capabilities to utilize Conifer’s ability to help with enrollment in our markets [and] in our clients’ markets on the exchanges if the exchange enrollment timeline gets delayed or extended,” Dr. Sutaria said. “The capabilities to help enroll in other products are there, but we’re also ramping up our investments and approach to support what might be a little bit of a dislocated enrollment timeline on the exchanges, given the potential for a later compromise.”
Universal Health Services
King of Prussia, Pa.-based UHS acknowledged possible risk tied to longer-term federal reimbursement trends, especially in behavioral health, which accounts for a large portion of its business.
As we discussed during our second quarter 2025 earnings call, the OB3 legislation includes several significant changes in the Medicaid program, including changes to state-directed payment programs and provider taxes.
“At this time, assuming no changes to our Medicaid revenues or other changes to related state or federal programs, we estimate that commencing with the 2028 fiscal years, our aggregate net benefit will be reduced on an annually increasing and relatively pro rata basis by approximately $420 to $470 million in 2032, “UHS CFO Steve Filton said. “This cumulative impact range has been increased to reflect recent supplemental program approvals. Given various uncertainties, including the evolving state-by-state interpretations and computations related to this legislation, our forecasted estimates are subject to change, potentially by material amounts.”
Mr. Filton also noted that UHS is tracking two pending Medicaid supplemental payment programs — one in Florida that could yield around $47 million annually, and another in Nevada estimated at $30 million — both of which are awaiting CMS approval. If approved, the combined benefit could total between $75 million and $80 million per year. He added that, to the company’s knowledge, no other material state-level approvals are pending.
On the ACA side, Mr. Filton said exchange patients now account for about 6% to 6.5% of UHS’ acute care admissions, with most of that growth seen in Texas and Florida. If enhanced ACA subsidies are not renewed, UHS estimates the financial hit could range from $50 million to $100 million annually.
“Given the increase in exchange volumes, we’re probably trending towards the higher end of that range,” Mr. Filton said.
