Health system finance leaders are seeing a common pressure emerge in 2026: As insurance coverage becomes less stable and patients shoulder more of their healthcare costs, some are putting off care until they can no longer wait.
CFOs at Phoenix-based Banner Health, Livonia, Mich.-based Trinity Health and Nashville, Tenn.-based HCA Healthcare, among other health systems, have noted that affordability and coverage pressures are influencing patient behavior, including elective surgery volumes. The effects vary by system, but all three are watching the intersection of rising uninsured volumes, out-of-pocket costs and delayed care.
The expiration of enhanced ACA premium tax credits at the end of 2025 has driven a larger-than-expected shift from exchange coverage to uninsured status at several of the country’s largest hospital operators. HCA, for example, now expects the payer mix shift to reduce its adjusted EBITDA by up to $1.2 billion in 2026.
The implications for health systems reach beyond payer mix, as affordability pressures increasingly shape when — and where — patients seek care.
Trinity Health sees patients waiting until conditions become critical
Daniel Isacksen Jr., executive vice president and CFO of Trinity Health, told Becker’s the system is seeing a significant increase in patients without insurance and signs that household financial pressures are affecting care decisions.
“Historically, household finances influence medical decisions and today’s patients are navigating a combination of factors including higher out-of-pocket costs, changes in insurance coverage and other household financial pressures,” Mr. Isacksen said.
“The number of patients we are seeing without insurance coverage is rising significantly, especially with the elimination of subsidies for ACA exchange plans,” he said. “This means patients are delaying care or waiting until health problems are critical and require emergency care.”
That shift poses both clinical and financial challenges. Patients who delay treatment may ultimately require more intensive care, while hospitals absorb a greater share of uncompensated costs when patients arrive without coverage.
The dynamic follows months of warnings from health system executives about growing uninsured volumes. Becker’s reported in May that fewer patients losing exchange coverage were transitioning to Medicaid than some hospital operators expected, adding another layer of pressure to payer mix.
Trinity Health is focusing on helping patients navigate coverage and financial assistance before those pressures lead to delayed treatment.
“Adequate health insurance coverage is critical to ensuring patients can access the care they need, when they need it,” Mr. Isacksen said. “We continue to help patients navigate their coverage and financial options so financial barriers do not lead to delays that can negatively affect their health.”
Banner: 3% of payer mix, 35% of elective decline
At Banner Health, the decline in hospital-based elective surgery has two distinct components: an intentional shift toward outpatient care and a more concerning drop among patients with individual exchange coverage.
“We’re seeing a decline in hospital-based elective surgeries in the first half of 2026 compared to last year, but the story is more nuanced than it might appear,” Staci Dickerson, executive vice president and CFO, told Becker’s.
“A significant part of the shift is actually intentional,” she said. “Banner has been investing in lower-cost ambulatory surgery centers for years, and patients are increasingly receiving the same high-quality care in those settings. That’s a good thing for affordability.”
The numbers for patients with individual exchange coverage tell a different story.
Those patients represent about 3% of Banner’s payer mix but account for 35% of its elective surgery decline, according to Ms. Dickerson. Elective surgery volume among that population has fallen 33%, compared with just a 4% decline across all payers.
“That disparity is something we’re watching closely,” she said.
Ms. Dickerson said about 300,000 Arizonans have lost coverage year over year through ACA and Medicaid changes.
“Coverage instability is a real factor,” she said. “When people are uncertain about their coverage, elective care is often the first thing they put off, which can lead to bigger health issues down the road.”
Banner entered 2026 preparing for that possibility. President and CEO Amy Perry told Becker’s in January that the system was working to get ahead of pressures including the prospect of fewer insured patients, while emphasizing operational discipline and efforts to expand access outside traditional hospital settings.
For patients losing coverage, Banner is connecting people with financial assistance and community resources.
“Our goal is simple: make sure cost or coverage uncertainty never gets between a patient and the care they need,” Ms. Dickerson said.
HCA sees the same pressure from two sides
HCA is seeing the affordability issue from both the coverage and patient-responsibility sides.
CFO Mike Marks said Sept. 15 at the Jefferies Healthcare Services and Technology Conference that patients losing ACA exchange coverage are migrating almost one-for-one into the uninsured population, while those who remain insured are shouldering a greater share of their healthcare costs.
“What we’re seeing this year is that our patients are owing a little bit more from benefit design, on employee-sponsored insurance, even a little bit on Medicare Advantage and then certainly on the exchanges,” Mr. Marks said. “There’s a bit of movement from silver to bronze and they’re owing more.”
But higher patient responsibility has not translated into greater collections.
“At the same time, given the economy, they’re not paying us more,” he said. “It’s one of the pressure points this year — we’ve seen a little bit of slowdown in our ability to collect out-of-pocket amounts due and they owe a little bit more.”
Becker’s reported that HCA’s same-facility inpatient surgeries fell 2.3% year over year in the second quarter and outpatient surgeries declined 3.4%. Elective inpatient procedures, which represent about one-third of its inpatient surgery volume, fell 6%.
Mr. Marks identified exchange coverage losses as the primary driver of HCA’s elective slowdown, with Medicare’s inpatient-only list changes contributing to shifts in orthopedic and spine procedures. But he also sees early indications that household finances may be influencing care decisions.
“It’s early, so this is still a bit of a hypothesis, but we believe we’re seeing some consumer sentiment on elective surgery,” Mr. Marks said. “Our early read is we think there could be some deferral of elective care right now that we saw in [the] second quarter.”
HCA’s experience is part of a broader divergence in elective surgery trends across large hospital operators. HCA, Franklin, Tenn.-based Community Health Systems and Dallas-based Tenet Healthcare all reported softness in elective procedures during the second quarter, while King of Prussia, Pa.-based Universal Health Services saw more modest weakness. Executives have pointed to different combinations of coverage losses, affordability and shifts toward outpatient settings.
The common thread across health systems such as Banner Health, Trinity Health and HCA is that affordability is becoming a more visible driver of hospital demand. As coverage becomes less stable and patients face higher out-of-pocket costs, health systems are watching more closely for signs that patients are delaying elective care, shifting to lower-cost settings or waiting until conditions become more acute.
