The four largest US for-profit hospital operators reported third-quarter results between Oct. 27 and Oct. 29, and the same pattern ran through all of them. More patients came in, but the average payment per patient was flat or falling.
The reason is payer mix. People who lost Affordable Care Act exchange coverage after the enhanced subsidies expired are still getting sick, and they are now arriving uninsured.
Same-facility adjusted admissions growth, Q3 2026 vs. Q3 2025
| Label | Value |
|---|---|
| UHS (acute care) | 4.9% |
| Community Health Systems | 3.6% |
| Tenet Healthcare | 3.2% |
| HCA Healthcare (equivalent admissions) | 3.0% |
Volume is up, pricing isn't
Admissions growth of 3% to 5% would normally carry revenue with it. This quarter, revenue per adjusted admission barely moved at the two largest operators and fell at Universal Health Services.
Revenue per adjusted admission, year-on-year change
| Label | Value |
|---|---|
| HCA Healthcare (per equivalent admission) | +0.6% |
| Tenet Healthcare (net patient service revenue) | +0.2% |
| UHS acute care | -1.7% |
Same-facility figures for the third quarter of 2026.
HCA put a number on the uninsured problem: about $400 million
HCA Healthcare, the largest operator, reported revenue of $19.85 billion, up 3.6%, and adjusted EBITDA of $3.92 billion. It said rising uninsured volume, mostly from patients who lost exchange coverage, cut pre-tax income by about $400 million in the quarter.
On the earnings call, CFO Mike Marks said uninsured patients made up about 10.5% of equivalent admissions, up from 8.5% a year earlier, according to an Investing.com transcript. Exchange volume was down about 19% from last year's peak, though it rose 8% from the second quarter.
Uninsured share of HCA's equivalent admissions
| Label | Value |
|---|---|
| Q3 2025 | 8.5% |
| Q3 2026 | 10.5% |
HCA estimates the shift cost it about $400 million in pre-tax income in Q3 2026.
Source: HCA Q3 2026 earnings call, via Investing.com; HCA Form 8-K
HCA beat consensus and said it now expects to land in the upper half of its 2026 guidance. Its shares still fell, because management said 2027 earnings would be roughly flat with 2026. It also expects Medicaid supplemental payments to fall by $550 million to $650 million next year.
Scale decided who absorbed the hit
The four operators started from very different margins, and that shaped how the payer-mix squeeze showed up in their results.
Adjusted EBITDA margin, Q3 2026
| Label | Value |
|---|---|
| Tenet Healthcare (includes one-time gain) | 24.1% |
| HCA Healthcare | 19.7% |
| UHS (net of minority interests) | 13.2% |
| Community Health Systems | 10.2% |
Tenet's margin is as reported. Margins for HCA, UHS and CHS are Rounds' calculations from adjusted EBITDA and revenue in each release.
- Tenet raised its 2026 adjusted EBITDA outlook to $5.05–5.20 billion. Its quarter included a net $147 million benefit from ending its Conifer revenue-cycle contracts with CommonSpirit early, and its ambulatory surgery business cushions it from hospital payer mix.
- UHS grew revenue 5.3%, but net income fell to $308.7 million from $373.0 million as acute-care pricing slipped.
- Community Health Systems, the most rural of the four, posted a net loss of $86 million and cut its 2026 adjusted EBITDA outlook to $1.225–1.275 billion, a 6.5% reduction at the midpoint.
We are seeing the deferral among patients that have copays and deductibles.
Kevin Hammons, CEO, Community Health Systems
CHS now expects exchange disenrollment to cost it $80 million to $90 million this year, up from its earlier estimate of $50 million to $75 million.
What to watch next
- Whether exchange volume keeps recovering. HCA's rose 8% from the second quarter to the third.
- Ardent Health's results, the next for-profit operator to report, for a read on whether the uninsured shift is spreading.
- HCA's full 2027 guidance in January, which will show how much of the Medicaid supplemental decline it can offset.
