Loss of ACA Tax Credits Strained Hospital Earnings

Hospital operators must brace for lower procedure volumes as patients face higher costs and coverage gaps.

Updated on Sept. 22, 2026 in Healthcare

Isometric editorial illustration of a surgical tray with a scalpel and gauze, representing a decline in medical procedure volumes. — Major health systems are reporting a decline in elective surgery volumes following the expiration of enhanced ACA tax credits, which has left patients facing increased out-of-pocket costs. AI Illustration. Upload story photo >

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The expiration of enhanced ACA premium tax credits at the end of 2025 has triggered a significant shift in patient insurance status, leading to widespread deferral of elective care. Major health systems are reporting reduced surgery volumes as patients navigate the resulting increase in out-of-pocket expenses.

Why it matters

Rising coverage insecurity has caused a drop in patient demand for elective procedures, forcing providers to adapt to lower margins and shifts in payer mix. This volatility is driven by the policy change which has pushed many patients toward uninsured status or lower-tier coverage plans.

HCA Healthcare faces an expected $1.2 billion reduction in 2026 adjusted EBITDA, following a 6% decline in elective inpatient procedures during the second quarter. Meanwhile, roughly 300,000 Arizonans lost health coverage year-over-year, impacting hospital systems like Banner Health.

The players

HCA Healthcare

A Nashville-based operator of over 180 hospitals and 2,000 sites of care across the U.S.

Banner Health

An Arizona-headquartered nonprofit health system operating in six states.

The details

Patients are increasingly delaying medical procedures due to higher out-of-pocket costs and uncertainty after the expiration of enhanced premium tax credits. This shift is causing a measurable decline in elective volume, with HCA Healthcare reporting decreases of 2.3% in same-facility inpatient surgeries and 3.4% in outpatient surgeries during the second quarter. Systems are responding by connecting patients with internal financial assistance programs and migrating care to lower-cost ambulatory surgery settings.

Enhanced ACA premium tax credits expired at the end of 2025.
Banner Health leadership prepared for coverage pressure in January 2026.
Becker's reported lower-than-expected Medicaid transitions in May 2026.
HCA Healthcare reported surgery volume declines throughout Q2 2026.
The HCA CFO discussed these affordability impacts on September 15, 2026.

Market Landscape

The expiration of the Affordable Care Act premium tax credits marks a reversal of the coverage trends established by earlier legislative expansions. This change creates a new hurdle for hospital systems that had previously seen volume growth fueled by expanded exchange participation.

Operators should re-evaluate their patient mix and financial assistance workflows to address the rising shift toward uninsured or high-deductible status. Monitoring elective procedure volume by payer class will be essential for adjusting near-term margin expectations.

The takeaway

The end of federal premium supports is forcing a structural shift in elective patient demand that requires closer scrutiny of revenue cycle management. Operators should track the decline in exchange-covered procedures as a leading indicator for potential EBITDA volatility in upcoming quarters.