Even as its inpatient occupancy surged near the end of 2025, the nation’s largest for-profit hospital system said it has generally managed to avoid revenue-limiting capacity constraints and should continue to do so through 2026 even as its volumes grow.
HCA Healthcare, with its stock sitting at an all-time pricing high, pleased investors earlier this year when announcing a better-than-expected fourth-quarter performance and bullish 2026 guidance despite hundreds of millions in expected headwinds due to changes in Medicaid policy.
But, while that quarter’s same-facility equivalent admissions rose 2.5% over the prior year, in line with expectations, its inpatient surgeries remained flat while its outpatient surgical volume dipped by about 1.5%. At the same time, its hospitals were filled to about 73% to 74% capacity, a historical high point that could place strains on the operating efficiency of hospitals pulling the average upward.
The company has also acknowledged an expectation that some portion of health exchange volumes will drop as patients covered under health exchange plans either shift to lower tier plans or become uninsured. Still, executives said they expect volumes to grow between 2% and 3% across 2026.
Speaking Tuesday morning at the TD Cowen Health Care Conference, Chief Financial Officer Mike Marks said those potential spoilers were baked into the 2026 volume and revenue forecast.
On the outpatient side, Marks said the company has seen “good activity” across each of its segments in the past quarter but acknowledged that its surgery centers had seen declines in lower acuity surgery categories, such as ENT, and a decline in Medicaid volumes. Rather, he pointed to outpatient revenue growth and broad investments the company is making into that area: 100 business units added in the past year and a goal of 20 outpatient facilities per hospital by 2030. (Currently, the company sits at about 14.)
For the inpatient business, Marks said the company has continuously been adding about 600 to 700 beds to its inpatient units per year as part of its capital expenditure strategy. That, a multiyear effort to similarly add more operating rooms to hospitals and an ongoing resiliency plan that focuses on, among other things, managing length of stay helped HCA largely avoid hitting a ceiling in 2025.
Still, he admitted that occupancy levels differ across HCA’s 191 hospitals and that when some “get to 80%, to 90% full, it does start challenging your operations. And so, we try to make sure, at a hospital level, that we’re looking at those units and hospitals that are running hot, and that those [overloaded hospitals] generate the funding request and, frankly, even the enhanced effort on length of stay.”
HCA’s capital expenditures reached $4.9 billion across 2025, with the company announcing during its earnings report an increased capital spending range for 2026, from $5 billion to $5.5 billion. Executives said at the time that HCA’s current capital for approved projects coming online over the next two years was at an all-time high of nearly $7 billion.
Marks referenced the planned spending bump in his recent comments, saying such decisions reflect multiyear project planning but that the company continues “to see good opportunities in the hospitals, in our markets to fund CapEx for organic growth. … That’s positive, signaling that the opportunities, the pipeline of projects that we continue to see come up from the field, warrant incremental increases in our investments there.” HCA’s strategic expansions to its outpatient network will also help relieve the strain on hospital capacity, he added.
With those plans in motion, the greatest area of volume uncertainty for 2026—and for HCA’s broader revenue and earnings guidance—is activity within the exchanges. Marks was hesitant to give any early indication as to whether the first two months of the year were so far in line with HCA’s predictions (15% to 20% decline in exchange volumes, within which 15% to 20% would move to employee-sponsored coverage). Though he promised an update with first-quarter earnings numbers, he said it wouldn’t be until April and May that the company gets a more complete picture of attrition, metal tier shifts and utilization stemming from the policy changes.
Despite the obscurity, volume growth between 2% and 3%, he said, “still makes sense to us. It feels durable from our past, it feels durable from the investments we continue to make and have been making.”