For-profit hospital chain HCA Healthcare thrilled investors Tuesday with a solid fourth-quarter performance and higher-than-expected guidance for 2026.
The company announced a 6.7% year-over-year increase in fourth-quarter revenue to $19.5 billion and a 30.6% increase in net income attributable to HCA to $1.9 billion. The former of these was a slight miss from Wall Street’s expectations, while the latter was a clear beat.
For the coming year, the company issued estimated guidance of revenues between $76.5 billion and $80 billion, net income attributable to HCA of $6.5 billion to just over $7.04 billion ($29.10 to $31.50 per diluted share) and adjusted EBITDA between $15.55 billion and $16.45 billion.
Capital expenditures for the year (excluding acquisitions) are expected to fall between $5 billion and $5.5 billion. HCA’s board also authorized a new $10 billion share repurchase program.
Investors’ strong response—its shares have been trading anywhere from 7% to 12% higher through the day—came even as the company’s executives said they expect an adjusted EBITDA hit of anywhere from $600 million to $900 million during 2026 due to changes in the health insurance exchange market. The estimate is inclusive of administrative reforms around enrollment from last summer’s One Big Beautiful Bill Act and the expiration of enhanced premium tax credits.
Chief Financial Officer Mike Marks, when running down the 2026 guidance during Tuesday morning’s earnings call, said HCA is expecting to partially offset the exchange market hit by $400 million “through resiliency initiatives designed to generate efficiencies throughout the organization.” Responding to an analyst’s request for more detail, he said those initiatives comprise efforts around strengthened revenue integrity, capacity management and variable and fixed-cost efficiencies and capacity management.
At the same time, executives sought to characterize the resiliency gains not as an offset to the exchanges hit but as an ongoing agenda likely to bring greater boons over time as the company becomes more established in areas like artificial intelligence or payer-provider data exchange.
“As we get more capable at using these tools, it’s going to help us find even more opportunities,” CEO Sam Hazen said during the call. “But this is not a one-time event. It’s a cultural dynamic in our company around being cost effective, being high quality and finding ways to improve from a process standpoint and a leverage standpoint with our overall scale."
Health exchange volumes in 2025 comprised about 8% of HCA’s admissions and 10% of its revenue. The company expects about 15% to 20% of those volumes to drop off in 2026, Hart said, with about 15% to 20% of those drop-offs shifting to employer-sponsored coverage. Additionally, HCA is keeping an eye on whether there will be a material shift in the portion of exchange patients who change from silver plans to bronze plans, which could have an impact on care utilization and how easily HCA can collect payments, he added.
Volumes for the coming year are expected to fall within HCA’s long-term expectation of 2% to 3% annual growth, though Hart acknowledged that a 30% decline in utilization is expected among patients who become uninsured after losing their coverage on the exchanges.
On other policy issues, executives said they are viewing the Rural Health Transformation Fund as an opportunity for HCA’s 15% of rural hospitals, but, due to a lack of guidance so far, have not yet added that optimism to their 2026 projections. The company also warned of a year-over-year decline in the net benefit of supplemental payment programs—an earnings lifeline in 2025—somewhere in the range of $250 million and $450 million.
More broadly, the executives said they were optimistic in the company’s trajectory and credited its performance to the aforementioned resiliency efforts and strategic network expansion, which helped outpatient revenues grow at a faster rate than inpatient revenues. They added that no particular squeeze on labor is expected for the coming year, though ongoing physician cost pressures will likely be sustained.
HCA operated 190 hospitals and about 2,500 ambulatory care sites as of Dec. 31 in 19 states and the U.K. It is the first of its large for-profit, publicly traded peers to report fourth-quarter numbers and more meaningfully quantify the coming year’s policy headwinds.
For the full year, HCA’s revenues rose about 7.1% to $75.6 billion. Net income attributable to HCA was $6.8 billion ($28.33 per diluted share), up from 2024’s $5.8 billion ($22 per diluted share). Adjusted EBITDA also rose to $15.6 billion, up from $13.9 billion.
For the full year and on a same-facility basis, equivalent admissions grew by 2.4% as net revenue per equivalent admission rose 4.1%.
HCA repurchased $2.6 billion of its outstanding shares during the fourth quarter and about $10 billion across the full year. Cash flow from operations was $2.4 billion for the quarter and $12.6 billion for the year, the latter of which was about a 20% increase from 2024.