It looks like it’s time to revisit most projections about the effect a major overhaul of health insurance exchanges will have on the number of uninsured in the U.S. healthcare system.

Reporting their second-quarter earnings last week, the top executives of three hospital companies said that more people than they had expected have become uninsured – and not picked up other forms of coverage – after leaving the insurance exchanges. In the first half of the year, leaders of HCA Healthcare Inc., the largest for-profit hospital operator, had forecasted that roughly one in five or six people leaving exchanges would find coverage in employer-sponsored plans or elsewhere.

HCA executives, as well as their peers at Tenet Healthcare Corp. and Community Health Systems Inc., also said they expected that people who lost exchange coverage would use the healthcare system less intensely. Heading into August, neither of those expectations is materializing.

To wit, from HCA CEO Sam Hazen: “We expected some of these patients to shift to other forms of coverage but this did not happen. Instead, these patients migrated almost one-for-one to uninsured.”

From Tenet CFO Sun Park: “We are roughly seeing a pretty consistent conversion from exchange patient volume into uninsured on a pretty much one-to-one basis.”

And from Kevin Hammons, president and CEO of CHS: “I think the increase in uninsured is primarily coming from the exchange business. You don’t have complete visibility into that but it seems to be the most direct correlation.”

The turmoil in the exchange markets produced a stunning statistic in the second-quarter results of CHS, which runs 60 hospitals in a dozen states: Same-store adjusted admissions rose 2.9 percent in the three months ended June 30 but about half of that number was due to visits by uninsured patients that generated “minimal” revenue.

Together with a relative drop in surgeries, that trend played a big part in the quarter’s net revenue per adjusted admission falling 0.5 percent from the spring of 2025. Hammons said on his team’s July 23 conference call that uncompensated or self-pay visits account for a little more than 6 percent of CHS’ second-quarter count, an increase of more than a percentage point from the prior-year period.

At Tenet, the exchange trends put a $65 million dent in revenues during the second quarter but Park told analysts and investors on July 24 that the company’s teams were able to contain costs and grow elsewhere to absorb that hit.

HCA’s numbers are far bigger at $400 million in pre-tax profits during Q2 and were detailed by Hazen and his team earlier in July. Speaking July 24, Hazen said three of the company’s divisions were particularly affected by the shift to uninsured volumes, which also grew in part to fewer Texas patients converting from Medicaid plans. In two of those regions, he added, volumes were actually up year over year but, as at CHS, driven in part by patients paying little or nothing for their care.

“Our payer mix is actually the same in Medicare as it was last year. Medicaid: as it was last year. Managed care and other: as it was last year,” Hazen said. “And then [exchanges] and self-pay uninsured together are exactly as they were last year. And so our conclusion on one-for-one is reinforced, we believe, by that sort of fact. For us, obviously, it’s not a good thing; we still have to take care of these patients. And we do and our people do a wonderful job. But it does put pressure on the P&L.”

Where to from here? Park told investors the Tenet team expects the link between people leaving exchanges and becoming uninsured to last through the second half of this year. But Tenet Chairman and CEO Suam Sutaria said he’s not interested in projecting very far into the future on exchange dynamics.

“I really don’t want to guess about exchange enrollment in the following year without the data points of seeing what happens in the next two quarters,” Sutaria said. “We planned for [the spike to] moderate into Q3 and Q4 based upon what we would imagine the trend line would look like and we’ve built that into our guidance.

“This is not a game of perfect forecasting,” Sutaria added. “It’s a game of using the available data.”

A native of Belgium, Geert De Lombaerde has more than two decades of business journalism experience and writes about markets and economic trends for Endeavor Business Media publications Healthcare Innovation, IndustryWeek, FleetOwner, Oil & Gas Journal and T&D World. With a degree in journalism from the University of Missouri, he began his reporting career at the Business Courier in Cincinnati and later was managing editor and editor of the Nashville Business Journal. Most recently, he oversaw the online and print products of the Nashville Post for more than a decade and reported primarily on Middle Tennessee’s finance sector as well as many of its publicly traded companies.