Interactive investigation · November 2026
More Patients, Less Money
Why America’s hospitals are busier and poorer at the same time, and how the Emrick Paid Volume Model separates paid growth from unpaid growth.
- Q3 2026: CHS, HCA, Tenet, UHS
- Live Paid Volume Model
- 2027 headwind ledger
- 90-day playbook
01 · The contradiction
Every major operator got busier. Almost none earned more per patient.
For a decade, hospital leaders treated rising volume as the cure for weak margins: fill the beds and the fixed costs take care of themselves. The third quarter of 2026 broke that assumption in public. HCA, Community Health Systems, Tenet, and Universal Health Services all reported more patients than a year earlier. Revenue per patient barely moved, and the weakest operator lost money while getting busier.
The cause is well documented. When the enhanced ACA premium tax credits expired at the end of 2025, subsidized enrollees saw premium payments rise an average of 114 percent and about three million people left the marketplaces by midyear. They kept arriving at hospitals, now as uninsured patients. Executives at HCA, UHS, and Tenet described the migration in nearly identical terms: almost one for one.
The central question
The question for every hospital board in 2027 is no longer “Are we growing?” It is “How much of our growth is paid?”
+27%
Rise in HCA uninsured admissions, against 3% growth in total volume
HCA 10-Q
~$400M
HCA’s estimated one-quarter earnings hit from the exchange to uninsured shift
HCA earnings call
+0.2%
CHS revenue per adjusted admission growth, down from +3.7% in Q1
CHS Q3 2026 results
32.9%
CHS uncompensated care as a share of adjusted net revenue, up from 25.2%
Jefferies via Healthcare Dive
$86M
CHS net loss in the quarter, versus $130 million net income a year earlier
CHS Form 8-K
43%
Share of U.S. hospitals operating in the red (August data), up from 33% before the pandemic
Kaufman Hall
Volume grew everywhere. Yield grew almost nowhere.
Q3 2026 vs Q3 2025, same-facility basis, percent change. UHS is acute care only; Tenet is its hospital segment.
View the published figure
Five findings
- Volume and yield have decoupled. Same-facility adjusted admissions rose 3.0% to 4.9% at all four operators; revenue per adjusted admission rose 0.2% to 0.6% at three and fell 1.7% at the fourth.
- The new volume is disproportionately unpaid. HCA’s uninsured admissions rose 27% while total volume rose 3%. CHS said roughly half of its admission growth was uninsured.
- Unpaid care is growing many times faster than care. HCA’s total uncompensated care rose 24% and charity care 38%; national bad debt and charity care per day rose 18% in March.
- The Tenet exception is not a hospital exception. Tenet’s hospitals grew yield only 0.2%. Its outperformance came from one-time items, cost control, and ambulatory surgery.
- 2027 adds pressure before it relieves it. Premiums rise again, Medicaid work requirements are scheduled for January 1, and the November 4 outpatient rule adds site-neutral imaging and 340B cuts.
02 · What the third quarter numbers say
Four operators, one pattern
Third quarter 2026 scorecard
| Measure (Q3 2026 vs Q3 2025) | Community Health Systems | HCA Healthcare | Tenet Healthcare | Universal Health Services |
|---|---|---|---|---|
| Net operating revenue | $2.757B (down 10.7%; ten hospitals divested; same-store up 3.8%) | $19.849B (up 3.6%) | $5.631B (up 6.5%), excluding $646M contract termination revenue | $4.733B (up 5.3%) |
| Net income attributable | $86M loss vs $130M income | $1,579M vs $1,643M | $1,000M vs $342M (includes termination revenue) | $308.7M vs $373.0M |
| Adjusted EBITDA | $280M vs $376M | $3,918M vs $3,870M | $1,355M vs $1,099M | $624.6M vs $670.6M (net of NCI) |
| Adjusted EBITDA margin | 10.2% vs 12.2% | 19.7% vs 20.2% (derived) | 21.8% excluding transition items (24.1% reported) | 13.2% vs 14.9% (derived) |
| Same-facility adjusted admissions | +3.6% | +3.0% (equivalent admissions) | +3.2% (hospitals) | +4.9% (acute care) |
| Net revenue per adjusted admission | +0.2% (vs +3.7% in Q1) | +0.6% | +0.2% (hospitals) | −1.7% (acute care) |
| Surgical trend | Surgeries +2%; commercial electives deferred | Inpatient −1.4%; outpatient −3.7% | Ambulatory cases −1.5%; revenue per case +6.1% | Not disclosed in sources reviewed |
| 2026 outlook | Cut again; medium-term targets withdrawn | Reaffirmed; upper half expected | Adjusted EBITDA raised $195M at midpoint | Not reviewed |
Derived margins divide reported adjusted EBITDA by reported revenue. Sources: company releases, Forms 8-K and 10-Q; Earnings Whispers; Fierce Healthcare; Becker’s Hospital Review.
The margin divide widened in a single year
Adjusted EBITDA margin, Q3 2025 (gray) vs Q3 2026. Tenet 2026 excludes one-time transition items, as reported.
View the published figure
CHS: every revision pointed down
2026 adjusted EBITDA guidance ranges, $ millions. Bars span low to high.
View the published figure
Where HCA’s volume growth came from
Q3 2026 vs Q3 2025, percent change by coverage group.
View the published figure
HCA revenue by payer, Q3
| $ millions | Q3 2025 | Q3 2026 | Change |
|---|---|---|---|
| Managed care and insurers | 9,267 | 9,574 | +3.3% |
| Medicare (traditional) | 2,728 | 2,925 | +7.2% |
| Managed Medicare | 3,306 | 3,530 | +6.8% |
| Medicaid (traditional) | 1,783 | 1,765 | −1.0% |
| Managed Medicaid | 949 | 961 | +1.3% |
| Other, including uninsured | 644 | 602 | −6.5% |
| Total uncompensated care | 1,188 | 1,477 | +24.3% |
| Of which charity care | 408 | 562 | +37.7% |
Uninsured admissions rose 27% while the “other, including uninsured” revenue line fell 6.5%. Source: HCA Form 10-Q.
“We continue to see patients who have lost coverage on the exchanges migrate almost one-for-one to uninsured.”
Taking the Tenet exception apart
Tenet adjusted EBITDA bridge, Q3 2025 to Q3 2026, $ millions. Tenet’s hospitals grew revenue per adjusted admission only 0.2%, the same as CHS.
USPI produced about 24% of revenue and 40% of adjusted EBITDA at a 39.2% margin. Uninsured patients rarely reach an ambulatory surgery center through an emergency department. Tenet has not escaped the payer mix shift; it has diversified earnings away from the part of the business that absorbs it.
View the published figure
03 · Where the uninsured came from
From a federal subsidy cliff to a hospital income statement
Policy and coverage, 2026
Hospital front door, Q2 and Q3 2026
Already scheduled for 2027
View the published figure
Unpaid care is growing many times faster than volume
Year-over-year growth in reported uncompensated care measures, 2026.
View the published figure
“It felt like virtually everyone who lost their exchange coverage became an uninsured patient.”
Kaufman Hall’s national data, drawn mostly from nonprofit hospitals, point the same way: bad debt and charity care per calendar day rose 8% in January and 18% in March year over year, and stood 46% above the first quarter of 2023. The investor-owned chains simply reported it first.
Original framework
The Emrick Paid Volume Model
Four measures that separate paid growth from unpaid growth, monthly, by site
“Busy” is not a financial result. The question every leader must answer is: how much of our new volume is paid?
Paid Volume Ratio
What share of our volume growth came from patients with coverage?
insured adj. admission growth ÷ total adj. admission growth
- ✓0.90 or higher
- !0.60 to 0.89
- ×below 0.60
Yield Drift
Is revenue per unit of care keeping pace with cost per unit of care?
% change revenue per adj. admission − % change cost per adj. admission
- ✓0 points or better
- !0 to −2 points
- ×worse than −2 points
Uninsured Absorption
How fast is the uninsured share of our volume rising?
change in uninsured share of adj. admissions, percentage points per year
- ✓under +0.5 points
- !+0.5 to +1.5 points
- ×above +1.5 points
Offset Ratio
How many insured cases does it take to cover one uninsured case?
(variable cost − uninsured collections) ÷ (insured revenue − variable cost)
- ✓under 1.0
- !1.0 to 1.5
- ×above 1.5
Score your hospital
Enter your own figures or start from a preset. Every output recalculates instantly. Defaults reproduce the report’s worked example (Table 5).
The Emrick Paid Volume Model: scorecard
Growth is consuming margin
Two red gauges: treat this as a financial event, not a census report.
0.23
Paid Volume Ratio
Red
−1.3 pts
Yield Drift
Amber
+2.4 pts
Uninsured Absorption
Red
1.33
Offset Ratio
Amber
| Measure | Prior year | Current year | Change |
|---|---|---|---|
| Total adjusted admissions | 16,000 | 16,560 | +3.5% |
| Insured adjusted admissions | 14,880 | 15,000 | +0.8% |
| Uninsured adjusted admissions | 1,120 | 1,560 | +39.3% |
| Uninsured share | 7.0% | 9.4% | +2.4 pts |
| Net patient revenue | $224.3M | $226.6M | +1.0% |
| Revenue per adjusted admission | $14,020 | $13,681 | −2.4% |
| Total cost | $219.0M | $224.0M | +2.3% |
| Cost per adjusted admission | $13,688 | $13,529 | −1.2% |
| Operating income | $5.3M | $2.5M | −52.6% |
| Operating margin | 2.4% | 1.1% | −1.3 pts |
+$6,000
Contribution of each insured case
−$8,000
Contribution of each uninsured case
587
Insured cases needed to offset this year’s uninsured increase
Illustrative model. Thresholds are proposed management heuristics, not externally validated benchmarks. © 2026 Kelly Emrick, DHSc, PhD, MBA, BSRT(ARRT)R.
1
Measure
Compute all four monthly, by hospital and by service line, from registration, claims, and cost accounting data you already have.
2
Diagnose
Two or more red gauges means growth is consuming margin. Treat it as a financial event, not a census report.
3
Act
Fix the front door first (coverage), then mix (paid capacity), then cost (unit economics). See the Playbook tab.
View the published model figure
View the published worked example figure
05 · Scenario explorer
How much unpaid growth can your hospital absorb?
Operating income change by volume growth and uninsured share of new volume
Uses every other input from the Emrick Model tab (mix, migration, unit economics). The outlined cell is the grid point nearest your scenario. Blue cells grow operating income; orange cells shrink it.
| Sensitivity grid loads with the interactive model. |
At 3.5% growth, operating income holds only if no more than a computed share of new volume is uninsured.
The Offset Ratio in plain numbers
From your unit economics on the model tab.
133
insured adjusted admissions are needed to offset every 100 new uninsured adjusted admissions
Break-even line
Highest uninsured share of new volume at which operating income does not fall, by volume growth rate.
06 · The model applied
The public operators, scored where disclosures allow
HCA Healthcare
Red on two gauges- Paid Volume Ratio
- About 0.25 Red
- Uninsured Absorption
- +2.0 pts (8.5% to 10.5%) Red
- Revenue per adjusted admission
- +0.6%
Derived: insured equivalent admissions grew about 0.75% (3.0% total growth with the uninsured share rising from 8.5% to 10.5%), divided by 3.0% total growth. Strong cost control kept margin nearly flat.
Community Health Systems
Red- Paid Volume Ratio
- About 0.5 Red
- Uninsured Absorption
- Not disclosed; uncompensated care up 7.7 points of revenue
- Revenue per adjusted admission
- +0.2%
Management said roughly half of admission growth was uninsured, so the ratio is approximate. Growth is consuming margin: adjusted EBITDA fell from $376M to $280M as admissions rose 3.6%.
Tenet Healthcare (hospitals)
Hospital yield flat- Paid Volume Ratio
- Not disclosed
- Uninsured Absorption
- Not disclosed; exchange admissions and revenue down 18%
- Revenue per adjusted admission
- +0.2%
The enterprise is protected by its ambulatory surgery mix (about 40% of adjusted EBITDA), not by different hospital economics.
Universal Health Services (acute)
Yield declining- Paid Volume Ratio
- Not disclosed
- Uninsured Absorption
- Not disclosed; Q1 uninsured discounts up 47%
- Revenue per adjusted admission
- −1.7%
The fastest volume growth of the group (+4.9%) came with falling revenue per unit of care.
Yield Drift and Offset Ratio require cost per case data that the companies do not disclose. Status chips carry text labels so they never rely on color alone.
07 · What is already known about 2027
The 2027 ledger: headwinds and tailwinds
ACA marketplace premiums
Benchmark premiums rise an average 13% for 2027 after 26% in 2026. At least 11 insurers announced exits from one or more state marketplaces. Open enrollment began November 1.
Medicaid work requirements
Community engagement requirements for expansion adults are scheduled to begin January 1, 2027. CBO estimates about 5.3 million people lose coverage from this provision by 2034.
Medicaid supplemental payments
HCA expects $550 million to $650 million less net benefit in 2027 as prior-year state program approvals roll off.
340B drug payment (OPPS final rule)
Payment for 340B-acquired drugs falls to average sales price minus 28%, and the 340B remedy offset rises from 0.5% to 2% of the non-drug conversion factor until about 2031.
Site-neutral imaging (OPPS final rule)
Imaging without contrast at excepted off-campus departments is paid at the physician fee schedule equivalent rate: about $260 million less in first-year Part B spending. Rural sole community hospitals are exempt.
Physician fee schedule final rule
Conversion factors fall 2.31% for most clinicians and 1.83% for qualifying APM participants, offset for office visits by a new E/M modifier.
OPPS base update
Outpatient rates rise 2.3% (3.2% market basket less 0.9 points productivity). 340B savings are redistributed to non-drug services budget neutrally. CHS cites roughly a 5% net Medicare outpatient increase.
Deductible reset and deferred electives
CHS expects deferred commercial electives to return in early 2027. HCA expects 2% to 3% volume growth.
Exchange losses slowing
HCA expects fewer people to lose exchange coverage in 2027 than in 2026, because the largest shock has already occurred.
Structural cost programs
CHS reports more than $100 million of annualized savings and $25 million to $30 million of Rural Health Transformation Program awards.
Sources: KFF; CMS CY 2027 OPPS/ASC final rule (CMS-1850-F), November 4, 2026; AHA summary of the CY 2027 physician fee schedule final rule; CBO; HCA and CHS Q3 2026 calls.
08 · What to do about it
A 90-day playbook to protect paid volume
Front door first, then mix, then cost. Check off actions as your team puts them in motion.
0 of 7
No actions underway yet.
Questions every board should ask in 2027
- What share of our volume growth this year came from insured patients, by quarter?
- Is net revenue per adjusted admission growing faster or slower than cost per adjusted admission?
- How much uninsured growth enters through the emergency department versus scheduled care?
- How many active patients could lose Medicaid under the work requirements, and what are we doing before January 1?
- How much of our earnings comes from settings the payer mix shift does not reach?
- What is our exposure to the site-neutral imaging and 340B changes finalized November 4?
- If our 2027 budget assumes volume growth, how much of it have we assumed will be paid?
09 · Methods and sources
How this investigation was built
Methods and limitations
This dashboard draws on third quarter 2026 earnings releases, Forms 8-K and 10-Q, and earnings call commentary from Community Health Systems, HCA Healthcare, Tenet Healthcare, and Universal Health Services, supplemented by trade press reporting and by CMS, KFF, the Congressional Budget Office, and Kaufman Hall. Values labeled derived were calculated by the author from reported figures.
Companies define volume differently (adjusted admissions or equivalent admissions) and same-facility definitions vary, so cross-company comparisons are directional. Investor-owned operators are not representative of all hospitals, though national data point the same way. The model’s worked example and presets are illustrative. Paid Volume Model thresholds are proposed management heuristics and have not been externally validated. Nothing here is investment advice.
Companion report: More Patients, Less Money, an investigative report by Kelly Emrick, DHSc, PhD, MBA, BSRT(ARRT)R, November 2026.
References
- American Hospital Association (2026, Nov 4). CMS issues CY 2027 physician fee schedule final rule. aha.org
- Centers for Medicare & Medicaid Services (2026, Nov 4). CY 2027 OPPS and ASC final rule (CMS-1850-F) fact sheet. cms.gov
- Community Health Systems (2026, Oct 28). Third quarter 2026 results, Form 8-K Exhibit 99.1. sec.gov
- Earnings Whispers (2026, Oct 29). Community Health Systems misses badly as payor mix erodes. earningswhispers.com
- HCA Healthcare (2026). Form 10-Q for the quarter ended September 30, 2026. sec.gov
- Healthcare Finance News (2026). HCA’s bottom line impacted by ACA policy changes. healthcarefinancenews.com
- Healthcare Dive (2026). CHS lowers full-year earnings forecast on uninsured volumes, surgery snags. healthcaredive.com
- Tenet Healthcare (2026, Oct 29). Third quarter 2026 earnings release. tenethealth.com
- Universal Health Services (2026). Q3 2026 Form 8-K Exhibit 99.1 and Q1 2026 Form 10-Q. sec.gov
- Becker’s Payer Issues (2026). UHS CFO on exchange coverage loss. beckerspayer.com
- Becker’s Hospital Review (2026). The hospital finance divide: 15 things to know (Kaufman Hall). beckershospitalreview.com
- Becker’s ASC Review (2026). Hospital bad debt is up 46% (Kaufman Hall). beckersasc.com
- KFF (2026, Jun 29). ACA marketplace enrollment is down by 3 million after big jump in premium payments. kff.org
- KFF (2026). How has ACA marketplace enrollment changed across states in 2026? kff.org
- WJLA, Sinclair national desk (2026, Oct 30). ACA premiums jump for second straight year. wjla.com
- Congressional Budget Office estimate of coverage effects of the 2025 reconciliation law, as summarized by AAPP. aapp.org