Hospitals are seeing more uninsured patients after ACA subsidy expirations

Hospitals say their finances are suffering after the expiration of pandemic-era subsidies that made Affordable Care Act (ACA) marketplace coverage more affordable.

These subsidies existed before Covid-19, but the government expanded their size and scope in March 2021. After that, marketplace enrollment ballooned from 11.4 million in 2019 to 24.3 million in 2025. On Dec. 31 last year, after a prolonged battle in Congress, the expansion ended.

Enrollment is on its way back down, too. About 1 million fewer people signed up for ACA insurance this year compared to last year and millions more may lose coverage as the year goes on, in part because they aren’t paying their monthly premiums, per KFF projections. Those who did enroll in the marketplace this year were more likely to join higher-deductible plans, per CMS data. KFF estimates average marketplace deductibles increased by 37% this year.

As coverage losses snowball, health systems are treating more uninsured patients. Unpaid medical debt—estimated to be at least $220 billion in 2021, per the Peterson-KFF Health System Tracker—is projected to get a lot bigger. Experts told Healthcare Brew it’s hard to budget for that debt, and vulnerable hospitals could crumble under the strain.

Estimating the impact. Mike Marks, CFO of national for-profit Tennessee-based chain HCA Healthcare, said during an April 24 earnings call that the system saw a 15% decrease in ACA-covered patient admissions and a 16% increase in uninsured patient admissions YoY in Q1 2026. He estimated the ACA coverage drop reduced the system’s quarterly EBITDA by $150 million compared to Q1 2025.

HCA is in a more privileged position than the average hospital. Even with the estimated loss, its adjusted EBITDA for Q1 2026 was $3.8 billion, per its earnings report. Rural hospitals, on the other hand, are barely staying afloat, Carrie Cochran-McClain, chief policy officer for the National Rural Health Association, told us. Healthcare Brew reported in March 2025 that about 768 rural hospitals are at risk of closing—and that was before the expansion ended.

When considering ACA losses plus future losses in Medicaid eligibility and funding as a result of policy changes, rural hospitals are going to be hit hard these next few years, Cochran-McClain said.

“We’ve had facilities that already are having to close because they can’t make ends meet. We also have seen facilities—clinics and hospitals both—close in anticipation, knowing that it’s unlikely that they will be able to survive,” Cochran-McClain said.

Hospitals expect ACA coverage losses will get worse as the year goes on. For instance, Pennsylvania-based Universal Health Services saw ACA-covered patients drop 5% this quarter, CFO Steve Filton said during an April 28 earnings call. But the national chain expects the real impact to go beyond that 5% drop because some of the ACA members it treated “will not sustain their premium payments.” The system anticipates $75 million in pre-tax losses.

Areas for improvement. To weather this storm, hospitals must improve cost containment, Seth Cohen, president of financial platform company Cedar, told us.

One way is for hospitals to encourage a payment plan from patients. But a survey conducted by Cedar in December 2025 found 30% of patients already felt the payment options offered to them were unaffordable.

“The traditional levers, the flexibility that the hospitals are leaning on, are just not working,” Cohen said.

Even patients with insurance may lose coverage or have high-deductible plans that make their medical bills unaffordable, making it difficult for hospitals to budget for which patients will be able to pay their bills and which will essentially become write-offs, he added.

“This is a moment where we need to look at not just the problem differently but also how we classify patients,” he said. “[If] your deductible is $10,000, you’re going to behave much more like a self-pay patient.”