HCA Healthcare (NYSE:HCA) executives pointed to continued demand growth, margin improvement, and disciplined capital allocation as the company closed out 2025, while outlining notable policy-related headwinds embedded in its 2026 outlook.
Fourth-quarter performance and volume trends
Chief Executive Officer Sam Hazen said the company finished the year with “strong results” that were largely consistent with prior quarters in 2025, marking its “19th straight quarter of volume growth.” Hazen credited network investments and improvements in capacity management and quality outcomes.
Chief Financial Officer Mike Marks provided same-facility volume details for the fourth quarter of 2025 compared with the fourth quarter of 2024:
- Admissions increased 2.4% and equivalent admissions increased 2.5%.
- Inpatient surgeries were flat, while outpatient surgical volume was down slightly.
- Emergency room visits increased 50 basis points.
- Respiratory volumes had “no material impact” on year-over-year volume.
On payer mix, Marks said same-facility commercial equivalent admissions increased 1.1%, including 2.5% growth in exchange volumes and about 1% growth in commercial excluding exchanges. Medicare equivalent admissions rose 3.5% and Medicaid grew 2.2%. Same-facility net revenue per equivalent admission increased 2.9% year over year.
Marks attributed an 80-basis-point improvement in adjusted EBITDA margin in the quarter to solid revenue growth, labor management results, and improvements in other operating expenses. He also said adjusted EBITDA benefited from an approximately $150 million increase in “our hurricane markets.”
Full-year 2025 results and capital deployment
In reviewing the year, Hazen said the company invested significantly in network expansion, workforce development, and clinical capabilities. He noted the system recorded approximately 47 million patient encounters during 2025, which he described as a record for the company.
Marks said full-year 2025 performance reflected “good demand growth” across HCA’s markets. On a same-facility basis, the company reported revenue growth of 6.6%, equivalent admissions growth of 2.4%, and net revenue per equivalent admission growth of 4.1% versus the prior year. Consolidated adjusted EBITDA rose 12.1%, accompanied by a 90-basis-point improvement in adjusted EBITDA margin.
Marks also highlighted the role of Medicaid supplemental payment programs. He said the net benefit from supplemental payments increased by $420 million in 2025. Hurricane-impacted markets contributed approximately $125 million in adjusted EBITDA growth for the year.
On capital allocation, Marks reported:
- Capital expenditures of $1.5 billion in the fourth quarter and $4.9 billion for 2025.
- Share repurchases of $2.6 billion in the quarter and $10 billion for the year.
- Dividends of $162 million in the quarter and $679 million for the year.
- Cash flow from operations of $2.4 billion in the quarter and $12.6 billion for the year, a 20% increase versus 2024.
Marks said leverage remained at the low end of the company’s targeted debt-to-adjusted EBITDA range, adding that the balance sheet position leaves HCA “well-positioned for the future.”
2026 guidance includes exchange and supplemental payment headwinds
For 2026, HCA guided to revenue of $76.5 billion to $80 billion and adjusted EBITDA of $15.55 billion to $16.45 billion. The company also guided to net income attributable to HCA Healthcare of $6.5 billion to $7.0 billion and diluted earnings per share of $29.10 to $31.50.
Marks said the company increased its capital spending range to $5.0 billion to $5.5 billion, citing continued opportunities for organic growth, including investment in high-acuity programs, new access points, and additional inpatient capacity.
Key assumptions embedded in the 2026 outlook include:
- Equivalent admission growth of 2% to 3%.
- An adverse impact to adjusted EBITDA of $600 million to $900 million tied to health insurance exchanges, including impacts from administrative reforms enacted in 2025, the “One Big Beautiful Bill Act,” and the expiration of enhanced premium tax credits.
- An expected offset of about $400 million from resiliency initiatives designed to generate efficiencies.
- A decline in supplemental payment program net benefit of $250 million to $450 million, driven by Tennessee’s program reverting to four quarters of benefit versus six quarters in 2025, a pause of a program in Texas, and a one-time retro payment from Virginia in 2025.
- No expectation of significant hurricane-market adjusted EBITDA growth versus 2025.
- Full-year margins “slightly above 20%,” consistent with 2025, and operating cash flow of $12 billion to $13 billion.
Marks emphasized that the supplemental payment guidance does not include potential impacts in 2026 from additional approvals of “grandfathered applications.” He said the company was not sizing those potential approvals until there is more clarity from the Centers for Medicare & Medicaid Services.
Resiliency program focus and exchange modeling details
Management provided more detail on how it is approaching the exchange-related headwinds. Marks said exchange volumes represented approximately 8% of admissions and 10% of revenue in 2025.
In modeling 2026, Marks said the company contemplates a 15% to 20% decline in health insurance exchange (HIX) volumes. HCA assumes a portion of those lives migrate to employer-sponsored insurance and the rest become uninsured. Of the decline in HIX volumes, Marks said HCA assumes about 15% to 20% move to employer-sponsored coverage, with the remainder moving to uninsured. For those becoming uninsured, HCA anticipates utilization declines “somewhere in the 30% range” compared with utilization when they had exchange coverage.
Marks also said exchange populations tend to use the emergency room more heavily than traditional commercial populations, and that the company is watching early-2026 enrollment-related indicators such as the ability to sustain premiums after tax credit expiration and potential metal-tier shifts from Silver to Bronze.
On the $400 million resiliency offset, Marks described four focus areas: revenue integrity, variable cost efficiencies, fixed cost efficiencies, and capacity management. He said the company is leveraging benchmarking and advanced analytics, digital transformation with AI and automation, and expanded shared services. He added that the plan includes efforts across corporate functions, shared service platforms, and hospital operations, including throughput and length-of-stay initiatives, labor efficiency, supply cost actions, and broader operating cost measures.
Shareholder returns and other operational commentary
Marks said the board authorized a new $10 billion share repurchase program, and management expects to complete a majority of the existing authorization in 2026 depending on market conditions. The board also approved an increase in the quarterly dividend to $0.78 per share from $0.72.
During Q&A, Marks said the midpoint of 2026 revenue and adjusted EBITDA guidance implies stable margins versus 2025, with mostly stable operating cost trends, though he cited expected continued physician cost pressure potentially in the “high single digits” year over year. He also noted contract labor was about 4.2% of salaries, wages, and benefits in the fourth quarter, which he characterized as the company’s current run rate heading into 2026.
Executives also discussed digital integration work with payers aimed at administrative simplification and dispute resolution. Marks said the company saw a reduction in net days in accounts receivable, particularly in the fourth quarter, which he said reflects some benefits of digital data sharing with payers.
On outpatient trends, Marks said outpatient revenue growth outpaced inpatient growth and that all four outpatient categories the company tracks posted solid revenue growth. For outpatient surgery, same-facility cases declined about 50 basis points year over year, with hospital outpatient surgeries about flat and ambulatory surgery center cases down about 1.5%. He said the decline in cases was influenced by payer mix, “primarily driven by Medicaid,” and a decline in lower-intensity cases such as ENT, though he said the company still produced good growth in net revenue and earnings in the outpatient surgery business overall.
Hazen said HCA continues to invest heavily in outpatient facilities and indicated the company added roughly 100 outpatient “business units” in 2025. He also said HCA sees a stronger pipeline for outpatient acquisition opportunities than in recent years and reiterated the company’s focus on expanding access points to strengthen local networks.
About HCA Healthcare (NYSE:HCA)
HCA Healthcare is a for‑profit operator of healthcare facilities headquartered in Nashville, Tennessee. Founded in 1968, the company owns and operates a network of hospitals and related healthcare facilities and has grown through organic expansion and acquisitions to become a large provider of inpatient and outpatient services.
The company’s core activities include the operation of acute care hospitals, freestanding surgical and emergency centers, and outpatient clinics. HCA’s services encompass inpatient care, surgical services, emergency medicine, diagnostic imaging and laboratory testing, and various outpatient and ambulatory care offerings.
