HCA Healthcare

On July 24, HCA finalized its second-quarter report, including 9% revenue growth, 5% adjusted EBITDA growth, and 11% adjusted EPS growth. It also maintained its preliminary 2026 guidance, which was lowered on July 14 due to higher-than-anticipated pressures from a rising uninsured population.

Why it matters: Shares rose 3% in early trading on this announcement, which appears consistent with the preliminary announcement given in mid-July that had caused shares to plummet amid investor fears about how new regulatory moves may affect HCA and the rest of the hospital industry's profit growth trajectory. Specifically, the individual exchange population is declining on expired subsidies, and on July 14, HCA raised its expected EBITDA headwind to $1.0 billion-$1.2 billion from $600 million-$900 million in 2026. That change pushed down HCA's adjusted EPS expectation for 2026 to $28.70- $30.50 from $29.10-$31.50, and this pressure may foreshadow 2027 headwinds when Medicaid spending cuts begin, particularly in expansion states that represent about 40% of HCA sales.

The bottom line: We had already trimmed our fair value estimate on narrow-moat HCA after the July 14 announcement, and we are maintaining our current $413 per share fair value estimate following the July 24 news. Shares are now trading close to the fair value estimate, following its steep fall related to the mid-July news. Positively for industry players, this mid-July guidance cut looks more like an estimation issue at HCA than something more widespread, especially when considering the strong performance and outlook increase issued by key peer Tenet on July 23, despite facing similar challenges. But investors should also know that headwinds are generally rising for the care providers, as the uninsured rate rises on lost coverage on the individual exchanges (2026) and Medicaid (2027). Also, supplemental payments from states in Medicaid look set to decline in 2028.

 

 

 

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We are reducing our fair value estimate to $413 per share from $444 to reflect the potentially higher profit headwinds related to a rising uninsured population and more uncompensated care in the near future. Coming off a strong 2025 base, we forecast about 5% revenue growth, 3% adjusted EBITDA growth, and 9% adjusted earnings per share growth through 2030, compounded annually.

Our long-term revenue assumption is underpinned by 1% equivalent admissions growth and 4% revenue per admission growth. We assume adjusted EBITDA margin will face some pressure, particularly over 2026-28, as uncompensated care rises with increasing uninsured rates in the US from the loss of Medicaid and individual exchange membership in 2026-27. Also, direct payments from state Medicaid programs to caregivers are set to drop starting in 2028. HCA's cost-control efforts may be needed just to keep margins from dropping substantially in the intermediate term from recent highs. We also assume that HCA buys back a significant percentage of its shares outstanding, which materially contributes to our adjusted EPS growth assumption over the next five years.

We believe that HCA Healthcare has dug a narrow economic moat, and we continue to think that its competitive advantages will help the largest US hospital operator generate economic profits well above capital costs for at least the next 10 years. We currently see one major moat source: intangible assets, including (1) a reputation for service quality and (2) efficient and convenient locations, which help attract patients and physicians to HCA's facilities.

HCA is renowned for systematically pushing best practices perfected at one facility across its entire network to boost overall service quality. Providing high-quality care can inform decisions by patients, payers, and physicians to use HCA facilities, and the firm’s increasing local market share suggests that this has been happening over time. With significant and growing share, HCA can also negotiate reasonable rates with key health insurers in those local markets. Revenue per equivalent admission typically grows in the midsingle digits, which we think is a decent proxy for HCA’s pricing power in its hospitals that should help it generate economic profits for the long run.

HCA appears to operate a highly efficient and convenient network of hospitals and related facilities. We remain especially impressed by its efficient operations, which we believe stem from its heavy focus on analytics across its wide network of facilities. These efficiencies can directly influence facility use. For example, physicians can benefit financially from HCA’s more efficient scheduling processes for surgical cases, which can lead to higher procedure volume and higher income for surgeons at those facilities. Also, HCA’s average length of stay is about half a day less than that of the average US hospital. That efficiency can positively influence payer satisfaction, as HCA is likely saving the payer money by reducing overall hospital-day charges. Payers may incentivize the use of HCA facilities over other local facilities or offer slightly higher reimbursement rates to HCA to reward such efficiencies.

While not a major source currently, some of HCA's efficiencies appear to offer cost-related benefits, helping the firm achieve top-tier profitability in the hospital space. Additionally, the firm benefits from efficient supply negotiations through its own top-tier group purchasing organization subsidiary.

HCA benefits when medical utilization rises, which may continue in the long run, given favorable demographic trends.

A focus on attractive geographic locations gives HCA a volume tailwind that should positively affect its top line.

Financial leverage appears manageable, giving HCA flexibility for US healthcare policy changes or other shocks to the system that could constrain demand for the more elective, and highly profitable, parts of its business.

Healthcare policy changes may pose a near-term headwind and may persist as a long-term ESG risk until universal, affordable coverage is achieved in the US.

If relatively low-margin government programs, such as Medicare, continue to grow at a faster pace than other US insurance programs, HCA's margins could face headwinds.

Economic or other shocks that reduce medical utilization or reimbursement rates could cut into HCA's profits due to the significant fixed costs in its hospital operations.