Community Health Sys (NYSE:CYH) released second-quarter financial results and hosted an earnings call on Thursday. Read the complete transcript below.
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Summary
Community Health Sys reported a 9.8% decline in net revenue for Q2 2026, primarily due to a decrease in state-directed payment benefits and recent divestitures.
Adjusted EBITDA was $330 million, down from $380 million in the prior year, impacted by increased uninsured volumes and decreased demand for elective surgeries.
Same-store net revenue grew by 2.4%, with a 2.9% increase in adjusted admissions, but revenue per adjusted admission fell by 0.5% due to unfavorable service and payer mix.
The company revised its full-year guidance, projecting net revenue between $11.4 and $11.6 billion and adjusted EBITDA between $1.3 and $1.375 billion, considering economic impacts and softer surgical demand.
Operational highlights include recognition for quality care and safety at various hospitals, as well as completing divestitures and acquisitions to strengthen positions in core markets.
Management noted ongoing challenges with payer mix, service mix, and increased uncompensated care, all contributing to financial pressure.
The company is focused on cost controls, with labor and supply expenses well-managed despite pressures from higher medical specialist fees.
Full Transcript
OPERATOR
Good day and welcome to Community Health Sys second quarter 2026 earnings conference call. All participants will be in listen-only mode. Should you need assistance, please signal a conference specialist by pressing the star key followed by zero. After today’s presentation, there will be an opportunity to ask questions. To ask a question, you may press star then one on a touchtone phone. To withdraw your question, please press star then two. Please note this event is being recorded.
I would now like to turn the conference over to Anton High, Vice President of Investor Relations. Please go ahead.
Anton High, Vice President of Investor Relations
Thank you, Bailey. Good morning and welcome to Community Health Sys’s second quarter 2026 conference call. Joining me on today’s call are Kevin Hammons, Chief Executive Officer, and Jason Johnson, Executive Vice President and Chief Financial Officer. Before we begin, I’ll remind everyone this conference call may contain certain forward-looking statements, including all statements that do not relate solely to historical or current facts. These forward-looking statements are subject to a number of known and unknown risks which are described in headings such as Risk Factors in our Annual Report on Form 10-K and other reports filed with or furnished to the SEC. Actual results may differ significantly from those expressed in any forward-looking statements. In today’s discussion, we do not intend to update any of these forward-looking statements. Yesterday afternoon we issued a press release with our financial statements and definitions and calculations of adjusted EBITDA and adjusted EPS. We’ve also posted a supplemental slide presentation on our website. All calculations we discuss today will exclude gains or losses from early extinguishment of debt, impairment gains or losses on the sale of businesses, and expense from employee termination benefits and other restructuring charges.
With that said, I’ll turn the call over to Kevin Hammons, Chief Executive Officer.
Kevin Hammons, Chief Executive Officer
Thank you, Anton. Good morning everyone and thank you for joining our second quarter 2026 conference call and for your continued interest in CHS. Before we get into the call, I want to acknowledge the ongoing commitment and effort of all of our teammates and thank them for the work they are doing toward advancing our vision to make the healthcare experience exceptional for our patients, our communities and each other. I am proud to say that in the face of a dynamic operating environment, we have continued to make progress on our top priorities of improving quality, physician experience, patient experience and employee satisfaction, in addition to improving Leapfrog safety grades and CMS Star ratings that we discussed on last quarter’s call which included 12 of our hospitals achieving a Leapfrog A grade and approximately 70% achieving Leapfrog A, A or B grades. We are proud of the recognition coming in from other noteworthy sources; for example, earlier this month our Lutheran Hospital in Fort Wayne, Indiana was awarded the American College of Cardiology’s Heart Care Center National Distinction of Excellence, the only hospital in the state and one of only 100 hospitals across the country to receive this designation.
Also, several of our hospitals were recognized by CMS for achieving zero hospital-acquired infections—some of the nation’s best performance in this area—and many others received recognition and designations reflecting the quality care we provide to our patients. These recognitions underscore the significant progress our clinical teams have driven across multiple measures of safety and quality over the past few years, including record achievement in risk-adjusted mortality index, sepsis mortality and hospital-acquired infection rates.
We are seeing positive movement in patient experience surveys and in the areas of employee satisfaction and physician experience. The record response rates to our recently completed employee surveys shows that we have a very engaged employee base even as we recognize that we have significant work still to be done. Our ability to continue advancing in each of these areas will drive enhanced financial performance over time and long-term value creation for our organization and our shareholders.
Turning to our operating performance for the second quarter of 2026, adjusted EBITDA was $330 million compared with $380 million in the prior-year period on a 9.8% decline in net revenue, primarily reflecting a smaller prior-period benefit from newly approved state directed payment programs as well as divestitures completed over the past 12 months. Results for the quarter include the benefits from recently approved Medicaid state directed payment programs in Indiana and Florida, which were offset by a prior-period adjustment to the Arizona state directed payment program and an unexpected increase in uninsured volumes and continued softness in demand for elective surgical procedures among commercially insured patients, which we attribute to continued consumer insecurity related to geopolitical instability and inflationary pressures. Same-store net revenue increased 2.4% over the prior-year period. Same-store adjusted admissions increased 2.9%. However, approximately half of that volume growth was driven by uninsured visits with minimal related net revenue. This factor, together with a lower surgical versus medical mix, was more than enough to offset the rate gains from the new state directed payment programs, resulting in a 0.5% decline in net revenue per adjusted admission for the quarter. We continue to believe that the non-ACA-related payer mix and service mix challenges that we experienced in the first half reflect a temporary disruption in demand for healthcare services in our markets, and in fact we were encouraged by the improving volume and surgical trends we witnessed exiting the quarter. However, as we consider deteriorating consumer confidence in the markets we serve, economic impacts from escalating hostilities in the Middle East, along with the softer surgeries and unfavorable payer mix we experienced this year to date, we believe it is prudent to be more cautious about the second half of the year and therefore adjusted our full-year outlook accordingly. Before handing it over, I want to reiterate how proud I am of the progress we are making as an organization and the focus on our top priorities, which we believe will help us navigate a dynamic operating environment and emerge positioned for long-term success and improved financial results. At this point, I’ll turn the call over to our Chief Financial Officer, Jason Johnson, to review financial results and other information in greater detail.
Jason Johnson, Executive Vice President & Chief Financial Officer
Thank you, Kevin, and good morning, everyone. For the second quarter of 2026, financial results came in below our internal expectations. The company continued to execute well on the controllable aspects of our business, including strong cost controls, demonstrated further progress on our top priorities, and saw sequential improvement in overall volume trends. However, service and payer mix did not improve as expected, reflecting continued softness in elective procedures along with higher uncompensated care, both of which drove lower margins.
Adjusted EBITDA for the second quarter was $330 million with a margin of 11.7% versus 12.1% in the prior year period. Results include approximately 40 to 45 million in combined EBITDA contribution from the recently approved Florida and Indiana state directed payment programs that were not in our previous guidance. Of this amount, approximately 20 to 25 million related to prior periods. However, a portion of this was offset by an approximate $15 million reduction in the Arizona state directed program because of a prior-period true-up.
Same-store net revenue for the second quarter increased 2.4% year over year. Same-store inpatient admissions increased 1.9% and adjusted admissions increased 2.9%. Meanwhile, same-store net revenue per adjusted admission declined 0.5% as the rate benefit from new state directed payment programs was more than offset by unfavorable shifts in payer mix and service mix. As Kevin previously noted, approximately half of the growth in adjusted admissions during the second quarter was from uninsured patients, and similar to other operators, we experienced continued soft demand in commercial elective procedures.
Same-store surgery declined 0.1% with a notable decline of 3.8% in inpatient surgeries. On the cost side, we performed well with a 0.3% increase in same-store operating expense per adjusted admission. Labor cost was well managed once again with same-store average hourly rate up approximately 1.1% year over year on a same-store basis and same-store contract labor spend down 5.6%. However, salaries and benefits expense as a percentage of net revenue increased 100 basis points year over year on a same-store basis due primarily to increased physician employment.
Supplies expense was well controlled, declining 70 basis points year over year to 14.2% of net revenue on a same-store basis, reflecting both the decline in elective surgical volumes and continued improved procurement under our ERP. Medical specialist fees, meanwhile, increased approximately 19% year over year on a same-store basis and represented 5.6% of net revenue, which was up from 4.8% in the prior-year period and outpaced our forecast for 5% to 8% growth.
Anesthesiology and radiology continue to be the largest pain points in this regard. The increase in anesthesia specialist fees is primarily due to higher salary subsidies from lower net revenues resulting from fewer surgeries. The increase in radiology fees is primarily due to an increase in imaging volumes. Cash flows from operations were $87 million for the second quarter, or $143 million when adjusted to exclude cash taxes paid out of divestiture proceeds, improving significantly from the use of $297 million in the first quarter.
Several of the items that affected the first quarter cash performance improved or reversed as expected, including improved Medicaid state directed payment cash flows, less interest paid, and no annual performance bonus payments in the second quarter. In May, we completed a tender offer using proceeds from recent divestitures to repurchase approximately $368 million of the 4.75% senior secured notes due 2031 and $231 million of the 10.875% senior secured notes due 2032.
The company’s leverage at quarter end was 6.7 times versus 6.6 times at year-end 2025. At quarter end, we had no amounts drawn on our ABL, and our next significant maturity is in 2029. During the quarter, we completed the previously announced divestiture of four hospitals in Arkansas for $110 million in cash and also completed the previously announced acquisitions of majority ownership percentages in Surgical Institute of Alabama in Birmingham and South Anchorage Surgery Center in Anchorage, Alaska.
These acquisitions are strengthening our positions in core markets and are meeting our expectations for operating and financial performance thus far. We will continue to evaluate opportunities for growth investments across each of our core markets. As noted in last night’s press release, we are updating our financial guidance for 2026. Specifically, we now expect net revenue to be $11.4 to $11.6 billion and adjusted EBITDA in a range of $1.3 to $1.375 billion.
The revised ranges reflect several puts and takes, most notably the full-year benefits from new Medicaid state directed payment programs in Georgia, Indiana, and Florida, which are more than offset by increased headwinds from macroeconomic factors and disenrollment from Affordable Care Act plans. On this second point, when we set initial guidance for 2026 in February, we had to make certain assumptions regarding member disenrollment rates, plan switching, and overall patient behavior due to the loss of enhanced premium tax credits.
Through the first half of the year, the impact to net revenue has tracked in line with our previous expectations. However, based on experience to date, we’ve updated our estimate of how many of these disenrolled patients are continuing to come to our hospitals, which is driving higher cost to provide care with minimal related net revenue. With our revised guidance, we are assuming a similar impact in the second half, along with continued softness in elective surgery volumes, resulting in lower midpoint for adjusted EBITDA.
This concludes our prepared remarks, so at this time we will turn the call back over to the operator for Q&A.
OPERATOR
We will now begin the question and answer session. To ask a question, you may press star then one on your touchtone phone. If you are using a speakerphone, please pick up your handset before pressing the keys. If at any time your question has been addressed and you would like to withdraw the question, please press star then two. Please limit yourselves to one question and one follow-up. At this time we will pause momentarily to assemble our roster.
Our first question comes from Ben Hendricks with RBC Capital Markets. Please go ahead.
Michael Murray, Analyst at RBC Capital Markets
Hi, this is Michael Murray on for Ben. Thanks for taking my question. I believe you mentioned a $20 million headwind related to the APTC expiry in the quarter and guidance contemplates a similar run rate for the remainder of the year. What gives you confidence that the APTC headwind doesn’t worsen through the balance of the year, given that 4Q is typically your highest-margin quarter and we’re seeing a higher mix of Bronze plan selections with very high deductibles?
Jason Johnson, Executive Vice President & Chief Financial Officer
Yes, this is Jason. I’ll start and then Kevin can jump in. So for the full year, just to clarify for everyone, we had initially estimated that the net revenue impact from ACA disenrollment would be between 90 and 110 million and the adjusted EBITDA impact would be between 20 and 30 coming out of the first quarter. Both of those assumptions—experience was right in line with those assumptions. And then in the second quarter we saw a more significant decline in our HIX volumes and obviously a correlation with our increase in self-pay.
So we estimate the quarter impact on the EBITDA front to be 20 million negative in the quarter and about 25 million for the first quarter—so 25 million for the first half of the year. We do think the back half of the year looks like the second quarter, so at the midpoint around 20 million-ish. The volume declines are consistent with what we expected in HIX and the revenue is still in our range. We’re assuming that the majority of the volume decline in HIX is offset by, or is also resulting in, an increase in self-pay.
So I feel comfortable with our increased range which now sits between 50 and 75 million dollars of impact on an annual basis. And I think that’s pure self-pay. So I think that people who have maybe metal down or tiered down are behaving more like any other person that has commercial plans that have a higher deductible, and I think their behavior will mirror more of that.
OPERATOR
Our next question comes from Brian Tanquilut from Jefferies. Please go ahead.
Brian Tanquilut, Analyst at Jefferies
Hey, good morning, guys. Thanks for taking the question. Maybe, Jason, as I think about the guidance that you gave, given what we’ve seen in the first half of the year, can you help me bridge to that guide as we think through the back half of the year and anything you’d call out in terms of moving pieces that we need to figure or factor into our models for Q3 and Q4 separately? Thank you.
Jason Johnson, Executive Vice President & Chief Financial Officer
Yes, thanks for the question, Brian. I’ll start. So if you talk about from the midpoint of our initial annual guidance in February, it was $1.415 billion. The miss in the first half of the year versus the expectations when we developed that guidance is between 60 and 65 million. So we reduced the annual guidance by that amount. We assume a similar impact in the second half of the year, so we took the second half down by 60 to 70 million. Both those reductions are inclusive of the higher estimated HIX impact that I just mentioned of 50 to 75.
And then on the benefit side, we layered in the back-half-of-the-year DPP benefits that we expect from the plans in states that were not approved when we set our initial guidance, that weren’t factored in—that’s Georgia, Indiana, and Florida. And for Florida, just to unpack that a bit, the amount that we recognized for Florida in the second quarter was 20 to 25 million dollars, and that related to the period from October ’24 through September ’25.
We did not continue to accrue at that higher rate for the plan year 2026, which runs from October ’25 through September ’26, because the plan hasn’t been submitted to the CMS yet and there’s some changes in the waivers from what was previously approved. So we think it’s prudent to kind of wait to see what’s ultimately submitted to CMS and how quickly CMS takes to review and ultimately approve the plan. However, we did factor in the possibilities for the Florida ’26 into our guidance.
At the low end of our guidance, we assume that the ’26 year is not able to be recognized by year end. At the high end, we assume that we are able to recognize the Florida 2026 and the benefit is consistent with the amount that we just recognized in the second quarter.
Brian Tanquilut, Analyst at Jefferies
Understand. And then maybe, Kevin, as I think about the guidance cut—I mean, I understand the payer mix headwind here—but when I think about the free cash flow or the operating cash flow adjustment that you made, it looks to be a little bigger. So just curious how you’re thinking about the drivers of that and what you’re able to do. I know some of that is AR related. So just curious if you can share with us, you know, some of the challenges you’re facing on the cash flow side that’s making it look worse than the payer mix headwind that you called out in the EBITDA line.
Jason Johnson, Executive Vice President & Chief Financial Officer
Sure. Thank you, Brian. One of the challenges that we’re experiencing on the cash flow side is really the slowdown of payments by the payers. Not only just slowing down in the normal course, but they’re now auditing more claims before they pay them and having additional record requests. Oftentimes in the past those things occurred after payment and then if there was a problem, there would be some true-up later. But now the behavior of the payers is such that they’re doing those exercises prior to payment, which just further slows down the payment process.
So our A/R is growing accordingly. That would, you know, assuming that continues forward, it’s—we ultimately get the cash, but it’s kind of a one-time slowdown in payment. So our A/R days are growing and we’ve seen some of the payers even talk publicly about, you know, increasing their days in A/P. So we’re on the other side of that equation with increase in days in A/R. So that said, we don’t believe it’s necessarily a collection issue. It’s just a timing issue.
And once we anniversary that then we’re back on a normal run rate.
Brian Tanquilut, Analyst at Jefferies
Thank you.
OPERATOR
Our next question comes from A.J. Rice with UBS. Please go ahead.
A.J. Rice, Analyst at UBS
Hi everybody. Just maybe to drill down on what you’re seeing in the surgical volumes a little bit more, I know you called out a couple of service lines. Would you say that the surgeries that you’re seeing the softness in are surgeries that traditionally are viewed as more elective and postponable procedures, is that what you’re seeing? And then can you break it down between is this a phenomenon of what you’re seeing around the public exchanges or is it broader than that?
And then also another element of it is you have, I know you have standalone ASCs versus your hospital surgery inpatient outpatient. Is there any distinction between what you’re seeing in the freestanding surgery centers with what you’re seeing in the hospital-based surgeries?
Kevin Hammons, Chief Executive Officer
So thanks, A.J. This is Kevin. I’ll start on this one. So definitely the procedural softness and service line softness is trending towards more elective procedures, orthopedics being the largest decline. So your hip and knee and shoulder replacements, those are typically procedures that people can delay or at least defer for periods of time, get a cortisone shot, maybe continue to try to manage the pain and manage through some rehab, at least for a period of time.
We are also seeing some softness in cardiac surgeries. And intuitively those seem less elective, but they really are more elective. And as people defer visits to their cardiologist and defer some of their screenings, oftentimes those procedures also get deferred. We saw that during COVID when there was a significant decline, again, not intuitive, but there was a significant decline in cardiac arrest procedures during COVID that were hard to explain, but we’re seeing some of that as well.
On the inpatient/outpatient, we’re seeing bigger declines in the inpatient side, but we are overall—we saw some increase in outpatient surgery, so our surgery centers are picking up, but it is kind of lower-acuity surgeries and not the orthopedic and some of the cardiac procedures that you would normally have expected. We are seeing really good increases in clinic visits and in things like orthopedic MRIs. So those continue to outpace prior year at a pretty significant rate, which would suggest we’re capturing the patients, they probably still need the procedures.
But those visits and screenings are not translating into surgeries, which lend us to continue to believe or support our belief that it’s more of an economic decision that people are delaying the follow-on procedures.
A.J. Rice, Analyst at UBS
Okay, then follow up. Maybe just ask about your uncompensated care. I know you gave the percentage of uncompensated care as a percent of revenue up significantly year to year. I wondered if do you have any color on the percent of your admissions that are uninsured this year versus last year? And also I was wondering, did it step up significantly from Q1 to Q2?
Jason Johnson, Executive Vice President & Chief Financial Officer
Sure. So we were approximately 5% of our visits, just shy of 5% of our visits prior year were uncompensated or self-pay patients. And this year we’re about 110 basis points higher. So just over 6% of visits. So, you know, roughly 20% increase or so in self-pay visits. And was that different than first quarter materially or was first quarter sort of similar to second quarter? Second quarter was greater than first quarter. We did not see that big of an increase in the first quarter.
A.J. Rice, Analyst at UBS
Okay, interesting. All right, thanks a lot.
OPERATOR
Our next question comes from Jason Casorla with Guggenheim. Please go ahead.
Jason Casorla, Analyst at Guggenheim
Great. Thanks for taking my question. Maybe can you just walk through some of the mechanisms on the medical specialist fees? Right. You’ve done a lot of work there to insource to help offset industry-wide pressures, but it does seem like these costs will pressure you regardless if volume trends are favorable or unfavorable to your enterprise. So I guess just like any updated thoughts on the medical specialist fee backdrop, like if you can revisit some of those subsidies if volumes remain pressured or anything else to help offset the growth there would be helpful.
Jason Johnson, Executive Vice President & Chief Financial Officer
Thanks. Yeah. So the most significant component of that is anesthesia that does have the income guarantee. So when volumes are down, surgical volumes in particular, and anesthesiologists are not collecting or generating as much revenue, [they are] guaranteed the minimums in the contract and we have to pay the subsidies. So that one is definitely volume-based to some extent. And then that’s where we are seeing the significant amount of increase. And I would say that we are doing several things and in fact we have insourced certain anesthesiologists and a few other specialties in certain locations.
And in some of those cases when we insource that may mean that we’re not just employing some of the docs, but we’re also contracting with some on a 1099 basis. And when that happens we end up with—we get the professional fee in revenue, but the payment to the docs for the professional providing the services still goes through medical specialist fees. And so that impact was about $3 million of net revenue in the quarter versus the prior year and about $6 million year to date.
So there’s a little bit of offset growth in revenue, but it’s still outpacing what we had expected. Kevin, if you want to have any more flavor.
Kevin Hammons, Chief Executive Officer
No, I think you covered that.
Jason Casorla, Analyst at Guggenheim
Okay, got it. Thanks. And maybe could you guys comment on your thoughts around the proposed Medicare OPPS rule, the outpatient rule, and focus more so on like the 340B proposal, the provision in there, if that were to be finalized, like how you’re balancing better OPPS rates against, you know, from that provision, against maybe any impacts to potential divestitures or otherwise. Just any thoughts on the proposed rates would be helpful.
Jason Johnson, Executive Vice President & Chief Financial Officer
Sure. So the for-profit hospitals did receive a pretty significant—I think it’s close to 10.5%—bump in the outpatient rates effective January 1, 2027. And yet we still—the for-profit hospitals who had received a benefit during the Trump administration’s first term had received some additional money that was taken out of 340B. We are faced with having to pay that back, so that payback begins next year. So that payback of the former 340B money will offset a pretty significant portion of that bump, at least for a few years.
All that said, we think the net increase in outpatient rate for 2027 should be around 5%. So it’s still a much better improvement in Medicare outpatient rates than we have been getting over the past several years, if not the best ever, even on a net basis. And then once the full 340B amount is paid back, then that base rate on the outpatient side has been elevated. So we view this as a very positive.
OPERATOR
Our next question comes from Steven Baxter with Wells Fargo. Please go ahead.
Steven Baxter, Analyst at Wells Fargo
Yeah, hi. Thanks. Just to kind of ask for a little bit more detail on the payer mix and service mix challenges, I guess, would you say that those are largely or almost entirely driven by what you’re talking about in terms of the exchange dynamics and the commercial elective procedures? Or would you say that that kind of extends maybe into the medical side of the business as well? Wondering if you could talk more about what you’re seeing for employer-based coverage and demand there and maybe how that compares to the demand growth that you’re seeing in Medicare and Medicaid in the quarter.
Thank you.
Kevin Hammons, Chief Executive Officer
Yeah, you know, I think the demand in Medicare continues to, you know, be about the same or continue to actually increase. So we’re seeing increase in Medicare-related population. Commercial—although we’ve seen some reduction in commercial business, it’s been a smaller percentage. 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.
There is also a decline in Medicaid and we’re hearing somewhat anecdotally, but, you know, more difficulty and some demographics not wanting to sign up for Medicaid or having a more difficult time signing up for Medicaid. And so there’s been some decrease in Medicaid volumes which could also be contributing to some of the increase in uninsured or self-pay. In terms of kind of the softness in surgeries, we think that is primarily commercially insured patients and as a result of kind of economic headwinds with co-pays and deductibles.
So, you know, we’re not seeing the decline in the emergency room business, which is where primarily the amount of uninsured care that we’re seeing or self-pay business is coming through the emergency room. It’s not the pressure that we’re seeing on surgeries.
Steven Baxter, Analyst at Wells Fargo
Okay. And then if we were to set aside the exchange headwinds in the back half and the moving parts on some of the Medicaid dollars, how should we think about what guidance assumes in terms of underlying performance? Do you assume these dynamics improve at all throughout the balance of the year or would you say you’ve reflected something closer to what you saw in the first half now? Thank you.
Jason Johnson, Executive Vice President & Chief Financial Officer
Yeah, this is Jason. It really does look similar to the first half. We in the range do expect on the higher end there could be some more growth in the second half as that commercial volume comes back in. They meet their deductibles into the third quarter, early fourth quarter, and try to get the procedures done before year-end. The risk, which is more reflected on the lower end, is that they don’t get to the point where they meet those deductibles this year and they continue to defer those elective procedures into next year.
Kevin Hammons, Chief Executive Officer
I think it’s fair to say that our back half range assumes a similar decline as we experienced in the first half, offset by then some of the approved state-directed payment programs.
OPERATOR
Our next question comes from Andrew Mock with Barclays. Please go ahead.
Andrew Mock, Analyst at Barclays
Hi, good morning. I think I heard at one point that the exit rate on surgeries was encouraging. Can you elaborate on that comment and how that’s informing your back half outlook? Thanks.
Kevin Hammons, Chief Executive Officer
Sure. As we just tracked kind of through the second quarter, June was our best month of the quarter. We did see a positive year-over-year improvement for the month of June. So despite kind of negative or slightly negative on surgeries for the quarter, we were positive year over year in the month of June.
Andrew Mock, Analyst at Barclays
Great. And then yeah, I appreciate the comments that consumer insecurity is driving lower elective surgeries. Overall, I think I’ve heard both sort of like macro concerns around gas prices as well as deductibles. Is there a view internally on what’s the bigger driver of this affordability issue? Thanks.
Kevin Hammons, Chief Executive Officer
Yeah, I think so. A couple things I’d point to: we look at the consumer confidence index, which has trended down. It was low in March, being a leading indicator which played out in the second quarter with continued softness. And that consumer confidence index continued to deteriorate through the second quarter, and I believe it’s at a 12-month low right now. It’s down around the lows of when we were during COVID. So as we look at that and look at the very near-term impact, I would say that we view that as a little bit of a headwind.
What’s contributing to that? A couple things. Gas, the price at the pump—as we saw, or what we thought may have been some improvements in Q1 in consumer confidence as some of the hostilities in the Middle East broke out and gas prices started to go up in that March and April time frame. I think that is having a big impact when you think about our communities and the median household income, which is about $64,000 compared to $81,000 national average.
Our communities sit well below national average. And as gas prices go up, that has a pretty significant impact on disposable income for those households. And healthcare seems to be one of the first things that people will delay, or at least attempt to delay if they can. So I would say that that’s probably one of the biggest drivers. I’d also point to, as we have a new Fed chair coming in at least early in the year, we were expecting rate decreases throughout the year, and now we’re looking at the potential of a Fed rate increase.
I think overall in the market that’s probably having a little bit of a muted impact, and we’re seeing higher inflation. The price of groceries is not coming down like we had anticipated earlier in the year—again, putting pressure on household incomes.
OPERATOR
Our next question comes from John Ransom with Raymond James. Please go ahead.
John Ransom, Analyst at Raymond James
Hey, good morning everybody. One thing we’ve been focused on is the silver-to-bronze migration in the ACA. Is that something that you saw in the quarter and, more broadly, has the collectability on self-pay deteriorated or do you think that’s possible? Thanks.
Jason Johnson, Executive Vice President & Chief Financial Officer
We don’t have complete visibility into what plan somebody may have elected or been under in previous years versus what tier they’re under this year. I do think we are seeing more business in the bronze plan this year than we have in the past, but we don’t have, again, complete visibility—at least on a patient-by-patient basis—to really analyze that. In terms of collectability of self-pay, we only collect a few pennies on the dollar anyway, so there’s no real room to get much worse on that.
We’re effectively not recognizing any revenue on that self-pay business.
John Ransom, Analyst at Raymond James
Okay, and then just the comment on the ACA. I think initially you said like $100 million-ish revenue and $20 to $30 of EBITDA, so the attach rate was 25%, whereas some of your peers talked about much higher decremental margins—I think Tenet was close to 100%. Can you just talk about kind of your current thinking? If you lose $100 of ACA revenue, how does that translate into losses?
Jason Johnson, Executive Vice President & Chief Financial Officer
Yes. Our initial guidance assumed that the folks who lost coverage from the credits expiring stayed out of the health system—or, to a large extent, stayed out. In reality, we’re seeing that those folks who relied on those enhanced premium tax credits to afford exchange insurance plans are continuing to utilize the health system largely in a similar fashion and rate than they did before. These populations of people were higher utilizers, and we’ve seen that trend.
We underestimated how much of an impact—how many people would continue to come to our health system.
John Ransom, Analyst at Raymond James
Okay, thank you, that’s very helpful.
OPERATOR
This concludes our question and answer session. I would like to turn the conference back over to Kevin Hammons for any closing remarks.
Kevin Hammons, Chief Executive Officer
Thank you everyone for joining the call today. If you have any additional questions, you can always reach us at 615-465-7000. Have a good day everyone.
OPERATOR
The conference is now concluded. Thank you for attending today’s presentation. You may now disconnect.
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