For all of President Trump's talk of Big Pharma and big insurers, hospitals are emerging as the group most rocked by the policy changes of Trump 2.0.

Why it matters: Hospitals account for the single biggest category of national health spending, but unfavorable shifts in their finances could lead to care disruptions for patients around the country.

Driving the news: Second-quarter earnings calls have begun to paint a picture of how the Republicans' actions — or lack thereof — are starting to impact for-profit hospitals.

• Citing the expiration of enhanced Affordable Care Act subsidies, HCA CEO Sam Hazen told investors last month that "many people became uninsured and still needed emergency care from hospitals," and the "impact was greater than our estimates."
• Admissions for patients who formerly had exchange coverage declined by 15%, he added. "We expected some of these patients to shift to other forms of coverage, but this did not happen. Instead, these patients migrated almost one for one to uninsured."
• Tenet is seeing much the same thing, with people dropping off ACA exchanges straight into the ranks of the uninsured "on a pretty much one-to-one basis," executive vice president and CFO Sun Park said on the company's earnings call.

The big picture: The first year of the second Trump administration featured high-profile Oval Office deals with pharmaceutical CEOs and much railing about health insurance premiums, but both industries have largely avoided painful policy outcomes.

• Drug companies, for example, ducked a worst-case scenario of wide-ranging tariffs and widespread most-favored nation pricing in Medicare.
• Insurers successfully lobbied to increase a proposed Medicare Advantage payment rate they argued was too low.
• Hospitals, on the other hand, are likely only starting to feel the financial fallout stemming from the GOP's major Medicaid changes passed last year, and there appears to be plenty of appetite for even more hospital reforms in the future.

Between the lines: Last year's Medicaid overhaul cracked down on how hospitals get paid by the program, limiting provider taxes and states' ability to direct enhanced spending to facilities. Republicans also added work requirements, which are estimated to swell the uninsured population by more than 5 million.

• Most of the biggest changes start taking effect next year.
• It "has introduced a new era of uncertainty, one in which the balance sheet cushion accumulated over the past five years will be tested," a recent Fitch Ratings report on nonprofit hospitals and health systems concluded.
• "Fiscal 2025 may ultimately prove to be an operational peak for the sector before a new and more challenging chapter begins."

The administration has also pushed regulatory changes opposed by hospitals, including recently proposing site-neutral payment reforms in Medicare for certain imaging services.

• There's also a new pilot program allowing drug companies to offer rebates, instead of up-front discounts, to certain safety net facilities for medicines under the 340B drug discount program.
• In Congress, House Republicans have particularly shown interest in more hospital legislation, including overhauling certain business practices they deem anti-competitive and implementing more aggressive site-neutral payment policies.
• Certain efforts attracted interest from some Democrats, as well.

What they're saying: Hospital policy is "where the money is," said Brian Blase, president of Paragon Health Institute, a conservative think tank that was highly influential in last year's Medicaid reforms.

• "If you're going to reduce federal health care spending and there's ultimately going to be less of it, you want less of it to go to big inefficient hospital systems."
• Blase said he's taking hospitals' alarm over rising uninsured populations with a grain of salt.
• "I'm very skeptical about what they say about uncompensated care based on the fact that we know nonprofits provide very little uncompensated care," he told me. "And hospitals are the least efficient part of our health care sector."

The American Hospital Association said it "remains deeply concerned about significant Medicaid cuts and other regulatory proposals that would make it harder for patients to access care."

As Democrats in Congress start building out an affordability agenda for when they're next in power, hospitals are noticeably absent.

Why it matters: It's extremely difficult — if not impossible — to significantly reduce what patients (and the government) pay for their health care without touching providers.

State of play: The most methodical effort to create a health care agenda is happening in the Senate Finance Committee, which has announced three projects on prescription drug prices, private health insurance and long-term care.

• I asked top committee Democrat Ron Wyden of Oregon, who is leading the effort, how hospitals fit into his work.
• "I believe that in terms of the longer term, hospital pricing needs to be part of the conversation, just like everything else," he said.
• When I asked him why hospitals weren't part of the initial list of topics they're focusing on, he replied, "Because we have our hands full, and you can only do so much."

The intrigue: Elected Democrats are, as a whole, much further behind some outside progressive groups.

• The Center for American Progress, in its own health care affordability proposal, calls for limiting hospital rates in concentrated markets to three times the Medicare payment rate.
• Patient advocacy group Families USA is running a campaign calling for Congress to stand up against "big hospital corporations" and enact site-neutral policies that pay the same price for a service regardless of where it's performed.

Yes, but: As I wrote above, there's bipartisan interest in legislation addressing certain hospital business practices or payment policies.

• Though it's hard for Congress to work together on much of anything these days, that does create an opening for dealmaking in the next Congress, even if it's a split government.

What they're saying: "There's a hesitancy on the Democratic side to constrain payment rates for hospitals if you don't reinvest some of those savings to ensure people are covered," Democratic consultant Chris Jennings said.

• "This is particularly the case as you've seen how the marketplace disenrollments in hospital land have imposed more and more uncompensated care burdens."