By Rebecca Pifer Parduhn
Published September 1, 2026
The landscape of American healthcare access is undergoing a profound and troubling transformation. A comprehensive new study from Epic Research—the analytical division of the nation’s leading electronic health record (EHR) provider—reveals that the percentage of emergency department (ED) visits paid for out-of-pocket by patients has surged to 7.6%, a marked increase from 5.5% in 2022.
This shift, which spans across inpatient admissions, maternity care, and primary care settings, serves as a stark barometer for the post-pandemic reality of the American safety net. As the nation grapples with the long-term consequences of the Medicaid "unwinding" process and the legislative impact of the federal government’s recent fiscal adjustments, millions of Americans are finding themselves increasingly vulnerable, facing the full brunt of healthcare costs without the shield of public insurance.
Main Facts: The Shift Toward Self-Pay
The data, drawn from an analysis of more than 550 million U.S. healthcare encounters, paints a vivid picture of a shrinking safety net. Epic Research defined "self-pay" as a primary indicator for uninsured status. The findings are consistent and concerning across multiple clinical touchpoints:
- Emergency Departments: The most acute impact is found in the ER, where self-pay encounters rose from 5.5% in 2022 to 7.6% today.
- Inpatient Admissions: Self-pay rates increased from 1.9% to 2.6%.
- Maternity Care: The share of self-pay births grew from 0.8% to 1.3%.
- Primary Care: Even in routine preventive settings, self-pay encounters ticked up from 1.8% to 1.9%.
Conversely, Medicaid enrollment—which reached a historic high during the pandemic—has seen a corresponding retreat. Medicaid-funded inpatient services dropped from 13.2% to 11.7%, while Medicaid-covered births fell from 23.1% to 21.5%, and primary care encounters dipped from 11.4% to 10.3%. These figures suggest that as patients are purged from Medicaid rolls, they are not necessarily transitioning to private insurance; rather, they are falling into a coverage gap where they remain responsible for the entirety of their medical bills.
A Chronology of Coverage Contraction
To understand the current crisis, one must look back at the legislative and administrative shifts that have defined the post-COVID-19 era.
2020–2023: The Pandemic Shield: At the onset of the pandemic, the federal government prohibited states from disenrolling individuals from Medicaid, leading to an unprecedented expansion that covered nearly 1 in 4 Americans. This period of "continuous enrollment" provided stability for low-income families during a time of extreme economic volatility.
Spring 2023: The Great Unwinding: The federal mandate protecting Medicaid enrollment expired, allowing states to resume eligibility redeterminations. This process, termed "unwinding," led to a rapid reduction in the Medicaid population. According to KFF, more than 25 million people lost their coverage during this period.
July 2025: The "Big Beautiful Bill": The federal legislative landscape changed dramatically with the passage of the GOP’s major healthcare reform package. This legislation introduced rigorous new barriers to entry, including more frequent eligibility reviews and a mandatory work requirement—forcing Medicaid adults in expansion states to log 80 hours of work, volunteering, or education monthly to maintain their benefits.
2026 and Beyond: We are now in the midst of the fallout from these combined policy shifts. The Congressional Budget Office (CBO) estimates that the current regulatory environment will lead to a loss of coverage for approximately 6 million additional individuals over the next decade.
Supporting Data: Understanding the Scale
The Epic Research study is significant not only for its findings but for its sheer scale. By analyzing 550 million encounters, the researchers have provided the most granular view yet of how policy changes filter down to the front lines of care.
The rise in self-pay encounters is a direct proxy for the "coverage gap." When a patient arrives at an emergency department without insurance, hospitals are mandated by the Emergency Medical Treatment and Labor Act (EMTALA) to provide a screening and stabilization, regardless of the patient’s ability to pay. However, the subsequent billing for these services often leads to medical debt, which is a primary driver of financial instability for low-income households.
The data suggests that the burden is not merely falling on the uninsured, but on the hospitals that serve them. As the volume of self-pay patients increases, providers face a higher risk of uncompensated care costs, which can destabilize the financial health of rural hospitals and safety-net clinics already operating on thin margins.
Official Responses and Political Implications
The intersection of rising costs and diminished access has made healthcare a central, if not the primary, issue in the upcoming midterm elections.
Recent polling by KFF indicates that healthcare costs are the top concern for voters across the political spectrum. While Republican voters have focused heavily on fraud and administrative waste—a sentiment reflected in the administration’s push for stricter eligibility verification—Democratic voters and independent analysts have expressed alarm over the "human cost" of the recent Medicaid cuts.
The administration has defended the new eligibility requirements, arguing that they encourage self-sufficiency and protect the long-term solvency of the Medicaid program. However, patient advocacy groups argue that the "Big Beautiful Bill" creates "bureaucratic traps." By requiring 80 hours of work documentation, the policy disproportionately penalizes individuals in unstable, gig-economy jobs where hours fluctuate or are not formally tracked, effectively pricing the working poor out of their own health benefits.
Implications: The Long-Term Outlook
The implications of this shift are profound and multifaceted:
1. The Erosion of Preventive Care
The rise in self-pay patients in primary care settings is particularly troubling. When patients cannot afford to pay for a visit, they delay care, often until a condition becomes acute. This shift from primary to emergency care is inefficient and significantly more expensive for the health system, ultimately increasing the overall cost of care for the public.
2. Widening Health Disparities
The decline in Medicaid-funded maternity care is a bellwether for maternal health outcomes. With fewer resources allocated to prenatal and postnatal care for low-income populations, there is a significant risk that the United States will see a further decline in maternal mortality rates, a metric in which the U.S. already lags behind most developed nations.
3. The Financial Burden on Healthcare Systems
As the volume of self-pay patients grows, hospitals will face increased pressure on their bottom lines. In regions where Medicaid enrollment was high, this represents a sudden and dramatic loss of revenue. To compensate, hospitals may be forced to raise prices for commercially insured patients, further driving up insurance premiums and exacerbating the affordability crisis for the middle class.
4. The Policy Pendulum
The current trend is a direct result of a policy shift toward austerity. As the midterm elections approach, the debate will likely intensify. Proponents of the current system argue that it incentivizes workforce participation and reduces federal spending, while opponents argue that it violates the fundamental promise of the safety net.
Conclusion
The data provided by Epic Research is a call to action. It confirms that the recent changes to Medicaid are not just administrative shifts—they are having a tangible, immediate impact on the ability of millions of Americans to access medical care. As the country moves into the next phase of the election cycle, the question of whether healthcare is a right or a benefit tied to strict administrative compliance will likely be the defining question of the debate.
The increase in self-pay patients is the "canary in the coal mine." Without a concerted effort to simplify access or bridge the funding gaps created by the latest federal laws, the nation risks a permanent widening of the gap between those who can afford to be healthy and those who are left to navigate the system on their own.
