Report: Self-pay patient encounters rose and Medicaid fell across all care settings

Emergency department self-pay visits saw the steepest rise, growing from 5.5% to 7.6% of encounters, while Medicaid's share declined in every setting studied over the same four-year window.

The share of U.S. health care encounters billed as self-pay rose across all four care settings tracked between early 2022 and mid-2026, according to a new analysis from Epic Research, while the share covered by Medicaid fell in each of those same settings.

The study, published Aug. 31, examined more than 550 million U.S. health care encounters recorded between January 2022 and June 2026 in Cosmos, a research dataset built from a collaboration of Epic health systems representing more than 310 million patient records across roughly 2,200 hospitals and 50,000 clinics in all 50 states plus Canada, Lebanon and Saudi Arabia.

Researchers calculated, for each quarter, the share of encounters in four settings — emergency department, inpatient admission, birth and primary care — whose primary expected payer was self-pay, Medicaid, traditional Medicare, Medicare Advantage or commercial/other coverage. Self-pay encounters, in which a patient rather than an insurer is the primary expected payer, are used in the study as a proxy for lack of insurance.

The increase in self-pay share was uneven across settings. It was most pronounced in the emergency department, climbing from 5.5% of encounters in the first quarter of 2022 to 7.6% in the second quarter of 2026. Inpatient admissions rose from 1.9% to 2.6% and births rose from 0.8% to 1.3% over the same period, while primary care moved only slightly, from 1.8% to 1.9%.

Medicaid's share declined across the board. Births carried the highest Medicaid share of any setting throughout the study period but still slipped from 23.1% to 21.5%. Emergency department encounters saw the steepest Medicaid decline, from 18.2% to 16.1%, followed by inpatient admissions, which fell from 13.2% to 11.7%. Primary care's Medicaid share dropped from 11.4% to 10.3%.

Researchers linked the trend to the end of the federal continuous-enrollment provision that kept nearly all Medicaid beneficiaries covered during the COVID-19 pandemic without routine eligibility checks. That provision lapsed March 31, 2023, prompting states to begin Medicaid "unwinding," or redetermining eligibility and terminating coverage for enrollees who no longer qualified or did not complete renewal paperwork. Because the timing of terminations was left to individual states, the unwinding rolled out on a staggered basis nationally beginning in spring 2023.

The findings build on earlier Epic Research work that found self-pay encounters climbing in emergency, hospital and primary care settings as Medicaid terminations resumed, and that self-pay emergency visits specifically rose in the months following the start of those terminations. With the unwinding process now largely complete, researchers said the longer window allowed them to assess whether those early shifts held across a broader span of time and care settings.

A closer look at the emergency department, where the coverage-mix movement was largest, showed self-pay and Medicare Advantage were the only two payer categories to grow between 2022 and 2026. Medicare Advantage rose from 10.3% to 13.0% of ED encounters. Traditional Medicare, Medicaid and commercial/other coverage all declined over the same period, with commercial/other slipping from 53.1% to 51.3% and traditional Medicare falling from 12.8% to 11.9%.

The study's authors cautioned that coverage-mix trends could partly reflect which health systems contributed data in a given quarter rather than true population-level change, and restricted the analysis to departments that contributed data across the full study period to help mitigate that risk. They also noted that self-pay status is a proxy for uninsurance, not a direct measure of it, and may capture cash-pay arrangements or encounters where coverage has not yet been adjudicated.

The research was conducted independently by two teams — one composed of Kersten Bartelt, RN, and Eric Barkley, the other of Louis Kazaglis, MD, Grant Keane and Joe Deckert, PhD — who Epic Research said reached similar conclusions.

For physician practices, the shift carries direct revenue-cycle implications: a growing self-pay population typically means lower collection rates and more uncompensated care, particularly in emergency and inpatient settings where the increases were largest.