Hospitals are seeing more self-pay patients as coverage losses mount across both the ACA and Medicaid markets.
In a study published Aug. 31, Epic Research found self-pay visits are increasing across hospital settings as Medicaid enrollment has fallen across the country following the expiration of continuous enrollment protections in place during the pandemic.
Epic’s research looked at more than 550 million U.S. healthcare encounters between the first quarter of 2022 and the second quarter of 2026 and found that self-pay visits are increasing the most in emergency departments, climbing from 5.5% to 7.6% during the period. Across the same timeframe, self-pay inpatient admissions rose from 1.9% to 2.6%, births from 0.8% to 1.3% and primary care from 1.8% to 1.9%.
At the same time, Medicaid coverage declined among patients across all four settings, falling from 18.2% to 16.1% in EDs, 13.2% to 11.7% for inpatient admissions, 23.1% to 21.5% for births and 11.4% to 10.3% in primary care.
The sharpest increase was in the second quarter of this year, when ED self-pay jumped a full percentage point and inpatient self-pay rose 0.6 percentage points from the prior quarter. Adults ages 18 to 34 have seen the largest increase with ED self-pay in that group rising from 9.9% in early 2022 to 15.3% in the second quarter of 2026.
On the ACA front, the nation’s largest for-profit health systems said on the most recent round of earnings calls that patients who previously had ACA coverage are largely going uninsured rather than finding coverage elsewhere following the expiration of enhanced premium tax credits. Nationwide, ACA enrollment fell to 19.2 million as of February, down 12% from nearly 21.8 million a year earlier as premiums increased.
In July, Nashville, Tenn.-based HCA Healthcare raised its full-year estimate of the payer mix hit from the ACA subsidy expiration to between $1 billion and $1.2 billion, up from an initial estimate of $600 million to $900 million.
“We expected some of these patients to shift to other forms of coverage, but this did not happen,” HCA CEO Sam Hazen said on the company’s second-quarter earnings call. “Instead, these patients migrated almost one for one to uninsured.”
Community Health Systems more than doubled its projected annual hit from the subsidy expiration to between $50 million and $75 million, up from $20 million to $30 million. Self-pay patients at the Franklin, Tenn.-based system rose to just over 6% of visits from slightly less than 5% a year earlier.
“We only collect a few pennies on the dollar” from self-pay patients, CHS CEO Kevin Hammons said on the earnings call, adding that the company is “effectively not recognizing any revenue on that self-pay business.”
Dallas-based Tenet Healthcare saw exchange revenue fall 17% and exchange admissions drop about 13.5% year over year, creating a $65 million quarterly revenue headwind. The system still raised its full-year adjusted EBITDA guidance, crediting cost reduction efforts it began planning in mid-2025.
H.R. 1, signed into law in July 2025, is expected to further accelerate coverage losses as Medicaid work requirements and more frequent eligibility checks begin in 2027. The CBO estimates the law’s Medicaid provisions will leave 7.5 million more people without health coverage by 2034.
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