---
title: "Self-pay encounters rose and Medicaid share fell across care settings, Epic Research finds"
id: "news-news-medical-economics-f19cfd191a07c82b5b6d732d"
canonical_url: "https://medichelpline.com/news/news-news-medical-economics-f19cfd191a07c82b5b6d732d"
content_type: "medical_news_article"
category: "Public Health"
source_name: "Medical Economics"
source_url: "https://www.medicaleconomics.com/view/report-self-pay-patient-encounters-rose-and-medicaid-fell-across-all-care-settings"
published_at: "2026-09-03T18:52:32.000Z"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Self-pay encounters rose and Medicaid share fell across care settings, Epic Research finds
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- **Category:** [Public Health](https://medichelpline.com/news/public-health.md)
- **Reporting Source:** Medical Economics
- **Original Source URL:** [Read Original Article](https://www.medicaleconomics.com/view/report-self-pay-patient-encounters-rose-and-medicaid-fell-across-all-care-settings)
- **Published At:** 2026-09-03T18:52:32.000Z
## Executive Summary & Key Highlights
- A new analysis from **Epic Research** of more than 550 million encounters (Jan 2022–Jun 2026) found the share of encounters billed **self-pay** rose across four care settings while **Medicaid** coverage fell in each setting. - The steepest increase in self-pay occurred in the **emergency department**, rising from 5.5% to 7.6% of encounters; inpatient admissions rose from 1.9% to 2.6% and births from 0.8% to 1.3%. - **Medicaid**'s share declined across settings: ED fell from 18.2% to 16.1%, inpatient from 13.2% to 11.7%, births from 23.1% to 21.5%, and primary care from 11.4% to 10.3%. - Within ED encounters, **Medicare Advantage** grew (10.3% to 13.0%) while traditional Medicare, Medicaid and commercial/other all decreased. - Researchers linked the trends temporally to the end of the federal Medicaid continuous-enrollment provision on March 31, 2023, and the subsequent state-by-state unwinding and redeterminations. - The authors cautioned that self-pay is a proxy for uninsurance and that shifting participation by contributing health systems could affect observed trends; they restricted some analyses to departments with continuous data across the study period to reduce that risk. - For physician practices, rising self-pay proportions imply potential revenue-cycle challenges, including lower collection rates and higher uncompensated care exposure, especially in ED and inpatient settings.
## In-Depth Reporting & Editorial Analysis
## New analysis shows broader shift toward self-pay and away from Medicaid across care settings An analysis published Aug. 31 by **Epic Research** found the proportion of U.S. health care encounters billed as **self-pay** increased across four care settings between early 2022 and mid-2026, while **Medicaid**'s share of encounters declined in each setting studied. The research examined more than 550 million encounters recorded in Cosmos, Epic’s research dataset, spanning January 2022 through June 2026. Cosmos includes records from a collaboration of Epic health systems representing over 310 million patient records across roughly 2,200 hospitals and 50,000 clinics in all 50 states and several international sites. For each quarter in the study window, researchers calculated the share of encounters whose primary expected payer was self-pay, Medicaid, traditional Medicare, Medicare Advantage or commercial/other coverage in four care settings: the emergency department, inpatient admissions, births and primary care. ## Where the changes were largest The most pronounced rise in **self-pay** occurred in the **emergency department (ED)**. ED self-pay visits increased from 5.5% of encounters in the first quarter of 2022 to 7.6% in the second quarter of 2026 — the steepest growth among the four settings tracked. Inpatient admissions’ self-pay share climbed from 1.9% to 2.6% over the same period, and births rose from 0.8% to 1.3%. Primary care showed only a small increase in self-pay, moving from 1.8% to 1.9%. At the same time, **Medicaid**'s share declined across all settings. Births consistently carried the highest Medicaid share but fell from 23.1% to 21.5%. The ED experienced the largest Medicaid decline, from 18.2% to 16.1%. Inpatient admissions fell from 13.2% to 11.7%, and primary care dropped from 11.4% to 10.3%. ### Coverage mix in emergency departments A closer look at ED encounters showed two payer categories increased between 2022 and 2026: **self-pay** and **Medicare Advantage**. Medicare Advantage rose from 10.3% to 13.0% of ED encounters. By contrast, traditional Medicare, Medicaid and commercial/other coverage all fell during the period. Commercial/other slipped from 53.1% to 51.3%, and traditional Medicare declined from 12.8% to 11.9%. ## Researchers point to Medicaid unwinding as a temporal factor Investigators linked the observed changes in payer mix to the end of the federal continuous-enrollment provision for **Medicaid**, which lapsed March 31, 2023. That provision had kept nearly all Medicaid beneficiaries covered during the COVID-19 pandemic without routine eligibility checks. After it expired, states began a staggered process of redetermining eligibility and terminating coverage for beneficiaries who no longer qualified or who did not complete renewal paperwork. Because states controlled the timing of these eligibility reviews, the unwinding occurred on a state-by-state schedule beginning in spring 2023. Epic Research noted earlier work that showed rising self-pay encounters as Medicaid terminations resumed and that self-pay ED visits increased in months following the start of those terminations. With the unwinding now largely complete, the longer study window allowed researchers to assess whether early shifts persisted across multiple care settings and a broader time span. ## Data source, methods and cautions The study used the Cosmos dataset, a large convenience sample drawn from Epic systems. The analysis included more than 550 million encounters and covered facilities in all 50 states plus Canada, Lebanon and Saudi Arabia. Researchers calculated quarterly payer shares in the four specified settings and used **self-pay** as a proxy for lack of insurance, acknowledging that the designation may also capture cash-pay arrangements or encounters with coverage not yet adjudicated. Authors cautioned that part of the observed coverage-mix trends could reflect which health systems contributed data in any given quarter rather than changes in the underlying population. To reduce that risk, the analysis was restricted in some parts to departments that contributed data continuously across the full study period. The research was conducted independently by two teams who reached similar conclusions, according to Epic Research: one team included Kersten Bartelt, RN, and Eric Barkley; the other included Louis Kazaglis, MD, Grant Keane and Joe Deckert, PhD. ## Financial implications for practices and hospitals The report noted direct revenue-cycle implications for physician practices and hospitals. A rising share of **self-pay** encounters generally corresponds with lower collection rates and increased uncompensated care. That exposure is especially concerning for **emergency department** and inpatient services, where patients have limited ability to delay care and where the study saw the largest shifts toward self-pay. The authors did not provide new estimates of dollar amounts of uncompensated care or specific impacts on collections; those details were not reported in the source article. ## What this means going forward Epic Research’s findings describe payer-mix shifts through mid-2026 and relate them temporally to the Medicaid continuous-enrollment expiration and state-level unwinding that began in spring 2023. The study’s expanded timeframe was intended to determine whether earlier, short-term increases in self-pay persisted; the analysis suggests those shifts held across a broader span and multiple care settings. Researchers reiterated methodological caveats — including the use of self-pay as a proxy for uninsurance and potential variation in contributing sites — and limited parts of the analysis to consistently reporting departments to help address those issues. The source did not report specific policy recommendations or projections beyond the observed coverage shares. ## Bottom line Between early 2022 and mid-2026, Epic Research found a clear upward trend in encounters billed as **self-pay** across emergency departments, inpatient admissions, births and primary care, accompanied by declines in **Medicaid** coverage shares in each setting. The trends were most pronounced in the ED and inpatient settings and were temporally associated with the end of the federal Medicaid continuous-enrollment provision and the subsequent state-level unwinding process.
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