Emergency physicians across Michigan, Wisconsin and Kentucky aren’t asking whether patients will continue coming to the emergency department if they lose Medicaid coverage.

They know they will.

What concerns them is what those patients’ conditions will look like by the time they arrive. A manageable case of depression becomes a mental health crisis. Diabetes becomes diabetic ketoacidosis. High blood pressure can lead to a stroke or a heart attack. The disease doesn’t change. The moment it’s caught does.

Sweeping federal Medicaid changes, including new work requirements, more frequent eligibility reviews and expanded verification requirements, are expected to reduce Medicaid enrollment over the coming years. Emergency physicians who spoke with ACEP Now said the policy discussion often focuses on enrollment numbers and federal spending. Their concern is what happens after coverage is interrupted, resulting in patients delaying care, chronic illnesses becoming medical emergencies, and additional strain on an emergency care system already under significant financial and workforce pressure.

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“We’re going to continue taking care of every patient who comes through the door,” said Dr. Aaron R. Kuzel, DO, MBA, assistant professor of emergency medicine at the University of Louisville School of Medicine and director of Observation Medicine at University of Louisville, aka, UofL, Hospital. “The question is what happens to the health care system around them.”

Dr. Chris Ford, MD, FACEP, an emergency physician in Wisconsin, put it more directly.

“Medicaid isn’t simply an insurance program,” he said. “It’s part of the infrastructure that keeps emergency medicine functioning.”

A Law Reshaping Coverage

The Congressional Budget Office (CBO) estimates that the health provisions in the reconciliation law signed July 4, 2025, will reduce federal Medicaid spending by approximately $911 billion between 2025 and 2034. CBO also estimates that the legislation will increase the number of uninsured people by about 10 million in 2034, according to KFF analysis. KFF reports that the Medicaid work requirement provision alone accounts for approximately $326 billion in federal Medicaid savings and is projected to increase the uninsured population by about 5.3 million people by 2034.*

The state-level numbers put faces on that scale. Wisconsin is projected to lose approximately $7 billion in Medicaid funding over the next decade, affecting roughly 54,000 residents, Ford said. Kentucky faces an estimated $12.3 billion loss in rural Medicaid funding alone, according to Dr. Kuzel. Three states, three physicians, one law, and in each case, a number large enough to reshape the health care landscape around it.

“Those aren’t just statistics,” Dr. Ford said. “They’re real people.”

For emergency physicians, those projections aren’t abstract policy estimates. They’re a preview of who may be sitting in their waiting rooms.

Beginning in 2027, many adults enrolled through the Affordable Care Act’s Medicaid expansion population will generally be required to document at least 80 hours per month of work, education, or another qualifying activity unless they qualify for an exemption. States also will be required to conduct more frequent eligibility reviews.

The physicians we spoke with said those additional administrative requirements could create new opportunities for otherwise eligible patients to lose coverage because renewal paperwork isn’t completed or eligibility cannot be verified.

RAND research, supported by the Emergency Medicine Policy Institute (EMPI), found that emergency physicians provided approximately $5.9 billion annually in unpaid professional services, with roughly 20 percent of allowed professional charges going unreimbursed. The report also found that Medicaid patients accounted for approximately one-quarter of emergency department visits nationally. Emergency physicians interviewed for this story said those findings help explain why potential Medicaid coverage losses are generating concern across the specialty.

When Coverage Disappears Without a Denial

Dr. Uren

For Dr. Brad Uren, MD, FACEP, an emergency physician who hails from Hancock, Michigan, one of the greatest concerns is that some patients may lose Medicaid coverage not because they no longer qualify, but because they become caught in the administrative process.

Patients move. Phone numbers change. Renewal notices are mailed to old addresses. Life gets busy. Dr. Uren said he worries that many patients may not realize they’ve lost coverage until they attempt to refill a prescription or schedule a follow-up appointment. Those concerns are informed by previous experience.

When Arkansas briefly implemented Medicaid work requirements, more than 18,000 residents lost coverage, according to KFF. Subsequent research found that many of those coverage losses resulted from reporting requirements and administrative barriers rather than from unemployment, and that the policy did not produce measurable increases in employment.

Dr. Uren compares emergency medicine to the Greek myth of Sisyphus, who was constantly pushing a boulder uphill only to watch it roll back down.

Emergency physicians stabilize patients during a crisis, he said. Still, if they cannot access medications, primary care, transportation or other community resources after discharge, many eventually return with preventable complications.

“We can do heroic things in the emergency department,” Dr. Uren said. “We can’t replace the rest of the health care system.”

Financial Pressure Extends Beyond the Emergency Department

For emergency physicians, the discussion isn’t simply about treating more uninsured patients. It’s about whether emergency medicine practices and hospitals can continue absorbing those costs while maintaining timely access to care.

Dr. Kuzel

The financial environment surrounding emergency medicine, however, continues to grow more challenging. “When patients lose coverage, they don’t stop needing emergency care,” Dr. Kuzel said. Instead, he expects more visits to shift from Medicaid reimbursement to self-pay or uncompensated care.

Those concerns build on findings from the RAND report, which concluded that emergency departments operate as a critical health care safety net while facing significant reimbursement challenges. Researchers noted that emergency physicians are legally required to evaluate and stabilize all patients, regardless of ability to pay, creating financial pressures not faced by many other health care settings. Physicians interviewed for this story worry that additional coverage losses could increase uncompensated care while reducing revenue needed to support staffing, specialty coverage and access to emergency services.

Dr. Kuzel also noted that caring for uninsured patients often extends beyond the emergency department encounter itself. Physicians and care teams spend additional time helping patients navigate follow-up care, locate community resources and reconnect with primary care, which is work that is rarely reflected in reimbursement.

When the Safety Net Has No Backup

Nowhere are the limits of emergency medicine more visible than in behavioral health, Dr. Ford said.

Dr. Ford

Dr. Ford described one recent patient whose state insurance had lapsed during a mental health crisis. The patient came to the emergency department, he said, “which is exactly what we hope people will do.” But because of insurance limitations, the hospital couldn’t secure timely inpatient psychiatric care, and the patient remained in the emergency department for days awaiting placement.

“On paper, these policy discussions focus on numbers,” Dr. Ford said. “In reality, they’re about people who need care and can’t access it when they need it most.”

That patient’s experience isn’t unusual, Dr. Ford said. Behavioral health patients frequently remain in emergency departments for days while awaiting placement, and older adults often face delayed discharges because appropriate post-acute resources aren’t immediately available. Increasingly, he said, emergency departments function less like treatment centers and more like holding areas for patients who have nowhere else to go.

Staffing shortages, particularly among experienced nurses, compound the problem throughout Wisconsin, he said, making it harder to move patients out of the emergency department even once a bed technically becomes available elsewhere in the hospital.

Dr. Uren has seen a similar dynamic play out in Michigan, where emergency departments increasingly become the default destination when other parts of the health care system are unavailable.

Rural Communities Face Unique Challenges

Although each physician described different circumstances within their state, all expressed concern about the impact on rural communities.

Dr. Kuzel said he worries about the combined pressures facing rural hospitals, independent emergency medicine groups and emergency medical services. Kentucky is projected to lose approximately $12.3 billion in rural Medicaid funding over the next decade due to Medicaid-related funding reductions.

Dr. Kuzel views the Rural Health Transformation Program as a positive step, noting that Kentucky may receive roughly $212.9 million over five years through competitive grants. But he questioned whether that investment would offset the broader financial pressures hospitals may face as Medicaid funding declines over time.

If rural hospitals reduce services or close altogether, he said, patients will travel farther for emergency care, ambulance crews will spend more time transporting patients between facilities and regional referral centers will absorb additional patient volume.

“I think EMS is the piece everyone overlooks,” Dr. Kuzel said. Longer transport times, he noted, leave fewer ambulances available to respond to the next emergency.

Michigan faces similar concerns. Dr. Uren pointed to communities in Michigan’s Upper Peninsula, where residents already travel significant distances for emergency care. Additional hospital or service-line closures could further increase travel times, particularly during severe winter weather.

“Healthy communities depend on healthy hospitals,” Dr. Uren said. “When health care services disappear, communities feel those effects in many different ways.”

Dr. Ford has seen similar dynamics play out in Wisconsin, where he has practiced everywhere from Level I trauma centers to rural hospitals, at times as the only physician within 40 miles. “When those services disappear, patients often have to travel an hour or more to receive emergency care,” he said. “In emergencies, minutes matter.”

Dr. Ford added that the consequences extend beyond Medicaid beneficiaries. “When one hospital closes,” he said, “every surrounding hospital feels that impact.”

Looking Beyond the Numbers

Much of the national discussion surrounding Medicaid has focused on projected enrollment changes and federal spending reductions.

Drs. Ford, Kuzel and Uren focus instead on what those changes may mean for individual patients.

They described people delaying treatment because they cannot afford medications, postponing primary care visits, or struggling to navigate increasingly complex eligibility and health care systems. Those interruptions in coverage, physicians said, often translate into delayed treatment and more advanced illness by the time patients seek emergency care.

Looking Ahead

Despite practicing in different states, the physicians’ perspectives converged on one central message: Emergency physicians will continue caring for every patient who comes through their doors.

That commitment has never changed.

What concerns them is whether an already strained emergency care system can continue absorbing increasing numbers of uninsured patients while maintaining timely access to care for everyone.

Independently, each of the three physicians reached for a version of the same image: a system built to catch people, now being asked to hold weight it was never designed to bear. “Every safety net has a breaking point,” Dr. Ford said. “If enough patients lose access to routine care, emergency departments eventually reach a critical mass where they can no longer absorb additional demand.”

The concern isn’t that emergency departments will stop caring for patients. RAND researchers noted that emergency physicians already provide billions of dollars in uncompensated care while serving as one of the few health care settings required to treat all patients. The question raised by Drs. Ford, Kuzel and Uren is whether an emergency care system already under financial and workforce pressure can continue absorbing additional strain without affecting access for patients and communities.

Dr. Kuzel said he believes policymakers benefit from seeing firsthand how emergency departments function and how broader health care challenges eventually reach them. Dr. Ford hopes conversations about Medicaid remain focused on patients and communities rather than politics. Dr. Uren encourages policymakers to consider not only the intended goals of policy changes but also their unintended consequences for patients, hospitals and local health care systems.

The physicians acknowledge that many implementation details remain to be addressed and that states will play a significant role in administering the new requirements. Even so, they believe emergency departments are likely to be among the first places where the practical effects become visible.

Dr. Ford still thinks about the patient who waited days in his emergency department for a psychiatric bed that never seemed to open up … one person, caught between a lapsed policy and a system with nowhere else to send them. Multiply that individual by 54,000 in Wisconsin alone, and the shape of what’s coming starts to come into focus. The larger question, physicians said, isn’t whether they’ll be there when those individuals arrive. It’s whether anything will be left to catch them once they let them go.

*Editor’s Note: The $911 billion and $326 billion Medicaid savings figures are confirmed against CBO’s estimates for the final enacted law. The 5.3 million uninsured figure for the work requirement provision, however, derives from CBO’s analysis of an earlier House-passed version of the bill. CBO has not yet published an updated coverage-loss estimate specific to the enacted law. KFF continues to cite this figure as the best available estimate for the provision’s impact.

Ms. Scott is a freelance writer based in Dallas.