The patient with chest pain hesitates before agreeing to admission.

Another asks whether the CT scan is truly necessary because they are worried about the bill.

A diabetic patient waits weeks before seeking treatment because of the deductible reset that occurred in January 2026. They cannot afford another round of medical expenses.

Across the country, emergency physicians are increasingly seeing the downstream effects of a health care system in which financial decisions shape medical decisions long before patients arrive in the emergency department (ED).

Cost-sharing mechanisms such as deductibles, coinsurance, and copays were originally promoted as tools to reduce unnecessary health care utilization. But emergency physicians and policy experts say the reality has become far more complicated. As out-of-pocket costs continue to rise, many patients are delaying or avoiding medically necessary care—sometimes until their conditions become emergencies.

According to the RAND report, Strategies for Sustaining Emergency Care in the United States, EDs increasingly serve as the health care system’s safety net, filling gaps created elsewhere. Increasingly, experts say financial barriers and insurance design are significant parts of that story.

The Rise of “Consumer-Driven” Health Care

Mr. Potter

Wendell Potter, a former health insurance executive turned health care reform advocate, said today’s high-deductible landscape did not happen accidentally.

“Cost sharing was something that, when I was in the insurance industry, I had to be a salesman for,” Potter said. “We pitched it as a way to reduce health care expenses and bend the cost curve.”

The concept was framed as “consumer-driven health care,” encouraging patients to become smarter shoppers. But Potter said the strategy primarily shifted financial responsibility from insurers onto patients, and the promised transparency never followed.

“There are two ways to control health care costs,” Potter said. “You either address unit costs, or you reduce utilization. Insurers chose utilization because it’s easier.”

The problem is that health care decisions rarely function like traditional consumer purchases. Research over the past two decades confirms that although higher out-of-pocket costs do reduce utilization, patients cut back on both unnecessary and necessary care. That distinction matters enormously in emergency medicine.

Dr. Maurer

Because emergency physicians are bound “both by oath and under the Emergency Medical Treatment and Labor Act (EMTALA),” said Lisa Maurer, MD, FACEP, Chair of the ACEP Reimbursement Committee, “EDs provide lifesaving emergency care to every patient regardless of their insurance status or ability to pay. Since it’s common for emergency physicians to collect only a minority of the patient’s share of the cost of services, as that patient responsibility increases as a function of shifting health insurance policy terms, physicians are left with an ever-increasing amount of uncompensated care.”

Dr. Cirillo

High-deductible plans can have a significant impact on patients’ health care decisions and physician reimbursement, noted ACEP President L. Anthony Cirillo, MD, FACEP. “Many patients only find out how much they are responsible for only when they actually need their ‘coverage,’ only to find out that they don’t have ‘insurance coverage’ until after they meet their deductible payments,” Dr. Cirillo said. “When a patient can’t afford to make these payments, it’s the physician who ends up not being fully paid, even though they provided care at the time of the patient’s need.”

Experiencing the System From the Other Side

One emergency physician interviewed for this article experienced those financial pressures firsthand after being struck by a car while jogging last year. Because of privacy concerns, identifying details are being withheld.

The physician suffered a traumatic brain injury, multiple fractures, and spent weeks hospitalized and in rehabilitation; the bills arrived before the recovery did.

“One of the first things that pinged me was MyChart asking for payment while I was still in rehab,” the physician said. “I still had a C-collar on and couldn’t move either arm.”

Because the injuries involved an automobile accident, billing became entangled between health insurance and the driver’s auto insurance. Months later, hundreds of thousands of dollars in bills remain unresolved.

“It became this strange stalemate,” the physician said. “Everybody basically said, ‘If you get money from the driver’s insurance, we get paid first.’”

Then, in January 2026, the deductible reset while rehabilitation was still ongoing. Physical therapy visits that had been manageable suddenly cost several hundred dollars each.

“That dramatically changed how I felt about continuing therapy,” the physician said. “Every visit suddenly felt like losing $300 to $500.”

Eventually, the physician began skipping appointments.

“Even I started avoiding care,” the physician said. “You immediately understand how an average American family would avoid care entirely.”

The experience also exposed how overwhelming these systems are for anyone without the knowledge to navigate them.

“I’m highly educated and understand how these systems work,” the physician said. “If this was overwhelming for me, I can’t imagine what it’s like for someone who doesn’t understand insurance terminology or know how to advocate for themselves.”

The physician now discusses lower-cost alternatives with patients whenever possible, directing them to purchase durable medical equipment online rather than through the hospital, where markups can be steep.

“A walking boot at the hospital may cost hundreds of dollars,” the physician said. “You can buy basically the same thing online for $25.”

Emergency Departments as Financial Shock Absorbers

Emergency departments have long served as the nation’s health care safety net under EMTALA, which requires physicians to evaluate and stabilize all patients regardless of ability to pay. But experts say EDs increasingly function as financial shock absorbers as well, absorbing the downstream consequences of delayed care, coverage gaps, and affordability failures elsewhere in the system.

According to the RAND report, approximately 20 percent of emergency department visits generate no reimbursement. The average emergency physician provides more than $150,000 in uncompensated EMTALA-related care annually.

Additionally, Dr. Maurer pointed out that payments to EDs under the Medicare Fee Schedule have decreased by 33 percent, but physician expenses have increased year over year.¹ The trend is concerning and threatens sustainability, she noted. “Stable Medicare and Medicaid physician payments are necessary to protect patient access to high quality emergency care, and to ensure the long-term viability of our nation’s safety net.”

“Emergency physician practices are at a critical breaking point,” said Dr. Cirillo. “The RAND report was published to highlight the overall value that emergency care provides to our country, and to also highlight the unsustainable current financial support of that system.”

Potter notes that rising cost burdens also create cascading financial strain for hospitals and health systems, with more than 100 million Americans now carrying medical debt.

“People delay care, get sicker, and eventually show up in the emergency room,” Potter said. “And often they’re carrying medical debt before they even arrive.”

Where Solutions Could Start

Experts have said that no single policy change will resolve the growing tension between affordability and emergency care access. But several reforms, they argue, could meaningfully reduce barriers for patients while strengthening the sustainability of emergency medicine.

The RAND report outlines alternative funding streams for services that extend beyond direct patient care, including disaster preparedness, public health screening, and EMTALA-related uncompensated care.

The RAND report estimated that emergency physicians lose out on some 20 percent of pay due to them for the patient care they provide, which is “equal to an amount of $5.9 billion worth of unreimbursed care every year,” said Dr. Cirillo, who pointed to “harmful payment policies of commercial insurers, including downcoding, denials, and delays in payment” among contributing factors.

Among changes that reform experts have said could make the greatest difference are:

• Improving price transparency,
• Lowering out-of-pocket maximums,
• Expanding primary care access for Medicaid patients,
• Reducing prior authorization burdens,
• Establishing dedicated funding tied to uncompensated EMTALA care and emergency preparedness.

Potter said emergency physicians are uniquely positioned to push for those changes.

“Physicians are influential,” Potter said. “They should use that influence to advocate for change, both for themselves and their patients.”

A System Patients Can Afford to Use

Cost sharing was designed to reduce unnecessary utilization. But the evidence and the experience of frontline physicians tell a more troubling story. Patients are not only avoiding unnecessary care. They are avoiding necessary care, then arriving sicker, later, and with fewer options.

The patient who delays treatment because the deductible reset. The patient who declines admission over observation costs. The patient who waits until symptoms become unbearable because the fear of the bill outweighs the fear of the illness itself. These are not cases at the margin. They are the daily reality of emergency medicine in 2026.

Emergency physicians cannot fix this alone. They did not design the deductibles, negotiate the contracts, or write the policies that put patients in these positions. But they are the ones in the room at the end of the delay, managing the heart attack that started as chest pain the patient ignored for three days, the sepsis that began as a simple infection the patient couldn’t afford to treat.

That is an unsustainable position for physicians and a dangerous one for patients.

Right now, for too many patients, the most dangerous moments in their quest for emergency care are the ones that occur before they decide to come to the emergency department.

Ms. Scott is a freelance writer based in Dallas.

References

1. ACEP Leadership & Advocacy Conference. Protecting and Preserving Medicare’s Promise. https://www.acep.org/siteassets/sites/lac/media/issues/protecting-and-preserving-medicare.pdf