When the ACA enhanced subsidies expired at the end of 2025, more than 22 million Americans enrolled in ACA plans saw their insurance rates as much as double overnight.1 The implications of this seismic shift are now rippling into nearly every sector in healthcare.
The original income-based subsidies were in place in 2014 with the launch of the Health Insurance Marketplace under the Affordable Care Act (ACA), and they partially covered premiums for lower income people who were not covered by employer-sponsored plans.2 During the pandemic, the American Rescue Plan Act and the Inflation Reduction Act temporarily increased and expanded subsidies through 2025, further reducing the cost of insurance and making coverage attainable for more people.2 As of last year, 90% of ACA Marketplace enrollees were assisted by subsidies.1
Now, without an agreement in Congress to extend the enhanced subsidies, many of the industry’s post-subsidy predictions are already coming true:
• Unable to afford higher premiums, nearly 10% of ACA Marketplace enrollees have dropped their coverage and are now uninsured.3
• Of those who still have coverage, 17% fear that high costs will force them to discontinue coverage before the end of the year.3 In all, nearly 5 million people are expected to become uninsured in 2026.4
• ACA Marketplace payers also raised premiums 26% for 2026, in part to cover anticipated shortfalls caused by healthier people dropping their plans when the subsidies expired.5
• New sign-ups through the ACA Marketplace fell by more than 1 million compared to last year, which is the first enrollment decline since 2020.4
What will this mean for the physicians at the front lines of an emerging insurance crisis? To begin, they must expect patient care and practice management to change in the following critical ways.
Lower Volumes for Elective and Preventative Care
Uninsured patients are likely to delay care. According to KFF research, 75% of uninsured adults skip or postpone health care due to cost.6 With a dramatic rise in uninsured patients this year, physicians in specialties including anesthesia and radiology will see a drop in volume for services such as joint replacements and routine mammograms. Overall, hospitals, physicians, and other healthcare providers are collectively expected to lose $32 billion in revenue as a result of the expired ACA subsidies.7
Rising Uncompensated Care
Delayed care will ultimately result in high-acuity patients seeking expensive care in the Emergency Department, and often for issues that could have been prevented. Uncompensated care is expected to increase by $7.7 billion this year, $1 billion of which will impact physician practices.7 The burden will be felt most strongly by emergency physicians, hospitalists, and on-call anesthesiologists who will manage the influx of high-acuity patients who need complex hospital-based care and cannot pay their bills.
Uneven Impact Across the U.S.
Some lower income Marketplace enrollees will qualify for Medicaid,2 and as of March 2026, 41 states had expanded Medicaid programs with higher income thresholds in order to serve more people.8 The 10 states that haven’t—Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming—will experience the post-subsidy fallout much more strongly without a larger Medicaid safety net. A greater percentage of their populations fall in a difficult middle zone, making too much for Medicaid but not enough to afford unsubsidized Marketplace insurance. Practices in those states will see more uninsured patients, deliver more uncompensated care, and face greater financial insecurity.
The rise of the gig economy is compounding the problem, increasing the number of workers who don’t qualify for employer-sponsored health plans. The gig economy of freelancers and short-term contractors is growing three times faster than the total US workforce and is expected to account for more than 50% of the workforce by 2027.9 Gig work includes everything from food delivery and childcare to freelance software development and creative services such as writing and graphic design. It is highest in states with large urban areas, including Florida, California, Texas, and Illinois.10, 11
Increased Administrative Burden
The cumulative effect of lower patient volumes and higher uncompensated care will impact practice management in far-reaching ways. In the short term, RCM workflows will become more complex, with an increase in eligibility changes, denials due to lapsed coverage, and more patients needing payment plans as coverage shifts to self-pay. Longer term, financial strain from reduced revenue could force practices to shorten hours, reduce services, or even eliminate jobs. In fact, nearly 340,000 healthcare jobs could be lost in 2026—a figure that includes not only providers but also the RCM and administrative staff who support billing and reimbursement.12
A Patient Payment Strategy Isn’t Optional
From an RCM perspective, all those market forces point to a significant new reality: More patients than ever will fall into the category of self-pay. Once considered a somewhat negligible budget line item, patient payments will become increasingly important this year as 5 million more people lose their coverage and providers strive to recover whatever revenue they can.
As practices adjust to a new reality following the loss of the ACA enhanced subsidies, we believe sustainability depends on a strong strategy for patient payments. These are the critical components.
Effective Front-End Workflows
Patients are in transition, and so are their records. Without effective systems in place to collect and update patient information, practices will see more denials for lapsed coverage and an increase in bad debt.
What your practice can do now:
• Improve intake procedures to capture current contact and insurance information. The benefits go beyond avoiding denials. A good patient payments partner will proactively search for coverage and exhaust all non-patient payment options before they ever bill a patient. Updated contact information gives them a place to start the insurance and eligibility discovery phase.
• Collaborate with facility intake teams. Even if intake procedures are managed by the facility, practices may be able to request specific information or help modify workflows to collect information that will improve future billing.
• Educate Patients About Physician Billing. Many downstream billing issues stem from patient confusion over facility bills versus physician bills. Instruct intake teams to explain to patients that they will be receiving two bills for their healthcare services: one from the hospital and a separate one from the physician. Upfront communication makes a big difference in patients’ willingness to pay.
Flexible Payment Options
Rigid three-month or six-month payment plans are too restrictive for the new self-pay RCM climate. Practices will need to get creative this year, working collaboratively with patients on manageable payment solutions that ease their stress and facilitate payment follow-through.
What your practice can do now:
• Customize payment plans. If $50 a month is what a patient can afford, practices need to be able to accept and manage that payment structure, even if it means modifying workflows. Patients fundamentally want to resolve their accounts. A flexible payment plan not only improves collections, it also relieves stress and creates goodwill.
• Go digital. Make it easier for patients to pay whatever they can by offering flexible digital payment options. Most patients now prefer to pay their bills online,13 and they’ll pay faster when they receive their statements through their preferred digital channels.14 Digital-first payment options are also less labor-intensive and more economical for the practice, which is ultimately what makes custom payment plans possible for practices.
Exceptional Service
Patient payments are as much about patient experience as they are about cash flow. Practices must be intentional in readying themselves for an increase in self-pay accounts. They need service experts who are trained to assist patients and that have the right resources to accommodate them promptly.
What your practice can do now:
• Listen. Each new post-subsidy self-pay account is a person who is experiencing two of life’s great stressors at once: a medical problem and a degree of financial insecurity. Focus first on listening to the patient’s story so you can understand their circumstances work together on a reasonable solution.
• Remove friction. A payment process that adds to patients’ stress creates long-term problems for the practice. Ninety percent of patients say a good financial experience is a deciding factor for returning to a medical provider—and 93% say that a poor billing experience would cause them to seek care elsewhere.15 Prioritize customized outreach to patients, short call center wait times, and technology that works consistently and effectively for both inquiries and payments. If your practice is not set up for a frictionless patient experience, consider partnering with a vendor who can help you deliver it at scale.
RCM Optimization
When patient payments become a bigger portion of a practice’s revenue, the rest of revenue cycle should be proactively aligned to support. Practices should examine their end-to-end RCM processes and procedures to ensure they are optimized to capture all appropriate reimbursement.
What your practice can do now:
• Reevaluate payer contracts. As your payer mix shifts, review contracts with commercial payers to limit rising exposure to uncompensated care. Look to leverage opportunities such as:
• Group negotiating power. Anesthesia and radiology practices serving multiple facilities may be able to secure more favorable payer rates.Selective payment structures. High-volume or high-acuity emergency practices may negotiate increased payment for specific CPT codes rather than an across-the-board rate increase. Bundled payments models. Bundled diagnostic imaging or bundled joint replacement anesthesia may make sense in cases where physician services play a predictable role in the treatment.
• Selective payment structures. High-volume or high-acuity emergency practices may negotiate increased payment for specific CPT codes rather than an across-the-board rate increase.
• Bundled payments models. Bundled diagnostic imaging or bundled joint replacement anesthesia may make sense in cases where physician services play a predictable role in the treatment.
Successful negotiations will depend on building a data-driven case to support the new payment terms you are requesting. A strong RCM partner can provide the performance metrics and benchmarking data you need, as well as draw on longstanding industry relationships to bring payers to the negotiating table.
• Follow the data. Actionable data may mean the difference between success and failure for medical practices in the coming years. A data-driven approach to revenue cycle management can proactively uncover and correct internal and external issues that lead to claim denials, downcodes, and underpayments from both commercial and government payers. An RCM partner can help you analyze your own reimbursement data along with industry benchmarking data to reveal opportunities to recover the reimbursement your practice is due.
How Ventra Can Help
While the expiration of the ACA enhanced subsidies is creating a new sense of urgency around patient responsibility, patient payments are not new to the Ventra Health team. Our leaders bring decades of experience deploying and optimizing strategies for patient payments, and they are fully integrated across our end-to-end RCM services.
Our patient responsibility strategy is the most comprehensive and compliance-focused in the industry, with services including:
• Digital-first patient billing, with online payment options, multi-channel digital communication, and both self-service and live-agent chat options
• White-glove contact center service, with wait times and call resolution rates among the best in the industry
• Customized, continually optimized patient outreach plans that use data to determine the most effective engagement strategy for each patient
• Proactive consultation with intake teams to improve front-end registration procedures
Ventra clients also have access to our full, end-to-end RCM services, including payer negotiation and contract strategy, provider education to help improve physician documentation, provider enrollment, and vSightTM, our power data & analytics platform. Ventra’s Performance Surveillance Team monitors client metrics 24/7, identifying and correcting issues before they can impact revenue. And, our vCisionTM revenue intelligence platform leverages the most advanced agentic AI technology and data models to target impactful opportunities for improvement in the revenue cycle, reducing preventable denials, adapting to changes in payer behavior, and maximizing reimbursement.
Conclusion
The expiration of ACA enhanced subsidies is more than a policy shift. It’s a rupture in healthcare system that was already weakened by a confluence of rising costs and declining reimbursement. Specialties such as anesthesia, emergency medicine, and hospital medicine that deliver a significant amount of urgent and unavoidable care will be hit hardest, but the changes will influence patient behavior and coverage patterns for everyone. A strong patent payments strategy that includes full RCM optimization can help practices protect revenue and survive the transition.
Resources
1 “The ACA health coverage subsidy lapse hit 22 million people. Here are some of their stories,” CNBC Investing Club with Jim Cramer, Feb. 24, 2026, accessed April 1, 2026, at https://www.cnbc.com/2026/02/24/aca-enhanced-subsidy-expiration-effects.html
2 “Understanding the ACA Subsidy Discussion,” Committee for a Responsible Federal Budget, Nov. 5, 2025, accessed April 1, 2026, at https://www.crfb.org/blogs/understanding-aca-subsidy-discussion
3 “Millions of Americans Are Going Uninsured Following Expiration of ACA Subsidies,” The Wall Street Journal, Mar. 19, 2026, accessed April 1, 2026, at https://www.wsj.com/health/healthcare/millions-of-americans-are-going-uninsured-following-expiration-of-aca-subsidies-0051240d
4 “Expiration of enhanced ACA subsidies: What it means for providers—and how to respond,” Definitive Healthcare, Feb. 10. 2026, accessed Apr. 1, 2026, at https://www.definitivehc.com/blog/provider-impact-of-enhanced-aca-subsidies-expiration
5 “ACA Insurers Are Raising Premiums by an Estimated 26%, but Most Enrollees Could See Sharper Increases in What They Pay,” KFF, Oct. 28, 2025, accessed Apr. 1, 2026, at https://www.kff.org/quick-take/aca-insurers-are-raising-premiums-by-an-estimated-26-but-most-enrollees-could-see-sharper-increases-in-what-they-pay
6 “Americans’ Challenges with Health Care Costs,” KFF, Jan. 29, 2026, accessed Apr. 1, 2026, at https://www.kff.org/health-costs/americans-challenges-with-health-care-costs/
7 “How Expiration of ACA Tax Credits Will Affect Healthcare Spending,” Robert Wood Johnson Foundation, Sept. 25, 2025, accessed Apr. 1, 2026, at https://www.rwjf.org/en/insights/our-research/2025/09/how-expiration-of-aca-tax-credits-will-affect-healthcare-spending.html
8 “Status of State Medicaid Expansion Decisions,” KFF, Mar. 12, 2026, accessed Apr. 1, 2026, at https://www.kff.org/medicaid/status-of-state-medicaid-expansion-decisions/
9 “Gig Economy Statistics: Demographics and Trends in 2024,” TeamStage, accessed Apr. 1, 2026, at https://teamstage.io/gig-economy-statistics/
10 “Nonemployer Businesses are Key Contributors to Gig Activities and Economic Growth Nationally,” United States Census Bureau, Jul. 1, 2025, accessed Apr. 1, 2026, at https://www.census.gov/library/stories/2025/07/nes-gig-economy.html
11 “Gig Economy Statistic in the US [2026 Data],” OysterLink, Jan. 14, 2026, accessed Apr. 1, 2026, at https://oysterlink.com/spotlight/gig-economy-statistics/
12 “The healthcare payroll hit stemming from termination of the Affordable Care Act enhanced subsidies,” HFMA, Oct. 21, 2025, accessed Apr. 1, 2026, at https://www.hfma.org/payment-reimbursement-and-managed-care/the-healthcare-payroll-hit-stemming-from-termination-of-the-affordable-care-act-enhanced-subsidies/
13 “Trends in Healthcare Payments report reveals patient collections are primary revenue concern for providers,” J.P. Morgan, May 21, 2025, accessed Apr. 1, 2026, at https://www.jpmorgan.com/payments/newsroom/healthcare-payments-trends-report-2025
14 “32% of People Will Pay Their Medical Bill Within 5 Minutes of Getting a Text About It,” HealthLeaders, Oct. 15, 2021, accessed Apr. 1, 2026, at https://www.healthleadersmedia.com/revenue-cycle/32-people-will-pay-their-medical-bill-within-5-minutes-getting-text-about-it
15 “90% of Patients Say Loyalty Relies on Patient Financial Experience,” Patient Engagement HIT, Dec.7, 2021, accessed Apr. 1, 2026, at https://patientengagementhit.com/news/90-of-patients-say-loyalty-relies-on-patient-financial-experience
The post Managing RCM Disruption with a Strong Patient Payments Strategy appeared first on Becker's Hospital Review | Healthcare News & Analysis.
