Richmond ER Uninsured Visits Climb Ahead of Medicaid Work Rules

The uninsured are showing up before the policy does

Virginia's emergency departments are seeing a rise in patients without insurance that began before the biggest federal Medicaid changes in years have even taken effect. Data from the Virginia Hospital and Healthcare Association (VHHA) show an 8% increase in uninsured, or "self-pay," emergency visits from 2024 to 2025.13 Over a longer period the rise is much steeper: uninsured ER visits are up almost 50% since 2022.1119

Outlets disagree on the exact total. CBS 6 in Richmond put last year's uninsured ER visits at more than 405,00011, and DC News Now reported more than 450,000 self-pay visits in 2025.19 Both agree on the overall direction and the roughly 50% growth since 2022, so the gap does not change the main finding. Readers should still treat the absolute number as approximate.

The category also needs some care. "Self-pay" includes people who have no insurance and people who could not prove coverage when they were treated.13 That will tend to overstate the number of truly uninsured patients somewhat. Even so, steady growth over several years is hard to blame on paperwork alone. Other payer categories held steady or rose only slightly over the same period.13

VHHA spokesman Julian Walker made the timing point clearly. He said it is worrying to see more uninsured patients in Virginia's emergency departments before the effects of H.R. 1, the federal reconciliation law, have really set in, because projections suggest it could cost hundreds of thousands of Virginians their coverage.19

What has already happened: the ACA subsidy cliff

If Medicaid cuts mostly haven't started, what is behind the rise? The best explanation in the coverage is the end of the enhanced Affordable Care Act premium tax credits on December 31, 2025.4 Nationally, KFF found that average premiums for subsidized marketplace enrollees rose 114% in 2026.10 A KFF survey found that 9% of 2025 marketplace enrollees now have no insurance at all, and another 17% are not confident they can keep paying.5 The Urban Institute estimates that 4.8 million Americans became uninsured because the subsidies lapsed, a 21% increase in the national uninsured population.4

Virginia's numbers depend on who is counting. The Virginia Health Benefit Exchange estimates that about 100,000 Virginians lost coverage after marketplace premiums rose an average of 75%.12 The Commonwealth Institute uses the same 100,000 figure.28 The State Corporation Commission reports a smaller drop, with more than 67,400 fewer Virginians in marketplace plans than a year earlier.13 The likely explanation is that the two counts measure different things at different times. Either way, tens of thousands of residents lost coverage in a single year.

Richmond's safety-net clinics are seeing the same thing up close. Daily Planet Health Services runs 10 sites in the region, and the share of its Richmond patients without insurance went from 36% in 2024 to more than 50% by mid-2026, according to director Anita Bennett.12 Statewide, the Virginia Community Health Care Association says the uninsured share of its clinics' patients rose from 14% to 17% after the credits expired.11 The group's CFO, Michael Jackson, said most of the newly uninsured patients had lost marketplace plans.12 The VHHA data do not yet reflect the subsidy expiration11, so the 2025 rise came before it. The 2026 figures could well be worse.

What is coming: Medicaid work requirements and six-month renewals

The next stage is Medicaid. Starting January 1, 2027, adults in Virginia's Medicaid expansion group, ages 19 to 64 with incomes below 138% of the federal poverty level, will have to meet a work or community-engagement requirement. Their eligibility will also be checked every six months instead of every year.23 They can qualify with 80 hours a month of work, volunteering, training, or school, or with household income of at least $580 a month. At each renewal, they need to have met the rule in at least one of the months since their last review.2124

Other changes come along with the work rules. On October 1, 2026, Virginia limited full Medicaid benefits for adult noncitizens to green-card holders, Cuban-Haitian entrants, and COFA migrants. People who lose coverage may still qualify for emergency-services Medicaid.2630 In January, retroactive coverage for expansion adults drops from three months to one, and for other Medicaid groups from three months to two.2430 Hospitals have reason to watch that change closely. Retroactive coverage is how a hospital gets paid for treating someone who was eligible for Medicaid but not yet enrolled when they arrived. Cutting that window most likely moves more emergency care into the uncompensated column.

There is also a less obvious penalty. People who lose Medicaid because they did not meet the work requirement will not be eligible for financial help to buy a marketplace plan.26 That closes off the most obvious fallback.

The estimates vary widely

Estimates of how many Virginians could lose Medicaid cover a broad range. Advocates estimate 188,000.12 The Commonwealth Institute projects 260,000 over nine years starting in 2027.28 An Axios report from 2025 cited projections of nearly 600,000 by 2027.18 The state's own dashboard says 296,288 members could be affected.22

The state figure is often misread. At a September legislative briefing, officials said about 300,000 of the 550,000 expansion enrollees are "at risk." That means the state lacks enough information to tell whether they qualify for an exemption, not that they will lose coverage.24 Federal guidance made the picture worse. It narrowed "medically frail" to conditions that also limit a person's ability to work, which cut the number of people the state expected to exempt automatically from about 300,000 to about 170,000.24

What matters most is the reason people lose coverage. Health and Human Resources Secretary Marvin Figueroa has said plainly that many enrollees already work. He expects a significant number to lose coverage because they can't document their work, not because they aren't working.29 Officials also noted that states that tried work requirements in 2019 saw large coverage losses, partly because of administrative failures.24 Outreach staff at Daily Planet, where about three-quarters of patients are homeless, expect most of them to qualify but doubt they can keep up with reporting every six months. As outreach director Diana Martinez put it, many don't know where their mail ends up.12 In Richmond City alone, the state dashboard shows 15,261 people who could be affected.24

Why insured patients will pay too

The biggest cost story here is who ends up paying. Federal law requires hospitals to treat everyone who comes to the emergency department. When patients can't pay, hospitals absorb the loss, and over time they recover it from everyone else.13 Walker described how this works. Insurers adjust their models to account for more uncompensated care, and those costs show up in employer premiums, paycheck deductions, copays, coinsurance, and deductibles.19 Aubry Layne of Sentara has been telling chambers of commerce that people with commercial insurance should not assume they are unaffected.13

Research reaches the same conclusion. The Urban Institute projected that the subsidy expiration alone would increase demand for uncompensated care by $7.7 billion nationally in 2026. Slightly more than half would fall on providers, 30% on the federal government, and 19% on state and local governments.8 One industry analysis cited by Definitive Healthcare found that a 10% shift toward self-pay billing costs a $1 billion health system almost $3 million, roughly a month of collections.3

For Virginia's institutions, the bigger risk is funding. The state projects it could lose between $1.8 billion and $2.6 billion a year in federal Medicaid money starting in 2028. Governor Spanberger's executive order says no combination of state tools can close a gap that large.22 VHHA has put hospital losses at about $2 billion a year once the changes are fully in place in October 2027.18 A state report found 13 rural hospitals at risk of closing.13 Some losses have already happened. A community health center in Southwest Virginia closed eight school-based clinics, and the association links that decision to financial pressure.11 Health centers expect to lose $36 million a year in reimbursements from the combined ACA and Medicaid changes.12

Virginia's response, and its limits

Richmond is trying to soften the impact. The 2026–28 budget includes more than $500 million in health spending tied to the federal changes. That covers $150 million for premium assistance, a $225 million federal contingency fund, and $15 million for health centers, free clinics, and outreach.22 The new state subsidy is expected to help about 200,000 Virginians, with enrollment starting in November.13 Executive Order 20, the "Keep Virginia Covered" order, directs state agencies to cut paperwork wherever federal law allows.22

These steps help, but they don't close the gap. The Commonwealth Institute estimates the premium fund will reach about 45% of the people priced out of marketplace plans this year.28 The state's own order admits it cannot replace federal Medicaid dollars.22

There is one real point of disagreement. Emergency physicians at CU Anschutz in Colorado say it is too early to tell whether the federal changes will raise ER volumes. They cite older research finding that uninsured adults do not use emergency departments more than insured people do, though they use other care less.20 That is worth keeping in mind. But Virginia's data, rising for three years in a row and climbing fastest in the uninsured category, suggest the state's emergency rooms are already seeing a shift in who pays, even if total volume hasn't jumped.

In short, Virginia's uninsured surge started with the ACA subsidy cliff, not with the Medicaid changes, and those changes start in January. If Medicaid renewals end coverage for paperwork reasons at anything like the rate seen in earlier states, Richmond's emergency rooms are likely to see a second, larger wave on top of the first, and the cost will reach people with insurance through their premiums.