Epic got stickier despite those pesky antitrust cases. And curiosity collapsed the agent layer.
Two years ago this site published a tight commentary on the trade-press habit of calling Epic a monopoly. The structural read at the time was that Epic was not a monopoly. Epic was a sticky incumbent in a concentrated market with substantial switching cost. The piece named the press framing as press-friendly but structurally imprecise, predicted that the right policy response was interoperability standards rather than antitrust enforcement, and closed with the operator-class advice to build assuming Epic would remain dominant.
KLAS dropped its 2026 EHR market share report today. Epic now holds 42.3 percent of the US acute-care EHR market, up from 39.1 percent in 2024. Epic added 77 hospitals and 18,679 beds in 2025. Of the two large health systems (more than ten hospitals) that made enterprise-wide EHR decisions all year, both picked Epic. Oracle Health, the largest competitor, lost 56 hospitals and 14,676 beds, its third consecutive year of major net losses. The acute-care market is in a documented purchase freeze. Switching cost did exactly what the 2024 piece said it would do, on a steeper slope than the 2024 piece would have predicted.
The 2024 piece was right about almost everything. It is now also wrong about some things, and the wrong parts are more interesting than the right ones.
Switching cost did the work
The structural argument in 2024 was that Epic's moat was switching cost, not market share. A health system that has run Epic for a decade has integrated it with two hundred internal systems, trained ten thousand users, and entangled the financial and clinical workflow so completely that switching is a five-to-ten-year project costing low-to-mid hundreds of millions. That kind of moat keeps an incumbent dominant. It does not, in the standard reading, also let the incumbent absorb every large-health-system replatform decision in a given year. The standard reading was generous.
What actually happened is that Epic kept gaining share while the rest of the market stalled. Oracle Health is in year three of major losses. MEDITECH had its strongest customer retention year ever, with 84 percent of its base electing to migrate to the Expanse platform, up from 30 percent in 2023. That is a vendor doing well at holding what it has. It is not a vendor adding share. The two big enterprise decisions in 2025 went to Epic because the migrating health systems wanted easier regional data exchange with the systems they were going to be working with, and the systems they were going to be working with were all on Epic. Network effects on the EHR runtime do not run through the press headlines. They run through the regional referral graph.
Meanwhile the rest of the market sat on its hands. KLAS describes 2025 as a purchase freeze, driven by government policy uncertainty and a strategic pivot toward artificial intelligence. The plain operator reading of "purchase freeze plus AI pivot" is that health systems would rather not commit to a new EHR until they understand which EHR has the best AI story. The vendor with the best AI story is the one whose foundation model already sits on top of the largest patient data graph in the United States. That is a different conversation, and it gets its own section.
The antitrust cases showed up anyway
The 2024 piece warned that the monopoly framing would produce bad regulatory framing. The piece was correct about that, and the bad regulatory framing showed up on schedule.
Texas Attorney General Ken Paxton filed an antitrust suit against Epic in December 2025 under the Texas Free Enterprise and Antitrust Act. The complaint asserts unlawful monopolization across multiple EHR-related markets, frames Epic's 325 million patient records (representing about 90 percent of the US population) as a private gatekeeping tool, and adds a parental-access angle that gives the press a sympathy hook. In September 2025, Judge Naomi Buchwald in the Southern District of New York ruled that Particle Health's Sherman Antitrust Act monopoly claims against Epic could proceed to discovery, which means Epic has to turn over internal corporate records relating to the monopoly claim. The FTC, by Lina Khan's public statements, is monitoring the case and has acknowledged hearing concerns from healthcare-startup founders about Epic-as-incumbent.
The structural argument that Epic is sticky-incumbent rather than monopoly remains correct. The policy framing battle was lost anyway. The two cases will drag for years. They will produce, if they produce anything, data-portability requirements rather than market-share remedies. Discovery will surface internal documents that the trade press will report selectively. Settlement, if it lands, will look like a refinement of the existing ONC information-blocking framework. None of it will move Epic's share.
This is the thing about being correct on the structural argument. You can be entirely correct that the monopoly framing is the wrong frame, and the policy system can still adopt the monopoly framing and run several years of legal process on it, and the trade press can still recycle the framing in every secondary coverage cycle, and the structural framing can still be the one that explains what actually happens in the market. Producing bad regulatory framing turns out to be exactly the sort of thing the policy system is good at when the trade press cooperates. The structural read does not get a vote.
The operator-class implication is unchanged from 2024: do not build assuming antitrust will move Epic. It will not move Epic. It will keep being a story.
Curiosity collapsed the agent layer
A 2025 piece in this catalogue framed the agent layer as the next surface where Epic's moat would meet competitive pressure. The implicit picture was a third-party integration tier sitting on top of multiple EHRs, commodifying the EHR plumbing, reducing switching cost over time by absorbing the workflow that used to belong inside Epic. That picture got the direction wrong by 180 degrees.
What actually happened is that Epic built the agent layer itself. Epic launched its own ambient AI scribe, Art, in 2025. Epic took the de-identified patient-data graph it has been quietly assembling since 2018 (covering roughly 70 percent of US Epic users and 300 million patients, originally called Cosmos and rebranded to Curiosity sometime last quarter) and turned it into a foundation model that no third-party clinical AI vendor can plausibly match. Epic's foundation model does not have the best model architecture in the world. Epic's foundation model has the best dataset in healthcare. The two are not the same thing, and the second one is much harder to acquire.
The third-party ambient-scribe vendors are still there. Abridge raised a $300 million Series E in June 2025 at a $5.3 billion valuation, which is the kind of round you raise when you are the leading independent scribe vendor and you have meaningful Epic integration. Suki and Nabla are competing. They are all real businesses, well-funded, with strong product. They also all integrate with Epic. The third-party scribe market, two years on, is not a competitive layer above Epic. It is a feature category inside the Epic platform, with Epic running its own first-party option and the third parties accepting that the addressable market is "physicians who prefer not to use the Epic-native scribe but still need their notes back inside Epic."
The agent layer was supposed to be the place where Epic's moat got commodified. It is, instead, the place where Epic's moat got expressed in a new vocabulary. Curiosity is the same moat, one floor up.
Epic renamed Cosmos to Curiosity last quarter. The product is the same. The patient records are the same. The renaming is, presumably, structurally important to someone at Epic. To everyone outside Epic, it is a rebrand. The brand work, however, did not change the underlying point: Epic now owns both the runtime that clinical workflow lives on and the foundation model that clinical reasoning runs on. That is one more floor of moat than the 2024 piece imagined Epic would build.
What aged how
Three things aged in two years, and they aged in three different directions.
The structural switching-cost argument aged emphatically well. Epic did not just stay dominant. Epic kept gaining. The trajectory was steeper than the 2024 piece would have called.
The "antitrust is the wrong response" argument aged well as a structural matter and lost the policy battle anyway. The cases are real, the discovery is happening, the framing is sticky in exactly the way the 2024 piece predicted, and none of it will move Epic. Being right about the analytical frame does not, by itself, win the policy frame. It rarely does. The 2024 piece should have said so more bluntly.
The agent-layer-as-switching-cost-reducer argument aged worst. The agent layer turned out to be the next floor where Epic extended its data moat, not the floor where the moat ran out. Curiosity is the moat with better marketing, and the marketing turns out to matter, because the AI strategic pivot that drove the 2025 purchase freeze is the thing that makes Epic's data moat newly legible to health-system buyers who used to think about EHR selection as a workflow decision.
The operator-class read in 2026: build assuming Epic remains dominant on the runtime layer, and assume the same on the foundation-model layer. Do not bet on antitrust to change Epic's market position. Do not bet on the third-party agent ecosystem to commodify the EHR plumbing. Build inside the Epic-plus-Curiosity envelope, or build for the narrow set of clinical workflows that genuinely do not need a foundation model trained on three hundred million patients.
The trade press will keep writing the monopoly story. The courts will keep working through it. The operator-class read should track Curiosity, not the courts.
—TJ