Nearly half of your patients struggled to afford care in 2025

Nearly half of working-age adults in the United States reported that their families had trouble affording health care in 2025, according to survey data from the Urban Institute, with the burden falling heavily on people with chronic illness, disabilities and lower incomes — even when they had insurance.

The findings, published in a June 2026 brief funded by the Robert Wood Johnson Foundation, are drawn from the Urban Institute's Well-Being and Basic Needs Survey, a nationally representative poll of more than 10,000 adults fielded in December 2025. Among the nearly 8,000 working-age respondents, 46% said their families experienced at least one of three affordability problems in the prior year: unpaid medical bills, unmet care needs because of cost or current medical debt.

Specifically, 16.9% of adults ages 18 to 64 reported problems paying family medical bills in the past 12 months, 34.9% said someone in the family went without needed care because of cost, and 29.4% said their family currently owed medical debt. Nearly 1 in 5 respondents, 18.9%, reported both unmet care needs and medical debt simultaneously.

The authors — Michael Karpman, Lisa Dubay, Jennifer M. Haley, Genevieve M. Kenney and Stephen Zuckerman — wrote that the results show insurance coverage "is not always sufficient to protect families from health care affordability difficulties," even as the uninsured remained the most exposed group overall.

Insurance helps, but doesn't fully protect

Uninsured adults were the most likely to report an affordability problem, at 60.4%. But coverage was no guarantee of financial protection: 39% of adults with employer-sponsored insurance, 53.8% with Marketplace or other individual market coverage, and 57% with Medicaid also reported difficulty affording care for their families.

The gap between coverage types narrowed sharply among lower-income households. Among adults with family incomes below 200% of the federal poverty level, 63% of those with individual market coverage and 54.3% of those with employer coverage reported affordability struggles, compared with 57.1% of those on Medicaid — differences the authors said were not statistically significant among the insured in that income bracket.

The report's authors attributed continued affordability problems among the insured to cost-sharing requirements, limited benefits such as dental coverage, out-of-network care and denied claims, even for Medicaid enrollees who typically face little to no cost-sharing.

Disparities by health status, race and geography

The data showed stark differences by health status. About two-thirds of adults in fair or poor health (65%) or with a disability (68.6%) reported an affordability problem, compared with roughly 40% of those without those conditions. Among adults ever diagnosed with one of nine chronic conditions tracked by the survey, more than 70% of those with stroke or chronic obstructive pulmonary disease, and more than 60% of those with cancer, heart disease or diabetes, reported difficulty affording care.

Race and ethnicity also factored heavily into the results. More than half of non-Hispanic Black adults (56.8%), Hispanic adults (56.2%) and adults of other races not classified as white or Asian (54.2%) reported affordability problems, compared with 41.6% of non-Hispanic white adults and 28.3% of non-Hispanic Asian adults. Geographically, difficulty affording care was most common in the South (50.9%) and in rural areas (50.2%), which the authors linked in part to higher uninsured rates tied to the lack of Medicaid expansion in many Southern states.

Rising premiums adding pressure

The brief also examined whether rising costs for those with private coverage are compounding the problem. About 1 in 5 adults with private insurance (19.8%) reported that their family's premiums increased "a lot" in the year before the survey, and a similar share (19.9%) said the same about out-of-pocket costs. Adults with individual market coverage were nearly twice as likely as those with employer coverage to report steep premium increases — 33.1% versus 18%.

The authors noted those findings may reflect early fallout from the expiration of enhanced Affordable Care Act premium tax credits at the end of 2025, as well as rising Marketplace premiums more broadly. They cited separate Urban Institute analysis finding that the average monthly premium for a 40-year-old buying an unsubsidized benchmark Marketplace plan in 2026 rose 22%, from $500 to $609, with deductibles typically exceeding $5,000.

That subsidy cliff has already shown up in physician-facing data. A recent analysis of athenahealth's fifth annual Physician Sentiment Survey found that 52% of physicians now consider patient affordability the most pressing policy issue facing the profession — a 14-point jump in two years that has pushed the issue ahead of administrative burden for the first time. The analysis cited a KFF survey in which 51% of returning Marketplace enrollees said their health costs were "a lot higher" in 2026 than the year before, with many downgrading from gold- to bronze-tier plans to keep premiums manageable.

Brian Outland, Ph.D., of the American College of Physicians, captured the toll that shift is taking on the doctor-patient relationship. "Physicians love their patients. Just not being able to see them because they don't have insurance is quite heartbreaking," Outland told Medical Economics. Nele Jessel, M.D., chief medical officer at athenahealth, said the lack of optimism among physicians in the survey was striking: "Only 32% of physicians in our most recent survey expressed optimism for the future of U.S. health care. That makes me, personally, very concerned." Jessel added that health care's pricing structure leaves practices little room to absorb the kind of cost increases patients are now facing: "Health care is probably the only industry where prices aren't actually controlled by the vendor offering the services, but prices are controlled by third parties. Practices have very limited ability to absorb cost increases, and those cost increases don't just include supplies — they also include staffing costs."

Insurance denials compound the cost burden

Affordability problems aren't limited to premiums and deductibles. A separate June 2026 Commonwealth Fund survey reported by Medical Economics found that more than 1 in 5 privately insured adults — about 21% — had a treatment delayed or denied last year because of a prior authorization or claim denial, a figure the survey's authors said translates to tens of millions of affected Americans nationally.

Among those who experienced a prior authorization denial specifically, 41% said it delayed their care and 28% said their health problem worsened as a result. Claim denials, which arrive after care has already been delivered, carried a heavier financial toll: nearly 70% of those denied said the experience cost their household more money, and 43% said it left them with medical debt they were still paying off. More than half of those denied claims were billed $1,000 or more.

Sara R. Collins, the Commonwealth Fund's senior scholar for expanding coverage and access, said the complexity of the system leaves many patients stuck between their doctors and their insurers. "The complexity of the U.S. health care system is leaving many patients and their families caught between their providers and their insurance companies," Collins said in a statement announcing the report. "When an insurer denies coverage for care their doctor recommends, patients are frequently unsure of how to appeal decisions or even if they have a right to appeal. We need greater transparency, expansion of appeal rights, and standardization of utilization review processes across all insurance plans to help patients have confidence in their insurance — that it will enable them to stay healthy and avoid medical debt."

Commonwealth Fund President Joseph R. Betancourt, M.D., a practicing primary care physician, said the denial process itself often works against good clinical care. "As a primary care physician, I've seen firsthand how challenging it is for patients trying to manage the complexity of the prior authorization process," Betancourt said. "It is difficult, time-consuming, and frustrating for all involved. In many cases, it leads to delayed care or no care at all; in the worst cases, it puts patients' lives at risk. When oversight overrides clinical judgment without good reason, quality of care and patient safety suffer, and that demands a policy response."

The survey found that despite the availability of appeals, only about half of denied patients challenged the decision, with many unsure they had the right to do so or doubtful an appeal would change anything. Among those who did appeal, the outcomes were often favorable — roughly 30% of prior authorization appeals resulted in the originally recommended care being covered, and a third of appealed claim denials were reduced or eliminated.

Looking ahead: More coverage losses expected

The Urban Institute authors warned that the affordability burdens documented in the brief are likely to worsen. The One Big Beautiful Bill Act, or OBBBA, is expected to reduce Medicaid enrollment through new six-month eligibility redetermination and work requirement provisions for expansion populations — changes the Urban Institute projects will result in between 4.9 million and 10.1 million fewer adults enrolled in Medicaid by 2028, depending on how states implement the rules.

Separately, the expiration of enhanced premium tax credits is projected to result in 7.3 million fewer subsidized Marketplace enrollees in 2026 and 4.8 million more uninsured individuals. Additional OBBBA provisions restricting subsidy eligibility for some lawfully present immigrants and eliminating automatic Marketplace enrollment could push enrollment down further, the authors wrote.

"Those losing Medicaid or Marketplace coverage who become uninsured are expected to face much larger affordability problems, but even those who can obtain employer-sponsored insurance could face financial hardships and barriers to care, depending on the premiums, cost sharing and benefits of those plans," the authors wrote.

The brief's findings echo broader concerns about how the U.S. health system compares with its international peers. A Commonwealth Fund report examined by Medical Economics found the U.S. spends nearly twice the OECD average on health care relative to GDP, yet posts among the shortest life expectancies and highest avoidable death rates of the 20 countries studied. The report also found that Americans spend more than $400 per person annually out of pocket on prescription drugs, compared with less than $100 in France.

Betancourt, addressing those global comparisons, said the gap reflects choices rather than constraints. "The U.S. has long prided itself on having the best health care in the world, but the population benefits from this excellence unevenly, and it remains largely out of reach for many Americans. This causes us to lag, not lead, when we compare our health outcomes to other nations," Betancourt said. "We spend more than any other nation on health care, so our poorer health outcomes aren't due to a lack of resources — it is about how we choose to use them. We know what high-performing health systems look like — other countries have them and are building them. It's high time the U.S. did better."

Policy levers cited by researchers

The Urban Institute authors pointed to several systemic factors driving high U.S. health costs, including elevated prices, hospital and insurer consolidation, prescription drug costs, and administrative middlemen arrangements that can create financial conflicts of interest. They cited antitrust enforcement, enhanced regulation of provider and insurer pricing, and pharmacy benefit manager oversight as policy options that could help slow cost growth.

States, the authors noted, have some ability to soften the impact of the OBBBA's new Medicaid redetermination and work requirement provisions by streamlining renewal processes and broadening the data sources used to verify work-requirement compliance and exemptions. Still, the brief concluded that "significant coverage losses — and increased affordability hardships — remain likely absent broader policy changes that strengthen the ACA marketplace and reduce enrollment and retention barriers for Medicaid and subsidized coverage.