Why doctors are worried about the patient affordability crisis

For years, if you asked a physician what kept them up at night, the answer was almost always the same: the crushing weight of administrative work. But as we move through 2026, a significant shift has occurred in the clinical consciousness. According to athenahealth’s fifth annual Physician Sentiment Survey, access to affordable health care has officially displaced administrative burden as the single biggest policy concern among U.S. physicians.

The numbers tell a stark story. Today, 52% of physicians consider affordability the most pressing issue for policy makers, a 14-point jump from just two years ago. For the first time in the survey’s history, the struggle to get patients into the exam room has overtaken the struggle to document what happens once they are there. This isn’t just a policy debate; it is a clinical reality that is reshaping the patient-physician relationship and the very stability of the medical profession.

The subsidy cliff: A cold winter for the individual market

The primary catalyst for this shift was the expiration of enhanced premium tax credits at the end of 2025. These credits, originally enacted via the American Rescue Plan and extended through the Inflation Reduction Act, were the lifeblood of the ACA Marketplace, allowing many consumers to find plans for very affordable monthly premiums. When those credits vanished, the impact was immediate and severe.

By March 2026, a KFF survey found that 51% of Marketplace enrollees who re-enrolled for the year say their health care costs are “a lot higher” compared with 2025. Four in ten report that their premiums specifically have skyrocketed. The human cost of these figures is best captured in the words of those navigating the system. As one 56-year-old man in Texas told KFF:

“Income exceeded the subsidy limit, forcing us to pay the full cost, so we switched down to a bronze from a gold plan. Even doing that, our premiums are three times what they were in 2025, with lower plan features and a higher deductible.”

For physicians, this means patients are not just paying more — they are getting less. The 2026 market is defined by a massive "buying down" of coverage. Enrollment in Bronze plans has surged, whereas Silver plan participation has declined, as low-income members accept higher out-of-pocket costs just to maintain a monthly premium they can afford.

The risk pool spiral

The volatility of the 2026 market isn't just about individual costs; it’s about the health of the entire insurance pool. Early data for 2026 indicate that only 86% of enrollees actually paid their first premiums in January, signaling deep-seated instability. Although initial plan selections were only down slightly, experts now project that actual enrollment will fall between 17% and 26% once unpaid premiums and ongoing attrition are factored in.

This exodus is not uniform. The healthiest, youngest enrollees are the first to leave. Nearly half (49%) of enrollees aged 18-29 reported leaving the Marketplace entirely, with many becoming uninsured.

Experts say that what we are seeing is not just a change in enrollment levels, but a shift in the profile of members who remain covered, the types of plans chosen, and the overall risk profile of the market.

When the "young invincibles" exit, the remaining pool is older and sicker, driving up morbidity and pushing premiums even higher. This pricing spiral threatens to leave physicians with a patient base that is increasingly underinsured or entirely without coverage.

The clinical toll of patient poverty

For the physician, the expiration of subsidies is not an abstract economic event — it’s a diagnostic barrier. When patients lose coverage, the clinical outcomes are predictable and painful. Brian Outland, Ph.D., of the American College of Physicians, notes the emotional weight this places on providers in an interview with Medical Economics: "Physicians love their patients. Just not being able to see them because they don't have insurance is quite heartbreaking."

The financial strain on patients has reached a point where it directly competes with basic survival. Fifty-five percent of returning Marketplace enrollees have cut back or plan to cut back on food or basic household items to afford health care. Among those with chronic conditions, that number rises to 62%. Furthermore, 73% of enrollees say they are worried about affording emergency care, and nearly half are concerned about the cost of routine visits and prescription drugs.

This environment creates a secondary crisis: administrative churn. The One Big Beautiful Bill Act of 2025 introduced Medicaid work requirements and ended automatic renewals for Marketplace plans, adding layers of bureaucracy that are expected to push millions off coverage through administrative churn. KFF estimates that up to 17 million people could be uninsured by the end of 2026 when combining the effects of the OBBBA and the expired subsidies.

Burnout and the rural-urban divide

This systemic instability is taking a heavy toll on physicians’ mental health. Only 32% of physicians say they are optimistic about the future of the U.S. health care system, a figure that has remained stagnant for three years. Nele Jessel, M.D., chief medical officer at athenahealth, finds this lack of optimism deeply concerning.

“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,” she told Medical Economics.

The strain is most acute in rural America. Sixty-three percent of rural physicians flag affordable access as their top priority, compared to 51% of their urban peers. These rural providers also report substantially higher burnout (67% vs. 52%), and nearly seven in 10 have considered leaving medicine altogether.

The financial stability of the practices themselves is also on shaky ground. Although 67% of physicians believe their practice is currently stable, 75% worry at least once a year about the long-term financial feasibility of their practice. Jessel points out the unique pressure physicians face as vendors who do not control their own prices.

“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,” says Jessel. “Practices have very limited ability to absorb cost increases, and those cost increases don’t just include supplies — they also include staffing costs.”

Lower reimbursement from Medicare and Medicaid remains the top financial fear (56%), followed closely by labor shortages and the rising cost of staff retention. For small practices, the situation is particularly dire, with 88% expressing fear about their ability to remain independent.

A digital silver lining? AI and the future of the EHR

If there is a bright spot in the 2026 landscape, it is the physician’s evolving relationship with technology. After years of skepticism, the athenahealth survey found 54% of physicians now say they feel comfortable using artificial or augmented intelligence (AI) in their practice, a significant jump from the previous year. This shift is led by millennial doctors, 65% of whom embrace the technology.

Much of this newfound comfort comes from ambient clinical documentation tools — AI that listens to the patient encounter and drafts the note. While these tools didn't initially save hours of time, they provided a massive psychological benefit.

“Even though initially, the early ambient note solutions didn’t create many time savings, the perception was that of reduced burden, because it allowed physicians to again refocus on the patient during the visit,” says Jessel.

Furthermore, there is a strong correlation between technological comfort and professional outlook: physicians comfortable with AI are twice as likely to be optimistic about the future of health care.

However, technology has not yet solved the information overload problem. While 81% of physicians feel they have enough data, 63% say they are overwhelmed by the volume of data in patient charts, and 73% still struggle to exchange data across different EHR platforms. The industry consensus is clear: physicians don't need more data; they need the right data at the right time.

The path ahead: Value-based care and uncertainty

As the 2026 market remains volatile, many are looking toward value-based care as a potential stabilizer. Interest is high — 69% of physicians want to learn more about value-based models — but trust in the financial reality of these models remains low. Only 36% of physicians say they are comfortable with shared risk models, where they could lose money if costs exceed targets.

The barriers to adoption are familiar: administrative burden, uncertain revenue, and patient engagement challenges. Yet, Jessel argues that this shift is inevitable and perhaps necessary.

“We firmly believe that the future will look like value-based care, and practices will have to be able to play in both worlds,” says Jessel.

In 2027, the central question for the American physician is whether the technological gains of the last two years can counteract the systemic erosion of patient coverage. The 2026 market is described by experts as a moment of transition characterized by higher costs, sicker risk pools and a patient population forced to choose between their groceries and their prescriptions.

For the physician in the exam room, the goal remains the same: provide high-quality care. But in 2026, the greatest obstacle to that goal isn't a complex diagnosis or a cumbersome HER — it’s the simple, devastating fact that for millions of Americans, the price of entry has become too high. Whether the system can adapt to this new reality before more physicians and patients exit entirely remains to be seen.