Affordability Is the New Clinical Variable

The spending trajectory is high and persistent

The United States spends more on healthcare than any peer nation, and the trajectory remains upward. CMS’s Office of the Actuary regularly publishes national health expenditure projections and summaries. The 2024 fact sheet on projected spending growth, available through CMS, outlines the expected pace of spending expansion, as described in the CMS national health expenditure projections fact sheet. These projections can feel abstract. Their practical meaning is clear: households, employers, and public programs face continuing pressure to finance care at higher prices.

Out-of-pocket strain is common, even among the insured

KFF’s work on affordability captures a basic reality. A substantial share of adults report problems paying for healthcare, and the burden is higher among uninsured adults and certain demographic groups. The December 2025 update Americans’ Challenges with Health Care Costs documents these patterns and provides a concrete measure of how often cost interferes with care decisions.

This interference changes clinical outcomes indirectly. A patient who skips a follow-up because of cost is more likely to present later with complications. A patient who takes medication every other day to stretch a prescription may have unstable control of chronic conditions. These behaviors rarely appear in claims data as “cost-related nonadherence,” yet they shape the clinical narrative.

Medicare costs remain politically salient because they are personal

Medicare beneficiaries track premiums and deductibles with precision because many live on fixed incomes. CMS announced that the standard Part B premium and deductible would increase in 2026, with details provided in the CMS fact sheet on 2026 Part B premiums and deductibles. For policy analysts, this is a line item. For patients, it is a monthly arithmetic problem, often compounded by prescription costs and supplemental plan complexity.

Medicare Advantage payment policy also shapes coverage design. CMS’s final rate announcement for 2026 projected increased payments to plans, described in the CMS 2026 Medicare Advantage rate announcement. Payment levels influence premiums, benefits, and plan behavior. They also influence provider networks and prior authorization patterns that patients experience as delays and denials.

Coverage churn: the Medicaid unwinding story continues to echo

Coverage is not a binary state. People move in and out of coverage due to eligibility redeterminations, administrative barriers, and income volatility. The Medicaid continuous coverage provisions that existed during the pandemic ended, and states began redeterminations. KFF’s Medicaid Enrollment and Unwinding Tracker aggregates state data and provides an ongoing view of renewals and disenrollments. This churn has clinical consequences. Patients lose continuity with clinicians, prescriptions lapse, and preventive care becomes sporadic.

Administrative coverage loss is often experienced as a moral judgment by patients, even when it is an eligibility or paperwork issue. Health systems then absorb the downstream effect through uncompensated care and delayed presentations.

Employer coverage is under strain, and benefit design is the response

Employer-sponsored insurance remains the primary coverage source for many working-age adults. Employers respond to cost trends by adjusting deductibles, narrowing networks, and expanding utilization management. These changes are often framed as “consumer-driven” models. In practice, they shift decision-making onto patients who have limited capacity to shop for care in urgent circumstances.

The result is a quieter form of rationing. It is not a denial letter. It is a high deductible that turns a test into a personal loan decision. It is a prior authorization delay that makes a patient reconsider whether care is worth the administrative burden.

Medical debt: the shadow outcome

When affordability fails, debt becomes the clinical afterlife. Medical debt shapes credit scores, housing access, and mental health. KFF Health News has documented the scope of medical debt and its consequences through the project Diagnosis: Debt. Debt influences care-seeking behavior. Patients who have been sent to collections are less likely to return for follow-up, even when they know care is necessary.

The social conversation is responding to institutional incentives

The online conversation about healthcare costs often appears chaotic. It is, in fact, responding to real incentives. Patients are reacting to surprise bills, opaque pricing, and coverage churn. Clinicians are reacting to prior authorization and administrative complexity. Employers are reacting to premium growth. Public programs are reacting to budget constraints.

A more coherent policy response would treat affordability as a quality measure. It would reward systems that provide clear pricing, predictable billing, and continuity-oriented coverage design. It would invest in administrative simplification, which is a direct cost reducer. It would also address the structural drivers of price growth, including market consolidation and prescription drug pricing, without assuming that individual consumer behavior can solve systemic price dynamics.

Affordability changes medicine even when clinicians pretend it does not

The most sobering part of affordability is how it invisibly reorganizes clinical practice. When patients delay care, clinicians see more advanced disease. When patients lose coverage, clinicians spend more time on paperwork and less time on counseling. When premiums rise, employers shift costs, and patients reduce preventive visits, which then worsens population risk.

Affordability is the new clinical variable because it changes health behavior upstream of diagnosis. The health system will continue to debate cost as a policy topic. Patients have already integrated it into every decision about whether care is feasible.