January 29, 2026

7 min read

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Key takeaways:

• Every 4 years, 17% of U.S. adults spend more than 10% of their family income on out-of-pocket health care costs.
• Some populations are more likely to be affected, aligning with known disparities.

Burdensome health care spending in the United States is a wide-reaching issue that requires multiple solutions, according to an expert.

Adam Gaffney, MD, MPH, an assistant professor of medicine at Harvard Medical School, and colleagues recently published the results of a cohort study evaluating burdensome health care spending over time among individuals in the U.S.

The study, which included 12,645 Medical Expenditure Panel Surveys respondents, revealed that the health care system “imposes cost burdens on a larger share of the population than suggested by cross-sectional analyses,” and that “most individuals in the U.S. will experience such burdens during their lifetimes,” so policies reducing out-of-pocket costs could help improve Americans’ well-being.

Healio spoke with Gaffney to learn more about the study’s findings, the real-world impacts here and what health care providers can do to help patients affected by burdensome out-of-pocket costs.

Healio: Why did you decide to research this? Why is it important for health care providers to know about?

Gaffney: Modern medicine really helps people, can save lives and can reduce suffering, but it can only do those things if people can actually afford to get the care they need and to not wind up poor as a result or, even worse, bankrupt. So, we wanted to better understand the financial strains that our health care system puts on Americans.

Usually, previous studies have just looked at 1 year: How at risk are you of having a heavy health care spending burden over the course of the year? But the reality is that life is long, and over the years, we figured that many more people would eventually be at risk from health care spending strains. So, we used data that allowed us to look over a 4-year period at Americans and how health care costs accumulated and how the risk for burdensome costs compounded over time.

Healio: Will you briefly describe your study and your findings?

Gaffney: We looked at three different metrics of health care cost strain: what we called health care cost burden, where more than 10% of your total family income is going to your out-of-pocket health care costs; catastrophic health care spending, where 40% of your total family income is going toward your out-of-pocket health care costs; and the share of people who didn’t get care they need because they couldn’t afford it.

What we found is that the risk for having one of those adverse financial outcomes goes up and up and up each year for an average American family. To give one data point, in 1 year, 6.5% of adults experience a cost burden, meaning more than 10% of their family income is going to their health care costs out of pocket. But it rises, and by year 4, 17% of Americans have faced a cost burden. You see even higher levels when you look at all the different metrics combined. For instance, about 12% experienced one of any of those adverse health care financial burdens in 1 year. But after 4 years, 27% of adults had experienced an adverse financial health care burden. So, the takeaway here is simple: many more Americans are affected by burdensome health care costs than you might think if you just looked at what happens in 1 year.

Healio: What are the real-world impacts here? What does cost burden look like aside from the numbers?

Gaffney: It can really play out in two different ways. On the one hand, people get the care they need, but accrue medical debt, deplete their savings — worst case scenario, could experience bankruptcy. So, people have health care financial strain, and that might require cutting back on other needed expenses — insurance, rent or food, education.

The other possibility is that to avoid those costs, people just don’t get the care they need altogether. And this is something that physicians see play out in their clinics: A patient who doesn’t fill a prescription because the copay or deductible is too high. A patient who hasn’t come to the doctor in years because they didn’t have any health insurance. Someone who delays coming to an emergency room even with something serious because they’re worried that they’ll be slammed by a giant bill.

So, these are the two ways this plays out. People’s finances are squeezed or they avoid care. And in many cases, this can happen to the same person: they can both be squeezed and avoid care.

Healio: You wrote that certain populations — adults who are lower-income, less-educated, uninsured, and have chronic diseases or hospitalizations — more often faced cost-related problems, “mirroring known disparities in U.S. health care.” Will you discuss the impact of these inequities?

Gaffney: People with lower incomes are going to be squeezed to a greater extent by that $1,000 or $2,000 deductible. If you have less money in your pocket, you’re going to be less able to afford the care you need. So, it’s no surprise that working-class people are more squeezed by our health care system than rich ones.

Many groups also have higher health care needs, and so regardless of their income, regardless of their wealth, they’re going to be at greater risk for going broke simply because they need a lot of health care. People who have cancer, heart disease, lung disease, other sorts of conditions are going to face higher risk for health care financial strain, regardless of their income because their needs are greater. Someone who’s uninsured — well, it’s quite obvious why they would be squeezed because they’re paying basically totally out-of-pocket, and as a consequence, they tend to get much less care — avoid the health care system altogether. Disadvantaged groups, including ethnic and racial minorities, often have less economic resources or greater health care needs.

We looked at people in the few years before their deaths — a time, obviously, where many people need a lot of health care. And, rather shockingly, we found that more than half of Americans will face a financial health care burden in the in the 4 years leading up to their death, which means that all of us are probably going to face a health care cost burden at some point in our lives.

Healio: What can be done to help this situation? What policies could be enacted to reduce the burden of health care cost in the U.S.? Are any in the works?

Gaffney: There are many things that can be done to help, and there are also things that can be done to make a bad situation even worse.

One thing we can do [to help] is cover everyone, and there are different ways to do that, but we’re currently moving in the opposite direction. With the expiration of the ACA subsidies that are now being discussed in Congress, as well as the Medicaid cuts that were passed in July of 2025, we’re actually expecting to see a lot more people lose coverage. That’s actually going to make things worse.

If we wanted to make things better, we would cover everyone, and that would help. But that wouldn’t be enough because the reality is that many people with health insurance are still squeezed, whether because of co-pays, deductibles, out-of-network care, uncovered services and onward. Many people with insurance are also squeezed, so having insurance is not enough.

So, what can we do? There have been little steps taken that have been helpful. Bringing down drug costs as part of Medicare drug negotiations can help. Steps to ensure that medical debt doesn’t go on credit reports can mitigate some of the harms of these costs. But at the end of the day, we need to have more comprehensive health coverage for everyone in order to actually ensure that people get the care they need and don’t pay the price for it in terms of either their family’s financial welfare or in terms of their lives.

So, I would support a universal Medicare for all health care reform that got rid of these burdensome health care costs, high deductibles. There’s a lot that can be done — some of it small, some of it big — but right now we seem to be moving in the wrong direction.

Healio: Is there anything health care providers specifically can do to help?

Gaffney: First off, it’s important to simply be aware of the reality that if a patient can’t afford something that we prescribe, it’s not going to help them very much. I think most doctors are aware of that. I think that advocacy absolutely — both taking a stand against things that are going to hurt and advancing things that are going to help our patients — is critical. There certainly is a role, too, when there are two equally efficacious treatments to choose the one that’s going to be less burdensome for the patient, although often that can be very obscure for the doctor and not totally clear. But, certainly, when we know that, we should do it. Certainly, steps by hospitals to help connect patients with resources, insurance coverage and that sort of thing are critical. I don’t think that hospitals should be going after patients aggressively for costs they can’t afford. I think that that compounds a problem as well.

There are things that providers can both do and not do that can help. But at the end of the day, our options are somewhat limited because these problems are larger. We need a health care system that provides full coverage for everyone in America if we want to really make health care available for all, and make people know that they can get the care they need and not have to worry about going into the poor house as a result.

Healio: What is the take-home message here?

Gaffney: That health care financial burdens are far more common than is typically realized. That even if a patient is unaffected 1 year, they might be the next. That even if we’re healthy 1 year, we might be burdened by medical debt when we get sick, which almost all of us will one day. This is a more universal problem than is commonly recognized, and that’s going to require universal solutions.

For more information:

Adam Gaffney, MD, MPH, can be reached at agaffney@challiance.org.

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