The High Cost of Living: What Working Families Pay for Health Care

 

By Emma Curchin, John Schmitt

Key Takeaways

• Ten percent of working families paid more than $14,800 on insurance premiums and other out-of-pocket health care expenses.
• The typical working family spent $3,960 on health care in 2024, including premiums and out-of-pocket costs.
• One in eight working families paid more than 10% of their income on health care, with burdens highest for low-income and rural households.
• Health care costs are rising faster than inflation, and future increases in premiums, ACA costs, and Medicaid cutbacks will worsen the burden.

Introduction

Since at least the mid-1980s, the price of health care has been rising much faster than the economy-wide average (Figure 1). As health care costs have risen, employers have shifted more and more of the burden for health care spending onto their employees through co-pays, deductibles, co-insurance, and excluding some forms of care from coverage. Private insurance policies and even some government-provided health insurance plans that fill the insurance gap for those without employer-sponsored coverage have taken similar measures.

This combination of rising underlying costs and cost-shifting has left a large share of working families burdened with high levels of health care expenses.

Using the most recent Census Bureau data, covering the calendar year 2024, we find that the typical working family (a family with at least one worker between the ages of 18 and 64) spent $3,960 per year on health care (calculated as their share of insurance premiums plus any additional out-of-pocket expenses).

Ten percent of working families with the highest levels of expenditures paid more than $14,800 out-of-pocket for their health care. And more than one of every eight workers (13.3 percent) are in families that spent greater than ten percent of their annual income on health care.

These figures are almost certainly conservative estimates of the health care cost burden facing working families in 2026 and beyond. While we don’t yet have complete data for the calendar year 2025, industry experts expect the premiums for employer-sponsored insurance will have increased faster than overall inflation in 2025 and will do so again in 2026. A comparable rise in the policies available on Affordable Care Act (ACA) exchanges, combined with the expiration at the end of 2025 of COVID-19 related tax subsidies for ACA coverage, will raise rates for the 24 million people currently covered by ACA policies.1 Various changes to the Medicaid eligibility requirements under the One Big Beautiful Bill Act will raise health care costs for a portion of the ten percent of workers who currently have health coverage through Medicaid.

The Data

As in two earlier related reports on health care for US workers,2 we analyze data from the Annual Social and Economic Supplement (ASEC) of the Census Bureau’s Current Population Survey (CPS).

The first report documented that over the six year period between 2018 and 2023, on average, one of every ten workers between the ages of 18 and 64 went without health insurance throughout the entire calendar year before they were interviewed.

The second report in the series examined where those workers who did have health insurance obtained it. About 70 percent of workers had employer-sponsored coverage, 10 percent had coverage through Medicaid, and 10 percent had coverage through a variety of other sources, including the Affordable Care Act (ACA) exchanges, military-related insurance, and non-ACA private policies. The remaining 10 percent had no coverage at all.

In this report, we use the ASEC data to examine how much working families pay each year for their health care. In order to provide the most up-to-date cost picture, we limit our analysis to only the most recent available year of ASEC data, released to the public in September 2025 and covering the full calendar year 2024.3,4

Our measure of family health care expenditures is the sum of each family’s total outlay for health insurance premiums, excluding any employer contribution in the case of employer-sponsored insurance, and any additional out-of-pocket expenses not covered by the family’s insurance.5 These additional out-of-pocket expenses may include co-pays, deductibles, co-insurance, uncovered services, denied claims, and other direct payments to health care providers.6 We report families’ annual expenditures both in 2024 dollars and as a share of their family income.7

An important difference between these two earlier reports and this analysis is that the ASEC records health insurance coverage at the individual level, but records health care expenditures at the family level. In our previous reports, we focused on health insurance coverage for individual workers. Here, we analyze both expenditures and income at the family level for “working families,” which we define as families that have at least one worker between the ages of 18 and 64.8 We focus on workers between 18 and 64 because workers 65 and older are almost universally covered by Medicare.

Total Expenditures on Health Care are Strongly Correlated with Family Income

In 2024, the median working family spent $3,960 on health care-related expenses (see the first column of Table 1).9 In what follows, we generally refer to the median family as the “typical” family since half of all families spent less than the median and half spent more.10

Typical health care expenditures, however, vary strongly with income. Working families in the lowest income quintile11 typically spent $650 per year in 2024, an amount that increases substantially as family income increases: $1,895 in the second quintile, $3,800 in the middle quintile, $5,925 in the fourth quintile, and $7,700 in the top quintile.

Many factors contribute to the strong positive correlation between income and expenditures. At the most basic level, lower income families are much less likely than middle and higher income families to have health insurance.12 Paying regular premiums, even with partial subsidies from employers, significantly raises family health care expenditures. Lower wage workers are also more likely to obtain coverage through Medicaid, which provides health care coverage at little or no direct cost to workers.

Other factors related to family size and composition also contribute to the positive relationship between family income and expenditures on health care. Higher income families are more likely than lower income families to be made up of older workers. Older workers generally earn more than younger workers and, on average, spend more on health care. Older workers are also: more likely to be in jobs that have employer-sponsored health insurance plans (and therefore more likely to make employee contributions to employer-sponsored plans); more likely to qualify for employer plans when offered; more likely than younger workers to feel that they can afford their employer plans; and more likely to believe that they are in worse health than when they were younger and therefore have more incentive to pay for coverage.

Older workers also pay more than younger workers for identical coverage. The Affordable Care Act allows insurers to charge older policy holders up to three times more than younger policy holders for the identical policy.13 As a result, even when younger workers participate in employer plans or buy health insurance on ACA exchanges, their family costs are lower than for older workers.

Families with the highest incomes are also more likely to have more than one worker in the family. All else constant, having more workers in a family is associated with a large family size and, as a result, is associated with higher health care expenses.

All of these factors contribute to the strong positive relationship between total family income and family health care expenditures. But, it is also the case that better-off families pay more for health care simply because they are receiving more, and likely better, health care. As we documented in earlier research, only about 3 percent of workers in the top fifth of the wage distribution lack health insurance, compared to about 8 percent of middle-wage workers, and about 20 percent of low-wage workers.14

Total Expenditures on Health Care are Also Strongly Correlated with Demographic Characteristics Associated with Family Income

Not surprisingly, the strong correlation between income and the level of health care expenditures is mirrored across demographic characteristics that are themselves strongly correlated with income.

Most obviously, health care expenditures vary tightly with the education level of workers in the family. Families with a worker who has an advanced degree typically spent $5,700 on health care, more than the $4,600 for families with a worker with a college degree, $4,000 for families with a worker with some college but not a four-year degree, $2,880 for families with a worker with a high school degree, and $1,575 for families with a worker who has less than a high school degree.

Working families’ health care expenditures also mirror racial and ethnic differences in family incomes. Working families with a white worker typically spend substantially more ($4,800) than working families with a Black ($2,650), Hispanic ($2,500), or Asian ($4,215) worker.

Families with workers between the ages of 18 and 25 spend less ($2,550) than families with workers between 26 and 50 ($3,865) and only about half of what families with workers 51 to 64 pay ($4,950).

Citizenship status, which is a strong predictor of income and of eligibility for government-sponsored insurance, is also a strong predictor of health care expenditures. Families with immigrant workers who have become US citizens and families with US-born workers (who as of current writing are automatically US citizens) typically spend similar amounts on health care ($4,200 to $4,300), a level that is more than twice that of immigrants who are not citizens ($1,900).

Marital status, another important predictor of family income and family size, is also associated with much higher median expenditures on health care. The median working family with at least one married worker spends more than twice as much ($5,846) as the median working family with no married worker ($2,300). Part of this difference reflects the greater likelihood of the presence of children in families with a married worker. Working families where a child is present, for example, typically spend $5,150 per year, compared with $3,200 per year for working families with no child present.

Typical health care expenditures differ little across three of the categories in Table 1.

Families with at least one working adult man spend almost an identical amount at the median ($3,900) as families with at least one working adult woman ($4,000). This small difference partly reflects both the composition of working families, which include a large share of two-earner households where both women and men work outside the home, and partly reflects the ACA’s explicit prohibition against charging women more than men for health insurance coverage, a common practice before passage of the ACA.15

Families with a working veteran ($4,410) spend only slightly more than families with no veterans in the workforce ($3,980).

Typical health care expenditures for rural families ($3,900) are almost identical to typical expenditures in urban and suburban areas ($3,990).16 But, as we shall see later, because rural incomes are generally lower, the same level of expenditure means a greater financial burden for working families in rural areas.

Health Care Expenditures are Significantly Higher for a Substantial Share of Working Families

The estimates of health care expenditures so far have all referred to spending by families whose expenditures fall exactly in the middle (the 50th percentile) of the payments made by working families. Half of families in each category paid less than the expenditures reported in the first column of Table 1 and half paid more. The nature of illnesses, accidents, and aging, however, means some working families pay far more than the typical figure.

The second column of Table 1 shows the annual health care expenditures at the 90th percentile for working families. The families at the 90th percentile paid more for their health care than 90 percent of all working families in the same category, but less than the amount paid by 10 percent of working families in the same category.

In 2024, the 90th percentile working family paid $14,800 per year on health care, more than three-and-a-half times more than the typical working family at the 50th percentile. A similar pattern — much higher expenditures for the top ten percent of families than for the typical family — is true across all demographic groups in Table 1.

The difference between typical health care expenditures (the median) and high-end expenditures (the 90th percentile) is particularly large for groups with lower incomes. Working families in the bottom 20 percent of family income that have the highest health care bills paid almost eight times more ($5,100) than the typical family in the same income range ($650). Black families with high expenses ($11,566) paid more than four times what the typical Black family paid ($2,650). For Hispanic families, the ratio is five times ($12,600 versus $2,500 at the median).

The Health Care Expenditure Burden is High Across Families in All Demographic Groups and for All But the Highest-Income Families

The preceding discussion of family expenditures on health care focused exclusively on the dollar amounts that working families spend each year. Those numbers in isolation, however, don’t tell us how those expenditures relate to the corresponding family incomes.

Following earlier research, we classify families that spend more than ten percent of their before-tax family income on health care as being “cost burdened.”17 The last column of Table 1 shows that more than one of every eight working families (13.3 percent) spent more than ten percent of their before-tax annual income on health care in 2024.

Among the lowest-income working families (those in the bottom quintile of the family income distribution), more than one of every five (22.1 percent) faced a health care cost burden of ten percent or more. One of every six families in the second income quintile (16.9 percent) and middle income quintile (17.0 percent) paid ten percent or more of their income on health care. Even in upper-middle-income households – those in the fourth quintile – more than one of every ten households (11.2 percent) paid more than ten percent of their annual income on health care.

Working families in rural areas face a particularly high burden. Almost one in five (18.8 percent) rural families spent more than ten percent of their total income on health insurance. Given that the median and the 90th percentile expenditures in rural areas are almost identical to expenditures in urban and suburban areas, this suggests that the main driver of the higher financial burden is lower incomes in rural areas.

With only two exceptions, every working family demographic group in Table 1 had health care expenses that took up more than ten percent of total family income; in the two exceptions, the rates were 9.4 percent (Advanced Degree) and 9.0 percent (Asian).

The data analyzed here on annual expenditures as a share of income are the most recent available snapshot of the extent of health care burdens, but they almost certainly underestimate the true extent of health care burdens. A recent longitudinal study published in JAMA Internal Medicine, which followed the same individuals over a four-year period through 2022 (rather than the one-year period analyzed here), found that almost three times more individuals experienced health care burdens at some point if the window of analysis was expanded from one year to four years. If the same ratio holds when using the ASEC data, more than one-third of working families would experience a financial health care burden over the longer, four-year period.18

High Health Care Expenses Cause Financial Distress, Harm Health, and Drive Up Health Care Costs

The ASEC data demonstrate that insurance premiums plus co-pays, deductibles, co-insurance, claims denials, and fees for uncovered health care services represent a substantial portion of many workers’ family incomes. The magnitude of these expenses relative to family incomes have a direct and immediate impact on the financial well-being – and ultimately, the health – of working families.

According to a recent KFF Health Tracking Poll, the high “costs and the prospect of unexpected medical bills … rank as the top financial worries for adults and their families.”19 Whether they are unexpected (as a result, for example, of a serious accident or a sudden illness) or they are longstanding (as is the case with many chronic health conditions) health care expenses can represent a significant financial burden, even for better-off working families.20 The KFF poll also found that 44 percent of adults reported it was “very difficult” or “somewhat difficult” to afford health care costs, including 49 percent of Black and 55 percent of Hispanic respondents, as well as 53 percent of all respondents with annual household incomes below $40,000. Almost half of respondents (49 percent) said that they would not be able to pay an unexpected $500 medical bill in full or would have to go into debt to cover it. For women, the share was 57 percent (versus 39 percent for men); for households with annual income below $40,000, the share was 79 percent; for non-Hispanic Black households, 75 percent; for Hispanic households, 66 percent; and for White households, 39 percent.21

High health care expenses can also lower consumer credit scores, reduce access to credit, increase the cost of credit, and even drive families into bankruptcy. According to the 2022 KFF Health Care Debt Survey, 24 percent of adults reported that they had “medical or dental bills that are past due or that they are unable to pay” and 17 percent said that they “owe[d] a bank, collection agency, or other lender” money “used to pay medical or dental bills.” In the extreme, health care expenses regularly lead to bankruptcy. A study published in the American Journal of Public Health analyzing a sample of all US bankruptcy filers between 2013 and 2016 concluded that there were about 530,000 medical-related bankruptcies each year over the period.22

The high cost of health care and related medical debt also has a direct impact on the utilization of health care services, putting family health at risk. More than one-third of the KFF Health Tracking Poll respondents (36 percent) said that they had “skipped or postponed getting health care they needed because of the cost,” including 75 percent of those who were uninsured. One in five (21 percent) said that they had “not filled a prescription for a medicine” due to cost. Another 15 percent reported that they “cut pills in half or skipped doses of medicine.”23 A separate Commonwealth Fund survey found that even insured adults “delayed or skipped needed health care or prescription drugs [in the past 12 months] because they couldn’t afford it,” including 29 percent of those with employer-sponsored coverage and 37 percent of those with ACA marketplace or individual-market plans.24,25 Financial barriers may pose particular problems for people with chronic illnesses such as diabetes.26

The harms are not limited to the individual working families who skip or postpone seeking health care for financial reasons. Delays in seeking health care can lead to treating illnesses after they have progressed or, in the case of contagious diseases, after they have been passed on to others. These delays can raise the societal costs of health care through contagion effects or because those who postpone coverage may ultimately need to resort to more expensive emergency room treatment or require more costly medical procedures to deal with later stages of an illness.

Estimates Here are Almost Certainly Conservative

The estimates here are almost certainly conservative descriptions of the situation that will face working families in 2026 and beyond.

As Figure 1 showed, the prices of health care services and prescription drugs have been rising faster than prices in the rest of the economy for decades. Every indication is that this pattern will continue.

A key reason is the rising cost of employer-sponsored coverage. Business-aligned groups that study health care benefits estimate that premiums for employer-sponsored health insurance increased about 6 percent in 2025 (the year after the data analyzed here) and they expect premiums to increase in a similar range, or higher, in 2026.27

Separately, KFF projects that the termination as of January 2026 in COVID-19-related premium tax credits for ACA marketplace policies will raise overall ACA premiums by 26 percent in 2026 relative to 2025.28 KFF estimates that average increase for those who had been receiving tax credits will be 114 percent.29,30

Large projected declines in Medicaid coverage through 2034 will leave an additional 7.5 million facing the choice of either paying for more expensive private policies or going without health coverage.31

Conclusion

The typical worker is in a family that pays almost $4,000 a year out-of-pocket for health care (insurance premiums plus other out-of-pocket expenses). Ten percent of workers are in families that pay almost $15,000 per year in health care related expenses. One in eight workers is in a family that spends more than ten percent of their total before-tax income each year on health care. Expenditures at these levels place substantial strain on family finances, leading some families to postpone or forgo acute and preventive care, imperiling their own and the nation’s financial and physical health.

Source: Bureau of Labor Statistics

Table 1: Financial burden of healthcare expenditures for working families, by demographics, 2024

Total working family expenditures on health insurance and out-of-pocket expenses (2024$) Share of workers in families that spend more than 10% of total family income on health insurance and out-of-pocket expenses Typical burden (50th percentile) High burden (90th percentile) All working families $3,960 $14,800 13.3% Income quintile Lowest $650 $5,100 22.1% Second $1,895 $8,200 16.9% Middle $3,800 $13,160 17.0% Fourth $5,925 $17,000 11.2% Top $7,700 $20,500 4% Women $4,000 $14,700 14.0% Men $3,900 $14,900 12.6% White $4,800 $16,085 14.1% Black $2,650 $11,566 13.8% Hispanic $2,500 $12,600 12.3% Asian $4,215 $14,600 9.0% Other race/ethnicity $3,200 $13,000 12.3% 18-25 $2,550 $14,300 12.8% 26-50 $3,865 $14,320 12.7% 51-64 $4,950 $16,148 14.9% Unmarried $2,300 $11,200 13.1% Married $5,846 $17,060 13.4% No children $3,200 $13,250 12.8% Children present $5,150 $16,500 13.8% Less than HS $1,575 $10,852 15.7% HS degree $2,880 $13,260 15.6% Some college $4,000 $14,900 15.5% College $4,600 $15,230 10.6% Advanced $5,700 $17,000 9.4% US born $4,200 $15,152 13.7% Foreign-born, citizen $4,300 $15,440 12.4% Foreign-born, non-citizen $1,900 $11,200 10.4% Not a veteran $3,980 $14,898 13.4% Veteran $4,410 $14,300 11.4%

Footnotes

1. For total annual enrollment in the ACA marketplace plans, see KFF, “Marketplace Enrollment, 2014-2025,” https://www.kff.org/affordable-care-act/state-indicator/marketplace-enrollment/
2. Emma Curchin and John Schmitt. “Despite Affordable Care Act Gains, Millions of Workers Still Lack Health Insurance.” Center for Economic and Policy Research, January 10, 2025, https://cepr.net/newsroom/despite-affordable-care-act-gains-millions-of-workers-still-lack-health-insurance/ and Emma Curchin and John Schmitt, “A Complicated Maze: How Workers Navigate the US Health Care System,” May 13, 2025, https://cepr.net/publications/how-workers-navigate-the-us-health-care-system/.
3. We use the ASEC extract prepared by IPUMS, which is prepared, maintained, and made available online at the University of Minnesota. Sarah Flood, Miriam King, Renae Rodgers, Steven Ruggles, J. Robert Warren, Daniel Backman, Annie Chen, Grace Cooper, Stephanie Richards, Megan Schouweiler, and Michael Westberry. IPUMS CPS: Version 12.0 [dataset]. Minneapolis, MN: IPUMS, 2024. https://doi.org/10.18128/D030.V12.0
4. The ASEC collects nationally representative information from approximately 60,000 households on demographics, incomes, work status, and other characteristics, including detailed information on health insurance coverage and health care-related expenses. While the data are gathered primarily in March, most of the supplement’s health care and labor-market-related questions focus on the household’s experience in the preceding calendar year. We focus on workers’ health insurance coverage and health-related expenses throughout the calendar year preceding their March interview. Our sample of workers includes full-time-full-year workers, part-time-or-part-year workers, and workers who experienced unemployment at some point throughout the year, including a small number of workers who were unemployed for the entire calendar year. A household’s answers provided in March of each year (March 2025 is currently the most recent survey) refer to their employment situation, health insurance coverage, and health care expenses throughout the preceding calendar year (2024 in the data analyzed here).
5. For more on out-of-pocket expenditures, see: Peterson-KFF, “Out-of-pocket spending,” Health System Tracker, https://www.healthsystemtracker.org/indicator/access-affordability/out-of-pocket-spending/#Per%20capita%20out-of-pocket%20expenditures,%201970-2022; and Heide Jackson and Katherine Keisler-Starkey, “Out-of-Pocket Medical Expenditures in the Redesigned Current Population Survey: Evaluating Improvements to Data Processing,” SEHSD Working Paper 2020-18, U.S. Census Bureau.
6. The ASEC does not report and we do not include any employer or government contribution toward the cost of health insurance. The family’s payment for health insurance measured here is, in most cases, largely the employee share of employer-sponsored health insurance, but also includes premiums for ACA policies, and may include smaller premiums associated, in some cases, with Medicaid and other government-sponsored insurance. For a recent, detailed analysis of premium costs with breakdowns by employer and employee contributions, see KFF, “Worker and Employer Contributions for Premiums,” 2025 Employer Health Benefits Survey, https://www.kff.org/health-costs/2025-employer-health-benefits-survey/; for other out-of-pocket expenses, see the corresponding chapter on “Employee Cost Sharing,” https://files.kff.org/attachment/Employer-Health-Benefits-Survey-2025-Annual-Survey.pdf.
7. Specifically, we use the IPUMS variable “moop,” which is derived directly from the ASEC variable MOOP, which is the sum of the ASEC variables PHIP_VAL (“Out of pocket expenditures for comprehensive and non-comprehensive health insurance premiums”), POTC_VAL (“Out of pocket expenditures for over the counter health related spending”), and PMED_VAL (“Out of pocket expenditures for non-premium medical care”). For further details, see the “ASEC 2024 Public Use Data Dictionary,” https://www2.census.gov/programs-surveys/cps/datasets/2024/march/asec2024_ddl_pub_full.pdf, p. 6C-59.
8. We define a worker as anyone between the ages of 18 and 64, who worked full-time or part-time for at least part of the year. A small share of workers included here were unemployed (out of work but actively seeking employment) for the entire calendar year.
9. We weight families by the sum of the CPS sample weight of the individual workers in the family.
10. We use the median (the 50th percentile) rather than the mean (the average) because the median is not sensitive to outliers. If, for example, the family with the highest expenditures in a subgroup of the population spent $1 million on health care expenditures, then the average expenditure for all families in that subgroup would increase substantially, even in our large sample. But one family with extremely high expenditures would have no effect on the median because it doesn’t change the relative position of the “typical” family right in the middle of the distribution.
11. We have ordered all working families by their total family income, lowest to highest, and then divided them into five groups with the same number of families in each group. The highest incomes in the lowest fifth is $42,000 (rounded to the nearest thousand dollars), where we have excluded from the analysis a small number of observations of families that report negative incomes. The highest incomes in the second fifth is $78,000. The middle fifth, $126,000. The fourth fifth, $203,000. All families with incomes above $203,000 are in the top fifth.
12. See, for example, Emma Curchin and John Schmitt, “Chronic Condition: Working Without Health Insurance,” Center for Economic and Policy Research, January 10, 2025, https://cepr.net/publications/chronic-condition-working-without-health-insurance/; and Emma Curchin and John Schmitt, “A Complicated Maze: How Workers Navigate the US Health Care System,” May 13, 2025, https://cepr.net/publications/how-workers-navigate-the-us-health-care-system/.
13. Under current law, for example, health insurance issuers in the individual and small group markets are allowed to vary premiums based on age and can charge the oldest customers up to a three times the rate for the youngest customers. See https://www.cms.gov/marketplace/private-health-insurance/market-rating-reforms, accessed November 19, 2025.
14. Curchin and Schmitt (2025), Table 3. https://cepr.net/publications/chronic-condition-working-without-health-insurance/
15. As KFF notes: “The ACA banned a number of practices that were common among non-group insurers prior to the law. In addition to excluding benefits important for women such as pregnancy-related care, many individual market insurers charged women more than men for the same coverage, a practice called gender rating. Although gender rating affected both women and men, younger women were routinely charged more than men for plans that typically did not include maternity care. One 2012 study that reviewed gender-based differentials in individual market premiums found that reproductive age women were consistently charged higher rates than men the same age, up to 85% higher depending on the state.” See: Usha Ranji, Laurie Sobel, Alina Salganicoff, and Juliette Cubanski, “Loss of the ACA Could Greatly Erode Health Coverage and Benefits for Women,” Oct 29, 2020. https://www.kff.org/affordable-care-act/loss-of-the-aca-could-greatly-erode-health-coverage-and-benefits-for-women/
16. The ASEC data do not allow for a clear distinction between urban and suburban.
17. For earlier research using similar measures of health care-related financial burden, see, among others: World Health Organization, “Financial hardship: population with household expenditures on health greater than 10% of total household expenditure or income,” https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4844, accessed November 18, 2025; USAID,”The ratio of household out-of-pocket payments for health care to household income,” https://www.data4impactproject.org/prh/health-systems/health-system-strengthening/the-ratio-of-household-out-of-pocket-payments-for-healthcare-to-household-income/, accessed November 18, 2025; and Didem M. Bernard, Thomas M. Selden, and Zhengyi Fang, “The Joint Distribution Of High Out-Of-Pocket Burdens, Medical Debt, And Financial Barriers To Needed Care,” Health Affairs, vol. 42, no. 11, (November 2023), https://doi.org/10.1377/hlthaff.2023.00604.
18. See Adam Gaffney, Danny McCormick, Samuel L. Dickman, “Risk of Burdensome Health Care Spending Over Time in the US,” JAMA Internal Medicine, December 22, 2025, https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2842979.
19. Grace Sparks, Lunna Lopes, Alex Montero, Marley Presiado, and Liz Hamel, “Americans’ Challenges with Health Care Costs,” KFF, July 11, 2025. https://www.kff.org/health-costs/americans-challenges-with-health-care-costs/.
20. For a discussion of the impact of cost-sharing on prescription drug adherence, see Sarah-Jo Sinnott, Claire Buckley, David O′Riordan, Colin Bradley, Helen Whelton, “The Effect of Copayments for Prescriptions on Adherence to Prescription Medicines in Publicly Insured Populations; A Systematic Review and Meta-Analysis,” PLOS One, May 28, 2013, https://doi.org/10.1371/journal.pone.0064914. For a pharmaceutical-industry funded discussion of the impact of cost-sharing on prescription drug adherence, see: Nicole Fusco, Brian Sils, Jennifer S Graff, Kristin Kistler, and Kimberly Ruiz, “Cost-sharing and adherence, clinical outcomes, health care utilization, and costs: A systematic literature review,” Journal of Managed Care & Specialty Pharmacy, vol. 29, no. 1, https://doi.org/10.18553/jmcp.2022.21270.
21. Sparks, Lopes, Montero, Presiado, and Hamel, previously cited. See also: Shameek Rakshit, Matthew McGough, Lynne Cotter, and Gary Claxton, “How does cost affect access to healthcare?” KFF, April 7, 2025. https://www.healthsystemtracker.org/chart-collection/cost-affect-access-care/ and Cynthia Cox, Jared Ortaliza, Emma Wager, and Krutika Amin, “Health Care Costs and Affordability,” KFF, May 28, 2024, https://www.kff.org/health-costs/health-policy-101-health-care-costs-and-affordability/.
22. David U. Himmelstein, Robert M. Lawless, Deborah Thorne, Pamela Foohey, and Steffie Woolhandler,  “Medical Bankruptcy: Still Common Despite the Affordable Care Act,” American Journal of Public Health, vol. 109, no. 3, March 2019, pp. 431-33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366487/
23. Sparks, Lopes, Montero, Presiado, and Hamel, previously cited.
24. The Commonwealth Fund, “Paying for It: How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer,” October 26, 2023. https://www.commonwealthfund.org/publications/surveys/2023/oct/paying-for-it-costs-debt-americans-sicker-poorer-2023-affordability-survey
25. Samantha Artiga, Petry Ubri, and Julia Zur, “The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings,” The Henry J. Kaiser Family Foundation, June 2017. https://collections.nlm.nih.gov/master/borndig/101707786/Issue-Brief-The-Effects-of-Premiums-and-Cost-Sharing-on-Low-Income-Populations.pdf
26. Puja B Parikh, Jie Yang, Steven Leigh, Kunchok Dorjee, Roopali Parikh, Nicholas Sakellarios, Hongdao Meng, and David L Brown, “The Impact of Financial Barriers on Access to Care, Quality of Care and Vascular Morbidity Among Patients with Diabetes and Coronary Heart Disease,” Journal of General Internal Medicine, vol. 29, no. 1, pp. 76–81 (Sep 27, 2013). https://pubmed.ncbi.nlm.nih.gov/24078406/
27. See, for example: Mercer: “In 2025, average cost per employee rose 6.0% and an even higher increase is projected for 2026 – 6.7%, the highest in 15 years.” https://www.mercer.com/en-us/solutions/health-and-benefits/research/national-survey-of-employer-sponsored-health-plans/; Business Group on Health: “…employers predict that health care cost trend for 2026 will come in at a median of 9%, which falls to 7.6% with plan design changes.” https://www.businessgrouphealth.org/resources/2026-employer-health-care-strategy-survey-executive-summary; and Millman, “2025 Millman Medical Index: How have healthcare costs changed over the past 20 years?” https://media.milliman.com/v1/media/edge/images/millimaninc5660-milliman6442-prod27d5-0001/media/Milliman/PDFs/2025-Articles/2025-Milliman-Medical-Index.pdf.
28. “The amount health insurers charge for coverage on the ACA Marketplaces is rising 26 percent, on average, in 2026. In states that run their own Marketplaces, the average benchmark (second-lowest cost) silver premium, on which the tax credit calculation is based, is rising 17 percent next year. In states that use Healthcare.gov, these premiums are rising an average of 30 percent.” according to Cynthia Cox, KFF, “ACA Insurers Are Raising Premiums by an Estimated 26 Percent, but Most Enrollees Could See Sharper Increases in What They Pay,” KFF Quick Takes, October 28, 2025. https://www.kff.org/quick-take/aca-insurers-are-raising-premiums-by-an-estimated-26-but-most-enrollees-could-see-sharper-increases-in-what-they-pay/
29. See Justin Lo, Larry Levitt, Jared Ortaliza, and Cynthia Cox, “ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire,” KFF, September 30, 2025. https://www.kff.org/affordable-care-act/aca-marketplace-premium-payments-would-more-than-double-on-average-next-year-if-enhanced-premium-tax-credits-expire/
30. Recent changes to Medicaid as part of the “One Big Beautiful Bill” Act will also raise health care costs for the 10 percent of the workforce that currently obtains their health insurance coverage through the program. These increases, however, will generally not go into effect until after 2026. Measures include cost sharing of up to $35 per service on adults with family incomes between 100 and 138 percent of the federal poverty line and tightening of work requirements, which may affect particularly workers with irregular work schedules. https://www.astho.org/advocacy/federal-government-affairs/leg-alerts/2025/one-big-beautiful-bill-law-summary/
31. Center on Budget and Policy Priorities, “By the Numbers: Harmful Republican Megabill Will Take Health Coverage Away From Millions of People and Raise Families’ Costs,” August 27, 2025. https://www.cbpp.org/research/health/by-the-numbers-harmful-republican-megabill-will-take-health-coverage-away-from

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