Health care in America was already unaffordable for millions of people and the numbers breaking down exactly who is suffering most are impossible to ignore.

More than half of Black adults (56.8%) and Hispanic adults (56.2%) cannot afford the costs associated with their health care needs, compared with 41.6% of white adults, according to the 2026 Urban Institute Well-Being and Basic Needs Survey.

And nearly half of all working adults said they had difficulty with healthcare affordability, citing at least one major health care affordability problem during the year. The findings come as healthcare costs continue to rise faster than wages and as federal policy changes to Medicaid work requirements and the marketplace are expected to increase the number of uninsured Americans by millions in coming years.

The data also underscore longstanding disparities in health care access and affordability in communities that already experience higher rates of chronic illness, lower incomes, and greater barriers to care.

Researchers found significant geographic disparities, with about 51 percent of adults living in the South and 50 percent of those living in rural communities reporting difficulty affording care.

Institute researchers measured affordability by having any difficulty affording health care with one or more of three different challenges: problems paying family medical bills in the past 12 months; an individual or their family member having unmet health care needs because of costs in the last 12 months; and having any medical debt at the time of the survey.

“One of the main ways health care unaffordability manifests as people going without health care, and this includes unmet needs for a range of services such as tests, treatments, dental care, mental health care, prescriptions, substance use treatment or counseling,” said Michael Karpman, lead report author.

Uninsured adults were the most likely to report affordability problems, but the report found that insurance coverage did not shield many families from financial hardship, highlighting the financial strain of medical costs even among people with health insurance.

For example, while more than half of adults enrolled in Medicaid or individual marketplace plans reported difficulty affording care, 39 percent of people with employer-sponsored insurance reported at least one affordability challenge.

Rates of health care access and affordability fall unevenly

“One of the most important takeaways is that health care affordability is pervasive, affects a large number of Americans, and falls unevenly across the population, their health needs, and where they live,” said Karpman, who is principal research associate in the Urban Institute’s Health Policy division.

The burden was not distributed equally across demographic groups besides race, ethnicity, geography, or health status.

People with chronic health conditions faced some of the highest levels of financial strain. More than 60 percent of adults diagnosed with cancer, heart disease, diabetes, or chronic lung disease reported struggling to afford care, as did nearly 69 percent of adults with disabilities, such as vision or hearing limitations, mobility issues, or communication or cognitive difficulties.

The Institute’s report aligns with research by the West Health-Gallup Center on Healthcare in America partnership, which found that fewer than half of Americans are considered cost secure, meaning they can consistently afford health care. The finding marks a five-year low of people being able to afford access to quality care and pay for visits and prescriptions in recent months.

Paying more for less care

Urban Institute researchers also pointed to rising insurance premiums such as the expiration of enhanced Affordable Care Act premium subsidies and out-of-pocket costs as contributing factors.

“As premiums expire in the marketplace, people are shifting to marketplace bronze plans that have higher deductibles and that could expose people to higher out of pocket costs when they get care. People are moving from silver plans to bronze plans, which have the lowest premiums and highest deductibles,” Karpman said.

But Karpman said people who make that shift to lower-premium marketplace plans run the risk of underinsurance.

That risk is exacerbated by fewer insurers participating in the ACA marketplaces, giving consumers fewer options.

Upcoming Medicaid eligibility changes could also worsen affordability challenges and increase the number of uninsured Americans. Separate Urban Institute research projects that between five million and ten million people could lose Medicaid coverage by 2028 as those policy changes take effect, for example.

Despite the expected effect of federal Medicaid and ACA marketplace policy changes, Karpman said certain policy interventions have proven effective in reducing health care unaffordability.

“ACA Medicaid expansion has reduced unaffordability, which resulted in declines in healthcare needs, medical debt and difficulty paying medical bills,” Karpman said.

However, there are 10 states that have not adopted the expansion and the new work requirements are expected to reduce coverage in the states that did adopt the expansion,” Karpman said.

In the face of health care unaffordability challenges, some working adults like Virginia paralegal and mom of three Noelle Stokes have opted to go without insurance altogether.

“My employer doesn’t offer insurance, and I cannot afford any of the ACA plans anymore.  They are too expensive now. So, I have had to pay for medicines and tests with my credit card. But every month I hold my breath that I don’t get sick,” Stokes said.

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