Risk of Burdensome Health Care Spending in the U.S., JAMA Internal Medicine, December 22, 2025, by Adam Gaffney, Danny McCormick, Samuel L. Dickman, David Bor, Lenore Azaroff, David U. Himmelstein, Steffie Woolhandler
Key Points:
Question:Ā How does the risk of incurring burdensome health care spending accrue over time for individuals in the US? [defined as OOP spending >10% of family income / >5% for low-income; >40% of post-subsistence income; and/or skipped care due to cost]
Findings:Ā In this 4-year longitudinal cohort analysis of national survey data including 12āÆ645 individuals, risk of burdensome out-of-pocket (OOP) costs for individuals in the US rose year after year: 6.5% of adults experience cost burdens after 1 year, 17.4% over 4 years. Lower income, lack of insurance, hospitalizations, chronic disease, and death were each associated with higher risks of facing heavy cost burdens. ā¦ Overall, 26.7% of adults experienced either foregone care due to cost or cost burden over 4 years.
Meaning:Ā The US health care system imposes OOP cost burdens on a much higher share of the population than suggested by cross-sectional analyses; policies that reduce such costs could improve the well-being of individuals in the US.
Conclusion: ā¦ OOP health expenditures burden a large share of individuals in the US over time, rather than a relatively small and stable population who incur high costs year after year. Patients in the US bear more costs than patients in other nations, a difference that reflects policy choices, such as the use of high-deductible health plans to mitigate moral hazard, and fragmented health financing and complex Medicaid eligibility requirements that lead to frequent coverage lapses. Tommy Douglas (the architect of Canadaās universal Medicare system) nearly lost a leg to an infection as a child because his family could not afford care. Reflecting on that experience, he ācame to believe that health services ought not to have a price tag on them, and that people should be able to get whatever health services they required irrespective of their individual capacity to pay.ā Abolishing price tags for care, as most other high-income nations have done, might enhance the financial welfare and health of individuals in the US.
Taking the Long View on Health Care-Related Financial Hardship, JAMA Internal Medicine, December 22, 2025, by John W. Scott
Our health care system has an affordability crisis: more than 20 million people in the US hold medical debt exceeding $220 billion despite health insurance coverage for more than 90%, making health care-related financial hardship one of the most pervasive yet underappreciated threats to patientsā well-being. Yet, most studies measure financial hardship in only 1 dimension or at only a single point, obscuring how financial risk accumulates as patients navigate illness over months and years. ā¦ Gaffney and colleaguesā¦ [measured] multiple domains of financial hardship (including cost burdens and foregone care) over an unprecedented 4-year period in the Medical Expenditure Panel Survey (MEPS). Their longitudinal approach reveals that prior cross-sectional studies captured merely the tip of the iceberg.
Three findings are particularly striking: first, rather than the 11% experiencing financial strain in any single year, nearly 26% of adults reported health care cost burdens or foregone care over the 4-year period. Second, even brief coverage lapses or continuous nongroup private insurance were associated with elevated financial hardship risk, highlighting the pernicious threat facing insured but underinsured families. Third, more than half of patients who died during the observation period experienced health careārelated financial hardship, highlighting the deep interactions between poor health and financial hardship.
Policies and politics aside, physicians cannot remain passive observers to the financial adversity that increasingly accompanies illness and medical care in the US. The finding from Gaffney et al that more than half of patients who died experienced health care-related financial hardship adds to a growing body of evidence suggesting that financial hardship is not merely an unfortunate byproduct of illness, but also a clinical risk factor that directly threatens health.
Regardless of our political perspectives or views on health care reform, we share a common commitment to patientsā welfare. In the face of policy debates that seem to prioritize politics over patients, we should each work within our spheres of influence to ensure that patientsā pursuit of health does not come at the cost of financial ruin.
Comment:
By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.
Dwell on this sad fact: More than one in four US adults lives in a family experiencing burdensome out-of-pocket medical costs over a four-year period. This doesnāt even count premium contributions, nor how employer-paid premiums depress wages.
In spite of high mortality in the US, when compared with thoughtful health insurance systems in other industrialized nations, we have by far the highest costs ā inherent to our fragmented approach.
Many believe that using market principles (making patients directly responsible for the costs of care via premiums, deductibles, and copayments) will help control costs by making the patients more sensitive to the cost of the care that they are consuming.
There are two fatal flaws with that line of reasoning. First: it has not worked. In spite of already forcing patients to bear a significant portion of costs, total US spending remains far higher than in any other nation. Second: as this study clarifies, needing health care often creates a serious financial hardship for the patient. This affects medical and other priority household spending, and can even cause bankruptcy. Other nations avoid this by not requiring patient cost-sharing at the time of medical need.
How can that be done? Well, you simply fund the entire health care system in advance so that no additional payments are needed at the time of service. The most equitable method would be through progressive income and wealth taxes. By making the taxes progressive, they would be based on ability to pay, and thus not unduly burdensome.
Income taxes are not a problem because thatās in place now. The health care expenses that we currently pay regressively through premiums would be moved into the tax system where a progressive scale would make them more equitable.
Wealth taxes are more controversial, but shouldnāt be. The nationās wealth has been rapidly and excessively moving up to the wealthiest sector of our society. We now have many billionaires and will soon have trillionaires. This represents an unfair, excessive upward distribution of our nationās productivity. Requiring the very wealthy to pay generously into the nationās health care trust pool would be fair since they derive their funds from the productivity that most of us are responsible for creating. Besides, their wealth is so great that they would hardly miss these funds. Currently some billionaires are moving out of states that intend to assess a wealth tax, but that can be easily countered by making it a federal tax.
We live in an era of growing wealth concentration, with a president who seems intent on amplifying that inequality, in general and for his friends and family. Happily, there is strong and growing resistance from progressive forces in our society. Single payer is the health care financing approach that is truly progressive ā and pragmatic, as proven around the world. It must be a central part of the progressive resurgence.
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