Don’t think that just because you have health insurance you won’t face burdensome medical costs sometime during your life.
Most Americans will be burdened by unaffordable healthcare costs before they die — more than found in earlier estimates, according to a new study published in JAMA: Internal Medicine.
The study by researchers at Hunter College, Harvard Medical School, and Public Citizen’s Health Research Group found that more than one in four (26.7%) were burdened by high medical costs or went without needed care because of the cost during a four-year period. Moreover, more than half (53.2%) of those who died during the study incurred burdensome costs, indicating that most Americans will face unaffordable healthcare costs eventually.
Those numbers demonstrate that cost burdens are higher than suggested by previous studies that examined only a single year, and which have failed to include people who died.
The researchers analyzed unique four-year longitudinal data on 12,645 Americans from the Medical Expenditure Panel Survey. They looked at three widely used measures of unaffordable healthcare: “cost burden” (out-of-pocket costs > 10% of family income, or > 5% among those with very low-income); “catastrophic cost burdens” (out-of-pocket costs > 40% of family income excluding food costs); and “foregone care due to cost” (not getting needed care as a result of costs).
They defined unaffordable healthcare costs, which they labeled “healthcare financial strain” as having at least one of the three problems. The numbers who experienced each outcome rose year after year. For example, while only 3.5% of adults had incurred catastrophic costs after one year, 9.4% experienced them during four years. Similarly, 5.8% of adults went without needed care because of the cost in a single year, but 12% after four years. Overall, the share who experienced at least one of the indicators of unaffordable care rose from 11.8% after one year to 26.7% by the end of the fourth year.
Study co-author Dr. Steffie Woolhandler, a primary care doctor, distinguished professor of public health at Hunter College, lecturer in medicine at Harvard, and research associate at Public Citizen noted: “If you’re not a billionaire you’re just one serious illness away from financial ruin. Even if you don’t need much care this year, you’ll get sick or injured at some point, and then the medical bills will pour in. And healthcare is set to become even less affordable, with enhanced Affordable Care Act subsidies expiring and President Trump’s deep Medicaid cuts ahead.”
Relative to other Americans, those who were uninsured were somewhat more likely to incur burdensome costs, while those with income below 200% of poverty ($64,300 for a family of four in 2025) were nearly nine times more likely than the highest-income group to incur catastrophic costs.
Other groups at especially high risk of financial burdens included adults without a college degree, older individuals, anyone who experienced a hospitalization, and those with chronic conditions such as asthma or hypertension. The researchers noted that their analysis understates affordability problems because their figures exclude individuals’ payments for health-insurance premiums. Moreover, the survey they analyzed excluded nursing-home residents, a group often impoverished by the costs of their care.
“Healthcare is even less affordable than previous studies have suggested. They’ve only looked at how many people are hit by unaffordable healthcare over one year. But the risks mount over time,” said Dr. Adam Gaffney, a critical care physician, assistant professor at Harvard Medical School ,and the lead author of the study. “And high medical costs don’t just devastate finances; they force people to skip care — which often further worsens their health. It’s time America joined other nations and implemented national health insurance. That would save hundreds of billions on insurance paperwork and profits, savings that we could use to provide the complete coverage needed to protect families’ finances as well as their health.”
