Key Takeaways
• Coverage is not the same as care when 40% of people have to delay or skip care because of costs.
• Three forces — Policy, the Affordability Arsenal, and Payment Timing — are finally converging to help brokers and their clients create more affordable benefits plans
• The first two forces are essential. The third force is the one that actually activates them.
Coverage Is Not the Same as Care
The most expensive line in your client's claims report isn't a disease or a diagnosis. It's the visit that didn't happen — the one that would have made the expensive one unnecessary.
Here is something many benefits brokers might not know and, more certainly, rarely say out loud:
Coverage is not the same as care. People still need to be able to pay.
An employee with a $1,735 deductible — the national average in 2023, per the KFF Employer Health Benefits Survey — and $200 in their checking account does not experience their health plan as protection. They experience it as a necessary evil. The promise is on the plan document. They pay for it. The card is in their wallet. And when something goes wrong and the cost of accessing care exceeds what they have in their savings, the promise and the reality part ways – they don't show up. There is no claim, no notification to your client. No one in the organization knows it happened. Thirty-eight percent of people in your clients’ organizations are choosing to skip or delay care, go into debt or buy less groceries for the week.
The appointment doesn't get made. The prescription doesn't get filled. The condition that was manageable in March becomes the higher cost emergency claim in August. And the claims report — which captures only what happens, never what doesn't — attributes the outcome to trend.
It's not 'trend.' It's a lost opportunity for your client and their people. Read on about the three tailwind forces your clients can harness to avoid those higher cost claims – including the one force that makes the other two actually work.
Three Forces. One Opportunity.
Something significant is happening in employee healthcare. Not one shift — three. Each arriving from a different direction, each long overdue, each more powerful in combination than alone. Are you clients harnessing them?
Forces 1 and 2 create the opportunity. The Payment Timing Force is what makes that opportunity accessible to every employee — at the moment care is needed.
The Policy Moment
After years of slow-moving, incremental movement, policy has become an accelerating one. Federal and state governments are producing a meaningful body of legislation that is restructuring the economics of healthcare in favor of patients and employers.
The Hospital Price Transparency Rule, enforced by CMS beginning in 2021, requires hospitals to publish the prices they charge — including negotiated rates with carriers — creating the data infrastructure for genuine cost comparison for the first time.
The Consolidated Appropriations Act of 2021 introduced new PBM transparency requirements for employer-sponsored plans, mandating disclosure of compensation arrangements that were previously invisible to plan sponsors.
The No Surprises Act, effective 2022, protects employees from unexpected out-of-network bills – previously among the most unpredictable costs in the system.
The Inflation Reduction Act of 2022 authorized Medicare to negotiate drug prices directly with manufacturers and capped insulin costs.
Across more than thirty states, PBM reform legislation is tightening fiduciary standards, and opening the pricing black box that has kept drug costs opaque for decades.
The Affordability Arsenal
The legislative infrastructure of the Policy Moment has enabled a generation of innovative tools that translate regulatory transparency into savings employees can actually capture.
Cash pricing platforms like GoodRx and Mark Cuban's Cost Plus Drugs have introduced price competition into a pharmaceutical market built to prevent it, with up to 80% savings on prescriptions.
Digital health and care navigation tools are rewarding better healthcare behaviors.
Medical bill advocacy services are applying price transparency data to individual claims, identifying errors, contesting overcharges, and unlocking the charity care that nonprofit hospitals are legally required to offer but rarely proactively provide.
Telehealth services are reducing the friction and cost of accessing routine care.
The Affordability Arsenal is not a single product. It is an ecosystem of instruments that are collectively making healthcare more navigable, more transparent, and more responsive to employees and the employers who fund their care.
The Payment Timing Force
This is the one that makes the first two work — for a reason that is both obvious and almost never stated: neither the Policy Moment nor the Affordability Arsenal helps an employee actually pay for care at the moment care is needed. The No Surprises Act does not cover the deductible. The Hospital Price Transparency Rule does not bridge the gap between what an employee owes and what they have. GoodRx makes a prescription less expensive — but only for an employee who can afford to pick it up. Every advance that policy produces and the Affordability Arsenal delivers is contingent on one thing: the employee being able to pay for their care in the first place. The Payment Timing Force is what makes that happen.
Together, the three forces create the conditions for a health benefit that restores the original meaning of three words that have been hollowed out by a decade of cost-shifting:
• Insurance means protected
• Coverage means cared for
• Access means affordable
These are not semantic improvements. They are the outcomes of a benefits strategy that deploys all three forces — and the standard Believers in Better is built on.
What the Research Tells Us About the Importance of the Payment Timing Force
The RAND Corporation's research on consumer-directed health plans produced a finding that deserves far more attention than it has received: when out-of-pocket costs increase, employees reduce their use of both necessary and unnecessary care at similar rates. They do not become more thoughtful healthcare consumers. They become non-consumers. The cost signal doesn't help them make better decisions. It helps them make fewer decisions — including the ones they can't afford to defer.
The 2023 KFF/CNN Health Care Poll confirmed the consequence: 38 percent of American adults delayed or skipped needed care in the past year because of out-of-pocket cost. Not because they lacked insurance. The care was covered. What they lacked was a way to afford their share of it when the moment arrived. In a workforce of 1,000 people, that is 380 individuals making financial decisions about their own health that will not appear in any claims report — until the deferred condition becomes a claim that everyone scrambles to explain.
38% of adults skipped needed care due to cost (KFF/CNN Health Care Poll, 2023)
$1,735 is the average single deductible today (KFF Employer Health Benefits Survey, 2023)
$400 is an unexpected expense most can’t cover (Federal Reserve SHED Report, 2023)
$12K+ is the average preventable ER claim (Peterson-KFF Health System Tracker)
In 2026 research conducted by Paytient (the pioneer in payment timing solutions), 78% of Paytient members received healthcare they would have otherwise skipped or delayed.
The Payment Methods Employers Offer and Employees Currently Reach For — and Why They're Not Enough
When an employee faces an out-of-pocket cost they can't immediately cover, the benefits system offers them tools. Each has genuine value. None was designed for this specific moment: the employee who needs care today, has coverage, but doesn't have the cash. Covered has come to mean 'technically eligible' — versus 'cared for.'
Health Savings Accounts (HSAs)
HSAs are the most tax-advantaged tool in the stack and a meaningful long-term savings vehicle — for employees who have had the income and time to fund them. The Employee Benefit Research Institute's 2023 HSA database found the average account balance was $4,397, but that average is heavily weighted toward older, higher-earning, longer-tenured account holders. For the employee who enrolled last year, or earns $80,000 a year, or hasn't been able to contribute consistently, the HSA balance at the moment of care is often close to zero. The account exists. The money doesn't.
Flexible Spending Accounts (FSAs)
Pre-tax and employer-accessible on day one of the plan year makes FSAs genuinely useful for predictable expenses. The structural limitation is the prediction requirement: FSAs reward employees who can forecast their healthcare needs at open enrollment. Care avoidance is not a forecasting failure. It is an in-the-moment financial reality that no amount of November enrollment planning fully anticipates.
Health Reimbursement Arrangements (HRAs)
These employer-funded benefits are meaningful when contributions are generous. A $600 HRA helps with $600 of a $1,735 deductible. It is better than nothing and insufficient as a complete answer when the deductible has already been partially drawn down, the plan year is three quarters through, or the employee is looking at a $900 balance they cannot absorb.
Credit Cards
The tool most employees actually use when the others fall short. Available, immediate, and carrying 20 to 28 percent annual interest on a balance that may take months to resolve. Medical debt, which credit cards frequently absorb, is the leading cause of personal bankruptcy in the United States according to research published in the American Journal of Medicine. The credit card closes the gap in the claims report and transfers the problem to the employee's financial life — where it drives the stress, absenteeism, and disengagement that show up in every HR metric except the ones that connect back to the benefit.
HSAs, FSAs, and HRAs each serve a genuine purpose. Paytient fills the gap they all share: the moment an employee needs care and can't cover their share of the cost right now.
Each of these tools addresses a real need. None of them addresses this one: the employee who has coverage, has a legitimate medical need, faces an out-of-pocket cost that exceeds what they have in the moment, and needs a way to access care now — interest-free, without a credit application, without a balance they never accumulated, without a use-it-or-lose-it restriction.
The Payment Timing Force was built to overcome the limitations of these traditional solutions – Paytient is that force.
How Paytient Closes the Payment Timing Gap
The $150 appointment that became a $12,000 emergency claim is not a story about what is inevitable. It is a story about what is preventable when one thing changes: the moment the employee calculates whether they can afford to go. Download The Hidden Lives of Workforce Insured Americans to learn about the realities of having to choose finances over healthcare.
When a payment timing layer exists – with zero interest, no credit check, no new account, repaid gradually from payroll, available to every employee at the moment of care — that calculation changes. The appointment gets made. The prescription gets filled. The Affordability Arsenal has something to work with, because the employee is now at the pharmacy counter, now at the clinic, now generating the appointment where an overcharge can be caught and charity care eligibility can be assessed. This is what Paytient enables and the results speak for themselves as found in the 2025 Paytient Impact Report and analysis:
• $1,000 in potential savings per employee, annually
• 80% received care they otherwise would have skipped or delayed
• 56% filled prescriptions they otherwise would have skipped or split doses
• 83% made purchases that were uncovered or too expensive through benefits
The plan doesn't change. The network doesn't change. What changes is whether the benefit your client has been funding can actually be used to fulfill the promise it was designed to keep.
About Paytient
Paytient is the healthcare benefits payment layer that closes the gap between having coverage and actually being able to get care — making every benefit in your client's stack more usable at the moment it matters most.
Brokers who understand all three forces are having a fundamentally different renewal conversation than everyone else in the market.
The posts that follow will go deeper into the three forces with an emphasis on exploring the one that makes the other two work – the emerging payment timing layer. By embracing all three, you'll help your clients develop more meaningful, usable and affordable benefit plans.
To learn more about how Paytient can help your clients:
Download 'The Hidden Lives of Workplace Insured Americans' Report
Request a meeting — paytient.com/contact (15 minutes)
Sources
KFF Employer Health Benefits Survey, 2023
KFF/CNN Health Care Poll, 2023
RAND Corporation. Analysis of High-Deductible Health Plans and Utilization Patterns
Employee Benefit Research Institute. HSA Database Annual Report, 2023
Federal Reserve Report on the Economic Well-Being of U.S. Households (SHED), 2023
Peterson-KFF Health System Tracker
Himmelstein, D. et al. Medical Bankruptcy in the United States. American Journal of Medicine
Paytient Employee Impact Report, 2025
.webp)
