Policy makers and companies across the country have been striving to make healthcare affordability a reality for decades. Strides have been made. They will continue through determination and continuous innovation. And yet, while the intent is outstanding and inarguable, the impact is not being felt by the masses and most certainly not by the people who need it most.
You've built the benefits program. You offer an HSA, an FSA, maybe even an HRA. You've added financial wellness tools, care navigation, maybe even telehealth. By every measure that matters whether it’s employee wellbeing, retention, financial security or something else, the results should be moving in the right direction.
So why aren't they? The answer may not be that we need better programs. It may be that we need to ask a different question.
The Numbers Don't Lie
Healthcare is now the number one domestic concern in America — ahead of the economy, ahead of inflation. Sixty-one percent of U.S. adults worry "a great deal" about the cost and availability of care. That's most of your workforce.
A 2025 survey of 2,500 insured American adults (80% with employer-sponsored coverage) found that 38% delayed or skipped care due to cost, a 41% increase over prior measurement. KFF's independent tracking puts the figure at 37% of insured adults in the past year. Two different methodologies. The same direction. These aren't the uninsured. These are people in your benefits plan who are covered, enrolled, and still unable to pay for their healthcare when it’s needed.
In an effort to help further, employer investment in financial wellness benefits has jumped from 59% to 70% in a single year. The EBRI Financial Wellbeing Employer Survey found 73% of employers said their programs were making a large impact in 2023. Today it's 43%. More investment. Less impact. That's not a coincidence. It's a signal that something structural is working against them and it starts with how we've been defining and trying to solve the problem.
How We Define Healthcare Affordability Today Hits Everyone Differently
There isn't one definition of healthcare affordability. There are at least three. Let’s discuss the two most common first.
The conventional definition comes from the ACA. Under IRS guidelines, employer-sponsored coverage is "affordable" if the employee's premium contribution for self-only coverage doesn't exceed 9.02% of household income in 2025. That's the entire definition. Out-of-pocket healthcare costs, including deductibles, co-pays, coinsurance and prescription drug costs, aren't counted. A plan with a $200 monthly premium and a $4,000 deductible passes the federal test. The employee who can't afford to see a specialist after hitting that deductible also, technically, has "affordable" coverage. The definition was built to set a floor for premium access. It was never designed to measure whether employees can actually pay for care.
A more inclusive benchmark comes from the Milbank Quarterly: total annual spending (premiums plus all out-of-pocket costs) should not exceed 10% of household income. That's meaningfully better. It includes the full cost of care, not just the premium. But it still has a ceiling.
The same percentage hits very differently depending on where an employee starts. After taxes, housing, food, transportation, and childcare, a $150,000 household likely has a manageable cushion. A $75,000 household in most U.S. cities has a fraction of that left and 10% of gross is closer to 25% of what's actually available to spend. The percentage is identical. The burden is not. And for employees at the lower end of your payroll, no percentage of income produces a number that makes a $1,735 deductible affordable.
Why Healthcare Affordability Will Never Reach Everyone
Every definition we've used — the ACA threshold, the income-based benchmarks, even the most sophisticated actuarial models — is a population instrument. It answers "is the system affordable on average?" It doesn't answer whether a specific employee, on a specific day, can pay for the care they need right now without sacrificing something else they need. The data shows us the failure. It doesn't correct for it.
For the employee with $200 in the checking account and is told he needs $400 in healthcare, the visit doesn't happen. The prescription doesn't get filled. The condition gets worse and much more expensive soon after that decision and the only record you have a higher cost claim months later, attributed to trend. That's not trend. That's a person who couldn't pay.
Your employee health benefits including the HSA, the FSA, the HRA, the point solutions are doing genuine work. HSAs and FSAs together represent only 14% of total out-of-pocket healthcare spend, and they help the employees who already have discretionary income to set aside. Your point solutions are probably reaching individuals too, even when the aggregate claims data can't prove it to a CFO. The employee who caught something early through telehealth doesn't generate a claim. The absence of a cost is invisible in a system built to measure costs.
The 3rd Definition of Healthcare Affordability: A More People-Centric Pursuit
Arguably, the most personal and true definition doesn't mention income percentages at all.
In 2019, the Connecticut Office of Health Strategy, the Office of the State Comptroller, and the University of Washington's Center for Women's Welfare collaborated to define healthcare as affordable only when a family can reliably secure medical services to maintain good health and treat illness “without sacrificing the ability to meet all other basic needs, including housing, food, transportation, childcare, taxes, and personal expenses — or without sinking into debilitating debt."
That is a definition that screams for a focus on the individual and their families.
This definition became the foundation of the Connecticut Healthcare Affordability Index (CHAI), which national health policy and advocacy organizations have since adopted as the most realistic benchmark for cost reform.
Under this definition, the employer-sponsored insurance system fails the moment any significant health event forces a trade-off. The $1,735 average single deductible doesn't just exceed what most employees have available. It forces a choice between care and their basic need to live. And the moment that trade-off exists, affordability has already failed. Not the plan. Not the program. The outcome.
In fact, the West Health-Gallup Affordability Index uses the CHAI definition to determine if people are "Cost Secure." In 2025, only 49% of Americans were considered Cost Secure, down from 61% in 2022. An estimated 2.8 million Americans dropped out of that category between 2024 and 2025 alone. One-third made direct trade-offs with groceries, rent, or utilities to cover healthcare costs. Forty percent went the other direction: they delayed or skipped care entirely.
The chronic condition numbers are harder still: only 34% of people with COPD are Cost Secure. 37% of people with depression. 38% of people with compromised immune systems. A 2026 Buzz Health survey found that prescription fill rates drop sharply when out-of-pocket costs reach $35 which is not an extreme price point for most. These are people with unavoidable, recurring healthcare needs with the coverage to address them but the least financial cushion to absorb them.
The double bind is direct: lower-income employees face the highest rates of chronic disease which generate the most consistent, unavoidable out-of-pocket costs. The people with the least margin need the most care. No affordability benchmark built at the population level was designed for them.
Let's Ask a Different Question
The intent behind healthcare affordability has always been right. Make care accessible to everyone. Reduce the financial burden. Keep people healthy. But today’s federal operating definition just isn’t meant to deliver on individual needs. It’s a population-based objective, not one to achieve for every individual.
The Connecticut Healthcare Affordability Index and West Health-Gallup Index challenge us to think differently about it — a person is cost secure if they can get the healthcare they need without losing something else to pay for it.
So - if we agree that, in the current U.S. system, healthcare will never be affordable for every individual — then we must ask ourselves a different question the CHAI challenges us to ask — one that operates where healthcare can be experienced by every employee. Not on average. Not for most. Every employee, every time.
Before the next open enrollment cycle and before you benchmark premiums, review plan designs, and decide which benefits to keep and which to cut, ask a different question worth asking alongside "is it affordable?" That question is:
Can we make it easier for every employee to pay for their healthcare even if it’s not affordable in the moment — without sacrificing anything else they need to live?
That question has an answer. And we'll get to it in our next blog.
Paytient helps your employees get the care they need when they need it.
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