Cost Keeps Many Working-Age Americans from Care, While Medical Debt Remains Widespread

Half of U.S. adults between 19 and 64 said they skipped needed health care because they could not afford it, according to the Commonwealth Fund's Biennial Health Insurance Survey. The share increased from 46% in 2022 to 50% in 2026, a statistically significant rise that also appeared among people who had coverage throughout the year.

The survey measured four cost-related barriers: not filling a prescription, putting off a recommended test or treatment, avoiding a doctor visit when sick, and going without needed specialist care. It also found that 3 in 10 working-age adults are still paying medical bills or debt over time.

Those decisions can come quickly for households. Open enrollment for 2027 Affordable Care Act marketplace plans begins soon, and families choosing lower-premium plans with higher deductibles may face the same kinds of tradeoffs described in the survey.

Even People With Insurance Are Struggling

Having insurance does not always make care affordable. Nearly half of working-age adults, 46%, were not adequately insured: 11% were uninsured at the time of the survey, 12% had a coverage gap in the previous year, and 23% had coverage all year but were underinsured, meaning deductibles or out-of-pocket costs were high compared with income.

More than half of people enrolled in marketplace plans said they went without needed care because of cost, and about one-third were paying off medical bills. People with employer coverage did somewhat better, but 43% still avoided care because of cost and 31% were paying medical bills over time.

Coverage is also weakening. The uninsured rate among working-age adults climbed from 8.9% in 2024 to 11.2% in 2026, according to the foundation's release. Among adults ages 19 to 34, the uninsured rate rose from 11% to 16%, while for adults in households earning less than 200% of the federal poverty level, it increased from 14% to 17%.

The report ties these changes to the expiration of enhanced marketplace premium tax credits and the end of pandemic-era Medicaid protections that helped keep people enrolled. It also says major Medicaid changes, including work requirements for most adults covered through the expansion, are scheduled to begin in 2027. Based on Congressional Budget Office estimates, the report projects that 37 million people could be uninsured by 2036.

The survey was conducted by SSRS from May 7 to July 20, 2026, and included 9,360 adults, including 7,362 people ages 19 to 64. The margin of error for that age group was plus or minus 1.5 percentage points. Because the answers were self-reported, the findings show how common cost-related gaps in care are, not how much harm they caused.

What the Numbers Look Like in Real Life

Reporting by KFF Health News shows how those percentages play out in everyday life. Bill McAdams, a 45-year-old travel nurse in Holiday, Florida, was uninsured when he had a stroke in 2025 and later received a $93,000 hospital bill. Months afterward, worried about more bills, he went to an urgent care center instead of the emergency room when he developed new vision and balance problems. Later that month, he ended up back in the ER with a second stroke.

Carmilla Collins, 52, of Omaha, Nebraska, had her wages garnished because of medical debt. She eventually qualified for hospital financial help, but said she delayed thyroid surgery for four months as a goiter pressed against her throat. Sheila Robinson, 61, of District Heights, Maryland, carries a $10,000 deductible and pays her $659 monthly premium with a credit card. "I am just afraid to even go to the doctor," she said.

Delays like these can turn manageable conditions into emergencies. Commonwealth Fund President Dr. Joseph R. Betancourt, a primary care physician, said that when people skip doctor visits and medications they cannot afford, "treatable illnesses become medical emergencies."

Costs are expected to keep rising. KFF Health News reported that insurers expect ACA marketplace premiums to increase by about 15% next year, while employer health costs are projected to rise 9.5%. The Commonwealth Fund said the out-of-pocket maximum for commercial plans is set at $12,000 for an individual and $24,000 for a family in 2027.

Ways to Limit a Bill Before It Turns Into Debt

Federal law requires nonprofit hospitals to maintain a written financial assistance policy, though many eligible patients never apply. Before paying, ask for the policy and an application, and ask whether assistance can cover bills that have already gone to collections. State protections vary widely, according to a Commonwealth Fund review of medical debt laws.

Ask for an itemized bill, challenge any charge that appears incorrect, and ask about an interest-free payment plan instead of using a credit card. Federally qualified community health centers use sliding fee scales based on income.

During open enrollment, compare total annual costs, including premiums and the deductible, rather than focusing only on the monthly premium. MedicalDaily's open enrollment guide says some insurers are leaving certain 2027 markets and warns that automatic renewal can be risky this year.

Never delay emergency care to save money. Symptoms of stroke, chest pain, difficulty breathing, or a severe allergic reaction require immediate attention, and federal law requires hospital emergency departments to screen and stabilize patients regardless of their ability to pay.

Questions and Answers

How many Americans skipped care because of cost? Half of adults ages 19 to 64 said they went without needed care because of cost in 2026, up from 46% in 2022.

How common is medical debt? About 3 in 10 working-age adults said they are paying off medical bills or debt over time.

Does having insurance protect me? Not always. About 23% of working-age adults were insured all year but underinsured, and 43% of people with employer coverage avoided care because of cost.

Who is most affected? Skipped care and medical debt were most common among adults who were underinsured or had a coverage gap. Adults under 65 on Medicare because of a disability also faced difficulties, and uninsured rates rose most among younger adults and lower-income households.

Can a hospital reduce my bill? Nonprofit hospitals must have a financial assistance policy. Ask for it, request an itemized bill, and ask about payment plans.

When can I change my marketplace plan? Open enrollment for 2027 ACA marketplace coverage begins soon.

Should I avoid the ER to save money? No. Hospital emergency departments must screen and stabilize patients regardless of ability to pay.