The Commonwealth Fund’s medical-debt numbers expose America’s affordability failure

The Commonwealth Fund’s latest survey gives a stark measure of American health-care unaffordability: half of working-age adults went without needed care because of cost, while three in ten are paying medical bills or debt over time.¹

That is not a story about a few uninsured households making bad choices. It is a system in which people postpone prescriptions, tests, doctor visits and specialist care because the price of using insurance is too high. The share skipping care rose from 46% to 50% between 2022 and 2026.¹

The crucial finding is that insurance does not end the problem. The survey counted people who had coverage all year among those avoiding care, while 46% of working-age adults were inadequately insured because they were uninsured, experienced a coverage gap or faced costs too high for their income.¹

“Covered” has become an unstable promise. More than half of marketplace enrollees skipped needed care because of cost, and 43% of people with job-based insurance did the same; 31% of the latter group were also paying medical bills.¹

The consequences are visible in the cases behind the percentages. Bill McAdams, a travel nurse in Florida, received a $93,000 hospital bill after an uninsured stroke and later avoided the emergency room before suffering a second stroke.¹ Carmilla Collins of Nebraska delayed thyroid surgery for four months while facing wage garnishment, and Sheila Robinson of Maryland put her $659 monthly premium on a credit card while carrying a $10,000 deductible.¹

These are not merely financial problems. They are decisions imposed by a billing system that turns medical risk into household debt, then treats delayed care as personal responsibility.

Joseph R. Betancourt, president of the Commonwealth Fund, put the mechanism plainly: “treatable illnesses become medical emergencies.”¹ The Board’s conclusion is equally plain: this is a mass condition, not individual misfortune.

Hospitals, insurers and policymakers all have a role in producing it. Federal law requires nonprofit hospitals to maintain financial-assistance policies, yet many eligible patients never apply, and protections against medical debt vary by state.¹ Charity care that patients cannot find or navigate is not a reliable safeguard.

Washington is also tightening the conditions around coverage. Enhanced marketplace tax credits expired at the end of 2025, pandemic-era Medicaid enrollment protections ended, and major Medicaid changes are scheduled for 2027; the Congressional Budget Office projects 37 million uninsured people by 2036.¹

Open enrollment advice cannot repair that architecture. Comparing deductibles may help one family choose less badly, but a system where a cheaper plan can still require skipping care is not affordable health care. The numbers show the failure is already widespread; policy choices risk making it deeper.