What We Talk About When We Talk About Health Care Affordability

In Raymond Carver’s “What We Talk About When We Talk About Love,” two couples banter about love’s precise nature. Over gin, they offer broad pronouncements and personal examples. The reader becomes increasingly aware of each person’s significantly different perceptions of love, and the power of both its presence and absence.

So it is with “health care affordability” in the United States today. Although health care access and affordability now ranks as Americans’ top domestic policy issue according to a March 2026 Gallup poll, a consistent definition remains elusive. For an employee, the size of their share of an insurance premium and what they pay at the time of a medical service have consistently risen faster than wages for the last 30 years, and they have relinquished pay increases for health care benefits. For an employer, health care is a burgeoning line item in their financial statement, currently just shy of $27,000 per family per year—even as they have shifted more and more costs to employees. And for a government official, health care is the “Pac-Man” of public expenditures, now gobbling up almost 30% of both federal and state budgets and forcing budget cuts elsewhere.

The absence of health care affordability in the United States exerts a cost on all of us. In any given year, according to KFF reports, over a third of people report skipping or postponing needed care because of costs. Health care costs that are almost twice as high as in any other country put US manufacturers at a significant competitive disadvantage in the global economy. And public money spent on health care is money not available for other services, many of which—like public health, SNAP benefits, child care, education, and support for housing and homelessness services—can reduce the need for medical care.

Unlike the absence of love, however, the absence of health care affordability in the United States can be readily diagnosed and falls into three broad categories.

First, private sector health care expenses are rising much faster than government health care spending. Research shows that employees with job-sponsored coverage are not using more health care; they and their employers are paying more for each service or item. This is particularly true for hospital-based services and pharmaceuticals.

Facing price constraints from Medicare and Medicaid, hospitals in the United States have become massive health systems—consolidating with one another and acquiring more outpatient medical services to integrate into their organizations. This creates economic power for negotiating higher rates from private insurers, which pass these costs on to employers and employees. Contrast this with government programs, where provider payment rates are set, not negotiated.

For their part, pharmaceutical manufacturers have used patent protection, federal approval laws that focus on efficacy and not cost-effectiveness, and marketing practices protected as free speech to create a powerful business model that generates financial as well as clinical success. In no other country, except New Zealand, will one see television advertisements for treatments for stage 4 breast cancer.

Second, since US health care is financed through myriad sources, it is much easier to shift costs than to reduce them. Like a game of hot potato, insurers look for ways to deny provider claims, and employers increase employee cost-sharing. Providers consider payment variations between private and public insurance for the same service of up to three-and-a-half times to be proof of government cost-shifting. And legislators, rather than tackling systemic costs, find it much easier to limit the number of people on government programs or subsidize the purchase of health care coverage.

Finally and foundationally, when faced with the question of whether health care is a private good to be consumed by individuals (with the resulting abundant choices and significant inequities that result from a market-based economy) or a public good available to all as a right and condition for a healthy community (with the attendant limitations and tradeoffs that result), our culture has responded with a resounding “Yes!”

This inability to agree on how we place economic value on health care services leaves us reaping the worst of both options—persistently poor and increasingly inequitable health outcomes, and an inefficient, rapacious health care sector that clothes itself in virtue even as it rakes in money, becoming, as Warren Buffet once said, “the tapeworm of the US economy.”    

By the end of Carver’s story, night has come, the gin bottle is empty, bitterness has surfaced, and the characters cannot make plans for dinner, let alone agree about love.

It is not clear the prospects for health care affordability are much better, at least in the short run.

When confronted with electoral concerns about affordability, Congress members have gone hunting for more money to address cost burdens for specific populations (such as subsidies for Affordable Care Act [ACA] Exchange enrollees and limiting Medicare copayments), or have picked a villain of choice—like pharmaceutical manufacturers, health systems, insurers, and, this year, perpetrators of fraud, waste, and abuse.    

Why are real health care affordability solutions evasive? Besides providing payments and coverage policy for Medicare (and, in partnership with states, for Medicaid as well), the federal government sets tax, patent, and antitrust policies, all of which can have profound effects on health care affordability. A key barrier is that the health care sector has emerged as a powerful economic and political player in US public policy. Health care companies—hospitals, pharmaceutical companies, physician groups, insurers, and nursing homes—spent an estimated $750 million in 2025 to protect their interests and defend their revenues in Washington.

Likewise, individual states have significant influence over health care affordability, given their Medicaid and commercial health insurance oversight, as well as their authority over decisions concerning provider consolidation and capital expenses. Yet, state policymakers are also confronted by the iron law of economics that one person’s expense is another person’s revenue, and the dependence of local economies on the health care sector for employment, and academic medical centers for civic status. The temptation for magical thinking persists: even as we call for making health care more affordable, it can be an economic engine.

One need not succumb to platitudes or bitterness and gin, however. A health care affordability policy agenda should acknowledge that affordability is in the eye (or wallet) of the beholder. To be both politically powerful and socially just, the agenda should first focus on solidarity: making sure that all of us have access to a basic set of health services. For many, the ACA was the first step on this path: it broadened a public entitlement and forced the question of what government could afford to finance and how it should do so. In this light, the Medicaid eligibility cuts of last year—financing tax cuts for the wealthy by cutting enrollment—constitute both a profound moral failure and a blow to a broad affordability strategy. Congress chose to cut people, rather than prioritize services or change payments.  

Coverage of a set of services for everybody is necessary but not sufficient. A health care affordability agenda should make sure that those without economic and political power do not face financial barriers to access these services. Medicaid, ACA, and Medicare coverage policies all do that in varying ways but no such protections against large cost sharing exist for low-income private sector employees. Limiting the harms of high-deductible health plans would be a positive step.

Finally, the agenda should focus on creating the political will for setting enforceable budgets for that basic set of services and reallocating existing funds within those budgets to prioritize those services that have been shown to have the greatest benefit for the most people, such as public health, prevention, and comprehensive primary care. These reallocation decisions should not be the culmination of personal choice by individuals with “skin in the game,” who purchase all their health care in a free market. Instead, depoliticizing Medicare’s provider rate setting process to permit more objective assessments of the costs and benefits of covered services should be the basis for these budgeting decisions.

Instead, individual states have made incremental progress with such an agenda. A number have tried to preserve Medicaid eligibility, supplement ACA subsidies, and reallocate health care spending by limiting what employers pay health systems, increasing spending on primary care, and throwing sand in the gears of health system consolidation and private equity investments. The federal government’s authority and its role in health care financing means that even the most ambitious state governments cannot do this work alone. With the Supreme Court’s 2010 Citizens United decision, current campaign financing rules favor those with economic power and health care industry players will fight any discussion in Congress that will reduce their ability to make money. 

Carver’s tale is, in part, about how love is hard to define and forever flawed, though essential to being human. Affordable health care is also definitionally elusive and essential to a healthy community. Like love, talk of health care affordability—and the policies to achieve it—must be based on a respect for human dignity, a recognition of our mutual dependence, and an acknowledgment of the reality of our limitations, both personal and collective.

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