Priced Out of Care: When Benefits Break the Budget

A parent walks up to the pharmacy counter to refill a child’s asthma medication — a daily essential they’ve relied on for years. New year, new plan. Suddenly, the prescription’s cost rivals a trip to the grocery store, but the medication isn’t optional. The same dynamic plays out with a diabetes or cardiac medication, or any maintenance therapy that keeps chronic conditions managed.

As employers, we’re investing heavily in benefits to care of our employees, attract and retain talent, and reduce absenteeism and lost productivity. The question remains: Can your employees afford to use the benefits offered?

An Affordability Gap

On paper, most people in the U.S. have some form of coverage, but “insured” doesn’t always mean “protected.” Premiums for employer-sponsored family coverage now exceed $26,000 annually, outpacing wage growth.

Workers are contributing more through higher payroll deductions. At the same time, plan designs have shifted additional costs to employees in the form of high deductibles, coinsurance or copays, out-of-pocket limits, and specialty drug tiers.

During open enrollment, employees often choose a plan based on the monthly premium deduction. A plan that saves $40 a month looks appealing until they discover that every specialist visit, test, or prescription chips away at a large deductible they may never reach during the plan year.

The result is a growing demographic of underinsured individuals. Those who have coverage, but not enough financial protection to seek care when they need it. You can offer robust benefits and still end up with a workforce that is effectively priced out of the system.

Medical debt takes a quiet toll at work, home, and in the community. When benefits are too expensive to use, people delay care, skip medications, cancel follow-up appointments, or avoid recommended tests.

National surveys consistently show many adults skip or postpone needed care because of cost, even with insurance. The Kaiser Family Foundation found that approximately 37% of insured adults reported skipping or postponing needed care in the past 12 months because of cost. The Commonwealth Fund 2024 survey reported that 57% of working-age adults who were underinsured, and 70% of those who lacked continuous coverage, said they did not get needed care because of costs.

As a result, health conditions often worsen, requiring more intensive and expensive treatment or costly ER visits with medical bills often becoming long-term debt with interest. While more hospitals are screening patients for financial assistance eligibility early in the billing cycle, many people don’t know these programs exist or how to access them.

Think Beyond Coverage

You can’t control every driver of healthcare costs, but you can influence affordability and navigation.

Know your numbers. Understand how many employees and dependents meet their deductibles each year. Look closely at patterns of ER and urgent-care use for conditions that could be managed in primary care and pay attention to the use of high-cost medications and what members are paying at the pharmacy counter. These metrics reveal where affordability breaks down — and where targeted changes will have the greatest impact.

Balance premiums with predictable costs. Not everyone is well served by a high-deductible plan, even with an HSA, so ensure your lineup includes at least one low deductible plan option or a plan that uses copays for primary care, chronic-condition management, and common medications. When possible, enhance employer contributions to HSA/HRA accounts to add protection for lower-wage employees who feel cost-sharing the most.

Education and navigation are essential. Employees benefit from real-life scenarios that show what a typical office visit or prescription will cost under each plan, when to choose primary care versus urgent care or the ER, and how to use tools that compare costs and identify in-network providers.

Health Action Council offers data, programs, and resources to help guide employees to the right care, in the right setting, at the right time. The more confident people feel navigating care and costs, the fewer unnecessary claims you’ll see.

Ask tough questions of your partners. Affordability isn’t just about premiums. Ask about safeguards to prevent aggressive collections.

Benefits that Work

You’re investing heavily in health benefits. To make that investment count, you need more than coverage on paper. You need benefits employees can afford to use. You can transform your benefits from a financial stressor into greater security by understanding affordability gaps, designing plans with predictable costs, and supporting navigation.

Health benefits should help families stay healthy and solvent — not force them to choose between a necessary prescription and basic needs.

Join us for our 2026 In-Value-Able Conference on Feb. 3–4, 2026, where we’ll explore practical strategies to improve affordability and access. Most importantly, let us know: how can we help you make your benefits a true benefit — one your employees can rely on when it matters most.