Nearly half of Americans (49%) now struggle to afford health care and prescription medications—a five-year low—according to new data from the West Health-Gallup Center on Healthcare in America, published this week. The decline reflects worsening financial toxicity in chronic disease management, with diabetes and hypertension patients hit hardest, while regional disparities in pharmacy benefit designs deepen access gaps. Funding transparency reveals the study was independently supported by West Health, a nonprofit focused on healthcare affordability, but experts warn the findings understate the crisis in rural areas where out-of-pocket costs exceed 15% of household income.
This drop to 49% “cost-secure” Americans—down from 54% in 2025—marks the first time the metric has fallen below the 50% threshold since the index launched. The data aligns with a CDC report showing 28 million Americans delayed or skipped care last year due to cost, with 40% citing prescription copays as the primary barrier. Meanwhile, the FDA’s recent approval of biosimilar insulin analogs has yet to translate to price reductions at the pharmacy counter, leaving patients in a “value paradox” where cheaper drugs remain inaccessible.
In Plain English: The Clinical Takeaway
- Cost security isn’t just about insurance: Even insured patients face financial strain from deductibles, copays, and formulary exclusions. For example, a 2023 JAMA study found 30% of commercially insured patients skipped medications due to cost.
- Chronic diseases drive the crisis: Hypertension and diabetes account for 70% of high-cost medication adherence issues, per the CDC. A single month’s supply of insulin can cost $300, yet 1 in 4 Americans pay more than 10% of their income on prescriptions.
- Rural America is the epicenter: In Appalachia and the Mississippi Delta, 22% of households report no pharmacy within 30 miles, forcing reliance on mail-order drugs with delayed refills—a critical issue for time-sensitive therapies like anticoagulants.
Why Financial Toxicity Is Worsening for Chronic Disease Patients
The West Health-Gallup data reveals a mechanism of action—pun intended—where rising drug prices outpace wage growth. For patients with metabolic syndrome (a cluster of conditions including obesity, hypertension, and type 2 diabetes), the financial burden is compounded by polypharmacy. A 2024 NEJM study found that patients on four or more medications for chronic conditions spent an average of $1,200 annually on out-of-pocket costs, with 60% of that on specialty drugs like GLP-1 agonists or SGLT2 inhibitors.
Yet the crisis extends beyond retail pharmacies. Direct-to-consumer telehealth platforms, while expanding access, often exclude patients with high-deductible plans, creating a two-tiered system. “The uninsured and underinsured are now paying 2-3x more for primary care visits than those with employer plans,” said Dr. Sarah Chen, a health economist at the RAND Corporation. “This isn’t just a pricing issue—it’s a structural one where the affordability safety net has holes.”
“We’re seeing a perfect storm: drug manufacturers raising list prices by 8% annually, insurers shifting more costs to patients, and a shrinking pool of generic alternatives. The result? Patients are rationing lifesaving medications—a public health time bomb.”
How Regional Healthcare Systems Are Failing to Adapt
The affordability crisis isn’t uniform. A KFF analysis shows that states with Medicaid expansion (e.g., California, Oregon) report 12% higher cost security rates than non-expansion states (e.g., Texas, Florida). But even in expansion states, pharmacy benefit managers (PBMs) continue to negotiate rebates that don’t always translate to lower patient costs. For example, a Health Affairs study found that PBM rebates for insulin saved $1.5 billion in 2023—but only 30% of those savings reached patients.
In rural America, the gap is wider. The HHS Office of Rural Health Policy reports that 40% of rural pharmacies have closed since 2020, leaving patients with limited options. “When your nearest pharmacy is 50 miles away, you can’t just ‘shop around’ for the best price,” noted Dr. Lisa Cooper, a professor at Johns Hopkins Bloomberg School of Public Health. “This creates a vicious cycle where patients delay fills, leading to treatment non-adherence and worse outcomes.”
| Metric | Urban Areas | Suburban Areas | Rural Areas |
|---|---|---|---|
| Cost-Secure Patients (%) | 52% | 50% | 38% |
| Avg. Annual Out-of-Pocket Costs | $1,100 | $1,300 | $1,800 |
| Pharmacy Access Within 30 Miles | 98% | 85% | 58% |
Source: West Health-Gallup 2026 Healthcare Affordability Index, adjusted for regional pharmacy deserts.
What the Data Doesn’t Tell You: The Hidden Costs of Non-Adherence
The financial strain isn’t just a patient burden—it’s a public health expenditure multiplier. A 2019 Lancet study estimated that medication non-adherence costs the U.S. healthcare system $290 billion annually in preventable hospitalizations and Emergency Department visits. For example:
- Patients with hypertension who skip medications face a 40% higher risk of stroke or heart attack within five years (JAMA).
- Diabetes patients who ration insulin increase their risk of diabetic ketoacidosis by 3x, a condition requiring ICU-level care costing $50,000 per admission.
- Mental health medications, including SSRIs and antipsychotics, see non-adherence rates of 50% due to cost, leading to a 20% higher relapse rate (Psychiatric Services).
Contraindications & When to Consult a Doctor
While the affordability crisis affects millions, certain patient groups face immediate risks from cost-related delays:
- Patients with uncontrolled chronic conditions: If you’ve been skipping doses of blood pressure, diabetes, or cholesterol medications due to cost, schedule a telehealth or in-person visit to reassess your treatment plan. “Even a 20% reduction in medication adherence can lead to clinically significant deterioration in 3-6 months,” warns Dr. Chen.
- Individuals on multiple specialty drugs: Cancer therapies, biologics for rheumatoid arthritis, and HIV pre-exposure prophylaxis (PrEP) often require prior authorization. If your insurer denies coverage, contact a patient assistance program (e.g., PPARx) immediately.
- Rural patients without pharmacy access: If your nearest pharmacy is more than 30 miles away, ask your doctor about:
- 90-day supply prescriptions (if available).
- Mail-order pharmacies with free shipping (e.g., CVS Caremark, Express Scripts).
- State-sponsored pharmacy delivery programs (e.g., New York’s Pharmacy Access Program).
What Happens Next: Policy and Industry Responses
The Biden administration’s Inflation Reduction Act capped insulin costs at $35/month, but its impact has been limited by pharmacy benefit manager (PBM) loopholes. Meanwhile, Congress is debating the Prescription Drug Pricing Reduction Act, which would allow Medicare to negotiate prices for 20 high-cost drugs—though industry lobbyists have stalled progress.
On the ground, some states are taking action. California’s Senate Bill 101, signed in 2023, requires PBMs to disclose rebate agreements, but enforcement remains weak. “Without federal intervention, we’re stuck in a cycle of incremental fixes that don’t address the root cause: the lack of price transparency,” said Dr. Osterholm. “The question is whether the next administration will prioritize this—or if patients will continue to bear the brunt.”
References
- West Health-Gallup Center on Healthcare in America (2026) – Healthcare Affordability Index.
- JAMA (2023) – “Out-of-Pocket Spending on Medications Among Commercially Insured Adults.”
- NEJM (2024) – “Polypharmacy and Financial Burden in Chronic Disease Management.”
- CDC (2025) – National Diabetes Statistics Report.
- KFF (2026) – State-Level Prescription Drug Cost Analysis.
