Recent polling from the West Health-Gallup Center revealed a troubling reality. Roughly one-third of Americans reported having cut back on spending to afford medical care, with consequences ranging from delaying retirement to skipping vacations and meals. These results reveal a deeper truth about how the system has changed. Insurance no longer acts as the shield it once did, and most Americans now pay out of pocket for their care. Like it or not, we are all cash payers now.
It wasn’t always like this. In 2009, the year before Obamacare was passed, the average annual premium for employer-sponsored insurance was $4,824 for an individual and $13,375 for a family. By 2025, those rates had nearly doubled to $9,325 and $26,993, which represented increases of 93% and 102%, respectively. During this same period, inflation increased by roughly 50%, with the consumer price index moving from an average of 214.5 in 2009 to approximately 323 in 2025.
But while premiums have gotten the most press, it’s the rise in deductibles that fundamentally changed the member experience. Over this same period, deductibles jumped from $826 to $1,886, and now apply to 9 in 10 workers. Further, modest copayments used to be typical, but now even after meeting the deductible, accessing care often means being subject to coverage that is limited to coinsurance — a percentage of the cost of a service — until another barrier, the out-of-pocket maximum, has been passed. In practical terms, that means that many Americans must pay cash for their routine care. While this shift began shortly before the Affordable Care Act’s passage, the trend accelerated in the years after it took effect.
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For years, cash-price healthcare existed as a kind of shadow market. It was mostly relevant to people who were uninsured or to the small segment of the population wealthy enough to shop for care and pay out of pocket. Assuming that costs were covered by insurance, physicians typically would refer patients to services such as MRIs without considering what those facilities charge. Few realize that an MRI might be a few hundred dollars at a nearby freestanding center or a few thousand within a hospital. Patients could accept this common practice in an era when deductibles were lower and modest copays were the norm, but it is an approach many no longer can afford.
In a normal market, such huge differences in what’s being charged for the same service wouldn’t be tolerated. Patients would take their business to the facility providing better value. The fact that millions of people with insurance are now bearing the cost of care directly, rather than having the tab picked up by insurance, should lead to greater efficiency in the market. Yet, there is one important difference with healthcare compared to other transactions. People are being asked to purchase healthcare without being given the most basic information consumers need in advance: the price.
Congress has recognized this problem, but with mixed results. The No Surprises Act, which passed in late 2020 with consumer protections, including a requirement for Advanced Explanation of Benefits, which would provide insured patients with an upfront price before scheduling care, and uninsured or self-pay patients a “Good Faith Estimate”. Yet, several years later, that AEOB requirement has still not been implemented, leaving patients in the same position they have faced for too long — being asked to make costly healthcare decisions without knowing in advance what the financial impact of those decisions will be.
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Crucially, there is pending legislation that would get to the heart of this issue. The bipartisan Patients Deserve Price Tags Act, sponsored by Sens. Roger Marshall (R-KS) and John Hickenlooper (D-CO), requires hospitals and insurers to publish clear, accurate, and comparable prices. It sets standards for how that information must be presented, and establishes meaningful penalties for those who continue to hide the true price of care. It makes price transparency real, rather than aspirational.
These reforms will not eliminate the financial pressures people face. But they are essential in addressing a basic flaw in today’s healthcare system. Most Americans, insured or not, are purchasing their healthcare out of pocket. If they are going to be treated as cash buyers, they should at least be allowed to see the price before they pay.
Monique Yohanan, MD, MPH, is a senior fellow for health policy at Independent Women.
