Affordability Strain Is Moving Up the Income Ladder

According to Alan Balch, PhD, CEO of the Patient Advocate Foundation and the National Patient Advocate Foundation, rising employer-sponsored insurance premiums—outpacing both inflation and wage growth—are creating severe financial pressure for low- and middle-income families. He describes a “perfect storm” in which healthcare costs are increasing alongside everyday expenses such as housing, food, and utilities, while household incomes fail to keep pace. For many families already managing serious or chronic illnesses, this imbalance forces painful trade-offs that directly affect access to care.

Balch emphasizes that these decisions are not discretionary or short-term choices, such as whether to seek treatment for a minor illness. Instead, patients are weighing essential household expenses against life-sustaining therapies for conditions like cancer, HIV, or diabetes. From a patient’s perspective, all out-of-pocket costs—insurance premiums, coinsurance, deductibles, medications, or basic living expenses—come from the same limited pool of income. As healthcare spending rises, patients face compounding financial strain.

The burden is often amplified by lost wages when illness requires time away from work, further reducing household income while medical expenses simultaneously increase. This dual pressure leaves families with little flexibility and increases the likelihood that they will delay or forgo necessary care. Balch notes that patients are increasingly forced to decide between paying rent, utilities, or groceries and covering the remaining costs of their healthcare.

These financial trade-offs have serious clinical and economic consequences. When patients postpone or skip treatment due to cost, diseases can progress, complications become more severe, and interventions become more complex, less effective, and more expensive over time. What initially appears as a short-term cost-saving decision ultimately leads to higher overall healthcare spending and worse health outcomes.

Balch’s perspective underscores the broader affordability crisis facing working families and highlights how rising premiums and out-of-pocket costs are eroding the ability of patients to remain insured, stay adherent to treatment, and maintain financial stability while managing serious illness.

He also discussed the policy solutions that advocates should prioritize and much more.

A transcript of his conversation with PC can be found below.

PC: Could you describe the types of affordability challenges that are now occurring at a higher income level? Why isn’t the public assistance safety net applicable to this particular group?

Balch: The Patient Advocate Foundation is our direct patient assistance foundation, where we're able to provide different forms of financial assistance to patients who qualify financially and/or provide them with a navigator, basically, who goes into the safety net and tries to find a resource for them. There’s always been a large number of low- and middle- income families in this country who can't afford or struggle with affordability when they're in the midst of treatment for all the reasons we describe.

What we're seeing now is those that are feeling that pinch—it's happening at a higher income level now. At lower income levels, or socioeconomic levels, there’s always been that challenge. Now we're seeing that creep up into the 600,700 800,000% federal poverty level (FPL), and we don't have the capability to raise our income qualifications to serve more patients, because there's only a certain amount of money and resources available, and we're one of many in the safety net.

I think a challenge across the board is there's only so many resources and places—whether it's in the federal government or private charities or public charities like ours—that have assistance, and many of those are means-tested, and we already didn't have enough money to support all the people who needed it. Now there's more people who need it at higher income levels. It’s not possible to increase our income qualifications to the levels where people really need help, because we don't have enough to help those at the lower income strata where there's always been need.

I think that's the challenge for us as an organization, and then across the board, for any of the entities that provide safety net resources to those who are struggling to afford the cost of their healthcare and of life's basic necessities. The other thing I will say to that is because we are also an organization that searches the safety net for resources, if we don't have them, we also know what's available in the safety net environment.

I will say that is also shrinking. There's not as much available. There's more demand for what is available. There’s just not enough safety net. There's more need for resources to help people, and there's less of those resources available.