Strengthening the Safety Net for Chronically Ill, Lower-Income Patients

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. Hello—

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: How crucial is it for advocates to protect the safety net ecosystem for lower-income patients who also have a chronic disease?

Balch: Regardless of what the answer is to trying to figure out this broader issue of what to do with the marketplace plans or healthcare in general, there is always going to be a segment of the patient population who is going to struggle to afford insurance and their healthcare, and the cost of living when they have significant disease.

One thing I would say is we have to shore up and protect the safety net ecosystem for patients who find themselves in a situation where they have significant chronic disease, and they also have lower income, and therefore, it's already a struggle to afford the basic necessities of life. You throw in the cost—even in the presence of insurance—and here's still significant out-of-pocket costs for patients through their healthcare journey, including, like I mentioned before, just the pressure to have to take time off work and be away from work, which creates downward pressure on your income.

At the same time, there're costs associated with using your insurance, not just the premium to have it, but then there's always copays and deductibles and co-insurance that come with utilization of your healthcare. I would argue, at the very least, we have to provide a robust safety net, and what form does that take?

It could come in lots of different ways, but we have to have some form of safety net available to patients who are going to need help affording life's necessities and/or their healthcare costs in the midst and presence of significant life-threatening or debilitating disease.