How to slow rising costs — and overall U.S. health spending — has long vexed elected leaders and policymakers.
That’s because reducing overall healthcare costs for patients means doctors, hospitals, drug companies, insurers, or other players across the health system would get paid less.
“For the most part, health spending for us is income to someone else,” said Zack Cooper, a health economist at Yale University.
Eliminating administrative complexity or setting price caps — which is how some countries lower overall costs — faces steep odds at the federal level. Since 1998, the health sector has spent more than $14 billion lobbying members of Congress in both parties, according to OpenSecrets, a nonprofit that tracks money in U.S. politics.
After Lynn Ludaway, 40, was diagnosed with multiple sclerosis three years ago, she said, she considered divorcing her husband just to make her eligible for aid to cover medical costs, even though they wanted to stay together.
She initially had coverage through her husband’s job but still faced large out-of-pocket bills. Ludaway, who lives in Evanston, Illinois, also racked up expenses from navigating life with a disabling health condition, such as paying for Uber rides and a cane as her mobility declined. Her medical bills stretched into the tens of thousands of dollars.
“I thought I was well prepared for an emergency,” said Ludaway, who gave up her consulting business and raided her savings and retirement accounts to pay for tests and treatment. “Nobody can prepare for this.”
She now pays a $500 monthly premium for coverage through Illinois’ ACA marketplace. But because of her husband’s job, the couple makes too much to qualify for state or federal assistance.
“I am in this weird in-between,” she said. “I need to rest to heal, but I need to work to live.”
Instead Ludaway relies on private financial aid programs, through foundations and the hospital system where she gets her care. She forgoes what she can’t afford, including dental and mental healthcare. She said she must be even more budget-conscious than she was in college.
“Broke undergrad has nothing on chronic illness,” she said.
Shifting Costs
Many current federal healthcare proposals focus on shifting costs rather than lowering them, and ideological differences about who should bear those costs deeply divide lawmakers.
The GOP has prioritized tax and spending cuts, which put the cost more on patients than taxpayers and are expected to boost the number of uninsured, to eliminate what they claim is pervasive fraud in government health programs. Last year, Democrats fought to extend enhanced subsidies for marketplace plans, which would buffer patients somewhat from premium hikes by pushing the bill to taxpayers.
Some progressive Democrats, including candidates winning primaries in battleground states, are reviving calls for “Medicare for All,” versions of which would create one centralized public insurer. Such a system could end out-of-pocket costs and provide major relief for patients such as Ludaway, but not necessarily cut overall health spending. Clinicians, hospitals, drugmakers, and other groups could still lobby for high prices, which taxpayers would then be on the hook to pay.
And some ideas with broad bipartisan support, such as forcing hospitals and doctors to publicly post medical prices, have had little effect on costs.
Policy debates about increasing access to coverage and improving quality of care should also focus on overall health spending, not just who’s picking up the tab, said Michael Chernew, a professor of healthcare policy at Harvard Medical School.
“We don’t have some rich uncle that’s coming and just paying for all of our care. One way or another, collectively we are paying,” Chernew said. “It’s just we’re shifting who is paying, how much we’re paying, and through which mechanisms we pay.”
Despite trillions in health spending, the nation’s system leaves millions of uninsured and underinsured people unable to afford care. About 27 million people — nearly 10% of the population under age 65 — didn’t have health insurance in 2024, according to KFF. And the nonpartisan Congressional Budget Office projects that number to grow by 10 million or more by 2034 because of policy and funding changes.
Melody Stephens in Berryville, Arkansas, became uninsured when she dropped her ACA marketplace coverage for this year after the monthly premium payments for her and her younger daughter jumped from just over $200 to more than $2,000. Stephens, 55, a geriatric nurse at an assisted living facility, said she also couldn’t afford the $1,000 monthly premium payment for her employer-sponsored plan.
“There was just no way I could do that,” Stephens said. “That was just not feasible.”
Stephens first got an ACA plan after she was diagnosed with anal cancer about a decade ago. Even with coverage, she filed for bankruptcy two years ago. While her plan largely covered cancer care, it left her with big bills for treatment of the side effects of radiation.
Now she and her daughter are relying on financial assistance and cutting back on care. When her daughter, a college student, had some surgeries, the hospitals wrote off the bills, Stephens said. But they still owe money for tests and treatments.
Stephens also stopped taking a GLP-1 that she was prescribed for diabetes and a medication for nerve pain because of the cost. Stephens can’t afford a colostomy, so she lives with incontinence, she said.
She said she wishes lawmakers in Washington would fix the healthcare system. “They just seem to fight,” she said.
A Tipping Point?
Next year, insurers say they expect to hike premiums for ACA marketplace plans by 15%, the second year in a row of double-digit premium increases. Employer health costs are expected to rise 9.5%, likely increasing the burden on workers.
Policy researchers and economists who have studied health costs say they are skeptical that federal lawmakers are ready to tackle overall health spending, even as the midterm elections loom.
But pressures are building, said Michael Cannon, a health policy analyst at the libertarian Cato Institute. “We cannot stay on this path forever,” he said.
The pain of high costs is felt throughout the economy, including by employers and state governments that help foot the bill for medical care. That reality is giving way to policy proposals that buck some past political positions.
Last year, the GOP-led legislature in Indiana capped how much some nonprofit hospitals can charge patients covered by employer health plans. Starting in 2029, five of the state’s largest nonprofit hospitals risk losing their tax-exempt status if they charge those patients more than the price limits. And this year, Texas Republican Gov. Greg Abbott proposed capping certain drug prices. Both cost-control efforts, along with Trump’s plans to lower prescription drug prices, are traditionally more the domain of left-leaning politicians.
For McAdams, the nurse in Florida, dealing with high health costs took a physical toll. He believes a subsequent stroke he experienced was caused by the stress of haggling over his hospital bill.
After his first stroke in September 2025, McAdams bought insurance, but it didn’t cover preexisting conditions. In March, he started experiencing problems with his vision and balance. He went to an urgent care center, instead of the emergency room.
“I was so afraid of dealing with the billing issues again that I did not want to go to the emergency room,” he said.
Then, after talking with the hospital regarding his stroke bill later that month, he said, he experienced problems again and landed back in the ER anyway — with the second stroke.
Now he is applying for Social Security Disability Insurance because he can no longer work as a nurse. The health system eventually lowered his total bill to $50,436 — but that’s still more than he can afford without a steady salary. He and his wife are also expecting a baby this fall.
McAdams was once proud to be part of the nation’s healthcare system, which saved his life and those of so many others. But the financial stress has changed his view. Now, McAdams said, his trust in it is gone.
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