Health Care Reforms Part 8 - Enough is Enough, It is Time For Reform Towards Affordability

I am working in the US health care domain for the past 6 years. My main motive is to strive for health care affordability and greater health outcomes for this country. This is what I am being paid for. Keeping this in mind, in the last 3.5 years, I had also written a series of articles on the state of health care - A series of posts on the health care striving for improvements, more than 7 articles on the subject. When so much time and energy is being spent on this area of my bread and butter, I hope things should improve or should atleast stay as they are. But worse, it is becoming bad and nosediving downhill. I am sorry about this but I don’t write articles for fun rather than to have some profound positive impact. When the receiving end is lifeless, clueless what can anyone do. I don’t talk with thin air as well nor I am a dumb person who can be discarded like nothing. To summarize, health care didn’t improve in the last 6 years and no one knows what is going on. Worse, the shutdown which US is facing right now is due to this indifferent inaction in this field. I am disappointed as an onsite worker in health care seeing this unfolding without drastic improvements in status quo. This is akin to Obama unveiling Affordable Care Act (ACA) and prices actually becoming unaffordable. Considering the gravity of the situation and the severity of the work done in two great client companies, nation; one can atleast expect common man to be in great standing with respect to health objectives and costs. But this isn’t taking us anywhere and there is no progress whatsoever. 

I tell about two personal examples about my pain, a common man in US – I am a frequent to US hospitals for my psychiatric medications. The hospitals charge hefty amounts which are mostly covered by my insurance. This is fine if it is once in a year but I am in need to medication once in a month administered in a hospital. The cost of the injection is exactly equal to $2700, just, with a frequency of once a month. A similar injection in India cost me around $6. The insurance and the drug manufacturer covered the cost of $2700 for three straight months and gave me at a nominal price of $10. In the last month when I went to get the same, the pharmacy told discount isn’t entirely applied and I still need to pay $300. Unaffordable, I came back without taking the medicine. I don’t know what other options I had and I don’t understand about this pricing a bit either. I am without medicine for the last 50 days – a month and a half, still looking for a solution. Second experience - few weeks back, my spouse was asked to get an x-ray. I thought a simple x-ray at first and went to a reputed hospital near my location to avail it as a walk-in as I couldn’t get a prior appointment. The service was quick and we returned without any issues from the test. Few days back, we received a message saying we need to pay $471 for the exam. Apparently insurance didn’t cover the entire cost which is $830. I am speechless and stunned at my own financial situation and unaffordability. We would have forfeited the test if the cost is known before. Better stay unhealthy than pay this ransom. I searched online and I thought this x-ray would cost $150 and not definitely ~800 which would not be covered by insurance on top of it. Needless to say the cost of this exam in India is $6 in private diagnostic labs and around $2 in government hospitals. India has a population problem for no reason. Not for no reason, I had written a post to Indianize US health care landscape and it fell on nobody’s ears for long. I cannot be the only one working while everyone watches the movie. These two are the personal examples of an H1-B worker with decent pay and basic insurance coverage. If this is unaffordable for me, what about much more common people who might need the care the most. A good guess is they might break their bank very bad to cough up enough money to pump into the devolving system asking for more. 

I will tell about the premium cost graph which will hit the cause of concern. U.S. health care is the most expensive in the developed world, and it's getting worse. The average annual premium for an employer-based health insurance plan for a family of four was more than $25,500 last year, according to the health policy nonprofit KFF. Of that average total, employers contributed about $19,200 and workers contributed about $6,300. Where in the world is the average cost of insurance $26000 for a family of four. Total premiums have risen more than 24% since 2019 and are widely expected to surge next year. Mark these words - ‘premiums are expected to surge next year’. Some 154 million people in the United States get health insurance through their employer — and many could see their paycheck deductions surge next year, by 6% to 7% on average. Annual premiums for employer-sponsored family plans have risen 342% since 1999. Employers often share these costs with their employees. Over that same time, worker contributions have increased by 308%. Where in the world is there 300% increase in premiums over 25-year period. For-profit companies — including drugmakers, pharmacy benefit managers, hospitals and insurance companies — have collectively driven up the costs of accessing medical care in the United States. The system is failed at best and feeding into itself. Sorry, I might be a beneficiary, and I don’t want to benefit at this surge but rather improve the status quo. 

What’s even more alarming is that these premiums have risen by more than 24% just since 2019, and experts warn the next wave of increases is imminent. In effect, this means the coverage cost rose by 24% since I began working in this domain. What a bad time to set foot into this field. You care no one – not the affordability, not the ACA, not the hard working employees or anyone with a purpose and objective. Instead of treating the problem at the root, evading responsibility and passing on costs is what is happening for years. Premiums are expected to surge again next year by 6–7%, driven by hospital labor shortages, rising pharmaceutical prices, post-pandemic care backlogs, and insurers passing through costs from delayed care during COVID years. For an American family, that could mean an additional $1,500–$2,000 in yearly premiums — at a time when inflation and mortgage costs are already squeezing household budgets. 

Employers, who cover about 154 million Americans, are feeling the strain as well. Many are forced to either shift more of the burden onto employees, cut benefits, or in some cases, drop coverage entirely. This creates a vicious cycle: the fewer healthy people who can afford coverage, the higher the premiums go for everyone else. It’s the death spiral economists have warned about for decades — and it’s getting dangerously close. This deadly spiral of more insurance claims from providers charging astronomical amounts has caused the premiums to rise in a linear graph over years. Surprisingly, there is no concerted effort to address this problem of death spiral from every stakeholder rather than push costs to consumers. 

What’s driving these relentless increases? A mix of factors, both visible and hidden: 

1. Hospital Consolidation: Over the past decade, mergers and acquisitions have created regional hospital monopolies, allowing them to set prices without competition. In some U.S. cities, a hospital stay now costs three to five times more than in Europe for the same procedure. 

2. Pharmaceutical Price Inflation: The U.S. continues to pay some of the highest drug prices in the world — up to four times more than comparable nations. The lack of centralized price negotiation, until recent reforms in Medicare, has allowed drugmakers to dictate terms. 

3. Administrative Overhead: Private insurers in the U.S. spend 15–20% of their revenue on administrative costs, compared with 2–4% in single-payer systems. Billing, coding, and compliance paperwork cost hospitals billions, all passed on to patients. 

4. Delayed Care and Aging Population: COVID-19 delayed routine care for millions, leading to more severe and costly treatments later. Simultaneously, the aging baby boomer generation is consuming more high-cost medical services. 

5. Employer Cost-Shifting: As businesses struggle to manage rising premiums, they’re increasingly transferring costs to employees through higher deductibles, co-pays, and out-of-pocket maximums. 

The recent U.S. government shutdown, triggered in part by disputes over health care budget provisions, underscores how fragile the system has become. The conflict exposed the deep tension between maintaining subsidies for low-income coverage, controlling Medicare spending, and financing pandemic-era expansions of Medicaid and ACA marketplaces. The fact that political gridlock could halt government operations over the health care budget reveals just how central — and explosive — the issue has become. 

If current trends continue unchecked, 2026 may see average family premiums approach or exceed $30,000 per year, according to projections by several health economists. This would mean the average middle-class worker would be paying nearly $8,000 annually just for insurance — before co-pays, deductibles, and prescription costs. For many, this will be the tipping point between maintaining coverage and going uninsured. 

This unsustainable trajectory highlights an urgent truth: the U.S. needs bold, structural reform — not patchwork fixes. Transparency in pricing, aggressive drug cost regulation, limits on hospital monopolies, and expanded public options could collectively reverse the spiral. Without intervention, the American dream will continue to erode under the weight of health care costs that no longer reflect care — but a broken market profiting from necessity. 

If there’s one message to take from the numbers, it’s this: the system is no longer merely expensive — it’s punitive. And as the next wave of premium hikes looms in 2026, the question is no longer whether Americans can afford to get sick, but whether they can afford to stay insured at all. 

Is there a backbone in government to arrest this trend. Apparently no. Even the very government mechanism is stopping funding to cover the uninsured under ACA. The 2025 U.S. government shutdown, which began on October 1, was triggered by a bitter standoff over health care funding—specifically, the expiration of enhanced Affordable Care Act (ACA) premium subsidies. These subsidies, originally expanded during the pandemic and extended through the Inflation Reduction Act, were set to lapse at the end of the year. Democrats pushed to include their renewal in the short-term funding bill, arguing that millions of Americans would lose coverage or face skyrocketing premiums without them. Republicans, citing long-term fiscal concerns, resisted, framing the extension as unsustainable spending. 

This impasse turned health care into the central fault line of the shutdown. The stakes were enormous: over 7 million Americans rely on these subsidies to afford insurance through the ACA marketplace4. Without renewal, premiums could double for many, and tens of thousands could lose coverage immediately. The shutdown also disrupted Medicaid negotiations and froze funding for community health programs, amplifying the crisis. 

In essence, the shutdown wasn’t just about losing coverage—it was about the broader affordability and stability of the U.S. health care system. The failure to compromise exposed how fragile access to care has become, and how deeply health policy is now entangled in partisan budget warfare. The drug manufacturers didnt’t mend, the hospitals didn’t mend, the providers didn’t mend, the insurance providers didn’t mend, and the government has its own strange way of functioning which has caused this stalemate or shutdown. In effect, the situation is gradually deteriorating as far as health care is concerned. The shutdown was a warning shot — a glimpse of what happens when the system buckles under its own weight. The time for reform is now.