HFMA pushes a new affordability truce as costs outpace access
Health care affordability has moved from a policy talking point to a bedside constraint. In a new Declaration on Healthcare Affordability and Sustainability, the Healthcare Financial Management Association is urging physicians, hospitals, insurers, employers and technology companies to stop trading blame and begin building solutions that can be measured against one question: does care actually become cheaper for patients?
The declaration is part of HFMA’s Vitalic Health initiative, launched earlier this year to bring in new partners, test interventions and track whether affordability improves in practice rather than in rhetoric. C. Ann Jordan, J.D., HFMA’s president and chief executive officer, framed the problem in direct terms: the system has become unsustainable, leaves patients with too little financial security and imposes heavy costs on employers and taxpayers. The association is asking leaders to endorse a set of commitments that includes moving beyond blame, facilitating dialogue, ending cost shifting disguised as cost reduction and reducing health care costs rather than simply reducing health care.
One sentence captures the tension running through the entire effort.
The system cannot keep asking patients to absorb more of the bill while promising them that coverage equals protection.
Patients are insured, yet still exposed to financial strain
The declaration lands in the middle of a mounting affordability problem that reaches far beyond the uninsured. A June Urban Institute analysis, funded by the Robert Wood Johnson Foundation, found that 46% of working-age adults said their families had trouble affording health care in 2025. The burden was highest among adults with limited coverage or no coverage at all, but it also reached people who are often assumed to be protected by insurance. Affordability problems were reported by 39% of adults with employer coverage, 53.8% of adults with Marketplace or other individual coverage, 57% of adults with Medicaid and 60.4% of uninsured adults.
Chronic disease sharpened the strain. More than 60% of adults ever diagnosed with cancer, heart disease or diabetes reported affordability problems, and more than 70% of those with stroke or chronic obstructive pulmonary disease said the same. In a health system built around episodic billing and fragmented cost sharing, a chronic diagnosis can become a long-duration financial hazard. Repeated visits, imaging, prescriptions and specialist referrals accumulate in ways that insurance design does not always blunt.
The authors of the Urban Institute analysis concluded that insurance often does not provide sufficient financial protection from the costs of obtaining care. That conclusion aligns with a separate signal tracked by West Health and Gallup: only 49% of U.S. adults could consistently afford needed care and medications in 2025, the lowest share since the index began in 2021.
Deferred care is already changing patient behavior
Once patients begin rationing care, the consequences show up in the exam room. In the 2026 PayZen Patient Affordability Survey, more than one in four respondents skipped or postponed care because of cost. Among those who delayed care, 52% skipped follow-up or specialist visits, 43% skipped prescription drugs and 34% skipped preventive visits.
The survey points to a practical change in how patients behave when prices are opaque or overwhelming. Forty-three percent said they had used an artificial intelligence chatbot instead of seeing a doctor because of cost concerns. Forty-two percent received no cost estimate, no payment plan offer, no financial assistance information and no conversation with a financial counselor. Nearly 9 in 10 said they would lose trust in a provider that does not proactively communicate about payment plans or financial assistance.
Affordability is therefore not a back-office issue. It shapes whether patients return for follow-up, whether prescriptions are filled and whether preventive care is delayed until disease is harder and more expensive to treat. In chronic illness, delayed contact often means worse control, more acute events and higher downstream costs for everyone involved.
Physicians are absorbing the pressure too
The financial strain is not confined to patients. In athenahealth’s Physician Sentiment Survey, access to affordable care became physicians’ top policy concern, named by 52% of respondents, up from 38% two years earlier. Ninety percent of small practices said they fear for their ability to remain independent.
That concern is not abstract. Practices operate within payment rules they do not set and price structures they cannot fully control. Nele Jessel, M.D., chief medical officer at athenahealth, described a market in which vendors deliver services but third parties control the price. For independent physicians, especially in primary care, that structure leaves little room to absorb rent, staffing, technology and compliance costs while also meeting patient expectations for lower out-of-pocket spending.
Site-based billing keeps widening the same-service gap
The affordability debate becomes especially sharp when the same service carries different prices depending on where it is billed. An Employee Benefit Research Institute analysis of 2023-2024 commercial claims found that hospital outpatient departments were paid an average of 102% more per unit than physician offices for the same physician-administered drugs, with a median markup of 64%. The analysis covered 106 high-spending infused and injected drugs and estimated that employers and workers would save about $12.7 billion annually if hospital departments were paid physician office rates.
The pricing difference does not appear to be explained by the service itself. EBRI’s authors argued that the gap reflects broader structural features of commercial health care markets rather than differences in the underlying care. The pattern has practical consequences: when a hospital acquires a physician practice, services that once billed as office care may be reclassified as hospital outpatient care even when the patient is still treated in the same physical setting. The bill changes because the ownership changes.
A separate data point from the Physicians Advocacy Institute and Avalere Health showed that as of Jan. 1, 2026, hospitals and corporate entities employed 82% of U.S. physicians and owned 63.9% of practices. Consolidation in ownership and consolidation in pricing reinforce each other. The result is a system in which patients can pay more without receiving more, and physicians can lose autonomy without seeing a corresponding improvement in access.
What the declaration can and cannot do
HFMA’s declaration does not take a formal position on specific policies such as site-neutral payment. It is a call for alignment, not a legislative blueprint. Still, the document lands in a policy environment already shaped by hospital and insurer consolidation, prescription drug costs, higher-than-expected provider payment rates and workforce shortages. The Urban Institute authors said lowering prices will require systemic reform, not isolated fixes.
The declaration’s value may lie in its insistence that affordability and sustainability are inseparable. If patients cannot afford to return, clinicians cannot deliver longitudinal care. If employers cannot sustain benefit spending, coverage erodes. If hospitals and physicians continue to operate inside a payment system that rewards setting over service, the pressure will keep shifting rather than receding.
HFMA is inviting sector leaders to endorse the pledge, but no timeline for results is attached. The measure of success will not be the number of signatures. It will be whether patients start seeing lower bills, whether practices can stay independent and whether care that is medically necessary becomes financially reachable again.