Prediction: 2026 is the year affordability rewrites patient behavior and health system margins

The past few years have tested health systems, but 2026 will bring an affordability shock that will alter patient behavior and health system margins dramatically. As enhanced ACA subsidies expire, Medicaid eligibility becomes more stringent, and employer-sponsored premiums reach their highest levels in over a decade, millions of Americans will transition from being insured to being un- or underinsured. The financial and clinical fallout will be immediate, and visible by the end of January as CFOs see the first signs of a measurable revenue gap.

For physicians, this shift will manifest in exam rooms, missed visits, and delayed presentations that spill over into emergency care. For health systems, it will surface as shrinking reimbursement, rising bad debt, and care deterioration tied to affordability rather than clinical need. The question is no longer whether affordability pressure will escalate, but how prepared systems are to absorb it once traditional assumptions about coverage begin to break down in Q1.

A national affordability shock arrives

The first months of 2026 will reveal instability across all payer categories. ACA marketplace enrollees will face steep premium increases as federal subsidies are set to expire. Many will fall behind on payments or drop coverage altogether. Medicaid redeterminations will continue removing eligible patients for procedural reasons unrelated to income or employment.

Even the employer market, long regarded as the most stable segment, will not be spared. Employer health plan costs are projected to increase, alongside rising deductibles. Many families will begin to feel the affordability shock in January and February, when they attempt to use their insurance during peak flu season and encounter dramatically higher out-of-pocket expense.

The IRS has already set the 2026 out-of-pocket maximum for high-deductible health plans at $17,400 for a family of four. That alone will push many insured patients into “functional underinsurance,” where care is technically covered but effectively unaffordable.

These pressures will lead to predictable behavioral shifts, including deferred primary care, postponed elective procedures, skipped tests, and inconsistent adherence to medication.

The financial breakpoint for health systems

By mid-year, affordability-driven stress will create measurable revenue pressure, likely resulting in a 3–4% revenue gap as three key forces converge:

1. Delayed elective procedures among high-deductible plan members
2. Faster bad-debt growth as patient liabilities climb
3. Coverage churn leading to eligibility denials and preventable write-offs

Systems with large Medicaid and ACA populations will feel the sharpest strain. All organizations will face more complex conditions, driven by affordability rather than access barriers. For physicians, this will mean more unmanaged chronic conditions, higher acuity at presentation, and patients making care decisions based on cost rather than medical need.

Emergency departments become the default access point

Families priced out of upstream care will rely on emergency departments (EDs), not because EDs are convenient, but because they are the only care setting where cost cannot be used as a barrier to entry. Volume will rise, acuity will rise, and reimbursement will fall. We witnessed early signs of this behavior post-pandemic. While overall ED visits declined in early 2020, by 2021-2022, many systems experienced rising acuity, crowding, and crowding as delayed care turned into urgent needs; 2026 will accelerate this trend.

Without intervention, many EDs will become the de facto primary care home for patients who can no longer afford traditional access points, an early indicator of affordability stress.

Patient financial access becomes a core capability
To avoid major revenue disruption in 2026, health systems must proactively treat patient financial access as a primary operational focus. Provide financial clarity early and address patients’ financial status before balance issues occur. This can be done via:

• Implementing real-time segmentation tools to identify patients’ insurance and financial status
• Offering simple financing options and early cost estimates to lower no-show rates and limit bad debt
• Guiding patients through renewals, subsidy checks, and premium support applications
• Connecting patients with foundation aid and manufacturer programs for high-cost therapies
• Adopting transparent digital tools for financial interactions that meet patient expectations

What physicians should expect, and how to prepare

Physicians will feel the affordability crisis as premiums rise and subsidies fall, more insured and underinsured patients delay care, skip visits, and ration medications. Expect worsening chronic disease control, heavier ED reliance, and greater clinical complexity. Financial strain shapes clinical outcomes, so physicians advocating for stronger financial-access programs will help preserve continuity of care.

The year ahead will test the resilience of care teams and the strength of patient relationships. Systems will begin having enough data to shift from “wait and see” to restructuring their entire financial access strategy. Organizations that treat financial access as part of the care experience will be far better equipped to protect access and affordability for patients, stabilize margins, and support the communities they serve.

Chris Stenglein is CEO of Curae, a patient financial care company headquartered in Atlanta, Ga.