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HKYNC News & Views October 18, 2026 – Executive Summary & References
Hickory Hound News & Views Archive
Executive Summaries for all News & Views are up to date!!!
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Economic Stories of Relevance in Today's World -- October 15, 2026 -examines whether substantial capital investment is translating into lasting household prosperity. From Hickory’s sewer expansion and regional manufacturing projects to Western North Carolina reconstruction, the report tracks how infrastructure, employment, wages, and purchasing power connect. North Carolina continues attracting major industrial commitments, yet local manufacturing remains weaker and national payroll growth has slowed sharply. Internationally, artificial intelligence fuels trade while energy pressures and uneven growth constrain broader gains. The central question is how much durable employment, supplier activity, and locally retained income each investment produces for the communities that support its development.
The next ESR will be released on the evening of Tuesday November 3rd.
-----The Next Economic Stories of Relevance article will be released on Thursday evening, October 15, 2026.-----
Monday's Mashup - Economic Stories of Relevance — 2020 examines the pandemic’s sudden interruption of employment, production, travel, and trade, alongside unprecedented government intervention that preserved much of the economy’s financial foundation. From American households to Hickory, Catawba County, and the broader Foothills Corridor, the report traces historic job losses, uneven recovery, and continued investment in essential manufacturing and distribution. North Carolina and the United States experienced sharply different outcomes across industries, while global supply chains revealed their vulnerabilities. The year ended with household purchasing power partly protected but productive capacity disrupted, establishing the conditions that would shape the lasting economic challenges of 2021.
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The upcoming Monday Mashup - Economic Stories of Relevance — 2021 - traces the reopening as consumer demand returned faster than businesses could rebuild productive capacity. At Ground Level, recovering employment and federal assistance collided with rising housing, gasoline, and everyday costs. Hickory and Catawba County saw furniture and fiber-optic investment accelerate, while the broader Foothills Corridor experienced manufacturing, tourism, and workforce pressures. North Carolina attracted record investment commitments despite persistent labor and infrastructure constraints. Nationally, supply shortages intensified inflation and prompted a Federal Reserve policy reversal. International shipping disruptions exposed fragile supply chains, leaving the economy entering 2022 with growth, shortages, and mounting affordability pressures.
🧠Opening Reflection
The Cost of Staying Well:
When Healthcare Competes with the Necessities of Life
A year ago, we examined the growing cost of healthcare as the fourth major component of household affordability, following our discussions of housing, food, and electricity. At the time, the concern wasn't simply that medical services were becoming more expensive, but that the financial arrangements surrounding healthcare were making it increasingly difficult for ordinary people to obtain treatment without jeopardizing their financial security. We considered the consequences of postponed appointments, rising insurance premiums, expensive prescriptions, and the uncertainty that accompanies an illness or injury when a family has little money remaining after meeting its other obligations.
One year later, the circumstances have become more difficult. Insurance premiums have continued increasing, financial assistance has been reduced for many households purchasing coverage through the Affordable Care Act, and employers are confronting another period of substantial growth in the cost of providing healthcare benefits. What we identified in 2025 as a continuing threat to household stability has become an increasingly immediate financial problem, with consequences extending well beyond the medical industry.
Healthcare occupies an unusual position among the necessities of everyday life. Most household expenses follow a reasonably predictable pattern. Mortgage payments or rent generally arrive monthly, utility bills fluctuate with consumption and seasonal conditions, and grocery expenses can be adjusted through purchasing decisions. Although families have become increasingly constrained in their ability to manage these obligations, they retain some opportunity to anticipate their expenses and make accommodations when circumstances require them.
Healthcare operates differently because the need for medical attention can't always be anticipated, and the consequences of postponing treatment can be considerably more serious than the immediate financial savings. A person may go years without requiring substantial medical attention and then experience an illness or injury that changes the financial circumstances of an entire household. Even routine medical care, which is supposed to identify problems before they become serious, can involve enough expense to discourage people from making appointments or following through with recommended treatment.
Health insurance was developed to provide protection against these uncertainties, but the growing cost of maintaining that protection has created another problem. Families must devote a portion of their income to premiums whether they require medical services or not. When they do need treatment, they may encounter additional deductibles, copayments, coinsurance, prescription expenses, and restrictions associated with their insurance coverage. The result is a financial arrangement in which paying for protection doesn't necessarily mean that the household can comfortably afford to use it.
The developments of 2026 illustrate how consequential this distinction has become. North Carolina approved an average premium rate increase of approximately 28.6% for individual Affordable Care Act policies taking effect this year, although the actual increase varied among insurers and policies. At the same time, the expiration of enhanced federal premium tax credits at the end of 2025 reduced the assistance available to many households purchasing insurance through the Marketplace. These changes have placed additional pressure upon people who were already struggling to reconcile healthcare expenses with the ordinary costs of maintaining their homes and supporting their families.
For people receiving insurance through their employers, the financial arrangements are different, but the underlying pressures remain. Employers absorb a substantial share of the expense associated with employee coverage, and increases in those costs affect the economics of maintaining a workforce. Businesses must determine how much of the growing expense they can absorb and how much will eventually be reflected in employee contributions, changes in benefits, compensation decisions, or the prices charged for their products and services. Healthcare costs therefore influence household finances even when employees don't directly see the full expense of their insurance coverage.
During the past year, we have also received additional evidence of how these expenses influence the decisions people make. National surveys indicate that insured households are reducing expenditures on food and other basic necessities to preserve their healthcare coverage, while others are reconsidering their insurance arrangements or going without coverage altogether. These aren't necessarily decisions made because people fail to appreciate the importance of their health. They are financial accommodations made when the combined cost of necessities exceeds the resources available to support them.
That distinction is especially important in communities such as Hickory, Catawba County, and the surrounding Foothills, where much of the local economy has historically depended upon working households whose earnings are closely connected to the hours they can work. Manufacturing employees, service workers, tradespeople, small-business owners, and others who depend upon regular income can't always accommodate an unexpected medical expense or an extended absence from employment. Even households with substantial work histories and responsible financial habits can find themselves vulnerable when the expense of treatment arrives alongside obligations that can't be postponed.
We should also recognize that the rising cost of healthcare involves more than insurance companies or the decisions of individual patients. Hospitals and medical practices must contend with increasing labor expenses, expensive equipment, advanced treatments, administrative requirements, and the financial challenges associated with maintaining services. At the same time, consolidation within parts of the medical industry, complicated billing arrangements, and the separation between the prices charged for treatment and the amounts ultimately paid create additional questions about competition, efficiency, and accountability.
These problems can't be resolved simply by expecting patients to make better financial decisions. Nor can they be corrected by assuming that every increase in medical spending is unnecessary. Modern medicine provides treatments and capabilities that earlier generations could scarcely have imagined, and many of those advancements have substantially improved the possibilities for recovery and longer life. The difficulty lies in establishing a reasonable relationship between the value of those services, the expenses required to provide them, and the financial capacity of the people who need them.
North Carolina has begun acknowledging this challenge more directly. In June 2026, the state established a Health Care Affordability Commission to examine rising costs, competition, healthcare workforce shortages, access to primary care, and the particular difficulties confronting rural communities. The establishment of such a commission recognizes that affordability has become a problem requiring examination beyond the decisions made by individual patients, medical providers, or insurance companies. Whether that examination eventually produces meaningful improvements remains to be determined.
For the households living with these expenses, however, the problem can't be postponed while policymakers develop recommendations. Medical appointments still must be scheduled, prescriptions must be filled, and insurance premiums must be paid. Families continue weighing the consequences of spending money today against the possibility of facing a more serious medical problem tomorrow. The uncertainty surrounding these decisions adds another burden to people who may already be working diligently simply to maintain the financial stability they have established.
Throughout October, our affordability series has examined how the cost of maintaining an ordinary life has changed over the preceding year. Housing determines whether people can establish a stable home. Food determines whether they can adequately nourish themselves and their families. Electricity provides the energy necessary to maintain a modern household. Healthcare connects these concerns because physical well-being influences a person's ability to work, earn income, meet financial obligations, and enjoy the life that those efforts are intended to support.
When healthcare expenses force households to compromise the other necessities of living, the financial consequences extend throughout the economy. Money devoted to higher insurance premiums can't be spent on groceries, home maintenance, transportation, or savings. When medical expenses become overwhelming, families may postpone other purchases, accumulate debt, or exhaust resources intended to provide protection against future uncertainty. The resulting pressure reduces the financial independence that stable employment and responsible household management are supposed to make possible.
This week's Feature will examine how healthcare costs have evolved since October 2025, what has changed in North Carolina's insurance market, why medical expenses continue increasing, and what these developments mean for households throughout Hickory and the surrounding Foothills. We will also consider whether existing approaches to financing healthcare can provide the combination of affordability, dependable access, and medical quality that people reasonably expect.
A year ago, we considered the consequences of a healthcare system in which people increasingly postponed treatment because they couldn't afford it. Today, we must consider the broader consequences of a system in which the cost of maintaining access to healthcare is itself becoming another source of household financial insecurity.
The purpose of economic progress should be to improve the conditions under which people live. That progress loses much of its meaning when families must devote an increasing share of their earnings to protecting themselves against the financial consequences of becoming sick.
A prosperous community should provide opportunities for people to earn a living, maintain their independence, and build a secure future. Increasingly, we must also ask whether those same people can afford to protect the health that makes such a future possible.
⭐ Feature Story ⭐
The Cost of Staying Well:
Healthcare, Insurance, and the Erosion of Household Financial Security
One Year Later — From the Cost of Medical Treatment to the Cost of Maintaining Access
When we examined healthcare affordability in October 2025, the central concern was that an increasing number of households were finding it difficult to obtain medical treatment without compromising their financial stability. Insurance premiums were consuming a larger portion of household income, deductibles and other out-of-pocket expenses were discouraging routine medical visits, and the consequences of serious illness extended well beyond the treatment itself. For many working families, the question was no longer simply whether they had health insurance, but whether they could afford to use the medical services their insurance was supposed to provide.
One year later, those concerns have become more immediate, and the financial pressures surrounding healthcare have expanded. North Carolina entered 2026 with substantial increases in individual health insurance premiums, while the expiration of enhanced federal insurance subsidies reduced financial assistance for many households. Employers continued confronting rising costs associated with maintaining employee healthcare benefits, and medical providers faced their own increasing expenses for labor, equipment, supplies, and operations. At the same time, federal and state policy changes introduced additional uncertainty concerning the cost and availability of coverage in the years ahead.
The result is a healthcare economy in which financial responsibility is distributed through an increasingly complicated arrangement involving patients, employers, insurance companies, medical providers, and taxpayers. Every participant has an interest in controlling expenses, but each also faces incentives and obligations that can shift financial responsibility elsewhere within the system. Eventually, however, much of that expense reaches households through insurance premiums, taxes, employee contributions, medical bills, or compensation that might otherwise have supported improvements in their standard of living.
Understanding what has changed since October 2025 therefore requires looking beyond the price of an individual medical appointment. The more consequential issue is how healthcare has developed into a substantial and increasingly unavoidable financial commitment, even for people who are currently healthy and require relatively little medical treatment.
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The Insurance Equation: What Changed During 2026
One of the most significant developments occurred immediately after our original healthcare affordability examination. On October 29, 2025, the North Carolina Department of Insurance announced approved rate increases for health insurance policies offered through the Affordable Care Act for the 2026 coverage year.
The average approved increase for individual-market policies was approximately 28.6%, with increases among participating insurers ranging from 16.88% to 36.4%. Small-group policies, which are generally purchased by qualifying smaller employers, faced approved increases ranging from 12.66% to 17.5%.
These figures didn't mean that every insured household in North Carolina experienced a 28.6% increase. The adjustments applied to particular insurance markets, and the amount paid by an individual policyholder depended upon the insurer, selected plan, age, location, and eligibility for federal financial assistance. Employer-sponsored insurance, Medicare, and Medicaid operate under different financing arrangements and weren't subject to the same statewide individual-market percentage increase.
Nevertheless, the approved increases represented a substantial escalation in the cost of purchasing private individual health insurance.
Consider the effect upon a household paying $600 per month for an insurance policy before the increase. An adjustment of 28.6% would raise that monthly premium to approximately $772, an increase of nearly $172 per month or more than $2,000 annually. This is a hypothetical illustration of the rate increase, not a quotation for a particular North Carolina insurance policy. It demonstrates how rapidly a major percentage adjustment can consume money that would otherwise support groceries, transportation, utilities, or household savings.
The situation became more complicated because another important financial change occurred at the beginning of 2026.
The enhanced premium tax credits established under the American Rescue Plan Act and subsequently extended through the Inflation Reduction Act expired at the end of 2025. These credits had increased the financial assistance available to many households purchasing insurance through the Affordable Care Act Marketplace, reducing the amount policyholders had to pay toward their monthly premiums.
The expiration didn't eliminate all federal premium assistance. The original Affordable Care Act tax-credit structure remained available to qualifying households. However, the reduction in assistance meant that some policyholders faced considerably higher monthly payments, while households above the restored income eligibility ceiling could lose premium assistance entirely.
It is important to distinguish between these two developments. The increase in the underlying price of an insurance policy and the reduction in federal financial assistance are separate financial changes, although they can affect the same household simultaneously. A policyholder could therefore experience an increase in the insurer's premium and an additional increase in the amount personally responsible for paying because the federal government was contributing less toward the cost.
This distinction helps explain why the amount some households were required to pay increased more sharply than the average approved insurance rate.
By the conclusion of the 2026 Affordable Care Act open-enrollment period, approximately 761,000 North Carolinians had selected Marketplace plans, compared with approximately 975,000 during the corresponding 2025 enrollment period. That represented a decline of roughly 214,000 plan selections, or nearly 22%.
Enrollment figures don't establish that every person who left the Marketplace became uninsured. Some people obtained coverage through employment, Medicare, Medicaid, or other insurance arrangements. Others may have reconsidered their choices because of changing income, household circumstances, or the availability of different policies. The enrollment figures also measure plan selections rather than continuously maintained coverage throughout the year.
However, when considered alongside substantial premium increases and reduced federal assistance, the decline provides evidence that the financial circumstances surrounding individual insurance coverage changed significantly between the two enrollment periods.
The consequences were documented in a March 2026 survey conducted by KFF, which recontacted people who had been enrolled in Marketplace insurance during 2025.
Among respondents who maintained Marketplace coverage in 2026, approximately 80% reported that their healthcare costs were higher than the preceding year. Just over half indicated that those expenses were substantially higher, while 17% expressed doubt about their ability to continue affording their premiums throughout the year.
The survey also found that approximately 9% of respondents who had been enrolled in Marketplace coverage during 2025 were uninsured when interviewed in early 2026. This was a finding among previous Marketplace enrollees, not an estimate of the uninsured rate for the entire country.
Taken together, these developments establish that the affordability problem identified in October 2025 wasn't simply continuing along its previous course. For a substantial portion of the individual insurance market, 2026 represented a significant change in the financial commitment required to maintain coverage.
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Employer-Sponsored Insurance:
The Expense That doesn't Appear Entirely on the Paycheck
Although individual Marketplace insurance has received considerable attention, most Americans continue obtaining their health insurance through employment. This creates a different financial arrangement because the full cost of coverage is divided between the employer and employee.
According to KFF's 2025 Employer Health Benefits Survey, the average annual premium for employer-sponsored family coverage reached $26,993, an increase of approximately 6% from 2024. Workers contributed an average of $6,850 toward those premiums, with employers paying the remaining portion.
This distinction is important because the amount deducted from an employee's paycheck doesn't represent the full cost of the insurance benefit. An employer may be paying substantially more than the worker to maintain the policy, and that expense becomes part of the total compensation associated with employing that individual.
For businesses, healthcare benefits aren't an abstract expense. They must be financed through the revenue generated by their operations, just as wages, equipment, utilities, insurance, rent, and other obligations must be paid. When benefit expenses increase faster than productivity or revenue, employers face difficult decisions about how much of the added cost they can absorb.
Some businesses respond by increasing employee contributions, modifying deductibles, limiting coverage options, or negotiating different insurance arrangements. Others absorb additional expenses that may influence future wage increases, hiring decisions, or the prices they charge customers.
These outcomes aren't inevitable in every workplace, and the extent of cost shifting varies among employers. Nevertheless, the relationship between healthcare benefits and compensation creates a broader economic consequence that is frequently overlooked when people examine only the amount deducted from their paychecks.
A dollar devoted to higher healthcare expenses is a dollar that can't simultaneously finance additional wages, equipment, business expansion, or other investments unless the employer generates additional revenue or reduces spending elsewhere.
The outlook for 2026 and 2027 suggests that this pressure is continuing. Preliminary results from Marsh's National Survey of Employer-Sponsored Health Plans indicated that employers projected an average increase of 6.7% in health-benefit costs for 2026. Their projections for 2027 called for an additional increase of 8.2% after anticipated cost-control measures, the largest projected increase since 2003. Without those measures, employers anticipated an average increase of approximately 11% in the cost of maintaining existing plans.
These figures are employer projections rather than confirmed increases in every employee's insurance premium. They nevertheless indicate the direction in which benefit expenses are moving and the financial decisions employers will confront as they prepare their compensation and operating budgets for the coming year.
For workers throughout Hickory, Catawba County, and the surrounding Foothills, these arrangements carry particular importance. Our regional economy includes substantial manufacturing, transportation, retail, hospitality, healthcare, and service employment. Many of these occupations depend upon regular schedules, hourly compensation, and the ability of businesses to maintain a predictable relationship between labor costs and operating revenue.
When the cost of healthcare benefits increases, employees may experience the consequences through higher paycheck deductions or changes in insurance coverage. Even when employers absorb those increases, the expense becomes another claim upon the financial resources available to support employment.
The employee may therefore experience little immediate change in the visible cost of an insurance policy while the underlying expense of maintaining that coverage continues increasing.
This is one reason healthcare affordability must be evaluated as part of the broader relationship between compensation, household income, and the rising cost of living.
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Why Does Healthcare Continue Becoming More Expensive?
The causes of rising healthcare expenses are more complicated than the decisions made by insurance companies alone.
The United States operates an extensive medical industry involving hospitals, physicians, specialists, pharmaceutical manufacturers, medical equipment suppliers, laboratories, insurance administrators, pharmacies, and numerous supporting services. Each component has its own operating expenses, financial arrangements, regulatory obligations, and expectations concerning revenue.
According to federal spending data, national healthcare expenditures reached approximately $5.3 trillion in 2024. Hospital services represent the largest category of spending, while physician services, prescription medications, nursing facilities, home healthcare, and other medical services account for additional substantial portions of the total.
The growing cost of healthcare therefore can't be attributed to a single industry or administrative decision. It reflects an accumulation of expenses associated with delivering medical services, financing improvements, maintaining personnel, developing treatments, and operating a system in which the prices charged for services are frequently disconnected from what patients understand those services to cost.
Labor represents a substantial portion of healthcare expenditures. Hospitals and medical practices require physicians, nurses, technicians, pharmacists, therapists, administrative personnel, maintenance workers, and other employees to maintain operations. Competition for qualified medical professionals, particularly within specialized fields or underserved communities, can increase compensation expenses and create staffing difficulties.
Medical technology introduces another layer of cost. Advanced diagnostic equipment, surgical procedures, pharmaceuticals, and specialized treatments can provide substantial benefits to patients, but the development, purchase, maintenance, and operation of these capabilities require considerable investment. Some innovations reduce long-term medical costs through earlier diagnosis or more effective treatment, while others add expensive new services that expand what the medical system can provide.
Population aging also influences healthcare demand. As people live longer, they are more likely to require ongoing treatment for chronic medical conditions, specialized care, rehabilitation, and medication management. These services can extend productive lives and improve personal independence, but they also increase the volume and complexity of medical care required by the population.
Another important consideration involves the structure of healthcare markets.
Over the past several decades, hospitals and physician practices have increasingly become part of larger healthcare organizations. Consolidation can provide advantages through shared technology, coordinated services, broader access to capital, and the ability to support facilities that might otherwise struggle financially. In some communities, integration into a larger organization may help preserve access to medical services that would be difficult for an independent provider to maintain.
However, consolidation can also reduce competition among providers and strengthen the negotiating position of hospital systems when they establish payment arrangements with insurance companies.
Research summarized by KFF indicates that healthcare-provider consolidation has generally been associated with higher prices, without consistent evidence of corresponding improvements in healthcare quality or access. The relationship varies among markets, but the underlying economic concern is straightforward: when fewer organizations control essential medical services within a region, patients and insurers have fewer realistic alternatives.
Insurance companies negotiate payment rates with hospitals, physicians, and other medical providers. When a dominant healthcare organization possesses services that an insurance company must include to offer an attractive provider network, that organization may possess substantial leverage in negotiating reimbursement.
Higher negotiated prices can eventually increase insurance claims expenses, which contribute to the premiums insurers charge employers and individual policyholders.
Insurers also have their own administrative expenses and financial incentives. They must process claims, manage provider networks, evaluate coverage, comply with regulations, maintain reserves, and administer complex payment arrangements. Their decisions regarding prior authorization, covered medications, reimbursement levels, and network participation can affect the cost and accessibility of medical treatment.
These administrative processes may help control unnecessary spending in some circumstances, but they can also create additional obstacles for patients seeking necessary care. A January 2026 KFF survey found that approximately 47% of insured adults reported experiencing a coverage denial or delay for a prescribed service, treatment, or medication within the preceding two years.
The problem therefore extends beyond the amount spent upon healthcare. It also involves the efficiency with which that spending produces medical services and the extent to which patients can obtain treatment without navigating unnecessary financial or administrative obstacles.
When the system becomes expensive to operate, expensive to insure, and complicated to use, the distinction between having healthcare coverage and receiving affordable medical treatment becomes increasingly significant.
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North Carolina and the Foothills: Access isn't the Same as Affordability
The financial pressures affecting the national healthcare system have particular consequences for North Carolina because the state contains major metropolitan medical centers alongside smaller communities where access to healthcare may depend upon a limited number of providers.
Hickory and Catawba County occupy an important position within the regional healthcare network. Medical facilities in this area serve local residents as well as people living throughout the surrounding Foothills, including communities whose access to specialized care may require travel outside their home counties.
The regional healthcare economy provides employment, attracts investment, and delivers essential services. However, the availability of medical facilities doesn't automatically establish that every household can afford their services or obtain appointments within a reasonable period.
The 2023 Catawba County Community Health Assessment provides an important local baseline. In that assessment, 36.4% of survey respondents identified access to affordable, quality healthcare as an important priority for improving community well-being. Another 24.9% identified mental-health services and support as a priority.
The assessment also documented specific services residents reported being unable to obtain because of cost during the preceding year. Approximately 16.6% cited dental care, 10.3% cited prescription medications, 9.5% cited vision care, and 9.1% cited mental-health services.
These findings were collected before the insurance changes of 2026 and can't be treated as current measurements of those conditions. Their importance is that they demonstrate how affordability problems were already affecting the healthcare decisions of local residents before the more recent increases in insurance expenses.
At the time of the assessment, approximately 9.6% of Catawba County residents were estimated to be uninsured, using 2022 data. The assessment also noted that North Carolina had begun expanding Medicaid eligibility in December 2023, creating the opportunity for additional lower-income adults to obtain coverage.
Medicaid expansion represented a meaningful improvement in access to insurance for qualifying residents. It allowed adults who previously earned too much to qualify under older eligibility rules, but too little to comfortably purchase private coverage, to obtain medical insurance through the state program.
Nevertheless, expanding insurance coverage doesn't automatically eliminate the other barriers associated with obtaining treatment.
A person may have insurance but still be unable to locate a specialist accepting new patients, secure an appointment without an extended delay, or obtain care without traveling a considerable distance. Transportation expenses, unpaid time away from employment, and the availability of family assistance can become part of the effective cost of receiving healthcare.
For an hourly employee, a medical appointment may involve more than a copayment. It may require several hours away from work, transportation to another community, and lost income that can't easily be recovered. For someone living alone or caring for an aging family member, the practical arrangements surrounding medical treatment can be almost as challenging as the financial expense.
These considerations are particularly important when evaluating the financial position of lower-income and middle-income households.
A family with sufficient savings may be able to absorb a medical deductible, take time away from work, or travel to a specialist without substantially changing its other financial commitments. A household living closer to the limits of its monthly income may confront the same medical need as a significant financial disruption.
The difference isn't necessarily the severity of the illness or the importance of receiving treatment. It is the amount of financial flexibility available to accommodate the expense.
This explains why healthcare affordability can't be determined simply by counting the number of insured residents or measuring the availability of medical facilities. The more meaningful question is whether people possess the financial and practical resources necessary to obtain appropriate care when they need it.
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The Cost of Postponing Treatment
One of the most troubling consequences of rising healthcare expenses is the incentive they create for people to postpone treatment.
For households with limited financial resources, delaying medical attention may appear to be a rational short-term decision. A person experiencing a relatively minor medical problem may decide to wait rather than incur an office visit, diagnostic test, prescription expense, or deductible payment.
Sometimes the condition improves without further intervention. In other cases, an untreated problem becomes more serious, leading to additional treatment, greater medical expense, or a loss of the patient's ability to work and maintain ordinary responsibilities.
The financial difficulty is that the consequences of postponement can't always be predicted.
An individual managing high blood pressure, diabetes, cardiovascular disease, or another chronic condition may require continuing medication, periodic testing, and regular medical supervision. These expenses aren't unusual emergencies but part of maintaining health over time.
When households begin postponing recommended appointments, reducing medication use, or avoiding follow-up examinations because of cost, they may expose themselves to health risks that are substantially more consequential than the immediate savings.
National research published by KFF in March 2026 found that approximately 17% of American adults had delayed or gone without some form of healthcare because of cost in 2024, including medical or mental-health care and prescription medications. That historical measurement predates the 2026 insurance changes, but it establishes that financial barriers to obtaining treatment were already widespread.
More recent evidence indicates that the problem remains substantial among people with serious medical needs.
A September 2026 KFF survey found that 68% of uninsured working-age adults with multiple health conditions reported skipping or delaying medical care because of cost during the previous year, compared with 35% of similarly situated adults who had insurance. The findings also demonstrated that insurance substantially reduced, but didn't eliminate, the financial difficulties associated with ongoing treatment.
These distinctions matter because healthcare isn't consumed in the same manner as most household goods and services. People don't generally choose to become ill, and the services required to treat a medical condition are frequently determined by circumstances beyond the patient's control.
A family may reduce its grocery spending by substituting less expensive foods, although such compromises can affect nutrition. It may adjust home temperatures to conserve electricity or postpone certain household repairs. Medical treatment offers fewer acceptable opportunities for substitution, particularly when a condition requires specific medications, procedures, or professional attention.
The resulting financial pressure can become self-reinforcing. The cost of receiving treatment discourages people from obtaining care, while the consequences of untreated illness may eventually produce expenses and limitations that are more difficult to manage.
This is where healthcare affordability becomes more than a discussion about medical bills. It becomes a question about the relationship between physical health, employment, household stability, and the ability to maintain financial independence.
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Healthcare and the Competition for Household Income
The most revealing evidence of how healthcare expenses affect ordinary living arrangements may be found in the decisions households make when medical costs compete directly with their other obligations.
The March 2026 KFF Marketplace survey found that approximately 55% of returning enrollees reported having reduced, or planning to reduce, spending on food and other basic household necessities to help meet healthcare expenses.
Approximately 43% reported working or planning to work additional hours or obtain another job, while others reported postponing bills or relying upon borrowing to manage their financial obligations.
These findings demonstrate how the consequences of healthcare inflation extend into the other areas of affordability we have examined throughout October.
A household doesn't maintain an independent pool of money for each necessity. Housing, food, electricity, transportation, insurance, taxes, and medical expenses must all be financed through the same available income.
When healthcare expenses increase, the household must either generate additional income, reduce other spending, draw upon savings, assume debt, or make some combination of those adjustments.
The problem becomes especially difficult when the other necessities have already absorbed much of the household's financial flexibility.
Housing expenses may be fixed by a mortgage or rental agreement. Food prices are influenced by market conditions and the cost of producing, processing, transporting, and distributing groceries. Electricity must be purchased to maintain a habitable household. Transportation remains essential for people who must travel to employment, medical appointments, and other necessary activities.
Healthcare enters this arrangement as another obligation that may be predictable in its insurance premiums but unpredictable in its actual medical expenses.
Consider a working household that successfully reduces grocery expenses or conserves electricity to save an additional $100 each month. Those savings represent progress only if the household is permitted to retain them. A $150 increase in monthly insurance premiums would consume the entire savings and require an additional adjustment elsewhere.
The household has made responsible financial decisions but has nevertheless moved backward.
This is an important distinction when evaluating economic progress. Personal financial discipline can improve the way resources are managed, but it can't guarantee that household earnings will keep pace with expenses determined by larger economic and institutional systems.
As more necessities rise in cost simultaneously, the capacity to offset one expense through reductions in another becomes increasingly limited.
Families may continue working, maintaining their property, minimizing waste, and fulfilling their obligations while finding that their financial circumstances are becoming less secure.
The resulting problem isn't necessarily a failure to manage money. It is a deterioration in the relationship between the cost of maintaining an ordinary standard of living and the income available to support it.
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What Has Improved, and What Remains Unresolved?
An examination of healthcare affordability should also recognize developments that have provided meaningful financial protection to particular groups of patients.
North Carolina's Medicaid expansion continues to provide access to medical coverage for qualifying lower-income adults who might otherwise face substantial difficulty obtaining insurance. The expansion has helped extend coverage for preventive care, prescriptions, dental services, and other treatment that can be financially inaccessible without assistance.
Medicare beneficiaries have also received additional prescription-drug protections.
Beginning in January 2026, negotiated Medicare prices took effect for the first ten medications selected under the federal Medicare Drug Price Negotiation Program. The program was designed to reduce spending on selected expensive medications without generic or biosimilar competition.
For 2026, annual out-of-pocket spending on covered Medicare Part D prescription drugs is also limited to $2,100. This protection doesn't apply to every possible medical expense, nor does it eliminate insurance premiums or costs associated with treatment outside the prescription-drug benefit. Nevertheless, it provides a meaningful limit upon covered medication expenses for beneficiaries who would otherwise face very high annual prescription costs.
These improvements demonstrate that healthcare policy can reduce financial exposure when reforms establish clear protections or strengthen the purchasing arrangements through which medical services and medications are financed.
However, the existence of improvements within particular programs doesn't establish that the healthcare system as a whole is becoming more affordable.
Medicare beneficiaries still confront premiums, medical cost-sharing, supplemental insurance decisions, and services that may not be fully covered. Medicaid beneficiaries may experience provider-access limitations or administrative requirements, while privately insured households face the continuing pressure of premiums, deductibles, and provider-network restrictions.
Additional changes are approaching in 2027. North Carolina Medicaid has announced new work and community-engagement requirements affecting many adults ages 19 through 64, with important exemptions for qualifying individuals and circumstances. The state also anticipates more frequent eligibility renewals for affected beneficiaries.
These requirements may alter how people maintain coverage, particularly workers with irregular schedules, seasonal employment, caregiving responsibilities, or changing income. The effect upon coverage will depend upon implementation, exemptions, administrative procedures, and the ability of eligible individuals to document compliance.
At the state level, Governor Josh Stein established the North Carolina Health Care Affordability Commission on June 30, 2026. The commission brings together representatives from medical providers, insurers, government, research organizations, and other parts of the healthcare economy to develop recommendations for reducing expenses and improving affordability.
The commission is expected to deliver its first report in January 2027.
Its establishment is an acknowledgment that rising healthcare expenses can't be resolved entirely through decisions made by patients at the point of treatment. The underlying prices, insurance arrangements, market structure, administrative processes, and availability of healthcare providers must also be considered.
The more difficult question is whether such an examination will produce changes that actually reduce the financial burden upon households.
Reducing premiums by shifting additional expenses into deductibles doesn't necessarily make healthcare more affordable. Limiting insurance payments by creating barriers to necessary treatment may reduce expenditures in the immediate term while leaving patients with untreated medical problems. Expanding coverage without addressing the price of medical services may improve financial protection while allowing underlying healthcare expenses to continue increasing.
A meaningful affordability strategy must therefore consider the total cost of obtaining appropriate care rather than concentrating exclusively upon the amount charged for insurance or an individual medical service.
The objective should be to preserve access to necessary treatment while improving the relationship between healthcare expenditures and the benefits those expenditures produce.
That requires examining competition among providers, the transparency of medical prices, the administrative costs associated with insurance, the cost.
α My Own Time Ω
The Cost of Being Able to Live Long and Prosper
A year ago, when I wrote about the cost of healthcare, I reflected upon the years I had spent working in professional kitchens and the physical demands that came with that occupation. I talked about how people learned to work through fatigue, aches, injuries, and illnesses because they had responsibilities that didn't disappear simply because they weren't feeling well. I had seen that throughout my working life, not only among cooks and servers but among people in almost every occupation where earning a living depended upon showing up and getting the job done. You developed a certain tolerance for discomfort because there wasn't always an alternative, and when you were younger, you generally believed your body would recover from whatever punishment you put it through.
As I've gotten older, I've come to understand that the body doesn't always cooperate with the expectations we place upon it. The aches and pains that once disappeared after a night's sleep can become persistent reminders of how much time has passed. You become more aware of your physical limitations, and things that once seemed relatively unimportant begin demanding greater attention. You also begin to recognize how much your independence depends upon remaining healthy enough to take care of yourself.
This past August, I had a stent placed in one of my coronary arteries. I don't intend to turn this reflection into a medical account, but the experience has certainly influenced the way I think about healthcare and the importance of maintaining my health. At sixty years of age, I find myself confronting circumstances that require more attention than I had previously devoted to them. There are medications to take, dietary adjustments to make, and medical recommendations that have become part of my everyday responsibilities. These aren't things I can simply disregard because I'm busy or would rather be doing something else.
I've spent more than forty years around food, with much of that time devoted to preparing meals for other people. I understand ingredients, preparation methods, nutrition, and the enormous difference between food that satisfies an appetite and food that contributes to maintaining good health. However, understanding those principles and having to apply them consistently to your own circumstances are two different matters. It's one thing to know how to prepare a meal, and another to examine nearly everything you purchase or consume because your health now depends upon making more deliberate choices.
That experience has also brought me back to the affordability questions we've been examining throughout October. When we discussed groceries earlier this month, we considered how difficult it has become for households to maintain a reasonable food budget. Yet when dietary restrictions become a medical necessity, the ability to economize becomes more complicated. You can no longer make every purchasing decision according to price or personal preference. You have to consider the nutritional content of what you're buying, the ingredients being used, and whether those choices are consistent with the treatment and prevention measures intended to protect your health.
The same principle applies to medical care itself. Once you develop a condition requiring continuing attention, healthcare becomes an ongoing responsibility rather than an occasional expense. Prescriptions need to be maintained, appointments must be scheduled, and the possibility of further treatment remains something you have to consider. Insurance may provide substantial financial protection, but that protection has a price of its own, and the costs associated with maintaining good health don't necessarily disappear after a successful medical procedure.
I am grateful that the medical intervention was available when I needed it. Modern medicine has developed capabilities that would have been unimaginable to earlier generations, and I have no interest in dismissing the importance of those advancements. However, having experienced the necessity of medical treatment, I also understand more clearly the circumstances confronting people who can't afford the insurance, medication, or follow-up care their conditions require. It troubles me to think about someone leaving a doctor's office with instructions intended to protect their health, only to return home and begin calculating which portions of that treatment they can afford.
What concerns me is how easily financial limitations can interfere with the decisions people ought to be making for their health. When someone is young and reasonably healthy, it can be tempting to view medical expenses as something that can be postponed until circumstances improve. There may be a mortgage payment due, a vehicle requiring repairs, or children who need something more immediately. As long as a person can continue working, the tendency is to address whatever demands attention today and hope that tomorrow will provide the opportunity to deal with everything else.
Unfortunately, tomorrow has a way of arriving with its own obligations. A year passes, then another, and the medical attention that could have been addressed earlier becomes another unresolved responsibility. Sometimes there are no consequences, but sometimes the problem develops into something far more serious. The difficulty is that people rarely know in advance which circumstances they can safely postpone and which ones will eventually change the direction of their lives.
There is another part of this situation that I find increasingly difficult to reconcile. For much of our working lives, we are encouraged to prepare for retirement, accumulate savings, pay down our debts, and establish enough financial security to enjoy the years when we are no longer obligated to work every day. That is a reasonable ambition, and it has been part of the American understanding of personal responsibility for generations. You work while you are able, make the best decisions you can with the resources available, and hope that your efforts eventually provide some freedom from the constant demands of earning a living.
Yet healthcare becomes more important during the very years when people are attempting to reduce their dependence upon employment. Someone who leaves the workforce before qualifying for Medicare must consider how they will maintain insurance coverage, and a person dealing with a chronic medical condition can't simply abandon necessary treatment because the expense interferes with retirement plans. Even after reaching Medicare eligibility, premiums, supplemental coverage, prescriptions, and other medical expenses remain part of the financial calculation.
That creates a peculiar contradiction. We spend much of our lives working toward the freedom to enjoy our remaining years, only to discover that maintaining our health during those years can become one of the most significant financial obligations we face. For some people, the cost of insurance may influence whether they can retire at all. Others may remain in jobs they would otherwise leave because they can't risk losing employer-sponsored healthcare coverage.
I don't believe everyone should expect the same financial circumstances, nor do I believe that medical services can be provided without recognizing the substantial expenses associated with delivering them. Physicians, nurses, technicians, hospitals, and the people who develop medicines and medical equipment provide services that require education, skill, investment, and continuing financial support. I understand the value of that work and recognize that its costs have to be paid.
Nevertheless, there ought to be a reasonable relationship between the cost of obtaining medical treatment and the financial means of the people who need it. A system that provides extraordinary medical capabilities but places those capabilities beyond the reach of substantial portions of the population has a problem that can't be explained away through ordinary economic reasoning. The purpose of healthcare is to preserve life, restore health where possible, and help people maintain the ability to function independently. When the financial arrangements surrounding that care become obstacles to receiving it, something essential has become disconnected from its intended purpose.
What bothers me most is how these obligations gradually consume the choices people have worked their entire lives to establish. I've reached an age when I would like to spend more time pursuing my own interests, enjoying my home, and doing things that provide some personal satisfaction beyond earning enough money to pay the next round of bills. I don't expect life to become free of responsibility, but I would like to believe that decades of work ought to provide some opportunity to enjoy what remains rather than continually preparing for the next expense.
My experience this year has reinforced how important that opportunity really is. Good health isn't simply the absence of illness. It is the ability to get up in the morning with enough strength and energy to do something meaningful with the day. It is the independence to make your own decisions, maintain your home, spend time with people who matter to you, and pursue the interests that make life worth living. Those are things that become more valuable as the years pass because you begin to understand that time isn't an unlimited resource.
Looking back over this month's affordability examination, I see the same relationship connecting housing, food, electricity, and healthcare. We work to establish a home, purchase the food necessary to sustain ourselves, and pay for the utilities that make modern life possible. We also have to maintain the health that allows us to earn the income supporting those obligations. When the cost of one necessity increases, it places additional pressure upon the others, and eventually the combined expense determines how much freedom remains after everything has been paid.
A year ago, I wrote about the physical consequences of working through discomfort and the deferred responsibilities that eventually catch up with people as they grow older. This year, those observations have taken on a more personal meaning. I am still responsible for my decisions, and I understand that maintaining my health will require continuing attention and discipline. What I question is whether the larger system surrounding healthcare is making that responsibility unnecessarily difficult for people who are already doing everything they reasonably can to support themselves.
I want to see people live longer, healthier, and more independent lives. I also want those additional years to mean something beyond another opportunity to pay insurance premiums, medical bills, and the increasing expenses associated with remaining alive. We have made remarkable advances in the treatment of diseases that once shortened lives considerably, and those accomplishments should provide people with greater opportunities to enjoy the time they have been given.
As I look toward the years ahead, I am increasingly conscious of the difference between simply surviving and having the freedom to live. I have spent much of my life working, meeting obligations, and attempting to establish enough stability to determine my own future. I would like to preserve that independence for as long as possible, and maintaining my health has become an important part of making that possible.
One year after our original examination, healthcare affordability is no longer simply another economic issue that I can observe from a distance. It has become part of the larger question of how I intend to live the remainder of my life.
I don't believe that spending a lifetime working should leave someone facing a choice between protecting their health and preserving the financial independence they worked so hard to establish. We should be capable of building an economy in which people can do both.
