By Matthew Fisher

The expiration of enhanced ACA subsidies, followed by the end of the open enrollment period, created significant uncertainty in the healthcare sector. Yet, despite initial concerns, analysts determined that margins have improved slightly, and ACA registration is down modestly (5%) from the previous year, far less than initially predicted. However, this is likely not the beacon of hope it may seem.

Our industry is experiencing a systemic increase in affordability risk: underinsurance. Market shifts are increasing enrollment in high-deductible health plans (HDHPs), such as ACA Bronze or Catastrophic plans, where patients remain insured but face high upfront out-of-pocket costs and, for some, rising premiums. Most patients, upon needing care, may struggle to afford care before their deductible is met, leaving them vulnerable.
At the same time, HDHP adoption rates have continued to rise in the employer-sponsored health insurance market, as employers shifted more of the cost to employees to cope with higher payer premiums. For many employers, shifting cost-sharing has become the only viable strategy to manage premium growth. The result is a growing population of commercially insured patients carrying higher financial responsibility, placing additional strain on engagement, point-of-service collections, and overall ability to pay.

Fitch Ratings analysts warn that healthcare financial leaders have only a short runway to act before affordability pressures resurface in even more destabilizing ways. Fiscal tensions will begin to resurface in a significant manner due to shifting policy changes that are causing further rises in uncompensated care, such as cuts to premium tax credits (PTC). The Urban Institute predicts that without enhanced PTCs, 4.8 million individuals will become uninsured in 2026.

Medicaid redeterminations, cuts, subsidy expirations, and premium increases are further affecting how patient populations view affordability within medical care. This can cause patients to delay or cancel care, forcing health systems to absorb the financial impact. Financial pressures ripple outwards, affecting all stakeholders and economic headwinds will inevitably drive cost-shifting to privately insured patients. Cost-shifting will deepen health inequities, and threaten the long-term viability of safety-net health systems, a problem even mission-driven, community-centric health systems cannot alleviate.

While outlooks may seem bleak, my experience working across multiple health systems to help revitalize payment operations has shown me that now is a moment of opportunity. To reduce the risk of uncompensated care and protect patient access, CFO's and revenue cycle executives can utilize insurance discovery, provide enrollment support and offer patient sponsorship. Embedding these into core revenue cycle workflows ensures affordability challenges do not become additional financial losses. Health systems that operationalize the following steps can preserve patient coverage, maintain access to care, and protect their system's margins.

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