This is the difficult decision that an increasing amount of people (our friends, our family) have to make everyday.
Health insurance is supposed to create peace of mind. But for millions of Americans, it’s become a monthly bill that still doesn’t protect them from big medical costs when they actually need care.
This is the modern reality: you can be “insured” and still be one surprise bill away from financial stress.
The number most people never plan for: the out-of-pocket maximum
Even when you stay in-network, many plans have a ceiling on how much you can be required to pay out of pocket in a year (not counting premiums). For 2024, the Affordable Care Act (ACA) maximum annual limitation on cost sharing was $9,450 for an individual and $18,900 for a family.
That’s the cap—the “worst-case” year. But you don’t have to hit the cap to feel the pain.
Before you ever get close, you’re often paying:
- A deductible before coverage really kicks in
- Co-pays for office visits, urgent care, and prescriptions
- Coinsurance (a percentage of the bill) for tests, imaging, and procedures
Most Americans don’t have that kind of slack in their budget
When budgets are already tight, health costs don’t show up as a single number—they show up as tradeoffs.
According to PYMNTS Intelligence, 67% of Americans say they live paycheck to paycheck.
Now add a common real-world scenario: a $2,000 deductible.
For many households, a $2,000 bill doesn’t mean “pay it and move on.” It means scrambling.
Here are the options people often feel forced into:
- Put it on a credit card (and carry the balance)
- Set up a payment plan with the provider and hope nothing else breaks that month
- Borrow from family or friends
- Tap savings (if they have it) and lose their emergency cushion
- Delay the care until it becomes unavoidable
And that last option—delay—can be the most expensive one over time.
What people sacrifice to afford care
When healthcare becomes a budgeting problem, people don’t just cut back on “extras.” They cut back on health.
Common sacrifices include:
- Preventive care and routine checkups
- Mental health support and counseling
- Dental and vision visits
- Prescriptions (delayed refills, half-doses, or stopping altogether)
- Follow-ups, labs, and imaging
This is what “coverage” looks like when the cost of using it is too high.
The hidden cost: people delay needed care
When people delay care because of cost, problems don’t disappear—they compound.
KFF reports that 36% of adults said they skipped or postponed needed health care in the past 12 months because of the cost.
Delaying care can mean:
- A manageable condition becomes a chronic one
- A minor issue becomes a major procedure
- A missed preventive visit becomes a serious diagnosis later
And the impact doesn’t stop with the individual. Employers feel it too—through absenteeism, lower productivity, and higher long-term claims.
A better standard: benefits people can actually use
If the goal is healthier employees and less financial strain, the solution isn’t always “more insurance.” It’s often more access—to care people will actually use.
That starts with benefits that:
- Reduce out-of-pocket friction
- Make care easy to access quickly
- Support everyday health needs (not just catastrophic events)
Because the real problem isn’t only the price of insurance.
It’s the price of using it.
Bottom line
When out-of-pocket maximums can reach $9,450 for an individual and $18,900 for a family—and 67% of Americans say they’re living paycheck to paycheck—it’s no surprise that people make sacrifices and delay care.
The question for employers and brokers isn’t just, “Do we offer insurance?”
It’s: Can our people afford to use the care they need—when they need it?
About the Author: Ricci DeRosa is the Co-Founder of The Part-Time Benefits Company and has 25+ years in the employee benefits field, serving brokers, associations, and employers. He believes everyone deserves fast, affordable access to healthcare—regardless of how they work—especially as 70% of Americans live paycheck to paycheck and traditional insurance can strain family budgets. Known for out-of-the-box thinking, Ricci builds practical benefit solutions for overlooked workers.