Patient Affordability as a Strategic Imperative: How 5 Leading Health Systems Are Responding to Rising Out-of-Pocket Costs

‍Out-of-pocket costs now make up 49.3% of large, slow-to-resolve hospital balances, up from 37.5% just one year earlier, according to a 2026 report from Cedar and The Health Management Academy (THMA). The research analyzed Cedar's aggregated billing data and case studies from five health systems.

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FAQ section

‍How much of their largest hospital bills are patients paying?

In Q1 2026, out-of-pocket costs made up 49.3% of the dollars in large, slow-to-resolve hospital balances, up from 37.5% in Q1 2025, according to Cedar's billing data.

‍Why are patients paying more of their hospital bills, even with insurance?

The shift is driven largely by the growth of high-deductible health plans and coinsurance, where the amount a patient owes rises along with the size of the bill. Smaller bills, under roughly $200, saw little change in the out-of-pocket share.

‍Who are the "underinsured," and why are they harder for hospitals to help?

The underinsured are patients with insurance whose income is too high to qualify for traditional financial assistance, but who still cannot afford a bill in the thousands of dollars. Health systems have established pathways for uninsured and very-low-income patients, and for insured patients who can pay. Underinsured patients fall between those two groups.

‍What are health systems doing to address rising patient out-of-pocket costs?

The five health systems studied are moving support earlier in a patient's financial journey, through self-service cost estimates, presumptive charity-care screening, and earlier payment-plan enrollment, while also widening options for patients with remaining balances, including tailored payment plans and financing.

‍What did the report find about coverage enrollment support?

One academic health system that helped self-pay patients enroll in marketplace coverage projected 200 to 225 enrollments in its first year and enrolled approximately 350.

‍Who conducted this research?

The Health Management Academy (THMA) conducted the research, which included an analysis of Cedar's aggregated billing data and interviews with chief financial officers, revenue cycle leaders, and operational staff at five health systems.

About the Research

Patient Affordability as a Strategic Imperative, published by Cedar and The Health Management Academy, examines how the shift toward high-deductible health plans and coinsurance is changing who pays for the largest hospital bills. The report pairs original billing data with five case studies of health systems that differ in size, market, payer mix, and electronic health record platform. It identifies a framework of four dimensions that shape each system's approach to patient affordability: market environment, digital infrastructure, systemness, and financial standing.

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