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

Patients are covering a growing share of the bill

Out-of-pocket costs made up 49.3% of the dollars in large, slow-to-resolve hospital balances in Q1 2026, up from 37.5% a year earlier, according to original data from Cedar and The Health Management Academy (THMA). As high-deductible plans and coinsurance grow, the biggest bills increasingly land on the patient, not the payer, and most health systems aren't built to catch the patients caught in between.

"This research underscores a critical issue for health system leaders: patients are bearing an increasing share of their healthcare costs. Underinsured individuals are particularly vulnerable to financial hardship, which our current infrastructure is not built to absorb."— Coltin Ball, Associate Director at THMA and lead researcher on the report

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What's inside

01 — The underinsured are the hardest patients to help

Health systems have built pathways for uninsured and very-low-income patients, and for insured patients who can pay. Patients who earn too much for financial assistance but still can't absorb a bill in the thousands fall in between, and the report shows how five health systems are rethinking charity care thresholds, payment-plan length, and presumptive assistance to close that gap.

02 — The gap is coordination, not tools

Most of the tools needed to support patients already exist inside health systems. The report finds the harder problem is coordinating them across teams, technology, and reporting lines as fast as the market is changing.

03 — Options matched to the patient produce the clearest results

The strongest outcomes came from coverage support, financial assistance, and payment plans built around each patient's specific situation. One academic health system that helped self-pay patients enroll in marketplace coverage expected 200 to 225 enrollments in its first year. It enrolled about 350.

04 — Access is becoming the new success metri

CFOs across the five systems studied agreed that success should be measured by whether patients can access care and manage what they owe, not just by collection rates, so that gains in one area don't quietly shift burden somewhere else.

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From the health systems in the study

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Build a strategy for the patients your current system misses

The health systems that identify underinsured patients early, and meet them with the right mix of coverage support, financial assistance, and payment options, are seeing real results. This report shows what that looks like in practice, across five systems of different sizes, markets, and EHR platforms.

"This is the moment patients are least equipped to handle, and it's exactly where most billing systems still fail them. Cedar exists to close that gap..."— Florian Otto, CEO and Co-Founder of Cedar

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Frequently Asked Questions

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.

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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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