For millions of Americans, having health insurance no longer guarantees that they can afford to see a doctor, fill a prescription or receive treatment when an emergency strikes.
In rural communities, that financial burden is colliding with another crisis: hospitals struggling to keep their doors open.
As insurance premiums and deductibles rise, some families are delaying medical care or abandoning coverage altogether. Meanwhile, rural hospitals are confronting growing financial losses, threatening access to essential services for entire communities.
The overlapping challenges were examined during a Sept. 18 national news briefing hosted by American Community Media in partnership with the Robert Wood Johnson Foundation. Healthcare experts described a system in which patients are paying more for coverage while hospitals face increasing difficulty financing the care they provide.
The high cost of being insured
Dr. Neale Mahoney, an economics professor at Stanford University, said the affordability problem extends well beyond Americans who lack health insurance.
Many people pay hundreds of dollars each month for coverage but still face substantial expenses when they need medical attention.
Over the past two decades, deductibles for employer-sponsored insurance have risen sharply, shifting more of the financial responsibility for healthcare onto patients.
That trend is reflected in national research.
According to KFF’s 2025 Employer Health Benefits Survey, annual premiums for employer-sponsored family coverage averaged $26,993, with workers contributing an average of $6,850 toward that cost.
Among workers with a general annual deductible for single coverage, the average deductible was $1,886. Employees at smaller companies generally faced higher deductibles than those working for larger employers.
For rural families with limited savings, a medical emergency can quickly become a financial crisis.
An emergency room visit, unexpected diagnosis or specialized treatment may generate substantial expenses even when a patient has insurance.
And in rural areas, those expenses can be compounded by transportation costs, lost wages and the need to travel considerable distances for care.
When insurance becomes unaffordable
For some Americans, the cost of maintaining health insurance is itself becoming an obstacle.
Dr. Amy Gordon Bono, a Tennessee primary care physician, shared the experience of a patient in her early 60s who worked as a caregiver but could not afford her own healthcare.
The woman had purchased coverage through the Affordable Care Act marketplace. However, rising costs eventually forced her to stop making payments.
Without insurance, she went without routine medical care and necessary medications.
She later suffered a stroke that Bono described as preventable.
The patient’s experience illustrates how losing affordable coverage can lead to devastating medical consequences.
It also creates financial problems for healthcare providers.
When uninsured patients require emergency treatment, hospitals may provide care without receiving adequate payment, adding to the financial strain on facilities already operating with limited resources.
For rural hospitals, where patient populations are smaller and operating costs remain high, those losses can be particularly difficult to absorb.
Affordable Care Act changes add pressure
Changes to federal healthcare subsidies are creating additional challenges for Americans who purchase their own insurance.
Enhanced premium tax credits that helped reduce the cost of Affordable Care Act marketplace coverage expired at the end of 2025.
A KFF analysis found that average monthly premium payments among marketplace consumers increased from $113 in 2025 to $178 in 2026, a 58% increase.
Some consumers responded by choosing plans with lower monthly premiums but higher deductibles.
As a result, the average deductible for marketplace coverage increased 37%, from $2,759 in 2025 to $3,786 in 2026.
Those changes are especially significant for self-employed Americans, including farmers, agricultural workers and small-business owners who may not have access to employer-sponsored insurance.
Dr. Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, said rural residents are particularly vulnerable because they rely more heavily on Medicaid and marketplace insurance than many urban populations.
When coverage becomes unaffordable, the consequences extend beyond individual households.
Hospitals may experience declining revenue, more uncompensated care and greater difficulty maintaining essential services.
Why private insurance isn’t saving rural hospitals
One of the briefing’s central concerns was the financial condition of rural hospitals.
According to a July 2026 analysis by the Center for Healthcare Quality and Payment Reform, 700 rural hospitals nationwide were at risk of closing, including 264 facing immediate financial risk.
Those classifications do not mean the hospitals are scheduled to close. They reflect financial conditions that could threaten their ability to continue operating.
While Medicaid and Medicare reimbursement rates are often cited as contributing factors, experts said payments from private insurers also play a significant role.
Bono pointed to research showing that rural hospitals can lose money treating privately insured patients when insurance payments fail to cover the actual cost of delivering services.
The Center’s analysis found that more than 40% of rural hospitals lose money on patient services.
The problem is especially difficult for small facilities that must maintain emergency departments, medical equipment and trained staff around the clock, even when relatively few patients require treatment.
Unlike larger hospitals, they cannot always spread those fixed expenses across thousands of patients.
When the financial losses become unsustainable, hospitals may reduce staffing, eliminate specialized services or close.
And when that happens, patients with Medicare, Medicaid and private insurance can all lose access to nearby healthcare.
Can federal funding solve the problem?
The federal Rural Health Transformation Program provides $50 billion over five years, from 2026 through 2030, to support improvements in rural healthcare delivery.
The program emphasizes initiatives such as technology, workforce development and new approaches to providing medical services.
However, Hempstead questioned whether those investments could adequately address the immediate financial challenges facing hospitals.
She noted that the program is temporary, while many of the underlying financial problems are ongoing.
The experts also discussed broader healthcare proposals, including reducing out-of-pocket expenses, strengthening insurance coverage and expanding public insurance options.
Mahoney argued that health insurance should provide meaningful financial protection when families need medical treatment, rather than leaving them exposed to overwhelming expenses.
A crisis affecting entire communities
Rural healthcare challenges extend far beyond the patients who cannot afford insurance.
When a community loses its hospital, residents may face longer drives for emergency treatment, fewer options for maternity care and greater difficulty managing chronic illnesses.
Local economies can also suffer as healthcare jobs disappear and families consider relocating to communities with better medical access.
Even hospitals that remain open may reduce services, forcing patients to travel elsewhere for specialized treatment.
The growing crisis raises a fundamental question about the American healthcare system: What does it mean to have insurance if the coverage is too expensive to use — or if the hospital a patient depends on can no longer afford to operate?
For rural America, the answer could determine not only whether families can afford to stay healthy, but whether their communities can continue to provide the care they need.
