When we talk about healthcare in America, we’re really talking about two interconnected problems: access and affordability. Public health policies are the primary tools—the levers, if you will—that determine whether you can get the care you need without facing financial ruin. Think of healthcare access as the physical ability to see a doctor or get a prescription, while affordability is the ability to pay for it. The two are inseparable.

The thesis is simple: Policy choices, made in state capitals and Washington D.C., directly create or eliminate the structural and financial barriers standing between you and good health.

In recent years, policy has been remarkably effective at one part of the equation. Thanks to existing legislative frameworks, the U.S. uninsured rate continued its decline, reaching a recent low of 7.6% in 2024.¹ That’s a major win. But the cost of that coverage, and the quality of the access it provides, remains a relentless challenge. National health spending keeps climbing, projected to hit nearly $5 trillion soon. So, while more people have cards in their wallets, the price of using those cards is still the real crisis.

The Role of Insurance Mandates and Subsidies in Affordability

The most direct way public policy influences your wallet is through the insurance market, primarily via the Affordable Care Act (ACA).

The ACA's mechanisms—specifically the premium tax credits (PTC) and cost-sharing reductions—are the engine of modern affordability. These subsidies don't just help low-income families; they now extend deep into the middle class, thanks to temporary improvements passed during the pandemic.

So what does this actually mean for your budget? A KFF analysis showed that those improved credits saved subsidized enrollees an average of $705 annually in 2024.⁵ Without those policy decisions, the average annual premium payment would have soared by more than 75%. That’s the difference between managing your bills and being financially crushed by them.

Then there’s Medicaid. The expansion of Medicaid to cover low-income adults has been monumental, adopted by 41 states. But this coverage is fragile. When the COVID-19 Public Health Emergency ended and states restarted eligibility checks (a process known as the "unwinding"), policy changes led to an estimated 8 million people dropping off the rolls in 2024. This dramatic shift shows how quickly policy changes—even administrative ones—can create sudden, massive gaps in coverage for the nation’s most vulnerable populations.

Regulatory Policies Controlling Healthcare Costs

Coverage is one thing, but if the price of the underlying service is astronomical, the insurance becomes worthless. This is why regulatory policies aimed at controlling baseline costs matter to affordability.

Take prescription drugs. For years, the federal government had its hands tied regarding drug price negotiation. The Inflation Reduction Act (IRA) finally gave Medicare some limited power to negotiate prices for certain high-cost drugs. This policy isn’t just about saving Medicare money; it creates a downward pressure on drug prices across the entire market, eventually benefiting everyone, including you.

Another important area is transparency and billing. Policies prohibiting surprise billing (when you receive unexpected charges from out-of-network providers used during an in-network procedure) are needed consumer protection tools. You shouldn’t need a lawyer to interpret your hospital bill, and these laws aim to prevent financial ambush.

We also see states stepping up. In 2024, state legislatures enacted nearly 100 bills targeting commercial health plan costs and coverage.⁴ These reforms addressed things like prior authorization—the bureaucratic process that delays or denies care—and making sure network adequacy. These policies are about making sure the insurance you bought actually delivers timely care without needless roadblocks.

Policies Addressing Structural Barriers Workforce and Infrastructure

Affordability means little if there’s no provider within a hundred miles. This is where public health infrastructure policies kick in, addressing the structural barriers to access.

Federal funding for Community Health Centers (CHCs) and Federally Qualified Health Centers (FQHCs) is foundational. These facilities operate on the front lines, providing complete primary care regardless of a patient’s ability to pay. They are policy solutions designed to fill gaps where the private market fails.

To make sure these centers have staff, policy must incentivize providers to work in underserved areas. This includes loan repayment and scholarship programs targeting physicians, nurses, and dentists willing to practice in designated Health Professional Shortage Areas. It’s a direct public investment aimed at improving the physical availability of care.

Perhaps the most transformative structural policy trend is the expansion of telehealth. During the pandemic, regulations were temporarily lifted, allowing doctors to treat patients remotely and receive proper reimbursement. Now, the battle is making those changes permanent. Expanded access under Medicare was scheduled to expire at the end of 2024, showing the constant policy threat to access.² Making telehealth reimbursement permanent is the digital equivalent of building a new clinic in a rural town—it dramatically expands access and, by increasing efficiency, helps manage costs.

The Looming Fiscal Cliff and the Path to True Affordability

Looking ahead to 2026, the primary challenge isn’t just expanding coverage; it’s making sure the system is fiscally sustainable while driving down the underlying cost of care.

The improved ACA subsidies are the first major hurdle. They are important for maintaining the current low uninsured rate, but they come with a hefty price tag. The Congressional Budget Office projects that permanently extending the improved premium tax credits would increase the federal deficit by nearly $350 billion over the next decade.³

That’s a massive policy decision hanging over the market.

Simultaneously, we must confront the soaring costs within public programs. The "unwinding" of Medicaid eligibility in 2024 led to an enrollment drop, yet total Medicaid spending still grew significantly. This resulted in a sharp increase in per-enrollee spending of 16.6% in a single year.² This divergence suggests that simply moving people onto public insurance doesn't solve the underlying issue of high healthcare costs.

Experts agree that while renewing the ACA subsidies is needed for maintaining coverage, the "real crisis is soaring health care costs."⁷ These costs are driven by factors outside the insurance mechanism: hospital and provider price growth, market consolidation through mergers, and the ever-increasing use of high-cost specialty drugs.

To achieve true affordability, policy must move beyond just subsidizing premiums and start regulating the core price structure of the system. This means adopting more aggressive policies around price negotiation, addressing anticompetitive hospital and physician practice mergers, and continuing the push for state-level reforms that limit prior authorization and make sure adequate provider networks.

The fight for affordable care isn’t just about whether you have insurance; it’s about making sure that the insurance you have actually works when you need it, without bankrupting you or the government. That requires smart policy, not just big spending.

Sources:

1. Coverage and Access to Care for the Nonelderly Population 2021-2024

https://aspe.hhs.gov/sites/default/files/documents/9a943f1b8f8d3872fc3d82b02d0df466/coverage-access-2021-2024.pdf

2. Despite Post-COVID Unwinding Medicaid Spending Increased by $58 Billion in 2024

https://paragoninstitute.org/paragon-pic/despite-post-covid-unwinding-medicaid-spending-increased-by-58-billion-in-2024/

3. ACA Marketplace Premium Payments Would More Than Double on Average Next Year If Improved Premium Tax Credits Expire

https://www.kff.org/affordable-care-act/aca-marketplace-premium-payments-would-more-than-double-on-average-next-year-if-improved-premium-tax-credits-expire/

4. Advancing Health Care Access and Affordability: Key Takeaways from the 2024 Legislative Session

https://www.ncsl.org/health/advancing-health-care-access-and-affordability-key-takeaways-from-the-2024-legislative-session

5. ACA Marketplace Premium Payments Would More Than Double on Average Next Year If Improved Premium Tax Credits Expire

https://www.kff.org/affordable-care-act/aca-marketplace-premium-payments-would-more-than-double-on-average-next-year-if-improved-premium-tax-credits-expire/

6. Policy Issues and Trends 2024

https://www.healthsystemtracker.org/brief/policy-issues-and-trends-2024/

7. Yale Expert: Renewing ACA Subsidies is Needed, But Real Crisis is Soaring Health Care Costs

https://ysph.yale.edu/news-article/yale-expert-renewing-aca-subsidies-is-needed-but-real-crisis-is-soaring-health-care-costs/

This article is for informational and educational purposes only. Readers are encouraged to consult qualified professionals and verify details with official sources before making decisions. This content does not constitute professional advice.