Part 2: Understanding US Healthcare Affordability: Increasing Plan Complexity Must be Met With Better Cost Estimate Data

The Rising Cost of Care

According to KFF's 2025 Health Tracking Poll, 37% of insured adults skipped or delayed care due to cost in the past year. Insurance should remove or at least lessen the cost barrier, but for more than a third of covered Americans, it doesn't.

Rising out-of-pocket costs explain part of this. Over the past five years, average deductibles for covered employees have climbed 17%, and 34% of covered workers now face deductibles of $2,000 or more. Premiums are projected to rise another 6-7% in 2026. These numbers have been increasing for years, and there are no signs of the trend changing. 

Another issue facing patients is understanding how much care will cost. In the first part of this series, we showed how patient costs vary dramatically by state. Deductibles ranged from $806 to $2,916. Out-of-pocket maximums ranged from $3,317 to $7,227. 

We examined how variability in deductibles, coinsurance rates, and out-of-pocket maximums create dramatically different financial experiences depending on a variety of factors.  When we aggregate the data at the state level, we see that a $10,000 medical procedure could translate to an estimated patient cost ranging from about $1,653 to $4,352, reflecting the combined impact of these benefit design differences and other local dynamics.

But the landscape isn't static year over year. Between 2024 and 2025, our eligibility data shows two factors that mean coverage is increasingly at odds with affordability and make understanding actual costs harder than ever before:

1. In general, patient burdens are rising. Average patient burden for a $10k procedure increased 1.8%, from $3,239 to $3,297 - despite regulatory changes that lowered out-of-pocket maximums.
2. Costs are moving asymmetrically. Some states saw patient burden drop 33.5%. Others saw it jump 18.9%. That's a 52.4 percentage point spread in how affordability changed year over year.

What Our Data Does (and Doesn't) Reveal

Nirvana processes millions of eligibility checks each year across all 50 states. That scale gives us visibility into how cost-sharing — deductibles, copays, and out-of-pocket maximums — varies by region, plan type, and payer. We can't pin that variation to any single factor. It emerges from a mix of state regulations, employer decisions, payer strategies, and local market dynamics. The result is that patients are often unsure what they owe until after care is delivered.

Our data reveals symptoms, not causes. Why one state's average deductible is three times another's involves regulatory history, market competition, and policy decisions that go beyond what eligibility data can show. Nirvana exists to rebuild trust in healthcare through real cost transparency, and we’ll keep surfacing where costs are moving whenever we’re able to.

Lower Limits Don't Mean Lower Bills

Regulatory changes between 2024 and 2025 lowered out-of-pocket maximums in many states, which in theory makes care more affordable. 

In our eligibility dataset, we see that average out-of-pocket maximums dropped 36.8%, from $7,788 to $4,926. Coinsurance rates decreased 6.2%, from 16.5% to 15.5%. Both reductions should have lowered what patients end up having to pay. However, deductibles jumped 8.4%, from $1,907 to $2,068 - offsetting those improvements. Overall, the average patient now pays 1.8% more in 2025 than they previously would have in 2024.

Healthcare Cost Year-Over-Year Changes (2024-2025)

Changes in key procedure cost drivers, based on weighted averages across commercial and government plans in each state.

Over this time period, employer health plans shifted away from PPOs and towards high deductible plans. PPO enrollment declined from 58% in 2010 to 46% in 2025. High-deductible health plans grew from 13% in 2010 to 33% in 2025. Traditional PPOs face sustainability challenges because they cannot control costs effectively. HDHPs offer 20-30% lower premiums but shift financial risk to patients through higher deductibles and narrower networks.

The lower monthly premiums in HDHPs mean higher upfront costs when care is needed. Thirty-four percent of covered workers now face deductibles of $2,000 or more. Average deductibles have climbed 17% over the past five years. 

These changes mean that knowing what a patient owes requires knowing what they've already spent. A patient with a $3,000 deductible could owe the full cost of care or just coinsurance (which varies by plan), depending on how much of that deductible they've met. This makes it difficult for practices to predict costs at the point of service (without reliable real-time eligibility verification) - and often leaves patients and practices in the dark about how much they’ll owe and need to collect, respectively.

Cost Change Variance by State

In the first part of this series, we looked at how current patient costs vary dramatically by state. Between 2024 and 2025, our dataset shows the change in costs over this period also differed significantly by state.

Some states saw patient burden drop substantially. Oklahoma's average patient cost for a $10,000 procedure fell 33.5%. Hawaii saw a 21.6% decrease. Wyoming dropped 13.7%. Other states moved in the opposite direction. South Dakota's patient burden jumped 18.9%. Rhode Island increased 16.8%. Mississippi rose 15.4%.

State-Level Patient Cost Burden Changes (2024-2025)

Cost to a patient for a $10k procedure without prior insurance usage. Based on averages across commercial and government plans in each state.

Behind the national average change - a 1.8% average increase in cost for a $10,000 procedure - is a 52.4 percentage point spread between the states that improved most and those that worsened most. A patient in Oklahoma saw costs drop by a third while a patient in South Dakota faced costs nearly 19% higher for the same treatment.

A large number of factors contribute to state-by-state cost profile variability, such as regulations, employer mix, and local market dynamics. These factors also appear to be moving at different speeds and in different directions. Overall, this makes healthcare cost prediction even more challenging than it was a year ago. 

Closing The Gap Between Coverage and Clarity 

The first article in this series showed how patient costs vary dramatically by state. This article demonstrates that, in the past year, patient costs have risen on average, and at the same time costs have significantly diverged between states.

Overall, coverage is getting less affordable. Average deductibles jumped 8.4% while out-of-pocket maximums dropped 36.8%. On balance, patients pay more upfront even as regulatory protections have lowered upper limits. The average patient now pays $58 more for a $10,000 procedure than they did a year ago.

Second, costs are getting even less predictable than before. On a state by state basis, costs have moved in significantly different directions, meaning the gap in patient responsibility (and the factors driving those burdens) between states is widening. Oklahoma patients saw costs drop 33.5% on average while South Dakota patients faced an 18.9% increase in a single year.

These trends exacerbate the challenges patients and providers face in understanding costs and achieving better health outcomes. Beyond general affordability, patients also need to know what they'll owe before committing to care. Providers need accurate cost information at the point of service, not weeks later after the claims process. Without that clarity, patients delay treatment and practices either avoid the cost conversation or surprise patients with bills they can't afford - and our country’s overall health suffers.

As health insurance complexity increases, there is more need than ever for accurate, real time, reliable information. Nirvana is working everyday towards our mission of restoring trust in the healthcare payment system.  If you or your organization is interested in learning more about partnering with Nirvana or using our Cost estimation API or administrative team application contact our team today. 

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