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Voice to Congress | |
Last Updated: 2026-07-25 15:42 UTC
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Color Rule: Red text = bad current value, bad trend, missing critical data, or unfavorable gap. Green text = favorable value or improving trend. Amber text = context-dependent, incomplete, pending, or source-method review needed. Neutral/gray text = descriptive value that is not inherently good or bad.
Evidence Table Types: Actual = a value published as-is by the cited source. Historical = a real data point shown for context only, not fully comparable to the row's main series (different question, methodology, or period). Projection = a future-year row -- this project's own target/glidepath math, an independently published forecast, or both; check the Source column for which applies. (This legend is a Healthcare-specific addition -- NDD's own data doesn't currently use a Historical row_type, so its real detail-page shell, if one is ever found, may not need this paragraph at all.)
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HC-COV-INS-001 Requirement: Congress shall enact, fund, and oversee national health coverage policies that increase the percentage of the U.S. population with health insurance from 91.8% in 2024 to at least 99.0% by 2036, with progress measured annually using the U.S. Census Bureau's American Community Survey. Legislative Key Phrases: Health insurance coverage expansion; Marketplace subsidy and premium assistance policy; Medicaid and CHIP eligibility and enrollment; individual health insurance market regulation. Feasibility Feasibility: A 99.0% coverage rate by 2036 is achievable in principle – ACS-measured coverage has moved by more than a full percentage point within a single year before (2013-2014, +2.8 points), and most OECD countries with insurance systems structurally comparable to the U.S. already sustain 99-100% coverage. It is not achievable on the current trajectory without a policy change: coverage is falling, not rising, and CMS's own projections show further erosion through at least 2028 before any recovery. Discussion: Coverage fell from 92.1% in 2023 to 91.8% in 2024, the first national ACS-measured decline since 2019. The headwind has strengthened since, though the exact scale depends on which measure is used. CMS's final report on the 2026 Open Enrollment Period shows Marketplace plan selections fell to 23.1 million, down from 2025's final 24.2 million – a decline of about 1.1 million (4.5%), the sharpest single-year drop since the ACA Marketplaces launched. A separate, larger effect shows up in effectuated enrollment (people who actually paid and kept coverage, not just selected a plan): CMS's Effectuated Enrollment: Early 2025 Snapshot reports total February 2025 effectuated enrollment of 23.4 million, of which 21.8 million (93%) received APTC subsidies. CMS has not yet published its February 2026 Effectuated Enrollment Snapshot; pending that release, KFF's analysis of Wakely Consulting Group data projects average 2026 effectuated enrollment could fall to roughly 16.5-17.5 million, down from a comparably-measured 22.3 million average in 2025. CMS also separately projects direct-purchase insurance enrollment (a broader category than just Marketplace plans) will decline by about 3.7 million in 2026 largely due to subsidy expiration; that figure is a projection, not an observed count, and covers a wider market than the Marketplace-specific numbers above. CMS's own National Health Expenditure projections (CMS Office of the Actuary, Health Affairs, June 2026) show the national insured share – measured on a different population base than the ACS series used above, so shown here for directional confirmation only, not blended into the same trend line – falling from 91.8% in 2024 to 90.8% in 2026, 90.4% by 2028, and 90.5% by 2034. What other countries do matters here: among OECD members, only four countries (Mexico, Costa Rica, Estonia, and the U.S. itself) report coverage below 95% on the OECD's core-services coverage measure; most OECD members sit at 99-100%, including mixed public-private systems like Switzerland (near 100% since 1996 reforms) and the Netherlands (above 99%) that are structurally closer to the U.S. system than fully tax-funded models like the UK's. Note the OECD measure (eligibility/coverage for a core service package) and the ACS measure (self-reported insurance status) are related but not identical, so this is a directional benchmark, not a one-to-one comparable series. A 99.0% target reflects that OECD norm, not an arbitrary round number, and is continued through 2036 to hold accountability for the full horizon rather than a single early checkpoint. Benefits If Met: Reaching 99.0% coverage would mean roughly 24 million more people covered relative to the 2024 baseline (91.8% of a total population of about 333 million), matching the typical OECD member's coverage level instead of remaining one of the four lowest-coverage countries in the OECD. If Not Met: Continuing the 2023-2024 pace of decline (about 0.3 points a year) would bring coverage to approximately 90% by 2030 and below 90% in 2031. CMS's own NHE baseline, reflecting current law including the expired enhanced subsidies, projects the insured share falling to 90.8% by 2026, 90.4% by 2028, and 90.5% by 2034 – well below both this target and where nearly every other OECD country already stands. |
HC-MET-COV-001: Insured rate Current Value: 91.8% (2024) Trend: -0.3 pp vs 2023 (Worsening) Metric Evidence:
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HC-COV-UNI-001 Requirement: Congress shall enact, fund, and oversee national health coverage policies that reduce the percentage of the U.S. population without health insurance from 8.2% in 2024 to no more than 1.0% by 2036, with progress measured annually using the U.S. Census Bureau's American Community Survey. Legislative Key Phrases: Health insurance coverage expansion; Marketplace subsidy and premium assistance policy; Medicaid and CHIP eligibility and enrollment; individual health insurance market regulation. Feasibility Feasibility: A 1.0% uninsured rate by 2036 is achievable in principle – the rate fell 2.8 points in a single year before (2013-2014) when ACA coverage provisions took effect – but not on the current trajectory without a policy change: the uninsured rate is currently rising, and CMS's own projections show it reaching roughly 9.5% by 2034, well above this target. Discussion: The uninsured rate fell 2.8 points in a single year (2013–2014) when the ACA's major coverage provisions took effect, showing the underlying policy lever can move this metric quickly. But the rate is currently moving the wrong way: up from 7.9% in 2023 to 8.2% in 2024, the first increase in the standard national ACS series since 2019. The headwind has strengthened since, though the exact scale depends on which measure is used. CMS's final report on the 2026 Open Enrollment Period shows Marketplace plan selections fell to 23.1 million, down from 2025's final 24.2 million – a decline of about 1.1 million (4.5%), the sharpest single-year drop since the ACA Marketplaces launched. A separate, larger effect shows up in effectuated enrollment (people who actually paid and kept coverage, not just selected a plan): CMS's Effectuated Enrollment: Early 2025 Snapshot reports total February 2025 effectuated enrollment of 23.4 million, of which 21.8 million (93%) received APTC subsidies. CMS has not yet published its February 2026 Effectuated Enrollment Snapshot; pending that release, KFF's analysis of Wakely Consulting Group data projects average 2026 effectuated enrollment could fall to roughly 16.5-17.5 million, down from a comparably-measured 22.3 million average in 2025. The enrollment decline coincided with the expiration of enhanced premium subsidies and the resulting higher premiums, federal program-integrity enforcement (CMS reports ending APTC payments or coverage for nearly 1.5 million people found ineligible or enrolled without authorization in 2025), and state-level policy changes; the relative contribution of each factor has not been definitively established. CMS separately projects direct-purchase insurance enrollment, a broader category, will fall by about 3.7 million in 2026, largely due to subsidy expiration; that is a projection, not an observed count. CMS's own National Health Expenditure projections (CMS Office of the Actuary, Health Affairs, June 2026) show the uninsured share reaching roughly 9.5% by 2034 (90.5% insured) – measured on a different population base than the ACS series used above, so shown here for directional confirmation only, not blended into the same trend line. That worsening baseline is the accountability problem this revision is meant to fix: the prior version of this requirement stopped at a single 2026 checkpoint, leaving nothing beyond it except CMS's own worsening projection to compare against, which reads as tacit acceptance that things get worse after 2026. Holding Congress accountable means the target has to keep improving for the full horizon, not just one good year. Among OECD members, only four (Mexico, Costa Rica, Estonia, the U.S.) report coverage below 95% on the OECD's core-services measure, meaning most peer countries run uninsured rates near zero; a 1.0% endpoint by 2036 reflects that norm, understanding the OECD and ACS measures are related but not identical. Benefits If Met: A decline to 1.0% would mean roughly 24 million fewer uninsured people at the 2024 population size (8.2% of a total population of about 333 million); the actual 2036 count will depend on population growth alongside the rate change, and would reverse CMS's own baseline trajectory of a rising uninsured rate through 2034 rather than merely slowing it. If Not Met: A simple continuation of the 2023-2024 increase – not a formal projection – would put the uninsured rate at approximately 10.0% by 2030 and 10.3% in 2031. CMS's own current-law baseline projects the uninsured share at roughly 9.5% by 2034, nearly ten times the proposed 2036 target. |
HC-MET-COV-002: Uninsured rate Current Value: 8.2% (2024) Trend: +0.3 pp vs 2023 (Worsening) Metric Evidence:
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HC-FIN-PCP-001 Requirement: Congress shall enact, fund, and oversee national health spending policies that hold U.S. health spending per capita at or below $18,863 by 2034, growing no faster than the Federal Reserve's 2.0% long-run PCE inflation target from the 2024 baseline of $15,474, with progress measured annually using CMS National Health Expenditure data. Legislative Key Phrases: Health care cost containment; provider and hospital payment policy; prescription drug pricing policy; national health expenditure oversight. Feasibility Feasibility: The $18,863-by-2034 ceiling is achievable only as a deliberate policy stretch, not a level CMS, OECD, or any external body has projected or endorsed: nominal spending grew 6.1% in 2024, more than triple the 2.0% ceiling, and CMS's own baseline projects $25,513 by 2034 – nearly $6,650 above this target. Discussion: Per-capita health spending grew 6.1% in 2024, from $14,580 to $15,474, using CMS's current-vintage NHE data (CMS's 2024 comprehensive benchmark revision retroactively revised the 2023 figure upward from an earlier-published $14,570; this row uses the current vintage throughout). The comparable measure is per-capita GDP growth, not aggregate GDP growth: GDP per capita grew 4.3% in 2024, so per-capita health spending outpaced per-capita GDP growth by 1.8 points. CMS's own National Health Expenditure projections (Fiore et al., Health Affairs, June 2026) put per-capita spending growth at an average 5.1% a year from 2025 through 2034, against 3.8% average GDP-per-capita growth over the same period, reaching $25,513 per person by 2034. An earlier draft of this requirement capped growth at a projected GDP rate; the current version instead ties the ceiling to the Federal Reserve's 2.0% long-run PCE inflation target. That is not the same as zero real healthcare-spending growth, though: the Fed's target tracks economy-wide consumer prices, while CMS separately projects its own healthcare-specific price index (the NHE deflator) to grow about 2.6% a year over 2025-2034. A nominal ceiling of 2.0% therefore implies roughly -0.6% annual real growth once deflated by healthcare-specific prices, not zero – a materially more demanding target than a "zero real growth" framing suggests, and one that would likely require declining real utilization or intensity of care, not merely flat real spending. Internationally, the U.S. spent an estimated $14,885 per person in 2024 on a purchasing-power-parity basis (OECD), against an OECD average of roughly $6,000 and $9,300-$9,963 for the next-highest spenders (Switzerland, Norway, Germany) – the U.S. was spending roughly 2.5 times the OECD average. PPP-adjusted international dollars and CMS's nominal U.S. dollars are not directly interchangeable units, so this comparison establishes relative scale, not a target level. $18,863 by 2034 remains a defensible high-ambition ceiling, but should be understood as a Voice to Congress stretch target informed by the Fed's inflation goal, not a level OECD, CMS, or any external body has itself projected or endorsed as achievable. A less aggressive, still internationally-informed alternative – a 3.0% nominal ceiling (roughly 2% general inflation plus 1% real growth) – would produce a $20,796 endpoint by 2034, still $4,717 below CMS's own baseline projection; that alternative was considered and not adopted – $18,863 by 2034 was Accepted by the user as the target. Benefits If Met: Staying at or below the inflation-only ceiling every year would mean healthcare stops consuming a growing share of real household and government budgets relative to the broader economy, directly easing the pressure captured in the Affordability metrics (HC-MET-AFF-001, HC-MET-AFF-002); it would also mean U.S. per-capita spending grows slower than CMS's own projected GDP-per-capita pace (3.8% average, 2025-34), a genuine reversal of the current pattern. If Not Met: Continuing CMS's own baseline trajectory pushes total national health spending to nearly $9.0 trillion and per-capita spending to $25,513 by 2034, with per-capita costs continuing to outpace both wage growth and general inflation by a wide margin. |
HC-MET-FIN-001: Health spending per capita Current Value: $15,474 (2024) Trend: +6.1% vs 2023 (Worsening) Metric Evidence:
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HC-FIN-GDP-001 Requirement: Congress shall enact, fund, and oversee national health spending policies that hold total U.S. health spending at or below 18.0% of GDP in every year through 2034, with progress measured annually using CMS National Health Expenditure data. Legislative Key Phrases: Health care cost containment; provider and hospital payment policy; prescription drug pricing policy; national health expenditure oversight. Feasibility Feasibility: Holding health spending at 18.0% of GDP every year requires reversing CMS's own baseline trajectory immediately, not catching up later: CMS projects the share climbing to 20.6% by 2034 absent a policy change. This is the flat "stabilize" reading of the requirement, not a level any external projection currently supports. Discussion: Health spending's share of GDP rose from 17.7% in 2023 to 18.0% in 2024. CMS's June 2026 baseline (assuming no policy change) projects that share reaching 20.6% by 2034, with spending averaging 5.4% annual growth against 4.1% average GDP growth over the period. Holding the line at 18.0% every year, not just by 2034, requires reversing that baseline trajectory immediately rather than catching up later. This is the flat "stabilize" reading of the original requirement language; a declining ceiling below 18.0% would be more ambitious and could be substituted once a specific pace is reviewed and agreed. Benefits If Met: Holding the line at 18.0% every year instead of climbing to 20.6% by 2034 would preserve roughly 2.6 percentage points of GDP for other public and private priorities, hundreds of billions of dollars annually at 2034's projected economic size. If Not Met: Continuing the current path reaches 20.6% of GDP by 2034 under CMS's own baseline, with national spending reaching nearly $9.0 trillion the same year. |
HC-MET-FIN-002: Health spending as % of GDP Current Value: 18.0% (2024) Trend: +0.3 pp vs 2023 (Worsening) Metric Evidence:
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HC-QLT-LEX-001 Requirement: Congress shall enact, fund, and oversee public health and health care policies that raise U.S. life expectancy at birth to at least 81.95 years by 2036, following this project's International Benchmark Convergence Policy (closing 50% of the gap to Japan's OECD-reported benchmark by year 10, 75% by year 20, 100% by year 30), with progress measured annually using CDC/NCHS final mortality data against the SSA's own actuarial baseline. Legislative Key Phrases: Public health policy; preventive care access; chronic disease prevention and management; environmental and social determinants of health policy. Feasibility Feasibility: Reaching 81.95 years by 2036 is achievable as a real intermediate milestone – life expectancy has recovered for three consecutive years, and the target requires closing only half the SSA-to-Japan gap, with full convergence deferred to 2056 – but it is more demanding than SSA's own passive baseline (79.8 by 2036), so it requires the recent recovery to continue and accelerate, not merely persist. Open item flagged for the next scheduled review: even hitting this target only narrows the absolute gap to Japan to about 4.2 years, less closure than the 50% framing implies. Discussion: Life expectancy has recovered for three consecutive years (77.5 in 2022, 78.4 in 2023, 79.0 in 2024) after the COVID-era decline to 76.4 in 2021. The SSA's own actuarial baseline (Actuarial Note No. 2026.2, June 2026) projects 79.8 by 2036 if nothing changes. OECD Health at a Glance 2025 identifies Switzerland, Japan, Spain, and Israel as leading a group of 27 OECD countries above 80 years in 2023; Japan's reported figure (84.1) was chosen as this policy's fixed benchmark because it is on the identical OECD basis as the U.S.'s own 78.4-year figure, a genuine apples-to-apples comparison, not because Japan is unambiguously the single highest performer among the four. This target applies a new policy: close 50% of the SSA-baseline-to-Japan gap by year 10 (2036), 75% by year 20 (2046), 100% by year 30 (2056), matching Japan's OECD-reported 2023 benchmark of 84.1 years by that final milestone. That gives 79.8 + 0.5 x (84.1-79.8) = 81.95 for 2036, 83.27 for 2046, and 84.10 for 2056. A straight line from the 2026 baseline (78.9) to 81.95 would require the U.S. to sustain roughly 3.4 times SSA's own baseline pace starting immediately, unrealistic given that policy changes take years to affect mortality data. The annual path below instead uses a quadratic ramp: each year's target equals SSA's baseline for that year plus an accelerating share of the total stretch (proportional to the square of elapsed time toward 2036), so early years track close to the passive baseline and the pace of improvement compounds over the decade. A floor was added so the target never falls below the most recent confirmed actual (79.0, 2024): the raw formula gives 78.90 for 2026, which would ask less of the system than it has already achieved; the floor raises that single year to 79.00. An alternative, more rigorous version of this policy exists: Japan's own population institute (IPSS) publishes annual sex-specific life-expectancy projections through 2070, which could replace the fixed 84.1 benchmark with a moving one specific to each milestone year. Combining IPSS's male and female projections into a unisex figure (using SSA's own birth-weighted combination method) gives approximately 86.14 (2036), 87.07 (2046), and 87.87 (2056), noticeably higher than the fixed benchmark used here. IPSS's near-term figures have historically run optimistic, though (its medium projection expected 2024 figures around 81.88/87.94 for men/women; Japan's subsequent official life tables reported 81.09/87.13), so a moving-benchmark version would need regular recalibration against Japan's actual releases. The fixed-benchmark version adopted here is simpler and more conservative; switching to the moving version remains a live option for a future policy revision. Benefits If Met: Reaching 81.95 by 2036 would close half the gap to Japan's OECD-reported 2023 benchmark, a real, achieved figure, not a hypothetical one, while still falling short of matching it outright until 2056 under this policy's 30-year full-convergence horizon. If Not Met: Falling back to a 2015-2017-style plateau, or another shock, would mean the U.S. fails to reach even SSA's own passive baseline (79.8 by 2036), let alone half the gap to a country whose latest OECD-reported life expectancy benchmark is 84.1 years. |
HC-MET-QLT-001: Life expectancy at birth Current Value: 79.0 years (2024, final, record high) Trend: +0.6 yr vs 2023 (Improving) Metric Evidence:
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HC-QLT-AVM-001 Requirement: Congress shall enact, fund, and oversee public health and health care policies that reduce U.S. preventable mortality from 217 per 100,000 (2022 OECD-verified baseline) to no more than 145 by 2036, and treatable mortality from 95 to no more than 77 by 2036 – both matching the current OECD average – with progress measured annually using OECD Health Statistics under the OECD/Eurostat avoidable-mortality definitions. Legislative Key Phrases: Public health policy; preventive care access; chronic disease prevention and management; primary and specialty care access. Feasibility Feasibility: The 145/77 target is achievable as a real but moderate benchmark: it matches the current OECD average, not the leading countries' considerably lower rates, so it doesn't require top-tier performance. The most recent U.S. data (2022) already improved from the pandemic-affected 2021 reading, though OECD hasn't yet published 2023-2025 U.S. observations to confirm the improvement has continued. Discussion: U.S. preventable mortality (217 per 100,000, 2022) runs about 50% above the OECD average (145), while treatable mortality (95) runs about 23% above the OECD average (77). The prevention-side gap is proportionally larger, pointing toward primary care access and public health investment as the higher-leverage fix. Three real OECD data points are available for this metric – 2013 (178/93), 2021 (238/98), and 2022 (217/95) – but they span different OECD report editions, and OECD does not yet publish a U.S. observation for 2023-2025 for this indicator, since mortality-cause data requires more processing lag than spending or coverage data. The recent trend is mixed depending on the comparison window: preventable mortality improved by 21 per 100,000 and treatable mortality improved by 3 from 2021 to 2022, but 2021 was a COVID-affected year; compared with the pre-pandemic 2013 baseline, 2022 was 39 points worse for preventable mortality and 2 points worse for treatable mortality. Given that mixed and thin history, a trend-fit Derived Projection isn't defensible; what remains possible is a straight-line glidepath from the current 2022 baseline to the OECD average itself, used here as the target endpoint since it's a real, external, defensible benchmark. Because no OECD actual exists after 2022, the glidepath treats the 2022 baseline as the administrative starting point and begins its first required step in 2026 – 11 equal annual steps, rather than a calendar-year interpolation from 2022, since retroactively treating 2023-2025 as policy-implementation years wouldn't be fair to a requirement adopted in 2026. This endpoint is a real but moderate benchmark, not a stretch to top-country performance: OECD's best performers post considerably lower rates still (preventable mortality below 85 in Luxembourg, Switzerland, and Israel; treatable mortality at 45 or lower in Switzerland, Luxembourg, and Korea), so reaching 145/77 would close the gap with the OECD average without matching the leading countries. Benefits If Met: Reaching 145/77 by 2036 would mean the U.S. reaches the current OECD average on both preventable and treatable mortality – substantially narrowing, but not eliminating, the gap with the highest-performing countries, which post considerably lower rates on both measures. If Not Met: The gap persists, and the U.S. continues recording avoidable deaths from both preventable and treatable causes at rates well above the OECD average, let alone the best-performing peer countries. |
HC-MET-QLT-002: Avoidable mortality (preventable & treatable) Current Value: 217 / 95 per 100,000 (2022) Trend: -21 / -3 vs 2021 (Improved vs. pandemic-era 2021, still worse than 2013) Metric Evidence:
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HC-AFF-MDR-001 Requirement: Congress shall enact, fund, and oversee medical debt protection policies that reduce the national medical debt incidence rate from the KFF/SIPP baseline of 6.0% of adults owing over $1,000 (2021, the latest published threshold-matched estimate) to 2% by 2036, with the data vintage of the SIPP wave in use disclosed in every public report. Legislative Key Phrases: Medical debt protection; consumer financial protection in health care; hospital billing and collections practices; charity care policy. Feasibility Feasibility: The 2% endpoint is an ambitious two-thirds reduction from the only available data point (6.0%, 2021) – not a level projected or endorsed by Census, KFF, CBO, or CMS. There's no newer data at this exact threshold to confirm whether the current trajectory supports or undercuts that ambition; achievability rests on a Voice to Congress judgment call, not external validation. Discussion: The 2% endpoint represents a proposed two-thirds reduction from the latest published threshold-matched baseline (6.0%, 2021 SIPP) – an ambitious Voice to Congress target, not a level projected or endorsed by Census, KFF, CBO, CMS, or another external authority. Newer SIPP waves exist – 2023 SIPP (covering 2022), 2024 SIPP (covering 2023), and the 2025 SIPP (covering 2024, released July 15, 2026, the most current wave available) – but Census does not publish the exact adults-owing-more-than-$1,000 percentage in its standard tables; KFF's specific measure must be recomputed from public-use microdata with person weights, and that recomputation has not yet been performed for any of the newer waves. There's also a variable break to account for whenever that recomputation happens: SIPP's amount variables were redesigned starting with the 2024 SIPP (the revised combined measure is TDEBT_MD; the basic indicator EDEBT_MED remains available), so any future recomputation needs to be version-aware. In plain terms: there is exactly one real data point for this metric at its actual threshold ($1,000+, adults) – 6.0% in 2021. Nothing newer at this specific threshold has been published or computed; the current value stays at 6.0% (2021) until that changes. A genuine historical-depth limit also applies: SIPP did not ask a medical debt question at all before its 2018 survey wave (covering 2017), so no 2001/2006/2011/2016 data points exist to find at any threshold. Census separately tracks a broader household-level "any medical debt" measure with a longer annual history (19% of households in 2017, trending down to roughly 14-16% by the early-to-mid 2020s) – a different metric, different population, and different threshold from the one this requirement targets, so it isn't used as evidence here. No external body publishes an annual national projection through 2036 for the adult $1,000+ threshold measure specifically; two related modeling sources exist (a longitudinal microsimulation called LHIEM, and a JAMA Health Forum scenario estimating $7.6 billion in additional medical debt by 2034 under a specific Medicaid-policy change) but neither supplies a ready-made incidence series for this exact metric, so the Value column stays blank for every Projection year rather than being filled with an approximation. Benefits If Met: A decline to 2% would mean roughly a third as many adults carrying significant ($1,000+) medical debt as today – at the 2021 adult population size, a reduction from about 14 million to roughly 4.7 million, or about 9.3 million fewer affected adults. If Not Met: Medical debt remains a major source of financial hardship. KFF's latest published SIPP-based estimate indicates Americans owed at least $200 billion in medical debt at the end of 2023; an earlier threshold-focused KFF analysis estimated at least $220 billion at the end of 2021. The two estimates aren't directly comparable year-over-year – aggregate survey debt totals are sensitive to a small number of very high-debt respondents. |
HC-MET-AFF-001: Medical debt incidence Current Value: 6.0% of adults, $1,000+ threshold (2021) Trend: Not yet established (Only one data point exists at this threshold) Metric Evidence:
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HC-AFF-FPR-001 Requirement: Congress shall enact, fund, and oversee health care affordability policies that reduce the percent of adults reporting delayed or skipped medical care due to cost from the Federal Reserve SHED 2025 baseline of 26% to 20% by 2036, with progress measured annually using the Federal Reserve's Survey of Household Economics and Decisionmaking. Legislative Key Phrases: Health care affordability; cost-sharing policy (deductibles and copayments); Marketplace subsidy and premium assistance policy. Feasibility Feasibility: The 20%-by-2036 target is achievable: a straight-line path over the full 11-year horizon (roughly 0.55 points/year) is gentler than the largest historical single-year move on record, and while real progress, it still leaves a large share of adults delaying or skipping care for cost reasons. The low-confidence regression stays out of the evidence table per the prior decision; the Target doesn't depend on it. Discussion: This metric has a longer, richer history than earlier drafts of this row used. Gallup tracked a similar (but not identical) question annually from 2001, showing 19% in 2001 and a jump to a roughly 30% plateau that held from 2006 through the late 2010s – useful historical context on scale, but not directly comparable to the Federal Reserve series that replaced it, since the two organizations ask about different reference periods and care categories. The Federal Reserve's own SHED series runs 2013-2025: 32% (2013), 31% (2014), 24% (2018), 25% (2019), 23% (2020), 24% (2021), 28% (2022), 27% (2023), 28% (2024), and 26% (2025). A SHED-comparable figure exists for 2016 and 2017 too, but the Federal Reserve's own documentation flags a question-wording change around that period that may make those two years non-comparable to the rest of the series, so they're excluded from the trend and regression here rather than included with uncertain footing. Across the 10 confirmed years, a linear regression is weak but usable (R-squared approximately 0.24, slope approximately -0.37 points/year) – weak because the series is genuinely noisy (a 2013-2014 high, a 2018-2021 trough, a sharp 2022 spike, gradual improvement since), not because too little data exists. That regression was initially shown as the evidence-table Value column for 2026-2036, but was removed on review: at R-squared 0.24, presenting it as a projected Value implied more confidence than a weak regression on a noisy series actually supports, even with a low-confidence label attached. The 2026-2036 rows now show Target only, consistent with how most other Target Pending rows on this page present a policy-chosen glidepath without an accompanying statistical projection. The target path changes with this revision: the original draft paired a 20% target with 2026, a single-year 6-point jump the data doesn't support (the largest year-over-year move on record is 4 points); a subsequent revision reached 20% by 2034 in roughly 0.75-point annual steps, then held flat as a ceiling through 2036. This version instead spreads the same 6-point improvement across the full 11-year horizon, reaching 20% by 2036 in roughly 0.55-point annual steps – gentler than the largest historical single-year move, with no flat-ceiling period needed since the endpoint now aligns with the horizon itself. Note the 2025 level (26%) is still above the 2021 low of 24%, so the recent improvement is a partial recovery, not a new record, and reaching 20% by 2036 – while real progress – still leaves roughly 1 in 5 adults delaying or skipping care because of cost. Benefits If Met: Reaching 20% by 2036 would represent the lowest cost-related care avoidance recorded since the Federal Reserve began this survey series in 2013 – real progress, though still meaning roughly 1 in 5 adults delay or skip care because of cost. If Not Met: Stalling above 24–26% keeps roughly 1 in 4 adults skipping needed medical care because of cost every year, in line with the regression's own low-confidence projection, which shows only gradual improvement absent a specific policy driver. |
HC-MET-AFF-002: Delayed or skipped care due to cost Current Value: 26% (2025) Trend: -2 pp vs 2024 (Improving, but still above the 2021 low) Metric Evidence:
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HC-ACC-PCP-001 Requirement: Congress shall enact, fund, and oversee primary care workforce policies that raise the national primary care Percent of Need Met to 70% by 2036, from the December 2025 baseline of 48.2%, including directing HRSA to incorporate nurse practitioner and physician assistant capacity into the underlying HPSA shortage-designation formula, with progress measured using HRSA's quarterly HPSA designation data. Legislative Key Phrases: Primary care workforce policy; graduate medical education funding; health professional shortage area programs; rural and underserved-area provider incentives. Feasibility Feasibility: Achievable as a moderately aggressive target, but only when paired with both policy and workforce growth: under HRSA's current physician-only formula, workforce growth alone supports closing to roughly 55-58% by 2036, not 70%. The additional 12-15 points depends on Congress also directing HRSA to count nurse practitioner and physician assistant capacity toward HPSA designation removal – combined primary care clinician density (106 per 100,000) already sits close to the international benchmark range (80-120 per 100,000), so pairing that formula change with continued workforce growth is what gets this target within reach by 2036. Discussion: Closing the current HPSA-designation gap requires 15,604 additional primary care physicians nationally (December 2025 baseline), and the most recently published quarter shows the gap widening, not narrowing: Percent of Need Met slipped to 47.74% (from 48.18%) and physicians needed rose to 17,306 (from 15,604) by March 31, 2026. There is no historical track record of improvement to extrapolate from – both real data points move the wrong way – so this target rests on supply-side analysis, not a trend fit. AAMC's most recent workforce projections put net new primary care physicians entering practice at roughly 6,000/year nationally, after subtracting hospitalist and non-primary-care diversion, against a workforce HRSA's own Health Workforce Simulation Model expects to keep losing ground to demand, not gaining on it, absent a specific new policy intervention. Each percentage point of Percent of Need Met costs roughly 300 additional physicians specifically practicing in designated shortage areas, not physicians anywhere in the country – most new primary care physicians do not locate in underserved areas, which is the maldistribution problem this metric exists to measure. Under the physician-only formula and current supply trends, a defensible 2036 endpoint is closer to 55-58%, not 70%. Benefits If Met: Reaching 70% need met by 2036 would mean most of the current gap is closed, provided Congress also acts on the NP/PA formula change this target assumes; HRSA's own broader workforce model still projects a 70,610 FTE shortfall by 2038 on a different, larger measure, so this would not fully close that broader gap, and full designation resolution would remain unfinished business beyond 2036. If Not Met: Over 92 million people (as of the December 2025 baseline) continue living in areas where under half the primary care capacity needed is actually available, and the trend since is not encouraging: the gap widened further by March 2026. Falling short of 70% is especially likely if Congress funds workforce growth without also directing the NP/PA formula change – the physician-only path alone supports only about 55-58% by 2036. |
HC-MET-ACC-001: Primary care shortage (Percent of Need Met) Current Value: 47.74% (latest published: Mar. 31, 2026) Trend: -0.44 pp vs Dec. 2025 baseline (Worsening) Metric Evidence:
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HC-MNT-MHR-001 Requirement: Congress shall enact, fund, and oversee behavioral health workforce policies that raise the national mental-health HPSA Percent of Need Met to 47% by 2036, growing by at least 2 percentage points annually from a 2026 baseline of 27%, with progress measured using HRSA's quarterly HPSA designation data. Legislative Key Phrases: Behavioral health workforce policy; graduate medical education funding (psychiatry and behavioral health); mental health parity enforcement; rural and underserved-area provider incentives. Feasibility Feasibility: A 2-point-per-year pace is moderately aggressive but defensible: it requires roughly 190 additional practitioners nationally per year (about 1,900 cumulative by 2036, close to a quarter of the current 6,800-practitioner gap) – a real draw on the broader core-mental-health-provider pipeline (psychologists, clinical social workers, marriage and family therapists), even though the psychiatrist-specific pipeline alone (roughly 1,500-1,900 new residency graduates a year nationally, against a workforce still net-contracting through the late 2020s per multiple independent projections) could not support this pace by itself. Discussion: This measures a specific HRSA designation – the Mental Health HPSA – not the full behavioral health workforce (a broader category that also covers substance-use services and a wider set of providers). Mental-health HPSA shortages are more severe than primary care's (27.3% vs. 48.2% need met, both December 2025). HRSA now publishes this data quarterly; the most recent published quarter, as of March 31, 2026, shows 26.78% need met (6,959 designations, 148,559,886 population, 7,393 practitioners needed) – worse than December 2025 on every measure, after having improved from 26.4% (December 2024) to 27.3% (December 2025) the year before. The trend isn't a clean line in either direction: it improved through 2025, then slipped again in early 2026, and there's no historical track record of sustained improvement to extrapolate a pace from. Benefits If Met: Reaching 47% by 2036 would mean the mental-health HPSA gap has been meaningfully narrowed, not just held from getting worse – roughly a quarter of the current practitioner shortfall closed, concentrated in the areas of highest need, though full designation resolution would remain a longer-term goal beyond 2036. If Not Met: Over 137 million people (as of the December 2025 baseline) continue living in a designated mental-health shortage area, and the most recent data available shows that gap widening rather than closing; falling short of even this moderately aggressive target would mean the practitioner pipeline isn't keeping pace with even a partial closing of the gap. |
HC-MET-ACC-002: Mental-health HPSA provider capacity – Percent of Need Met Current Value: 27.29% baseline (Dec. 31, 2025). Latest published: 26.78% (Mar. 31, 2026) Trend: -0.51 pp vs Dec. 2025 baseline (Worsening in the latest snapshot, after improving through 2024-2025) Metric Evidence:
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HC-QLT-PHO-001 Requirement: Congress shall enact, fund, and oversee preventive and chronic-disease-management policies that reduce U.S. preventable hospital admissions for ambulatory care-sensitive conditions (AHRQ PQI-90) among the general adult population from the 2017 baseline of 1,328.4 per 100,000 to 1,062.7 (a 20% reduction) by 2036, with progress measured annually using AHRQ's Healthcare Cost and Utilization Project (HCUP). See Row 20 (HC-QLT-PHM-001) for the companion Medicare fee-for-service beneficiary requirement. Legislative Key Phrases: Chronic disease prevention and management; primary care access; care coordination and case management policy. Feasibility Feasibility: Only one data point under the current PQI-90 definition exists (2017), so no trend fit is possible – the 20% endpoint is a policy choice, not a data-fitted number. It's informed by real precedent, though: AHRQ's own Statistical Brief #195 documented an 18.5% decline in just 7 years (2005-2012) under an earlier, larger version of this composite. Spreading a comparable-magnitude reduction across the full 19-year horizon to 2036 is a conservative ask relative to that historical pace, not an aggressive one. No confirmed national figure exists between 2017 and today despite a dedicated search pass, so the current trajectory is genuinely unknown. Discussion: This row returns to AHRQ's Prevention Quality Indicator (PQI-90), reversing the OECD switch made earlier this year, and splits the Medicare fee-for-service population out to its own row (20) rather than blending it in. The reasoning for the OECD switch at the time was that classic AHRQ PQI-90 data was fragmented with no clean current national figure; further research found that's only half true – HCUP's all-payer data does support a genuine multi-year trend, it just isn't one continuous series. Three different PQI software vintages appear across this row's history, each with a documented reason for the level differences between them, not just an unexplained gap: 2001 and 2009 (from a CDC/AHRQ report on 2001-2009) used a modified version 4.2 of the PQI software, age-sex adjusted to the 2000 U.S. standard population, over an 8-condition scope that still included angina without procedure and dehydration as full components. Interpolating those two points predicts roughly 1,515 for 2005 – a full 28% below Statistical Brief #195's actual confirmed 2005 figure (1,941), confirming the two series aren't on the same scale. For that reason, 2001 and 2009 are shown as Historical context only, not blended into the tracked trend or the target math. Statistical Brief #195 (2005-2012) used PQI software version 4.4 and the 2010 standard population, a single consistent methodology across all six of its points, and is this row's primary trend evidence: 1,941 (2005) falling to 1,582 (2012), an 18.5% decline. Statistical Brief #259 (2017) used the current PQI software (version 2019.01), which retired the dehydration and angina-without-procedure components from the composite in 2016 – part of why its value (1,328.4) sits well below Statistical Brief #195's last point (1,582, 2012) is this narrower definition, not necessarily faster real progress. That 2017 figure is nonetheless the right baseline for this row's target, since it's the definition future actuals will be measured against. A dedicated search for bridging data between 2013 and 2016, and for anything after 2017, found nothing – AHRQ's Statistical Brief series has a real gap there, confirmed by two separate search passes, not an unsearched one. Benefits If Met: Reaching 1,062.7 per 100,000 by 2036 would represent a real, historically-grounded continuation of two decades of progress and meaningful savings in avoidable hospital costs. If Not Met: Progress for the general adult population stalls or reverses, continuing to cost billions in avoidable hospital spending and forgone quality of life that this platform doesn't otherwise measure. |
HC-MET-QLT-003: Preventable hospitalizations, general adult population (AHRQ PQI-90) Current Value: 1,328.4 per 100,000 adults 18+ (2017, current PQI-90 definition) – the most recent confirmed figure; no national data point has been found for any year since Trend: Historically improving under earlier composite versions (1,941 in 2005 to 1,582 in 2012, an 18.5% decline), but no confirmed data exists to establish the current-definition trajectory past 2017 Metric Evidence:
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HC-MAT-MMR-001 Requirement: Congress shall enact, fund, and oversee maternal health policies that reduce the U.S. maternal mortality rate from the 2024 final baseline of 17.9 deaths per 100,000 live births to 10.0 by 2036, matching a common peer-country benchmark, and shall reduce the racial disparity ratio between Black non-Hispanic and White non-Hispanic maternal mortality rates from the 2024 baseline of 3.2 to 2.0 by 2036. Legislative Key Phrases: Maternal health policy; postpartum coverage policy; obstetric and maternal care access; maternal health equity reporting. Feasibility Feasibility: The 10.0-by-2036 national-rate endpoint is achievable as a round, defensible benchmark inside the range many OECD countries report, but the trend evidence behind it is thin: only 3 real data points exist, too few for a reliable regression (an attempted fit produced an impossible negative rate by 2034). The companion disparity-ratio target (3.2 to 2.0 by 2036) is more aspirational than feasibility-grounded: the ratio has held close to 3.2 for roughly two decades in published surveillance research, not just this row's 3-year window, and even jurisdictions running active reduction initiatives report the disparity currently widening, not narrowing. This target reflects an equity-priority judgment, not a precedent-backed pace. Discussion: The rate has fallen for two consecutive years (22.3 in 2022, 18.6 in 2023, 17.9 in 2024), though CDC notes the 2023-to-2024 change was not statistically significant. The disparity is the more actionable finding: Black non-Hispanic women die at 3.2 times the rate of White non-Hispanic women (44.8 vs. 14.2 per 100,000 in 2024), a gap that has persisted across all three years. A trend fit was tried and rejected: 3 points is enough to compute a line (R-squared 0.87, deceptively strong-looking), but extrapolating it forward predicts a negative mortality rate by 2034, which is impossible, and CDC's own "not statistically significant" caveat on the latest year-over-year change means the apparent steep decline may partly be noise. Three points is not enough data for a reliable linear-fit Projection the way HC-MET-QLT-001 got one with 10. What's proposed instead is a straight-line glidepath from the 2024 baseline to 10.0 per 100,000 by 2036, a round number inside the range of "under 10 per 100,000" that many OECD countries report. Benefits If Met: Reaching 10.0 by 2036 would represent hundreds of prevented maternal deaths annually; closing the disparity ratio to 2.0 would mean a meaningfully larger share of that improvement reaches Black mothers specifically, not just the national average. If Not Met: The U.S. continues recording maternal mortality at multiples of peer-country rates, with Black women bearing a disproportionate share of that burden – a burden that national-rate progress alone, without the disparity ratio narrowing specifically, would leave largely unchanged. |
HC-MET-MAT-001: Maternal mortality rate Current Value: 17.9 per 100,000 (2024, final) Trend: -0.7 vs 2023 (not statistically significant) (Improving) Metric Evidence:
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HC-FWA-IPR-001 Requirement: Congress shall enact, fund, and oversee program-integrity policies that hold improper payment rates across Medicare Fee-for-Service, Medicare Part C, Medicare Part D, Medicaid, CHIP, and ACA Advance Premium Tax Credits at or below their FY2024 levels in every fiscal year beginning FY2026, with progress measured annually using CMS's Comprehensive Error Rate Testing program and the HHS Agency Financial Report. All public reporting of this metric shall explicitly state that improper payment measurement is not a fraud measure. Legislative Key Phrases: Program integrity oversight; Medicare and Medicaid payment accuracy; federal health program administration and auditing. Feasibility Feasibility: The target is achievable in the sense that it only asks each program to return to, and hold at, a level already reached as recently as FY2024, not a stretch beyond recent history. Applying it every year starting FY2026, not just at one FY2028 finish line, gives the report card real annual checkpoints instead of a single distant deadline – and shows plainly that 4 of 6 programs are already failing this ceiling on FY2025's actual data, exactly the kind of backslide this near-term ceiling exists to catch early. Discussion: The Medicare FFS improper-payment rate has remained below the statutory 10% compliance threshold for nine consecutive years, and improved further in FY2025 (7.66% to 6.55%), showing the underlying measurement-and-correction process works. Its longer history (the only one of the six programs with a comparable trend back to 2001) shows this is a genuinely volatile metric, not a steadily-improving one: 6.3% (2001) fell to 4.4% (2005), rose to 8.6% (2011), peaked at 12.7% in 2014 (the actual high point of the entire series, not 2016 as an earlier draft of this page stated), fell to 11.0% (2016), then continued down toward today's 6.55%. A linear fit across all 7 verified Medicare FFS points, now including 2014, was tried: it produces an even weaker model than before (R-squared 0.07, down from 0.12 with 6 points) that projects the rate rising toward 9.8% by 2034, essentially ignoring the recent improvement and getting dominated by the mid-series swings instead. That result is a clear signal not to extrapolate a decade-long glidepath on a metric this volatile, unlike HC-MET-QLT-001's much cleaner trend. The other 5 programs have only 2 data points each (FY2024, FY2025), also too few for a meaningful fit, and FY2025 saw 4 of the 6 programs move the wrong direction. Given the volatility, the proposed target is deliberately near-term and conservative rather than an ambitious decade-long stretch: each program holds at or below its FY2024 level every fiscal year starting FY2026, a flat ceiling against further deterioration rather than a bet on a specific long-run trajectory or a false-precision interpolation between two points on a metric that has already reversed direction three times in 25 years. As of FY2025's actual data, 2 of 6 programs (Medicare FFS, ACA APTC) already meet this ceiling and 4 (Part C, Part D, Medicaid, CHIP) do not, giving the report card a real, gradable baseline from the first year this requirement takes effect rather than nothing to check until FY2028. The ACA APTC figure applies specifically to the federally-facilitated exchange and does not necessarily represent every state-based marketplace. Benefits If Met: All six programs holding at or below their FY2024 level every year from FY2026 onward would reverse the FY2025 backslide seen in four of the six programs and demonstrate the volatility can be managed continuously, not just checked once at a distant deadline. If Not Met: Continuing FY2025's mixed pattern leaves Medicaid ($37.39B) and Medicare Part C ($23.67B) as the largest dollar sources of improper payment, both trending worse, and Medicare FFS's own volatile 25-year history offers no guarantee that today's improvement continues rather than reverses as it has three times before (after 2005, after 2011, and after the 2014 peak). With annual checkpoints starting FY2026, a renewed slide would show up immediately rather than waiting until FY2028 to be visible. |
HC-MET-ADM-002: Improper payment rate (by program) Current Value: Mixed across 6 programs (FY2025) Trend: Mixed by program (4 of 6 worsening) Metric Evidence:
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HC-AFF-PMB-001 Requirement: Congress shall enact, fund, and oversee health care affordability policies that reduce the share of adults reporting problems paying family medical bills in the past 12 months from the 2025 baseline of 17% to 8% by 2036, with progress measured using the Urban Institute's Health Reform Monitoring Survey / Well-Being and Basic Needs Survey. Legislative Key Phrases: Medical debt protection; consumer financial protection in health care; hospital billing and collections practices. Feasibility Feasibility: Achievability is conditional: the 2021 low (12.2%) shows an 8%-adjacent level is reachable, but the trend since isn't a simple line – it's a U-shape that rose back to roughly 17% by 2025, erasing the pandemic-era improvement entirely. The target treats what was achieved once, temporarily, as evidence of what's possible with the right policy conditions, not as a level currently being approached. Discussion: This metric was added after reviewing whether "medical debt incidence" (HC-MET-AFF-001) is the clearest affordability indicator for public communication. Independent research (verified against the primary sources, not taken on faith from an AI-generated summary) confirmed that Urban Institute, funded by the Robert Wood Johnson Foundation, has run a consistent annual survey since 2013 asking this exact question, giving it a real multi-year trend that medical debt incidence's two SIPP data points can't match. The trend, however, is not simple: problems paying bills fell sharply during the pandemic (17.0% in March 2019 to 12.2% in April 2021, as federal relief and coverage protections took effect) and has since risen back to roughly 17% in 2025, erasing the pandemic-era improvement entirely. A linear fit across these 3 points was tried and rejected (R-squared 0.04, essentially no explanatory power) since a U-shaped recovery-then-relapse pattern can't be captured by a straight line. The proposed target treats 2021's low (12.2%) as evidence that a level near 8% is achievable with the right policy conditions, even though the current trajectory is moving the wrong way. This metric complements rather than duplicates two existing ones: HC-MET-AFF-001 (medical debt already accrued) and HC-MET-AFF-002 (care skipped due to cost); this one captures the acute experience of struggling to pay a bill, a distinct moment in the same financial-strain pathway. Benefits If Met: Reaching 8% by 2036 would mean returning below the pandemic-era low of 12.2% and sustaining it, rather than the current pattern of falling only when extraordinary federal relief is in place. If Not Met: The 2019-2025 round trip (17.0% to 12.2% back to roughly 17%) shows this metric can improve quickly under the right conditions and can just as quickly give that progress back once they end, meaning underlying affordability was never actually fixed, only temporarily masked. |
HC-MET-AFF-003: Problems paying family medical bills Current Value: ~17% (2025) Trend: Reversed pandemic-era improvement (Worsening since 2021) Metric Evidence:
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HC-ADM-OVH-001 Requirement: Congress shall enact, fund, and oversee administrative simplification and insurance oversight policies that hold the combined share of national health expenditures devoted to government program administration and the net cost of private health insurance at or below its 2024 level of 7.0% through 2036. Legislative Key Phrases: Administrative simplification; health insurance regulatory oversight; health care price and cost transparency. Feasibility Feasibility: Achievable only as a genuine corrective target, not a continuation of recent progress: CMS's own category-level NHE data (Health Affairs, June 2025, Exhibit 4) now confirms the combined ratio is projected to rise from 7.36% (2024) to 8.10% (2027) to 8.39% (2033) under current law – the opposite direction from the 2020-2024 decline the Actual data above shows. Holding at 7.0% through 2036 means reversing a confirmed unfavorable trend, not maintaining a favorable one. Discussion: This combined category – CMS's own "Government Administration and Net Cost of Health Insurance" line in the National Health Expenditure Accounts – has been part of the NHEA's standard structure since 1960, so a long historical series exists. But the series is not a steady trend: it rose from 5.9% of NHE in 2000 to a peak of 8.4% in 2020 (likely reflecting pandemic-era insurer administrative costs and public-program surges), then declined for four consecutive years to 7.0% in 2024. A linear regression across the full 2000-2024 span is a poor fit (R-squared 0.33) precisely because of this hump shape, so extrapolating a single trend line across the peak would be misleading. The four-year post-2020 decline (8.4% to 7.0%) is real and recent, but four years is a short base for a decade-long extrapolation, and it is not yet clear whether the improvement will continue, plateau, or reverse. Benefits If Met: Administrative and insurance overhead would be held at the 2024 level even as CMS's own projections point toward a substantially higher share by the early-to-mid 2030s, preserving that difference for direct patient care spending instead. If Not Met: Continuing CMS's own projected trajectory – in which private insurance overhead alone is projected to more than double in dollar terms by 2034, clearly outpacing NHE's own roughly 70% growth over the same decade – would push this ratio meaningfully above its 2024 level, redirecting a rising share of a projected $9 trillion 2034 NHE base toward administration and insurance overhead rather than care delivery. |
HC-MET-ADM-004: Administration and insurance overhead (percent of National Health Expenditures) Current Value: 7.0% (2024) Trend: -0.5 pp vs 2023 (Improving) Metric Evidence:
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HC-AFF-RXN-001 Requirement: Congress shall enact, fund, and oversee prescription drug affordability policies that hold the share of adults aged 18-64 who do not take prescription medication as prescribed due to cost at or below its 2021 level of 8.2% through 2036, with progress measured using NCHS/NHIS survey data. Legislative Key Phrases: Prescription drug affordability; pharmacy benefit and formulary policy; drug pricing and rebate policy. Feasibility Feasibility: Achievable as a near-term ceiling at the already-improved 2021 level (8.2%), not a continued-decline extrapolation: a regression on the comparable points fits well on paper but goes impossible (negative) within a decade, so holding the line, rather than projecting further improvement, is the defensible ask. Discussion: NHIS has asked a version of this question since at least 2011, but NCHS changed the measure's denominator partway through the series: 2011 and 2013 (as originally published) computed the rate as a share of all adults 18-64, including people not on any medication, while starting with a 2019 data brief (covering 2013-2017) NCHS switched to a share of adults who were prescribed medication – a materially smaller, more targeted denominator. NCHS's own recomputation of 2013 on the new basis (14.9%) is nearly double the originally-published all-adults 2013 figure (8.5%), confirming this is a real, large effect and not noise. The 2011 figure (12.6%) was never recomputed on the new basis, so it is shown here as Historical context only, excluded from any trend calculation. On the conditional (comparable) basis, the rate fell from 14.9% in 2013 to 11.1% in 2015, ticked up slightly to 11.4% in 2017, then fell further to 8.2% in 2021 – the most recent year for which NCHS has published this specific measure for adults 18-64 (checked directly against NCHS's data brief index; no newer edition covering this exact composite for this age group has been located). A straight-line regression on these four comparable points fits well on paper (R-squared 0.87), but extrapolating it forward crosses zero by 2030 and goes negative shortly after, which is impossible for a percentage – the same problem this project encountered and rejected for HC-MAT-MMR-001's three-point maternal-mortality series. The proposed target is therefore a near-term ceiling at the 2021 level, not a continued-decline extrapolation. Benefits If Met: Roughly 9.2 million adults reported skipping doses, taking less medication, or delaying a prescription fill due to cost in 2021 (the 8.2% base year, per NCHS's own estimate); holding at or below that level would prevent this from creeping back toward the 11-15% range seen in 2013-2017. If Not Met: A return toward the 2013-2017 range (11-15%) would mean a meaningfully larger share of adults on prescription medication making cost-driven adherence tradeoffs, which the clinical literature links to worse health outcomes and higher downstream emergency and hospital utilization. |
HC-MET-AFF-004: Cost-related prescription medication nonadherence Current Value: 8.2% (2021) Trend: -3.2 pp vs 2017 (Improving) Metric Evidence:
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HC-AFF-OOP-001 Requirement: Congress shall enact, fund, and oversee health care affordability policies that hold out-of-pocket health spending per person to no more than the Federal Reserve's 2.0% long-run inflation target from the 2024 baseline of $1,632, reaching no more than $1,989 by 2034. Legislative Key Phrases: Cost-sharing policy (deductibles and copayments); out-of-pocket maximum policy; health care affordability. Feasibility Feasibility: Feasibility rests on the same logic as HC-FIN-PCP-001 (already locked): capping growth at the Federal Reserve's 2.0% long-run inflation target rather than extrapolating history. Out-of-pocket spending has risen every measured year on record with no exception, so this target is a real reversal of pattern, not a continuation of any existing trajectory, and it isn't confirmed as achievable by any external projection. Discussion: Out-of-pocket spending per person has risen every measured year on record, from $115 in 1970 to $1,632 in 2024 (nominal dollars). The 2000-2016 figures in the evidence table are this project's own calculation: total out-of-pocket spending (CDC/NCHS, sourced from CMS's National Health Expenditure Accounts) divided by the Census Bureau's resident population estimate for the same year. The 2023 and 2024 figures are not derived – they are Peterson-KFF Health System Tracker's own directly-reported per-capita figures, cross-checked against $556.6 billion total 2024 out-of-pocket spending (CMS NHE Fact Sheet) divided by an approximate 2024 population of 340 million, which lands within rounding of the reported $1,632. A linear regression across all six points fits well (R-squared 0.94) and projects roughly $1,898 by 2034 – but a raw continuation of the historical trend is not a meaningful target, since nominal dollar spending mechanically rises with general inflation and health care utilization even absent any change in underlying affordability. This project used the same reasoning for HC-FIN-PCP-001 (per-capita health spending overall): rather than extrapolate the trend, cap growth at the Federal Reserve's 2.0% long-run inflation target, which is a genuine constraint given the historical nominal growth rate (about 3.6% per year, compounded, 2000-2024) has run meaningfully faster than general inflation. Benefits If Met: Real (inflation-adjusted) out-of-pocket burden per person would stop rising, holding steady from the 2024 level rather than continuing to outpace general prices. If Not Met: Continuing the 2000-2024 nominal pace (about 3.6% per year, compounded) would push out-of-pocket spending per person toward roughly $2,324 by 2034 – a real (inflation-adjusted) increase on top of the already-elevated 2024 level, not merely a nominal one. |
HC-MET-FIN-004: Out-of-pocket health spending per person Current Value: $1,632 (2024) Trend: +$118 vs 2023 (Worsening) Metric Evidence:
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HC-COV-UND-001 Requirement: Congress shall enact, fund, and oversee health insurance design policies that hold the share of working-age adults who are insured all year but underinsured – meaning their out-of-pocket costs or deductible are high relative to their income – at or below its 2024 level of 23% through 2036. Legislative Key Phrases: Underinsurance and minimum coverage standards; cost-sharing policy (deductibles and copayments); health insurance market regulation. Feasibility Feasibility: Achievability is genuinely uncertain: the underlying series is volatile (12% to a 28% peak and back), not trending, so the proposed target is a near-term ceiling at the 2024 level rather than a projected trajectory. A 2022 sampling-method change also means the two most recent readings aren't strictly comparable to the 2003-2020 series, adding real measurement uncertainty on top of the volatility. Discussion: The Commonwealth Fund's Biennial Health Insurance Survey has tracked underinsurance among adults 19-64 since 2003, using a consistent definition: insured all year but out-of-pocket costs (excluding premiums) at or above 10% of household income, or at or above 5% for households under 200% of the federal poverty level, or a deductible at or above 5% of household income. This is a respected, independent, nationally-representative survey, not an official federal statistical source, and it is fielded roughly every two years, not annually – so this row cannot follow the same 2001/2006/2011/2016/2021 pattern used elsewhere on this page, and no year has data for every even year. The rate rose sharply from 12% in 2003 (when the measure was first introduced) to 22% in 2010, then stayed roughly flat through 2014 (23%) before spiking to a peak of 28% in 2016, falling back to 21.3% by 2018-2020, then rising again to 23% in 2022 and 2024. That is a genuinely volatile series, not a clean trend – a full-history linear regression was not attempted given this shape (the admin-ratio row on this page rejected a much better-behaved series, R-squared 0.33, for the same reason). Two data-quality notes carry forward from the primary source itself: the 2018 estimate was originally published as 22.6% but was revised to 21.3% in 2020 after the Fund discovered a coding error in how income was recoded during 2018 questionnaire development; the revised figure is used here. Separately, the Fund switched its sampling method in 2022 (from phone random-digit-dial to an address-based/panel/cell-phone design) and changed some measures again in 2024, and its own 2024 report states it "does not report trends" for that reason – the 2022 and 2024 figures shown here are on a different sampling basis than 2003-2020, though the level does not show an obvious discontinuity at that transition. Given the volatility and the sampling-method change, the proposed target is a near-term ceiling at the 2024 level, not a projected trajectory. Benefits If Met: Underinsurance would be held at roughly 1 in 4 working-age adults with continuous coverage rather than climbing back toward the 2016 peak (28%, roughly 1 in 3.5), a level the Fund's own reporting links to sharply higher rates of medical debt and forgone care. If Not Met: A return toward the 2016 peak would mean several million more continuously-insured working-age adults facing out-of-pocket costs or deductibles high enough, relative to income, to functionally erode the financial protection their coverage is supposed to provide. |
HC-MET-COV-003: Underinsured rate (working-age adults, insured all year) Current Value: 23% (2024) Trend: Not assessable vs 2022 (sampling-method change) Metric Evidence:
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HC-ACC-TAR-001 Requirement: Congress shall enact, fund, and oversee primary care access policies that hold the share of adults who, among those who made a routine-care appointment in the past 12 months, sometimes or never got that appointment as soon as they needed it at or below its most recently confirmed level of 14% through 2036. Legislative Key Phrases: Primary care workforce policy; network adequacy standards; primary care access and capacity. Feasibility Feasibility: Achievability is now provisionally assessable rather than fully unknown: a follow-up search found the same measure reported for 2017 (national total 16.4%, higher than this row's 14% baseline), but different NHQDR chartbook editions report meaningfully different values for overlapping years and subgroups, so no single, confidently-current national topline could be confirmed this pass. Locking the provisional 14% ceiling now, flagged clearly for revisit once a single authoritative figure is pulled directly from AHRQ's primary data tables, follows the user's own instruction rather than waiting indefinitely for data that may not resolve cleanly. Discussion: This replaces the originally-held "Appointment Wait Time" concept (average days until the next available primary-care appointment), for which no reliable annual national federal source could be found – commercial wait-time surveys exist but cover selected cities, specialties, or provider samples, not a controlled national series. AHRQ's Medical Expenditure Panel Survey (MEPS) does field a comparable question nationally, using CAHPS-derived items, and the National Healthcare Quality and Disparities Report (NHQDR) tracks it as an official access-to-care measure: the percent of adults who had a routine-care appointment in the past 12 months who "sometimes" or "never" (versus "usually" or "always") got that appointment as soon as they needed it. NHQDR's own reporting gives a clean national figure for this exact measure in 2016 (14%), with an explicit note that "for this measure, lower rates are better" – this is the only year this pass could confirm using precisely that question wording and response-category cut. Two earlier MEPS Statistical Briefs report related but not clearly identical figures for 2007 (42.5% of adults who made an appointment said they "always" got it as soon as wanted) and 2011 (52.7% "received routine care appointments as soon as they thought they needed them") – both use a favorable framing, but it isn't clear from the published briefs alone whether "as soon as they thought they needed them" in the 2011 brief means "always" specifically or a broader "always or usually" cut, so these two points are shown as Historical context rather than folded into a trend with 2016. This pass could not locate a confirmed national topline for this exact NHQDR measure more recent than 2016 – consistent with the held-back review's own warning that MEPS has a real publication lag and that exact current values need to be pulled from AHRQ's summary tables or public-use files directly, which this pass did not have access to. That means the "Current Value" below is roughly a decade old, and the target proposed here should be treated as provisional until a more recent figure can be confirmed. Benefits If Met: Confirms patients are not waiting longer than they themselves consider acceptable for routine, non-urgent care at a rate any worse than the last confirmed national baseline – though "met" against decade-old data is a weak claim until this pass's data gap is closed. If Not Met: A rising share of adults reporting they sometimes or never get routine appointments as soon as needed would point to a primary-care access or capacity problem – a concern independently consistent with widely-reported primary-care workforce shortages, though this row does not itself measure workforce capacity (see HC-ACC-PCP-001 for the primary-care shortage metric). |
HC-MET-ACC-003: Adults not getting routine-care appointments as soon as needed Current Value: 14% (2016 – stale, see Feasibility) Trend: Not assessable (insufficient comparable data) Metric Evidence:
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HC-QLT-PHM-001 Requirement: Congress shall enact, fund, and oversee preventive and chronic-disease-management policies, with particular attention to care coordination for Medicare beneficiaries, that hold U.S. preventable hospitalizations among Medicare fee-for-service beneficiaries (AHRQ PQI-90) at or below the 2023 level of 2,768 per 100,000 in every year from 2026 through 2036, with progress measured annually using CMS's Mapping Medicare Disparities Tool. See Row 11 (HC-QLT-PHO-001) for the companion general-adult-population requirement. Legislative Key Phrases: Medicare beneficiary chronic care management; care coordination and case management policy; primary care access for older adults. Feasibility Feasibility: This ceiling is deliberately conservative, not aspirational. Only two confirmed years exist (2021: 2,681; 2023: 2,768), both showing the rate rising (about +1.6%/yr), so asking for improvement isn't yet evidence-backed the way most rows on this page are, so we hold the line at the worst confirmed point. As more years of CMS's annually-published data accumulate, this target should be revisited – a real downward-trend target likely becomes possible within a few years. Discussion: This row splits out from Row 11 (HC-QLT-PHO-001, the general adult population), which this session found cannot be reduced to a genuine Medicare/non-Medicare split by subtraction: HCUP's own methodology documentation states that population-based rates aren't reported by expected payer nationally, because no population denominator by payer currently exists that matches HCUP's definition, and Row 11's all-adult figure already includes Medicare beneficiaries within it rather than excluding them. Tracking Medicare separately captures a real and currently-worsening disparity instead: Medicare fee-for-service beneficiaries are hospitalized for preventable conditions at roughly double the general adult rate (2,768 vs. 1,328.4 per 100,000 – different populations, not directly comparable, but illustrative of scale), and nationally, adults 65 and older have a preventable-hospitalization rate more than 12 times that of adults 18-44. Two data points is thin, but both are independently verified against primary sources this pass: the 2021 figure directly against America's Health Rankings' own 2023 Annual Report PDF, not a secondary write-up, and the 2023 figure directly against AHR's live measure page. One definitional break is worth flagging for anyone extending this series later: it switched source and denominator in 2019, from the Dartmouth Atlas of Health Care (per-1,000 beneficiaries) to CMS's Mapping Medicare Disparities Tool (per-100,000) – nothing published before that switch should be spliced in. Benefits If Met: Holding at or below 2,768 every year from 2026 would reverse the recent uptick for a population already bearing a disproportionate share of preventable hospitalizations, and preserve the Medicare program savings that come with fewer avoidable admissions. If Not Met: The gap between Medicare beneficiaries and the general adult population continues widening, and Medicare program costs from avoidable hospitalizations continue rising rather than stabilizing. |
HC-MET-QLT-004: Preventable hospitalizations, Medicare fee-for-service beneficiaries (AHRQ PQI-90) Current Value: 2,768 per 100,000 Medicare FFS beneficiaries 18+ (2023, most recent confirmed) Trend: Worsening (+1.6%/yr, 2021 (2,681) to 2023 (2,768)) Metric Evidence:
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