In Part 1 of this series we looked at the table, in Part 2 at the body, and in Part 3 at the test. Suppose a person changes the table, keeps the body moving, and gets the screening that finds a disease early. One question still remains. Does that person actually get treated? Skipping medical care due to cost is not rare in the United States, and the choice carries consequences.
The United States spends more per person on health care than any other country. In 2024 the figure was about $14,885 per person, far above Switzerland, the next highest. But that average hides something. It is the average spent by people who reached care. A person who does not get care because of cost generates none of that spending and does not appear in the average at all. This article is about the people outside the average, not the people inside it.
On the ward, I do not often ask my patients whether they exercise enough. In the same way, I am careful with the question of why they did not come in sooner. Some of the patients I admit have carried a symptom for a long time and arrive only when the situation can no longer wait. When I ask what happened in between, cost is often the reason. They thought about the visit, the test, or the prescription, put it off once, then again, and arrived here.
This article looks at uncomfortable facts in the American picture through data. It asks how many people delay or give up needed care because of cost, and how that choice connects to outcomes. The point is not to blame anyone. It is to see the choices made every day a little more clearly.
The 3.7-year gap in life expectancy is not built from a single cause. The table, the body, and the test were each part of it. This final part looks at what remains even for the person who clears all of those steps. The bill.
Skipping medical care due to cost is more common than most Americans think
Start with how common it is to delay care because of cost. In the 2024 National Health Interview Survey, about 17% of adults, or roughly 1 in 6, reported delaying or going without medical care, prescription drugs, or mental health care because of cost. You can read the figures at the Peterson-KFF Health System Tracker.
Asked a different way, the number runs higher. In a KFF health tracking poll from the same period, 36% of adults said they had skipped or postponed needed care in the past 12 months because of cost. Depending on how the question is framed, the figure moves between 1 in 6 and roughly 1 in 3.
There was a difference between men and women. The share who said they had put off needed care because of cost was 32% for men and 38% for women.
A common assumption is that having insurance lets a person escape this problem. The data says otherwise. Even among insured adults, 37% reported not getting needed care because of cost. Insurance lowers the cost barrier but does not remove it.
The widest difference falls along insurance status. In 2024, 38.6% of uninsured adults reported delaying, skipping, or not getting needed care or medication because of cost, according to KFF data on the uninsured population. That is more than double the rate for those with private coverage (17.0%) or public coverage (18.8%).
Adults who delayed or went without needed care or medication because of cost, by insurance type (2024)
| Insurance type | Delayed or went without care |
|---|---|
| Uninsured | 38.6% |
| Public (Medicaid or Medicare) | 18.8% |
| Private | 17.0% |
What happens after care is skipped
The rate of delay matters less than what comes next. The question is what happens to the people who put off care.
In KFF survey data, 18% of adults who skipped or delayed care because of cost said their health got worse as a result. Among uninsured adults under 65, that figure rose to 42%, more than double the 20% seen in insured adults of the same age group. The full breakdown is in the KFF analysis of Americans’ challenges with health care costs.
Consider one person here. Call him Glenn. The age, the location, and the identifying details have all been changed, and the case combines patterns that appear again and again in patients who delay or reduce care because of cost. He had type 2 diabetes and used insulin. When the monthly cost became a strain, he began taking less than his prescribed dose.
This is not a rare behavior. In 2021, 16.5% of American adults with diabetes who use insulin, about 1.3 million people, skipped, delayed, or used less insulin than needed to save money. That means about 17 out of every 100 did what Glenn did, a finding published in Annals of Internal Medicine.
Taking less insulin saves money in the short term. But a sustained shortage of insulin can lead to diabetic ketoacidosis (DKA). Glenn was eventually brought to the emergency department.
The pattern shows up in the data. In a study published in Diabetes Care, younger adults who skipped insulin doses were more likely to report an emergency department visit or hospitalization than those who did not (56% versus 35%), with an adjusted odds ratio of 2.4. Cutting the dose and ending up in emergency care turn out to be linked.
The rate of cutting or skipping insulin varied by group. It was 18.6% in people with type 1 diabetes and 15.8% in those with type 2. It was highest among the uninsured at 29.2%, and 18.8% even among those with private insurance. It was 20.4% in adults under 65 and 11.2% in those 65 and older. Once people reach the age of Medicare eligibility, the rate falls by nearly half.
Adults who cut, skipped, or delayed insulin because of cost, by group (2021)
| Group | Rationed insulin because of cost |
|---|---|
| Type 1 diabetes | 18.6% |
| Type 2 diabetes | 15.8% |
| Uninsured | 29.2% |
| Under 65 | 20.4% |
| 65 and older | 11.2% |
When the wait runs until age 65
This is not only a story about diabetes and insulin. The decision to delay because of cost takes a particular shape among people in their fifties and early sixties, the years just before Medicare eligibility at 65. Some in this age group, for whom insurance costs are a strain, put off tests until 65, when Medicare will cover the cost.
Consider a second case. Call him Ray. Again the identifying details have been changed, and the case combines people who show the same pattern. He was in his early sixties and knew he needed a colonoscopy. But he decided to wait until his 65th birthday, when Medicare would handle the cost. Research from the University of Michigan describes adults who delayed procedures until they reached Medicare or their insurance changed, waiting for the cost to drop. His partner had been putting off a CT scan for years for the same reason.
Why this delay matters shows up in the relationship between stage and survival. According to the American Cancer Society’s 2026 statistics, the 5-year relative survival for colorectal cancer depends heavily on the stage at diagnosis. Found at a localized stage, it is 91%. Found at a distant stage, after it has spread, it is 15%. Stage at diagnosis is the strongest single predictor of survival. The figures are in the ACS report in CA: A Cancer Journal for Clinicians.
A third case involves chest symptoms. Call him Stan. In his late fifties he felt intermittent chest pain and shortness of breath, but he put off the visit, thinking about the cost of the tests and the appointment. In a study of adults just before Medicare eligibility, those who had little or no confidence in affording insurance after retirement were about 2.89 times as likely to avoid needed care as those who were confident (95% CI 1.86 to 4.49). In the same survey, over the past year 13% had gone without medical care and 12% had not filled a prescription because of cost. The analysis appears in the study on health insurance affordability and care avoidance near retirement.
Age itself adds to this. In the same colorectal cancer data, for disease found at the distant stage, 5-year survival was 23% in those under 50, 17% in those aged 50 to 64, and 10% in those 65 and older. At the same stage, survival is lower with age. The American Cancer Society attributes this to fewer other illnesses, more physical activity after treatment, and the ability to tolerate more aggressive treatment in younger patients. So the time that passes while a person delays because of cost weighs more heavily on the body around 65, the very age when Medicare begins to cover the cost. Insurance widens at 65, but the body’s capacity to recover narrows in the meantime.
The same diagnosis, a different decision
To see whether a patient with the same diagnosis makes a different decision depending on the country, you need data that compares countries on the same scale. The Commonwealth Fund’s Mirror, Mirror 2024 report does that. It compares the health systems of 10 high-income countries across the same 70 measures. It plays the same role that NOVA did in Part 1, the Stanford accelerometer data in Part 2, and SEER in Part 3.
In that report, the United States ranked last on access, equity, and health outcomes. Its cost barrier to care, the difficulty of getting care because of cost, was the highest among the countries compared. The full ranking is in the Commonwealth Fund Mirror, Mirror 2024 report.
Out-of-pocket spending was large as well. In the Commonwealth Fund’s 2023 international survey, 41% of Americans reported paying $1,000 or more out of their own pocket for health care in the past year. In the other comparison countries, far smaller shares reported out-of-pocket spending at that level.
Inside one country, that level of out-of-pocket spending looks normal. But set side by side with a neighbor on the same scale, the size of the cost barrier becomes clear. It connects back to the figure from the opening. That the United States spends the most per person on health care and still has the highest cost barrier means that large spending does not reach everyone evenly.
What the U.S. system does well
For balance, the data on the other side deserves the same weight. In the same Mirror, Mirror 2024 report, the United States was not behind on every measure. On care process, it ranked 2nd of the 10 countries. It scored well on the delivery of preventive services, such as mammography and flu vaccination, and on patient safety.
The United States is also ahead on speed of access to treatment. In a study of 89 cancer drugs approved by both the FDA and the EMA, the FDA approved 95% of them first. Market approval came a median of 241 days earlier than in Europe. New cancer drugs reach American patients at an earlier point.
Put plainly: once a patient reaches care, the U.S. system shows leading results in innovation and speed. The gap opens not at the quality of treatment, but at the step of whether cost lets a person reach that treatment at all.
Where cost stops explaining
This series has divided the roughly 3.7-year life expectancy gap between the United States and its peers into four pieces. Part 1 looked at the table, Part 2 at the body, and Part 3 at the test, and this Part 4 has looked at cost. We have seen, in the data, how large the share of people delaying care because of cost is, and how it connects to worse health and emergency use.
But cost does not explain the whole gap either. Add the table, the body, the test, and cost together, and 3.7 years is not neatly filled. The four pieces are the large axes that explain the gap, but a remainder still remains. Honestly stated, the life expectancy gap is not a problem with a single cause.
There are real cases where the friction of cost was resolved by a different route. ManClub’s Korea Cases series records patients who, facing the prospect of delaying or giving up care in the United States because of cost, reached the same treatment by another path. The knee replacement cost case and the cataract surgery cost case show the concrete size of that friction.
Plain-Language Reference
If you want to ask “where am I” on the cost side of this, a couple of the tools on this site line up with what this article covered.
· Emergency Fund Gap Calculator (see how many months you could cover if income stopped or a medical bill hit, and how large the gap in your emergency fund is)
· Blood Work Decoder (read what the numbers on a lab report actually mean)
The Bottom Line
The share of Americans who delay care because of cost runs between 1 in 6 and 1 in 3. Of those who delayed, 18%, and 42% of the uninsured, said their health got worse as a result. The United States spends more per person on health care than any other country, but that average belongs to the people who reached care. The person pushed outside the average is not counted in it.
The U.S. system is fast and innovative for the patient who reaches care. The gap opens not at the quality of treatment, but at the step of reaching it. The fourth piece of the life expectancy gap sits at that step.
One more thought belongs here. The life expectancy numbers can mean different things to different people. One more year does not carry the same weight for everyone. What matters may be not simply a longer life, but how many days are spent without illness, and whether care is available when illness comes. That is where the four pieces this series followed finally point. Not more time, but time spent in health.
This data does not tell anyone what to do. It only shows that delaying care because of cost is not a single decision but a choice that accumulates over a long stretch of time. What to do with that choice is yours to decide.
This article is for general educational purposes and does not constitute medical advice. Figures come from different surveys and survey years, so they should be read as broad comparisons rather than exact rankings. Talk with your own physician about your individual health.
Take care of yourself. Nobody else will do it for you.
Eleanor Hayes, M.D., is a practicing, board-certified Family Medicine physician with extensive hospital-based clinical experience across multiple U.S. regions. At ManClub she writes data-driven pieces on public health, healthcare systems, and population health trends, and serves as the site’s independent medical reviewer. “Eleanor Hayes” is a professional pen name used to protect patient privacy; all credentials are verified internally. She is the author of “Reading the Table” (2026). Full bio and credentials: Dr.Hayes-reviewer. Contact: [email protected].