There is a basic premise embedded in the structure of modern medicine: when a treatment exists, access to it should not be determined by whether a person can pay for it. That premise is aspirational almost everywhere, but in the United States it collides daily with the specific and measurable reality of prescription drug pricing. When a medication has been developed, approved, manufactured, and dispensed — when it is sitting on a pharmacy shelf — the question of whether a patient receives it is, in millions of cases, a financial question. For the people on the losing end of that question, the consequences are not theoretical. They are clinical. In some cases, they are fatal. Understanding what drug prices actually cost people — in health, in money, in life — is the first step toward an honest conversation about what, if anything, should change.
The Scale of the Problem
The numbers describing who cannot afford medications in the United States are large enough that they risk becoming abstract. A 2023 survey conducted by Gallup and West Health found that 18 million Americans — 7% of all adults — were unable to pay for at least one prescription medication for their household in the prior three months. That figure rises sharply for the lowest-income households: nearly 20% of Americans with annual income below $24,000 reported the same inability. People managing three or more chronic conditions were roughly 2.5 times more likely than their healthier counterparts to skip purchasing a medication they needed.
By 2025, the burden had broadened. GoodRx Research surveyed more than 1,200 people who had filled a prescription in the prior year and found that 67% described the cost as at least a minor burden — up from roughly 64% the prior year. The share describing the burden as “moderate” or worse held in the 30% range. Only one in three people said the cost was not a burden at all.
What does burden look like in practice? The GoodRx data maps it in material terms: 28% of people with prescription costs cut spending on food or clothing — nearly double the 16% who said the same the year before. Twenty-five percent took on credit card debt. Eighteen percent borrowed from friends or family. Nine percent sold personal belongings. These are not the choices of people managing a minor inconvenience. They are the choices of people absorbing a serious financial injury.
The international comparison sharpens the picture. West Health and Gallup data show that American per-capita prescription spending exceeds $1,200 per person annually — the highest among 12 high-income nations studied, and roughly double what people pay in countries like Germany, the United Kingdom, and Japan. Other countries pay between 24% and 30% less for the same drugs.
Rationing as a Medical Reality
Medication rationing — taking less than prescribed, skipping doses, or delaying refills — is not a financial strategy. It is a medical intervention, and an unauthorized one, with measurable consequences for health outcomes.
According to a 2021 CDC analysis, 9.2 million American adults between the ages of 18 and 64 skipped doses, took less medication than prescribed, or delayed refills due to cost in the prior 12 months. That figure represents 8.2% of adults who took prescription medication in the prior year — not a fringe phenomenon, but a common adaptation to a pricing environment that outpaces what many people can pay.
By 2025, the GoodRx data showed that 1 in 5 Americans who filled a prescription in the prior year reported rationing their medications due to cost — up from 15% the year before. Thirteen percent stopped taking a medication entirely, compared to 8% the prior year. The trend line is moving in the wrong direction.
What does rationing do to health? The clinical literature answers this clearly, and the mortality data is unambiguous. A study published through the National Bureau of Economic Research found that a $10 increase in per-prescription cost leads to a 33% increase in mortality. The effect, the researchers found, is not because patients are selectively cutting low-value medications they could afford to skip. Patients at the highest risk of heart attack and stroke — those who would benefit most from statins and antihypertensives — cut back on those drugs more than lower-risk patients. When cost rises, people reduce medication use broadly, and the most vulnerable bear the severest consequences.
For Medicare beneficiaries, the projections are stark. A 2024 study from the West Health Policy Center modeled cost-related non-adherence among Medicare patients with chronic conditions over a ten-year period. The result: more than 1.1 million Medicare patients are projected to die over the next decade because they cannot afford their medications. That is approximately 112,000 people per year — a figure the researchers note would place cost-related medication non-adherence ahead of diabetes, influenza, pneumonia, and kidney disease as a cause of death. These are not deaths from treatment failure. They are deaths from an inability to purchase treatment that exists and could work.
Insulin as a Case Study
Insulin is not a new drug. Its discovery dates to 1921. The researchers who isolated it sold the patent for one dollar, on the explicit premise that a life-sustaining medication should not become the property of commercial interests. A century later, 1.3 million Americans living with diabetes are rationing their insulin due to cost — a figure drawn from CDC data and reported in 2023.
Rationing insulin is not the same as missing a dose of a less critical medication. Insulin is not optional for people with Type 1 diabetes, and it is essential for many with Type 2. Without adequate doses, blood sugar rises to dangerous levels. Diabetic ketoacidosis — a life-threatening emergency — can develop within hours in people with Type 1. Emergency room visits, hospitalizations, and organ damage follow inadequate insulin management. The person who rations insulin to cover rent is not simply going without a convenience. They are trading a certain financial crisis now for an uncertain medical crisis later — and the medical crisis, when it comes, is frequently catastrophic.
That 1.3 million people are making this calculation, in the wealthiest country in the world, for a drug that has existed for more than a century, is worth holding in view before any discussion of policy.
The Disparity
Prescription drug costs do not distribute their burden evenly. The CDC NCHS Data Brief on cost-related non-adherence contains a disparity map worth examining in detail.
Among uninsured adults, 22.9% reported failing to take medications as prescribed due to cost — more than three times the rate of adults with private insurance (6.5%). Adults with no prescription drug coverage reported cost-related non-adherence at a rate of 18.1%, compared to 6.6% for those with private drug coverage. Insurance status, in other words, is the single strongest individual predictor of whether a person will take their medication as prescribed.
Disability status produces a similarly sharp divide. Adults with disabilities reported cost-related non-adherence at 20.0%, compared to 7.1% among adults without disabilities. People in fair or poor health — often the same population — reported non-adherence at 18.0%, compared to 6.3% among those in excellent, very good, or good health. The people who most depend on medications are the people most likely to be unable to afford them.
Income follows the expected gradient: 14.5% of adults below the federal poverty level reported non-adherence due to cost, compared to 3.9% of those at more than 400% of the poverty level. People living near or below the poverty line are nearly four times more likely than their higher-income counterparts to skip, ration, or delay medications they have been prescribed.
Women report higher rates of cost-related non-adherence than men — 9.1% versus 7.0%. Non-Hispanic Black adults report non-adherence at 10.4%, and Hispanic adults at 9.7%, both significantly higher than Non-Hispanic White adults at 7.4%.
The West Health/Gallup data adds another layer: Americans managing three or more chronic conditions are roughly 2.5 times more likely than those without chronic conditions to have skipped purchasing a medication in the past three months. The relationship between need and inability to meet that need runs in exactly the wrong direction — the sicker a person is, the more medications they require, and the more likely they are to be unable to afford all of them.
What This Means for the Sentiment Stage
America’s Plan is at an early point in its work. The purpose of this piece — and of the broader documentation effort at this stage — is not to advance a solution. It is to ground a conversation in what is actually happening to people, stated plainly, before any argument is made about what should change.
The data collected here describes a specific condition. Millions of people have been prescribed medications by physicians who determined those medications were medically necessary. They leave pharmacies without those medications, or they ration them, or they stop taking them entirely — not because the drugs do not work, not because they have been advised to stop, but because the price is more than they can pay. Some of them die as a result. Some of them experience permanent health deterioration that could have been prevented. Some of them borrow money, sell belongings, or eat less to cover costs. Some of them use medications prescribed to other people, or buy drugs from other countries, because those are the options available to them.
None of this requires assigning blame to document it. The pricing dynamics that produce these outcomes are real and complex, involving manufacturers, pharmacy benefit managers, insurers, and government programs operating under legal frameworks built over decades. The question of what produced the current system is different from the question of what the system is producing — and the latter is where documentation has to begin.
What the current system is producing, in measurable terms, is preventable suffering at a scale that is rarely framed as a rights issue, though it is. When a treatment exists and a person cannot access it because of price alone, something has gone wrong between the promise of medicine and its delivery. How wrong, and what to do about it, are questions for later stages of this work. For now, the record of what these prices cost — in health, in dollars, in life — is worth stating as clearly as the evidence allows.
This article was researched and drafted with AI assistance under human review. See our full AI and editorial practices.