Americans have complained about health care costs for decades, but a new survey shows the problem is bigger than most people realize, reaching past the doctor’s office and pharmacy counter into decisions about jobs, homes, and basic daily expenses.
And the federal program that exists to blunt some of those costs for the most vulnerable patients is under sustained attack from the drug industry.
West Health and Gallup surveyed nearly 20,000 adults and found that almost 70 million Americans delayed a surgery or other medical treatment during the period studied, as reported by Axios. Delaying care is not a neutral decision. Conditions worsen. That leads to more procedures, more drugs, more tests, and higher costs, which push more people to skip care again. The cycle continues.
The Costs Are Landing on Every Income Level
An estimated 46 million Americans delayed changing jobs because of health care costs. Forty million scrapped plans for additional education or training. Thirty-seven million put off buying a home. One-third of American adults, roughly 82 million people, cut back on at least one daily expense to cover medical bills. Many are skipping meals, driving less, or cutting utilities.
The income breakdown makes clear this is not just a low-income problem. About half of households earning between $48,000 and $180,000 put off at least one major life decision because of health costs over the past four years. A third of households earning between $180,000 and $240,000 said the same. Even above $240,000 a year, one in four adults said health costs forced them to defer something significant.
What 340B Does and Why It Matters
Running parallel to all of that is a fight over the program most people have never heard of, one that directly determines whether safety-net hospitals can keep their doors open and their services intact.
The federal 340B drug pricing program has been in place since 1992. Under it, drug manufacturers that participate in Medicare and Medicaid are legally required to sell certain outpatient drugs at a discount to safety-net hospitals. Those hospitals use the savings to provide free or reduced-cost care and medications to low-income, uninsured, and underserved patients. For rural hospitals, community health centers, and critical access facilities, often the only hospital within 35 miles, 340B savings are not a revenue bonus. They are what keep specialty services, drug assistance programs, and uncompensated care from being eliminated.
In 2022 alone, according to the American Hospital Association, 340B hospitals provided nearly $100 billion in benefits to their communities, including free and discounted drugs, uninsured care, mental health services, and vaccine programs.
Drug Companies Started Cutting the Program in 2020
Starting in July 2020, a growing number of drug companies began unilaterally restricting those required discounts whenever medications are dispensed through community or specialty pharmacies rather than a hospital’s own in-house facilities. Many safety-net hospitals, particularly rural ones, do not have in-house pharmacies and depend entirely on those community pharmacy partnerships to get medications to patients.
340B Health, which represents roughly 1,600 hospitals and health systems in the program, reports that 21 major drug companies, including AbbVie, AstraZeneca, Bristol Myers Squibb, Eli Lilly, Johnson & Johnson, Merck, Novartis, Novo Nordisk, Pfizer, and Sanofi, have now imposed those restrictions. Federal data shows the first five companies with restrictions in place throughout 2021 cut safety-net hospital savings by an estimated $1.1 billion in that year alone. Current estimates put collective annual losses at approximately $3.2 billion, with up to $8.4 billion in total 340B savings at risk as restrictions tighten further.
And the restrictions are not random, either. According to 340B Health, for 20 of the 21 companies cutting discounts, at least half of the targeted drugs are either high-cost specialty medications or drugs carrying the largest inflation-penalty discounts, meaning drugs whose prices drug companies have repeatedly raised faster than the rate of inflation.
In other words, the cuts are concentrated precisely where discounts are largest, and where patients’ needs are most expensive.
The consequences are real and documented. One in three critical access hospitals has been forced to cut services. Two in three hospitals with affected drug assistance programs report patient harm, including patients losing access to medications or experiencing dangerous delays in obtaining them. 340B Health surveys have found that 80 percent of affected hospitals expected to cut patient care services if the restrictions became permanent, and 21 percent said their hospital could be at risk of closure.
Drug Companies, HHS Tried to Restructure It
Beyond direct discount cuts, drug companies have been pushing a different approach to reshape 340B from the ground up. Rather than providing discounts upfront when hospitals purchase drugs, several major manufacturers have proposed flipping to a rebate model, where hospitals would buy drugs at full commercial price and then submit data to drug companies and wait for reimbursement.
Five companies, Bristol Myers Squibb, Eli Lilly, Johnson & Johnson, Novartis, and Sanofi, proposed their own versions of this model. In August 2025, the Health Resources and Services Administration announced a 340B Rebate Model Pilot Program, which would have let approved manufacturers test the rebate approach on a defined set of drugs.
Hospitals saw the model as a financial threat and said so immediately. 340B Health estimated the rebate model would force disproportionate share hospitals to float an average of $72.2 million annually to buy drugs at full price while waiting for reimbursement. For critical access hospitals, the average float would be $1.7 million, a massive burden for facilities that often operate on margins of a few percentage points. Ninety-three percent of hospitals surveyed said the model would challenge their ability to maintain uncompensated care. Eighty-six percent anticipated staffing cuts.
In December 2025, the American Hospital Association, the Maine Hospital Association, and four safety-net health systems filed suit to block the pilot program, arguing HHS had rushed the change into effect without following basic administrative law requirements or adequately responding to concerns from more than 1,000 hospitals. In February 2026, a federal district court in Maine agreed, vacating the pilot program entirely. HHS subsequently dropped its defense of the model.
The court win stopped the rebate pilot. It did not stop the underlying pressure on 340B.
States Are Moving to Fill the Gap Congress Has Not
With federal enforcement of 340B hamstrung by ongoing litigation, states have started moving on their own. As of 2025, 21 states have enacted laws prohibiting drug manufacturers from restricting access to 340B discounts through contract pharmacies. Arkansas was the first in 2021. Numerous others followed in 2025 sessions, though the laws vary in scope and several face active legal challenges from pharmaceutical industry groups.
Drug companies have sued to block those state laws in multiple jurisdictions, arguing federal preemption. Federal appellate courts have split on the question, and the Supreme Court has declined to take it up, leaving the legal landscape unsettled state by state.
Meanwhile, HRSA has referred companies violating 340B requirements to the HHS Office of Inspector General for potential fines, which can reach nearly $6,000 per violation. But litigation filed by the drug companies has slowed or blocked enforcement at every turn.
The Survey’s Warning and the Program’s Stakes
The West Health-Gallup survey is straightforward on what comes next without policy change: care gets less affordable. That trajectory intersects directly with the 340B fight. The hospitals absorbing the discount cuts are the same hospitals patients turn to when they cannot afford care elsewhere. When those hospitals cut services or close, the people the system leaves behind have nowhere left to go.
For millions of families, the cost of health care is already showing up in skipped surgeries, deferred careers, and rationed prescriptions. The program that was built specifically to reduce that burden for the most vulnerable patients is being steadily dismantled, one legal challenge and one discount cut at a time.
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