Across the globe, the struggle to afford and access quality health care is intensifying, from the rapidly expanding cities of India to the insurance marketplaces of the United States. Recent data, legislative efforts, and public debates reveal a landscape where rising costs, patchy insurance coverage, and systemic distrust threaten to leave millions exposed to financial and health risks. The challenges—and the proposed solutions—underscore how deeply health care is woven into the fabric of economic opportunity, social mobility, and trust in institutions.
In India, the story of urban transformation is often told as one of progress and prosperity. But, as highlighted by a December 9, 2025 analysis from People Research on India’s Consumer Economy (PRICE), the reality for many urban residents is far more precarious. Drawing on ICE 360 data from 2023 and the latest National Family Health Survey, the report paints a picture of an urban health ecosystem under strain, where the promise of rising incomes has not translated into robust health protection.
The numbers are stark. Only 11% of urban Indian households reported paying a health-insurance premium, despite 34% experiencing hospitalization and 68% seeking doctor consultations or diagnostics. That means the vast majority of families are left to shoulder the costs of illness themselves, often with little or no financial buffer. According to PRICE, “High utilization paired with minimal financial protection reveals a system in which households must absorb most of the cost of illness.”
The situation is especially acute in India’s largest metropolitan regions, including Delhi, Mumbai, and Kolkata. Despite boasting the country’s most sophisticated private healthcare infrastructure, these cities recorded effective insurance coverage rates of just 23-25%. The paradox is striking: scale and wealth have not translated into institutional strength or security for most residents. Instead, these cities spend a higher share of income—roughly 5-7%—on health, compared with about 4% in other metropolitan areas. Lower incomes, weaker public provisioning, and higher disease burdens all contribute to a cycle of vulnerability that insurance enrollment alone cannot break.
Yet, there are glimmers of hope in some mid-sized cities. Udaipur (84%), Jodhpur (81%), Cuttack (80%), Srinagar (75%), and Kozhikode (65%) have managed to build relatively effective risk pooling systems, thanks to administrative consistency and well-designed state programs. Their success suggests that financial protection is not simply a matter of income, but of governance capacity and effective enrollment. As the PRICE analysis notes, “Their performance shows that financial protection is not determined by income alone, but by governance capacity and enrolment effectiveness.”
Patterns of care-seeking further reveal the fragmented nature of India’s urban health systems. Cities with functional public health networks, such as Kozhikode, Udaipur, Cuttack, and Bilaspur, report high reliance on public facilities, with utilization levels between 74% and 82%. Stable staffing and dependable primary care have fostered trust in these places. In contrast, cities like Patna, Jalandhar, Bareilly, and Nanded see 70% to 85% of households depending on private providers, despite low insurance coverage—a situation that amplifies financial risk for already vulnerable families.
Why do so many households avoid public healthcare? The reasons are telling. Nationally, 52% cite long waiting times as the biggest deterrent, a figure that rises to 69% in Delhi and 71% in Kolkata. More than 40% of households in cities such as Agra, Firozabad, Saharanpur, and Dhanbad report no accessible public health facility nearby. Quality concerns are also widespread, with dissatisfaction levels reaching 61% in Hyderabad, 64% in Patna, and a staggering 76% in Dhanbad.
Institutional trust—or the lack of it—emerges as a central thread in these findings. Among uninsured households, 25% cite distrust in claim settlement as the primary reason for not purchasing insurance. This skepticism stems from lived experiences with unclear procedures, slow responses, and weak grievance redressal mechanisms. The report warns that without stronger accountability and transparent processes, insurance expansion risks remaining more symbolic than meaningful.
The implications are clear: India’s urban health trajectory will depend on aligning public provisioning, financing mechanisms, and institutional reforms. Health infrastructure must be treated as core urban infrastructure, not an afterthought. The report urges policymakers to strengthen state insurance schemes, prioritize staffing stability and quality assurance in public systems, and push private providers toward greater transparency and affordability. Insurers, too, must adapt to the realities of urban informality and fluctuating incomes, designing products that reflect the lived experiences of city dwellers.
Meanwhile, across the world in the United States, millions are facing their own health care affordability crisis. On December 8, 2025, U.S. Senator Ron Wyden, joined by colleagues including Senator Jeff Merkley, introduced the Restoring Patient Protections and Affordability Act. Their goal: to protect health care coverage for millions of Americans and improve the effectiveness of the Affordable Care Act (ACA) Health Insurance Marketplace.
The stakes are high. As reported by The New York Times, millions of Americans are confronting the highest health insurance costs in years. For those enrolling in Obamacare plans for 2026, deductibles are rising significantly, and premiums could more than double if enhanced federal subsidies are not extended. Some families are even considering dropping their insurance altogether, or forgoing medical care, despite being eligible for subsidies. The causes are many: higher prices for prescription drugs, the surging use of expensive obesity drugs, tariffs, and rising labor costs all play a part.
Wyden’s proposed legislation seeks to renew enhanced premium tax credits for another three years, extend the 2026 open enrollment period, reduce paperwork, and lower out-of-pocket costs. The bill also aims to restore navigator funding, reinstate special enrollment periods for low-income Americans, increase transparency from insurance companies, reinstate automatic reenrollment, and protect consumers from surprise premium bills. “Americans today are waking up to a cold reality: health care costs are doubling, tripling, or even worse,” Wyden said. “While Trump is playing the blame game on America’s affordability crisis, Democrats are working day and night to extend ACA tax credits so that working families nationwide can access quality care without breaking the bank.”
The debate in Congress is heated and ongoing. While most people will still qualify for some federal tax credits in 2026, many will find that their monthly costs are soaring if the generous subsidies are not renewed. President Trump has suggested he might support some sort of extension, but it’s unclear whether enough Republican backing exists to pass the measure. As The New York Times notes, Congress could delay a decision until early next year, even after the subsidies have expired.
More than 20 million Americans rely on ACA Marketplace plans, including small business owners, farmers, independent contractors, and those without employer insurance. Senators Lisa Blunt Rochester, Cory Booker, and Tina Smith have joined Wyden and Merkley in sponsoring the bill. Merkley, for his part, has been outspoken: “I refuse to let folks be left out in the cold—Congress needs to act now to fix the Republican health care crisis and lower the cost of health care for folks in Oregon and across the country.”
The challenges faced by India and the United States, though shaped by different histories and systems, share a common thread: the tension between rising health care needs and systems ill-equipped to assure financial protection, equitable access, and public trust. Whether in the bustling streets of Mumbai or the legislative halls of Washington, D.C., the health of a nation’s people remains inseparable from the strength and fairness of its institutions. The coming months will test whether leaders can rise to the challenge—and whether health systems can adapt to meet the needs of all.
