By Joe Paradza Allied Health Leader & Healthcare Economics Analyst Therapy Insights - Independent Australian Publication
Published: 28 March 2026 

There is a word that rarely appears in policy documents about healthcare, a word that describes what the system is quietly becoming, even as the rhetoric of universal coverage remains intact.

That word is luxury.

Not in the sense of treatments confined to the wealthy. In the more unsettling sense of routine care, a GP visit, a follow-up appointment, a specialist referral, a dental check, becoming something that a growing proportion of people in wealthy, developed nations can no longer reliably afford. Something accessed conditionally, based on income, geography, and the capacity to wait.

This is not a crisis of poor countries or broken systems. It is a crisis unfolding in the most sophisticated healthcare economies on earth, in nations with universal coverage frameworks, in countries with publicly funded systems, in households that consider themselves solidly middle class.

According to the World Health Organization and World Bank's 2025 Universal Health Coverage Global Monitoring Report, 2.1 billion people experience financial hardship to access healthcare, including 1.6 billion pushed into poverty or deeper into it by health expenses. The scale of that figure makes the language of universal access sound increasingly aspirational rather than descriptive.

The shift that is underway is not dramatic. It is structural, gradual, and measurable. And most health systems are not designed, or funded, to stop it.

The Affordability Shift: When Access Follows Income

The founding principle of modern public healthcare, that access should be determined by need, not by the ability to pay, has never been fully realised. But for several decades across the developed world, it was sufficiently approximated that most people, in most circumstances, could access most care most of the time.

That approximation is eroding. The mechanism is not the elimination of public healthcare entitlement. It is the quiet multiplication of barriers, gap fees, wait times, transport costs, specialist charges, pharmaceutical co-payments, and the growing privatisation of services once considered part of the public offer, that collectively make access conditional on something other than need.

Despite most OECD countries having universal healthcare systems, access challenges remain significant. Persons in the lowest-income quintile are 2.5 times more likely to report unmet medical care needs than persons in the highest-income quintile.

That ratio, 2.5 times, is the data point that encodes the shift. In a system of genuinely universal access, the income quintile of the patient should be irrelevant to whether their medical needs are met. The fact that it is not, and that the gap is this wide, across countries whose systems are designed for universality, tells the structural story that official coverage statistics do not.

The shift from universal to conditional access does not announce itself. It accumulates, appointment by appointment, deferral by deferral, until the population of people reliably accessing care and the population of people who nominally have the right to access it are no longer the same group.

Global Healthcare Inequality: The Data Across Countries

The healthcare inequality global picture is most extreme in the United States, where the architecture of the system has never fully committed to universality. But the trend is visible across systems of every design.

In 2024, the United States spent an estimated $14,885 per person on healthcare, the highest per capita costs across comparable wealthy countries. Switzerland was second at $9,963 per capita, while the average for wealthy OECD countries excluding the United States was $7,371. Despite that spending premium, the US records some of the worst health outcomes among high-income nations, lower life expectancy, higher preventable mortality, and wider socioeconomic gradients in health access than most peer nations.

Nearly half of US adults with lower or average incomes reported at least one cost-related problem accessing healthcare in the past year, including not receiving medical care, skipping a recommended test or treatment, or not filling a prescription. US adults with lower or average incomes were statistically more likely to have a cost-related access problem than their counterparts in any of the other countries surveyed.

In the United Kingdom, the stated principle of the NHS, care based on need, free at the point of use, is coming under structural pressure from a different direction. The UK now has the fastest growth in spending on private insurance and out-of-pocket healthcare among all G7 nations. With many struggling to access NHS services or having to wait for procedures, private healthcare use has dramatically increased.

Waiting times for private providers in England are half those for the NHS, and the poorest 20 percent of patients wait longer than the richest 20 percent. The system has not formally created a two-tier structure. It has allowed one to emerge through the differential capacity to pay for faster access.

When those with more disposable income can opt out of the long waits that many reliant on the NHS face currently, health inequalities widen. This leads to a two-tier system where those with more disposable income receive care before many who have been waiting for months or even years with no other option.

In Canada, the median wait time between a GP referral and receipt of treatment is now 28.6 weeks, 208 percent longer than the 9.3 weeks that patients could expect in 1993. In Australia, the bulk billing rate, the practical measure of whether the universal Medicare system is functioning as intended, fell sharply over recent years before a significant government intervention, as documented in our global healthcare access crisis analysis.

The pattern differs in form across these systems, but the direction is consistent: access is becoming more dependent on income, more mediated by the ability to pay for speed or choice, and less reliably universal in practice even when nominally guaranteed in principle.

The Middle-Class Squeeze: No Longer Just a Poverty Problem

The shift toward conditional access is no longer confined to populations at the margins of the income distribution. It is moving steadily into the middle.

This is the feature of the current affordability crisis healthcare that distinguishes it from previous decades. The concern was once primarily about those who lacked coverage entirely, or who fell through categorical gaps in eligibility. What is emerging now is broader: a compression of access affecting households with stable employment, insurance coverage, and incomes that place them comfortably in the middle of the income distribution.

About two-thirds of US adults, 66 percent, say they worry about being able to afford healthcare expenses for themselves and their family, including 32 percent who are very worried and 34 percent who are somewhat worried.

In 2025, the average annual deductible for employer-sponsored health coverage in the United States was $1,886, with the average co-insurance rate being 20 percent for a hospital visit, and nearly half of employer-sponsored plans, 46 percent, having an out-of-pocket maximum over $5,000. For households with limited liquid savings, these thresholds represent not just financial inconvenience but genuine barriers to care.

The expiration of enhanced Affordable Care Act subsidies at the end of 2025 created what experts described as an "ACA cliff", a sharp cutoff of premium tax credits for people earning over 400 percent of the federal poverty level. Middle-class families earning too much for Medicaid but now facing unaffordable marketplace premiums are likely to go without coverage. As one commentator noted, this will increase the uninsured rate and raise the risk of delayed care, medical debt, and financial instability.

The middle-class squeeze operates through a different mechanism from poverty-based access failure. It is not that people lack the income to survive, it is that the cost of healthcare, as a proportion of household income and in absolute terms, has risen to the point where it competes directly with housing, education, food, and fuel for priority in a budget that cannot accommodate all of them. Healthcare is the item that can be deferred. The mortgage cannot.

As healthcare expenses continue to go up, household budgets have to adjust, which means people can't afford the same kind of groceries or housing they're used to. Surveys consistently show that people delay or forgo care due to cost, worry about their ability to pay for healthcare bills, and incur medical debt.

The public health consequence is that the deferral behaviour once associated predominantly with the uninsured or underinsured is now observable across a much wider income range. The cost of that deferral, in worsening health outcomes, emergency presentations, and late-stage diagnoses, is accruing across middle-income populations that health systems were not designed to lose.

System Consequences: What a Luxury-Tier Healthcare System Produces

When healthcare becomes stratified by income in practice, the consequences operate at multiple levels simultaneously.

At the individual level, the hierarchy of access produces hierarchy in outcomes. Those who can afford private care or supplementary insurance access timely diagnosis and treatment. Those who cannot wait, and while they wait, their conditions evolve. Over three million premature deaths occurred in 2023 among people aged under 75 that could have been avoided through better prevention and healthcare interventions. These deaths are not randomly distributed across the income spectrum. They concentrate where access is thinnest.

At the system level, a two-tier structure creates a compounding problem. As wealthier patients exit the public system for private alternatives, the public system absorbs a higher proportion of complex, high-need, lower-income patients, with the same or reduced funding. The political constituency for maintaining strong public healthcare funding diminishes as those with the most economic and social influence opt out of the system they would otherwise advocate for.

With a two-tier system comes a more fundamental long-term threat: that public healthcare might increasingly be left as the health system for the poor. If public healthcare became primarily a service for the poor, it would gradually become a poorer service, as few wealthier, influential people would be willing to demand it be properly funded.

This dynamic has historical precedent in other public services, education being the most instructive parallel. The withdrawal of middle and upper-income households from publicly funded education systems typically precedes sustained periods of underfunding and declining quality, creating a self-reinforcing cycle that becomes progressively harder to reverse.

Healthcare is following a similar trajectory in several countries, with the difference that the stakes, measured in health outcomes, preventable deaths, and system sustainability, are higher.

The Policy Gap: Funding That Has Not Kept Pace

The political and policy response to the healthcare becoming expensive trend has been inconsistent. In some systems, targeted interventions, subsidy expansions, bulk billing incentives, drug price negotiations, have provided partial relief. In most, the structural gap between what systems are funded to deliver and what populations need has continued to widen.

OECD public spending on health is set to grow on average by 1.5 percent of GDP by 2045, driven largely by technological change, rising expectations, and ageing populations. Financing these higher spending needs may be challenging, given competing policy priorities and public finance constraints.

The challenge is not simply fiscal. It is structural. Prevention spending, the most cost-effective lever in the system, remains chronically underweighted. OECD Secretary-General Mathias Cormann identified the core imbalance directly: countries currently allocate only 3 percent of total health expenditure to preventive healthcare and 14 percent to primary healthcare, levels the OECD argues should increase to enhance both the effectiveness and the fiscal sustainability of health systems.

The gap between the economic case for investing in prevention and primary care, and the political decisions being made about health budgets, is where the affordability crisis has its deepest roots. Every dollar not spent on prevention and early access generates a larger future liability in acute and emergency care. The system does not become cheaper by being less accessible. It becomes more expensive, and less equitable, over time.

Prevention initiatives are often seen as discretionary, making them particularly vulnerable to budget cuts during times of fiscal constraint. Addressing this imbalance requires a shift in perception, emphasising prevention as a strategic investment that delivers both health and economic returns in the long term.

That shift has not occurred at the scale required. And the gap between the investment made and the investment needed is widening precisely at the moment when cost-of-living pressures on household budgets are at their most acute.

Australia: The Warning Signs in a Universal System

Australia sits at an instructive point on this spectrum. Medicare, the publicly funded universal health insurance scheme, remains one of the most comprehensive in the world. Its founding principle, that care should be available regardless of income, has broad political and social support.

Yet the practical signals from recent years are a case study in how universal systems drift toward conditional access without any single decision that makes it so.

The decline in bulk billing, the geographic maldistribution of GP services, the structural underfunding of allied health under Medicare, the growing out-of-pocket costs for specialist consultations, the NDIS funding pressures affecting care access for people with disability, each of these is a discrete policy problem. Collectively, they describe a system in which access is becoming more dependent on where you live, what you earn, and how well you can navigate an increasingly complex landscape.

Now, the hidden healthcare crisis of rising fuel costs is adding another barrier. As analysis in Therapy Insights has examined, for people in regional and remote Australia, the effective cost of a healthcare visit, when transport, time, and fuel are included, is substantially higher than the out-of-pocket consultation fee alone. For households managing disability, chronic care, or aged care needs across geographic distances, the fuel cost barrier is not marginal. It is, in many cases, decisive.

This is the Australian dimension of a global pattern: a system that remains universal in formal entitlement is becoming conditional in practical access, and the conditions are determined by factors that health policy has not yet fully accounted for.

What Happens If the Trend Continues

The trajectory, if unaltered, points toward a global healthcare landscape that is structurally bifurcated, not by design, but by the accumulated consequence of underfunded systems, rising costs, declining prevention investment, and household budgets unable to absorb the gap.

In that landscape, healthcare is not a luxury in the sense that only the very wealthy can access any care. It is a luxury in the more insidious sense that timely, high-quality, comprehensive care, the kind that produces good health outcomes, is reliably accessible only to those with the income to navigate, supplement, or bypass a public system under chronic strain.

The consequences of that bifurcation are not limited to health. They extend to workforce productivity, to the sustainability of social insurance systems, to the intergenerational transmission of health disadvantage, and to the political legitimacy of public institutions whose founding promise is no longer being kept in practice.

As the World Inequality Report 2026 observed, inequality is silent until it becomes scandalous, and the resources needed for healthcare are among the casualties of a system in which tax progressivity collapses at the very top, depriving societies of the revenue needed to maintain public goods.

Healthcare is among the most fundamental of those public goods. Its gradual privatisation, through cost transfer to households, through differential wait times, through the retreat of the public system from the full scope of need, is not a sudden crisis. It is a slow one, accumulating quietly in the gap between what health systems promise and what they deliver.

That gap is widening. And the systems responsible for closing it are, in most cases, not yet oriented to do so at the scale or speed that the data demands.

Conclusion: The Question of What We're Willing to Fund

Healthcare becoming a luxury, accessible to all in principle, conditional in practice, is not a fate. It is a choice. It is the aggregate outcome of many smaller choices, made over many years, about how much to invest in prevention, how aggressively to maintain universal access, how to fund the systems that protect the most vulnerable, and how to respond when cost-of-living pressures begin to erode the effective reach of nominally universal entitlements.

Those choices remain open. The data on what prevention investment returns, what early access saves, and what deferred care costs is clear and consistent across health systems globally. The economic case for reversing the drift toward conditional access is as strong as the moral one.

What is required is not a new idea. It is the political and institutional will to act on evidence that has been available for decades, before the drift becomes a divide too wide to close.

Joe Paradza is an Allied Health Leader and Healthcare Economics Analyst. He writes on healthcare economics, disability service delivery, and access policy for Therapy Insights, an independent Australian publication covering the forces shaping care delivery across Australia.

Related reading:
→ People Are Skipping Healthcare Because They Can't Afford It — A Global Crisis Is Emerging
→ The Real Cost of Skipping One Doctor Visit — Global Data Reveals a Growing Risk
→ The Hidden Healthcare Crisis: Rising Fuel Costs