This document discusses issues of affordability within cost-effectiveness analysis and value-based healthcare systems. It makes three key points: 1) For a healthcare system to be sustainably affordable, the cost-effectiveness threshold and budget must be related - a higher budget allows for a higher threshold, reimbursing more drugs at higher prices. 2) Expanding what is included in measuring healthcare value, such as secondary benefits, could raise or lower cost-effectiveness thresholds but may not support a higher overall healthcare budget given fixed resources. 3) Drugs with either very high prices but high patient volumes (e.g. breakthrough therapies) or very high prices but low patient volumes (orphan drugs)