1 in 5 households carries medical debt, risks falling into ‘downward spiral of ill health and financial precarity’
Insured or not, few Americans are immune to medical debt. And when a budget-busting event comes, it can significantly worsen such basic social determinants of health (SDOH) as housing security and food affordability.
These are among the findings of researchers at City University of New York who explored possible associations between SDOH and medical debt. JAMA Network Open published the research online Sept. 16.
David Himmelstein, MD, Steffie Woolhandler, MD, MPH and colleagues analyzed three years’ data from the U.S. Census Bureau’s annual Survey of Income and Program Participation (SIPP).
The data reflected responses from almost 136,000 nationally representative participants.
The researchers found that, from 2017 through 2019, 18% of households and 11% of individuals were saddled with medical debt.
U.S. residents with middle-class or low incomes “bear the brunt of this debt burden,” the authors comment. “[O]nly the highest-income and most educated segments of society are relatively spared” [1].
The team did not examine specific sources of medical debt, but a study published earlier this year found many patients worry about their wherewithal to pay for advanced imaging, with some 15% risking their health by foregoing ordered CT or MRI exams [2].
Other key findings from Himmelstein, Woolhandler, et al.:
- Persons with low and middle incomes had similar rates of burden—15.3% of uninsured persons carried debt, as did 10.5% of the privately insured.
- In 2018 the mean medical debt was $21,687 per debtor.
- Acquiring medical debt between 2017 and 2019 was associated with worsening SDOHs, with odds ratios of 2.20 for becoming food insecure, 2.29 for losing ability to pay rent or mortgage, 2.37 for losing ability to pay utilities and 2.95 for eviction or foreclosure in 2019.
The team further found that living in a Medicaid-expansion state was protective against accruing medical debt.
By contrast, losing coverage, becoming disabled or experiencing a new hospitalization all correlated with acquiring medical debt.
Similarly budget-draining were having private high-deductible coverage, coverage by Medicare Advantage or no coverage at all.
In their discussion, Himmelstein and co-authors state their findings suggest incurring medical debt often leads to falling social determinants of health that tend to presage adverse health outcomes.
These include inability to pay utility bills, rent or mortgage, as well as to afford groceries. Resulting adverse outcomes can include such avoidable harms as frailty at birth, the authors point out.
“Hence, unaffordable medical bills may constitute an SDOH in their own right and contribute to a downward spiral of ill health and financial precarity,” they add.
More:
Hospitals and clinics might attenuate these problems by upgrading financial assistance programs, and forbearance in collecting debts. Clinicians’ efforts to screen for adverse SDOHs and make appropriate referrals may also be useful.”
However, clinicians’ efforts “cannot substitute for policy change,” Himmelstein et al. conclude. “Expanding Medicaid coverage nationwide may help reduce medical indebtedness. Eradicating medical debt would require implementing universal coverage that eliminates burdensome out-of-pocket costs.”
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.