Medical Debt Associated With Worse Population Health, Higher Mortality

March 08, 2024 - Medical debt was associated with worse population health, including poor physical and mental health and higher mortality rates, a study published in JAMA Network Open indicated.

Medical debt can force patients to delay or forgo care, hinder medication adherence, and exacerbate existing health disparities. Certain populations are particularly susceptible to medical debt, including racial and ethnic minorities, women, uninsured people, those living in rural areas, and those with multiple chronic diseases.

Researchers used 2018 data from the Urban Institute Debt in America project, 2018 data from the County Health Rankings & Roadmaps, and 2015 to 2019 mortality data from the National Center for Health Statistics to determine the associations of medical debt with health status, premature death, and mortality.

Almost 3,000 counties were included in the analysis. A median of 18.3 percent of the population was 65 or older. A median of 0.4 percent were American Indian or Alaska Native individuals, 0.8 percent were Asian or Pacific Islanders, 3.0 percent were Black, 4.3 percent were Hispanic, and 84.5 percent were White.

The average share of people with medical debt was 19.8 percent, ranging from 0 percent to 53.6 percent across counties. Counties with lower shares of White people and higher shares of Black people tended to have higher shares of individuals with medical debt. In addition, medical debt was more common in counties with populations with low educational attainment and higher shares of people with household incomes below the federal poverty level.

People in US counties experienced an average of 4.4 physically unhealthy days and 4.7 mentally unhealthy days per person during the past 30 days in 2018. They lost an average of 85.2 years per 1,000 people due to premature death.

After adjusting for county-level sociodemographic characteristics, a one-percentage-point increase in the population with medical debt was associated with 18.3 more physically unhealthy days and 17.9 additional mentally unhealthy days in the past 30 days per 1,000 people. The increase in medical debt prevalence was also associated with 1.12 more years of life lost per 1,000 people.

The mean county-level all-cause mortality rate was 824.6 per 100,000 person-years from 2015 to 2019. A one-percentage-point increase in the population with medical debt was tied to an increase in the mortality rate of 7.51 per 100,000 person-years. The increase in medical debt prevalence was associated with increases of 1.39, 1.12, 0.71, 0.30, and 0.09 per 100,000 person-years in mortality rates of heart disease, malignant cancers, chronic obstructive pulmonary disease, diabetes, and suicide.

In the 1,949 counties with medical debt information available, every $100 increase in median medical debt was associated with 8.0 more physically unhealthy days and 6.8 more mentally unhealthy days per 1,000 people, with 0.64 more years of life lost per 1,000 people. This increase was also tied to an increase of 4.81 per 100,000 person-years in all-cause mortality rate.

The study findings reinforce medical debt as a social determinant of health that policymakers must address. Expanding insurance coverage, including Medicaid eligibility, has been shown to help minimize medical debt, researchers noted.

Additionally, the No Surprises Act aims to protect consumers from unexpected medical bills, while the Inflation Reduction Act will lower out-of-pocket costs for prescription drugs and extend Affordable Care Act subsidies.

Major credit bureaus have also taken action to reduce the repercussions of medical debt by removing unpaid medical collections under $500 from consumer credit reports.

Extending financial assistance policies to all types of hospitals, establishing clear eligibility criteria for charity care, and imposing stricter regulations on hospitals on medical debt collection could relieve medical debt burdens for patients and improve population health.