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Medical Debt Prevalence, Risk Factors, & Effects on Social Determinants of Health

Summary: A representative multi-year survey of US adults found medical debt in 18% of households, with higher risk for those with no insurance, high deductible private insurance, or Medicare Advantage. Medical debt worsened social determinants of health: more food insecurity, inability to pay for housing and utilities, and eviction or foreclosure.

Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US
JAMA Network Open
September 16, 2022
By David Himmelstein et al.

From the Abstract:

Among 51 872 adults surveyed regarding 2017, 40 784 regarding 2018 and 43 220 regarding 2019, … 10.8% (95% CI, 10.6-11.0) of individuals and approximately 18.1% of households carried medical debt. Persons with low and middle incomes had similar rates; 15.3% (95% CI,14.4-16.2) of uninsured persons had debt, as did 10.5% (95% CI, 10.2-18.8) of the privately-insured. In 2018 the mean medical debt was $21 687/debtor (median $2000 [IQR, $597-$5000])  . . . hospitalization, disability, and having private high-deductible, Medicare Advantage, or no coverage were risk factors associated with medical indebtedness . . .

Acquiring medical debt between 2017 and 2019 was a risk factor associated with worsening social determinants of health, with odds ratios (ORs) of 2.20 (95% CI,1.58-3.05) for becoming food insecure; 2.29 (95% CI, 1.73-3.03) for losing ability to pay rent or mortgage; 2.37 (95% CI, 1.75-3.23) for losing ability to pay utilities; and 2.95 (95% CI, 1.38-6.31) for eviction or foreclosure in 2019.

Comment by: David Himmelstein and Steffie Woolhandler

A raft of previous studies have established that each year millions of Americans suffer catastrophic financial harm from medical debt, and it’s no surprise that people needing hospitalization, the uninsured, and those with disabilities are at highest risk.  So what’s new here? (Disclosure: we’re study authors)

Two findings stand out.  Individuals with Medicare Advantage coverage are, like the uninsured, at high risk of running up medical debts.  And second, that incurring medical debts causes housing and food insecurity – key social determinants of health.

Health system leaders and policy wonks often point to poor housing and nutrition as root causes of ill health, and they’re right.  But they conveniently avoid noting that the health care system itself is a big contributor to housing problems and food insecurity.  As we note in this article, “Unaffordable medical bills … contribute to a downward spiral of ill-health and financial precarity.”

Practicing medicine in American is akin to bailing a boat as the ship’s owners – i.e. the people who make health policy and run our medical institutions – continually drill holes in the hull.

Our patients desperately need national health insurance.

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