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137 million adults face medical financial hardship

May 2, 2019

Topics: Quote of the Day

By K. Robin Yabroff, Jingxuan Zhao, Xuesong Han, Zhiyuan Zheng
Journal of General Internal Medicine, May 1, 2019



High patient out-of-pocket (OOP) spending for medical care is associated with medical debt, distress about household finances, and forgoing medical care because of cost in the USA.


To examine the national prevalence of medical financial hardship domains: (1) material conditions from increased OOP expenses (e.g., medical debt), (2) psychological responses (e.g., distress), and (3) coping behaviors (e.g., forgoing care); and factors associated with financial hardship.

Design and Participants

We identified adults aged 18–64 years (N = 68,828) and ≥ 65 years (N = 24,614) from the 2015–2017 National Health Interview Survey. Multivariable analyses of nationally representative cross-sectional survey data were stratified by age group, 18–64 years and ≥ 65 years.

Main Measures

Prevalence of material, psychological, and behavioral hardship and hardship intensity.

Key Results

Approximately 137.1 million (95% CI 132.7–141.5) adults reported any medical financial hardship in the past year. Hardship is more common for material, psychological and behavioral domains in adults aged 18–64 years (28.9%, 46.9%, and 21.2%, respectively) than in adults aged ≥ 65 years (15.3%, 28.4%, and 12.7%, respectively; all p < .001). Lower educational attainment and more health conditions were strongly associated with hardship intensity in multivariable analyses in both age groups (p < .001). In the younger group, the uninsured were more likely to report multiple domains of hardship (52.8%), compared to those with some public (26.5%) or private insurance (23.2%) (p < .001). In the older group, individuals with Medicare only were more likely to report hardship in multiple domains (17.1%) compared to those with Medicare and public (12.1%) or Medicare and private coverage (10.1%) (p < .001).


Medical financial hardship is common in the USA, especially in adults aged 18–64 years and those without health insurance coverage. With trends towards higher patient cost-sharing and increasing health care costs, risks of hardship may increase in the future.



By Don McCanne, M.D.

This study from the Surveillance and Health Services Research Program of the American Cancer Society once again confirms what we already knew. Medical financial hardship is common in the United States. It affects about 137 million adults. Although hardship is greater in the 18-64 age group, the prevalence in the Medicare age group is significant as well.

This study is particularly important right now because there is a debate raging over whether we should enact a genuine single payer Medicare for All program to replace our current health care financing system, or if we should perpetuate the current system, heavily dependent on employer-sponsored plans, while adding a public option – the option of a buy-in to the Medicare program.

Unfortunately, our Medicare program has significant deficiencies, as this study further confirms. Merely adding a Medicare-like public option will make only a dent in the 137 million adults that already face financial hardship. It would leave in place the tremendous administrative excesses and other deficiencies of our dysfunctional multi-payer financing system.

In contrast, the true single payer Medicare for All model introduces major improvements in the Medicare program that would prevent financial hardship, and then this improved version of Medicare would be expanded to include everyone. Plus the universal risk pool established is funded with equitable progressive taxes, making it affordable for everyone, while replacing our inequitable, fragmented, often regressive financing system of premiums, deductibles, taxes, cash, and perpetual debt.

So we can prevent financial hardship due to health care, but we cannot do it by merely adding a public option. We need the real thing – a genuine, single payer, improved Medicare for all, not the outdated and inadequate Medicare for some.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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