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Medical Debt – Inadequacy of Mainstream Policy Options from Our Best Policy Think Tanks (Or: Public Policy Think Tanks are Not Thinking)

July 2, 2022

Summary: Today’s post by a visiting blogger reflects on recent policy think tank reports on medical debt, and bemoans the lack of attention to a much-needed major financing makeover.

Comment by: Ana Malinow

It always goes like this: excellent reporting and analysis from the best health policy think tanks detailing how the US health care system is failing, building up to a crescendo that surpasses credulity, followed by a conclusion full of banal suggestions as to how we can address these failures. The storyline never deviates.

Take the Urban Institute’s Which County Characteristics Predict Medical Debt? (covered yesterday in HJM), which maps the geographic distribution and drivers of medical debt, a problem unknown in other high-income countries. To our dismay, we find that “the county’s prevalence of chronic conditions is the strongest predictor of a county’s medical debt in collections.” That means, these human beings and their families, who should be worried about their health, are instead worried about their bills.

And the policy insights to address this unimaginable suffering? Let’s see: first, because many of the counties with the highest rates of medical debt are from states which didn’t expand Medicaid, let’s expand Medicaid, the country’s racialized, second-class health care system for the poor. Forget that these people with chronic illnesses will have to prove their poverty month after month to meet criteria.

What else does the Urban Institute suggest? Consumer protections against surprise bills, even though the Kaiser Family Foundation just wrote that “surprise bills” represent just a fraction of the unexpected and large medical bills many Americans face. Oh, and yes, increase these poor people’s access to more credit, so they can become even more indebted.

What Urban Institute also finds, yet never elaborate upon, is that “counties with a higher share of the population ages 65 and older have lower rates of medical debts in collections.” That’s the age when people become eligible for Medicare – near universal coverage for the elderly. Not worth highlighting, apparently.

I can’t say with certainty what’s driving these very modest policy proposals rather than system-changing reform. I do know that Urban Institute funding is from mainstays of the current system. According to their 2020 Annual Report, that’s 35% federal government (including HHS and MedPAC), 34% foundations (including Merck, Walmart, Gates, Charles Koch Institute, and Walton Family), and 20% corporations (including JP Morgan Chase, Wells Fargo, Bank of America, Salesforce, AARP, Amazon, GM, Microsoft, QuickenLoans, Blue Shield Blue Cross Massachusetts, H&R Block, Lyft, National Associations of Realtors, etc).

And while we are on the subject of excellent reporting and analysis with lame conclusions, the Kaiser Family Foundation, in their recent publication on the burden of medical debt (covered in HJM) goes through excruciating detail describing who has medical debt: just about anyone in the US, but especially people with disabilities, those in worse health, those who live in poverty, Black Americans, people living in the South, and again, people living in Medicaid non-expansion states. At least the KFF has the integrity to write that “simply expanding coverage” will not solve the problem of medical debt in the US. But they refuse to connect the dots they so painstakingly displayed to major system change.

A national, single payer, universal, comprehensive, accessible, equitable health care system would abolish medical debt. Think about it. Why not just come out and say it?


Dr. Malinow is a pediatrician, former president of PNHP, and lead organizer for National Single Payer.

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