Medical Debt Linked to Worse Health Status, Greater Mortality Rates in US

Xuesong Han, PhD

Credit: American Cancer Society

A new study found medical debt is associated with worse health status, physically and mentally, more premature deaths, and greater mortality rates in the US.¹

“Along with accumulating individual-level evidence that medical financial hardship is associated with delayed health care and worse health outcomes, our findings reinforce medical debt as an important social determinant of health, which may threaten public health in the US,” wrote investigators, led by Xuesong Han, PhD, from the Surveillance and Health Equity Science, American Cancer Society.

Medical debt is common in the US. A study of credit report data estimated 17.8% of individuals had medical debt in collections in 2020.² Populations susceptible to getting into medical debt are individuals who are female, younger, rural residents, uninsured, with high-deductible insurance plans, limited health insurance literacy, living in states that have not expanded Medicaid income eligibility under the Patient Protection and Affordable Care Act, and those in racial and ethnic minority groups.¹

Not only is medical debt a financial burden, but it is associated with impacting well-being as these individuals may delay or avoid recommended health care, not take prescription medication, and face food and house insecurity. Medical debt can worsen existing health disparities.

Investigators conducted a cross-sectional study to evaluate the association of medical death with health status, premature death, and mortality in the US. The team leveraged 2018 county-level medical data from the Urban Institute Debt in America project linked with 2018 data on self-reported health status and premature death from the County Health Rankings & Roadmaps, as well as 2015 – 2019 county-level, age-adjusted mortality data from the National Center for Health Statistics. Data was analyzed from August 2022 – May 2023.

Investigators measured health status as the mean number of physically and mentally unhealthy days in the past 30 days per 1000 people. Premature deaths were measured as years of life lost before age 75 years per 1000 people. Lastly, age-adjusted all-cause and 18 cause-specific mortality rates, such as malignant cancers, heart disease, and suicide, were measured per 100,000 person-years.

Han and colleagues used multivariable linear models to estimate the associations between medical debt and health outcomes. In total, 2943 counties were included in the analysis, with 93% of the counties in the US. The median percentage of the county population ≥ 65 years old was 18.3%.

Most of the participants were White residents (84.5%; interquartile range [IQR], 65.7% - 93.3%), followed by Hispanic (4.3%; IQR, 2.3% - 9.7%) Black (3%; IQR; 1.2% - 11.9%), Asian or Pacific Islander (0.8%; IQR, 0.5% - 1.6%), and American Indian or Alaska Native (0.4%; IQR, 0.3% - 0.8%). A mean of 19.8% of the population had medical debt, with a range of 0% - 53.6%.

People in US counties experienced, on average, 4.4 physically unhealthy days and 4.7 mentally unhealthy days per person during the past 30 days and lost 85.2 years per 1000 people, equaling to losing 31 days per person, due to premature death in 2018.

After adjusting for country-level sociodemographic characteristics, investigators found a 1-percentage point increase in the population with medical debt was linked with 18.3 more physically unhealthy days (95% confidence interval [CI], 16.3 – 20.2) and 17.9 more mentally unhealthy days per 1000 people (95% CI, 16.1 – 19.8) during the past month. Additionally, in the past month, investigators observed 1.12 years of life lost per 1000 people, indicating premature deaths (95% CI, 1.03 – 1.21), and an increase of 7.51 per 100,000 person-years in the age-adjusted all-cause mortality rate (95% CI, 6.99 – 8.04).

Furthermore, investigators found consistent associations between medical debt and increased mortality rates for the leading causes of death, including cancer (1.12; 95% CI, 1.02 – 1.22]), heart disease (1.39; 95% CI, 1.21 – 1.57]), and suicide (0.09; 95% CI, 0.06 – 0.11]) per 100 000 person-years.

Investigators said a limitation of the study was the missing medical debt estimates for less populated counties due to using a 2% nationally representative sample of individuals from credit reports. Additionally, they were not able to assess the source of the debt, such as hospitalization or prescriptions, due to a lack of data. They also mentioned not being able to include individuals with medical debt if they were not in the credit system, such as undocumented immigrants.

“These findings suggest that efforts from multiple stakeholders, including federal, state, hospital and health care systems, and employers, to address medical debt may also improve population health in the US,” investigators concluded.

^References

1. ^{Han X, Hu X, Zheng Z, Shi KS, Yabroff KR. Associations of Medical Debt With Health Status, Premature Death, and Mortality in the US. JAMA Netw Open. 2024;7(3):e2354766. Published 2024 Mar 4. doi:10.1001/jamanetworkopen.2023.54766}
2. ^{Kluender R, Mahoney N, Wong F, Yin W. Medical Debt in the US, 2009-2020. JAMA. 2021;326(3):250-256. doi:10.1001/jama.2021.8694}