Patient health is worse in counties with greater medical debt

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It appears patients have worse health in counties where they also have more medical debt across the United States.

A new study across 2,943 counties found populations with more medical debt also had more days of poor physical and mental health, more years of life lost, and higher mortality rates for all-cause and leading causes of death. The American Cancer Society published the original investigation in JAMA Network Open.

“Patients are increasingly burdened by high out-of-pocket costs for health care in the U.S. including problems paying medicalbills and medical debt, but little was known about county-level associations of medical debt with population health,” lead author Xuesong Han, PhD, said in a news release. Han is scientific director of health services research at the American Cancer Society. “Our findings reinforce medical debt as an important social determinant of health, which, unfortunately, may threaten public health in the country.”

By the numbers

Researchers found an average of 19.8% of people per county had medical debt in collections. Adjusting for sociodemographic characteristics, a one percentage point increase in population with medical debt was associated with 18.3 physically unhealthy days and 17.9 mentally unhealthy days per 1,000 people in the last month.

The same increase was associated with 1.12 years of life lost per 1,000 people, and 7.51 per 100,000 years in age-adjusted, all-cause mortality rate, according to the study.

“Associations of medical debt and elevated mortality rates were consistent for all leading causes of death, such as cancer, heart disease, and suicide,” an accompanying news release said.

Those rates are up from average rates of 4.4 physically unhealthy and 4.7 mentally unhealthy days per person in the past 30 and lost 85.2 years per 1,000 people, or 31 days per person, due to premature death in 2018.

There were 1,949 counties with median medical debt information available. In financial terms, every $100 increase in median medical debt was associated with 8.0 more physically unhealthy days, 6.8 mentally unhealthy days in the past 30, per 1,000 people, 0.64 more years of life lost per 1,000 people, the study said.

The associations between medical debt and mortality rates held in both sexes, with the magnitude generally larger in men than women.

Medicaid expansion

Han noted state expansion of health insurance coverage has helped patients with medical debt. In states that expanded Medicaid income eligibility through the Affordable Care Act, patient medical debt declined by 34 percentage points more than in states that did not expand Medicaid, from $330 to $175, compared with $613 to $550, respectively.

States with counties with the greatest levels of medical debt were Texas, Louisiana, Georgia, Tennessee, South Carolina, North Carolina, and West Virginia. The study noted those also are the states that did not expand Medicaid income eligibility.

Policies to help

The researchers said the findings call for action by lawmakers at every level. The study noted some recent federal policies may help.

For example, in November 2021, the U.S. Consumer Financial Protection Bureau required debt collectors to communicate with debtors before turning over collection information to consumer reporting companies, and to itemize the debt.

The No Surprises Act, signed into law in August 2022, aims to lower out-of-pocket costs for prescription drugs. In April last year, credit bureaus Equifax, Experian and TransUnion announced they removed unpaid medical collections less than $500 from consumer credit reports.

Private employers also can help patients by offering health insurance, providing paid sick leave and health savings accounts when offering high-deductible plans.

Hospitals and health systems also should expand financial assistance and strengthen cost communications to patients, the study said.

At the clinical level, medical staff attempting to identify patients struggling with debt and to connect them with financial and other supportive services, she said.

“Today’s study reiterates how the rising cost of health care in the U.S. continues to take a significant toll on patients and their families,” noted Lisa Lacasse, president of the American Cancer Society Cancer Action Network (ACS CAN). “With a system that continues to be unaffordable for too many touched by cancer, addressing medical debt is a growing public policy priority among cancer patients and survivors. We need lawmakers at all levels of government to take action to make health care more affordable and address medical debt now."

The study was based on data from 2015 to 2019 from sources including the Urban Institute Debt in America project, the University of Wisconsin Population Health Institute, the National Center for Health Statistics and the U.S. Census Bureau.