Study: Medical Debt can Lead to Housing, Food Insecurity

Medical debt is common, even among those who have insurance, and that debt can impact housing and food security, finds a recent study published in JAMA Network Open.

“Our findings implicate poor and worsening health, and particularly hospitalization, as risk factors for medical debt. For those who became disabled or newly experienced hospitalization, health insurance offered only partial protection,” researchers wrote. “Unaffordable medical bills may constitute an SDOH [social determinants of health] in their own right and contribute to a downward spiral of ill-health and financial precarity.”

David U. Himmelstein, M.D.

Researchers, led by David U. Himmelstein, M.D., professor of Health Policy and Management, City University of New York, analyzed data from the Census Bureau 2018, 2019, and 2020 Survey of Income and Program Participation (SIPP). They assessed risk factors for medical debt in two models. The first stratified health-related risk factors, including disability status, hospitalization, or self-reported health status. The second model assessed insurance-related risk factors for medical debt: type of insurance, type of Medicare coverage among beneficiaries., and residence in a Medicaid-expanded states.

They found that a total of 10.8% of adults (and about 18.1% of households) had medical debt, a proportion that declined slightly between 2017 and 2019. Among people who provided data in all three years, 19.75% reported medical debt in at least one year. People with low and middle incomes had similar rates: 15.3%. Of those with private insurance, 10.5% had medical debt.

In 2018, the mean medical debt was $21,687.

In cross-sectional analyses, hospitalization, disability, having private high-deductible, Medicare Advantage, or no coverage were risk factors associated with medical debt. Additionally, losing insurance coverage between 2017 and 2019 was associated with acquiring medical debt by 2019, as was becoming newly disabled or newly hospitalized.

This medical debt was associated with a significant 1.7-fold to 3.1-fold higher risk of worsening housing and food security, the researchers found.

Researchers found that the uninsured and those with high-deductible plans had the highest rates of medical debt. But the authors point out that even those with insurance are at risk for debt. One-fifth of insured adults aged 18 to 64 years incurred unaffordable out-of-pocket costs in 2020, and insurance deductibles left another 7% financially vulnerable. Among Medicare beneficiaries, half spent at least 12% of their income on out-of-pocket medical costs, and one-quarter spent at least 23%. Those with military coverage or traditional Medicare plus private coverage had the lowest rates of medical debt.

The debt for those with Medicare Advantage plans, researchers wrote, may reflect the fact that these plans offer low upfront costs but require high out-of-pocket payments for out-of-network care, prolonged hospitalizations, and other services.

Among the limitations, researchers said, is that the timing of medical events and worsening social determinants of health could not be determined in the Survey of Income and Program Participation. Additionally, these data are self-reported, and data collection difficulties in 2019 and 2020 compromised response rate. In 2019, a government shutdown forced SIPP staff to curtail enrollment and to abandon plans to follow up that panel.

The researchers also said that detailed data on the components of out-of-pocket costs or specific insurance provisions that might increase such costs were not available.