In a recent cross-sectional study published in JAMA Network Open, researchers from the United States of America (US) examined at the county level the relationship between medical debt and health outcomes in the US population.
They found that medical debt was associated with poorer health and increased premature mortality and mortality in the population.
Survey: Associations of medical debt with health status, premature death, and mortality in the United States. Image credit: Pormezz/Shutterstock.com
Background
The increasing economic burden and personal health care costs in the US have led to an alarming rise in medical debt, affecting 17.8% of people in 2020.
Certain vulnerable populations, including racial and ethnic minorities, women, younger individuals, and people with chronic illnesses face a higher risk of incurring medical debt.
This debt is associated with adverse welfare impacts, such as delayed health care, non-adherence to prescriptions, and increased food and housing insecurity. Despite these individual-level associations, the impact of medical debt on county-level health outcomes remains poorly understood.
The current study aimed to address this gap by examining the relationships between medical debt and health status, mortality, and premature death at the US county level using data from the Urban Institute Debt in America project.
About the research
In the present study, debt data were obtained from a 2% nationally representative panel of de-identified credit bureau records. A total of 2,943 US counties were included, of which 39.2% were in metropolitan areas. Counties have an average of 18.3% residents over the age of 65.
The median racial breakdown of residents is as follows: 0.4% American Indian/Alaska Native, 0.8% Asian/Pacific Islander, 3.0% Black, 4.3% Hispanic, and 84.5% White.
Excluded counties are mostly outside the metropolitan area and have smaller population sizes and reduced socio-demographic diversity.
The study examined three sets of health outcomes from public data sources, including self-reported health status, premature death as measured by years of potential life lost, and age-adjusted all-cause and cause-specific mortality rates for leading causes such as cancer, heart diseases, Alzheimer’s, diabetes and suicide, at the US county level.
Additionally, the study considered county-level sociodemographic factors from US Census data, including racial distribution, educational attainment, uninsured status, unemployment, and metropolitan status, as potential confounders.
The analysis examines two measures of medical debt: the primary measure estimates the percentage of individuals with medical debt in collections, while the secondary measure focuses on the average amount of medical debt (in 2018 US dollars).
Total debt, including medical and other types of debt, was also included in additional analyses.
Statistical analysis included the use of descriptive analysis as well as bivariate and multivariate linear models including random intercepts at the state level and weighted by county population size.
Results and discussion
On average, 19.8% of the study population has medical debt. Counties with fewer white and more black residents, lower levels of education, increased poverty, lack of insurance, and unemployment appear to have higher rates of medical debt.
It found that a 1% increase in the population of medical debt holders was associated with 18.3 more physically unhealthy days and 17.9 more mentally unhealthy days per 1,000 people over 30 days.
It also found that a percentage increase in medical debt holders was associated with 1.12 years of life lost per 1,000 person-years and an increase of 7.51 per 100,000 person-years in the age-adjusted all-cause mortality rate.
Consistent associations were found for major causes of death, including heart disease, cancer, chronic obstructive pulmonary disease, diabetes, and suicide.
Patterns were found to be similar for associations between average medical debt and selected health outcomes. Additional analyzes showed similar patterns of association between medical debt and health outcomes.
This nationwide survey confirms that medical debt remains an important social factor in public health.
However, the study is limited by the potential underrepresentation of medical debt in less populated counties, the inability to examine specific sources of medical debt, the exclusion of individuals not in the credit system, and the need for further research into the impact of the coronavirus. Disease 2019 (COVID-19) related policies on medical debt and population health.
Additionally, the broader focus on total debt suggests that policies targeting different types of debt, such as student loans, can affect population health.
Conclusion
In conclusion, the study revealed links between medical debt and adverse health outcomes, such as increased unhealthy days, premature deaths, and increased mortality rates.
The results highlight the need for a collaborative effort among various stakeholders, including government agencies, health systems, hospitals, and employers, to mitigate medical debt with paid sick leave, clear financial assistance policies, and improved cost-related communication with patients.
Additionally, improving access to affordable health care through policies such as health insurance expansion can improve the overall health of the US population.
