Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US.
Level 3 - non-randomized controlled study
Prospective cohort and cross-sectional survey analyses using nationally representative longitudinal panel data
PubMed 36112374 · doi:10.1001/jamanetworkopen.2022.31898
What was done
Researchers conducted cross-sectional and prospective cohort analyses using data from the 2018, 2019, and 2020 Survey of Income and Program Participation (SIPP) representing US adults across 2017 (n = 51,872), 2018 (n = 40,784), and 2019 (n = 43,220). Multivariable logistic regression models adjusted for demographic, financial, insurance, and health variables to assess risk factors for medical debt and the longitudinal impact of acquiring medical debt between 2017 and 2019 on four social determinants of health (SDOH): food insecurity, inability to pay rent or mortgage, inability to pay utilities, and eviction or foreclosure.
What was found
Medical debt was held by 10.8% (95% CI, 10.6%-11.0%) of individuals and 18.1% of households, with a 2018 mean debt of $21,687 per debtor (median $2,000, IQR $597-$5,000). Indebtedness occurred in 15.3% (95% CI, 14.4%-16.2%) of uninsured and 10.5% (95% CI, 10.2%-18.8%) of privately insured adults. Living in a Medicaid-expansion state was protective (2019 OR, 0.76; 95% CI, 0.70-0.83). Prospectively, acquiring debt was linked to losing insurance (OR, 1.63; 95% CI, 1.23-2.14), new disability (OR, 2.42; 95% CI, 1.95-3.00), and new hospitalization (OR, 2.95; 95% CI, 2.40-3.62). Acquiring medical debt between 2017 and 2019 significantly increased the odds of worsening SDOHs by 2019: food insecurity (OR, 2.20; 95% CI, 1.58-3.05), inability to pay rent/mortgage (OR, 2.29; 95% CI, 1.73-3.03), inability to pay utilities (OR, 2.37; 95% CI, 1.75-3.23), and eviction or foreclosure (OR, 2.95; 95% CI, 1.38-6.31).
Why it matters
Medical debt is widespread even among insured Americans and directly precipitates severe housing and food instability. Expanding insurance and reducing out-of-pocket exposure may prevent downstream deterioration in fundamental social determinants of health.
Limits
The study relies on self-reported survey data, which is vulnerable to recall and misclassification bias. Despite longitudinal adjustment for confounders, observational analysis cannot establish definitive causality, and unmeasured economic shocks or specific clinical diagnoses were not captured in the abstract.