Debt and foregone medical care

Medical Debt and the Mental Health Treatment Gap Among US Adults

Importance

Medical debt is common in the US and may hinder timely access to care for mental disorders.

Objective

To estimate the prevalence of medical debt among US adults with depression and anxiety and its association with delayed and forgone mental health care.

Design, Setting, and Participants

Cross-sectional, nationally representative survey study of US adult participants in the 2022 National Health Interview Survey who had current or lifetime diagnoses of depression or anxiety.

Exposures

Self-reported lifetime clinical diagnoses of depression and anxiety; moderate to severe symptoms of current depression (Patient Health Questionnaire-8 score ≥10) and anxiety (Generalized Anxiety Disorder-7 score ≥10) irrespective of lifetime diagnoses; and past-year medical debt.

Main Outcomes and Measures

Self-reported delaying and forgoing mental health care because of cost in the past year.

Results

Among 27 651 adults (15 050 [54.4%] female; mean [SD] age, 52.9 [18.4] years), 5186 (18.2%) reported lifetime depression, 1948 (7.3%) reported current depression, 4834 (17.7%) reported lifetime anxiety, and 1689 (6.6%) reported current anxiety. Medical debt was more common among adults with lifetime depression (19.9% vs 8.6%; adjusted prevalence ratio [aPR], 1.97; 95% CI, 1.96-1.98), lifetime anxiety (19.4% vs 8.8%; aPR, 1.91; 95% CI, 1.91-1.92), current depression (27.3% vs 9.4%; aPR, 2.34; 95% CI, 2.34-2.36), and current anxiety (26.2% vs 9.6%; aPR, 2.24; 95% CI, 2.24-2.26) compared with adults without the respective mental disorders. Medical debt was associated with delayed health care among adults with lifetime depression (29.0% vs 11.6%; aPR, 2.68; 95% CI, 2.62-2.74), lifetime anxiety (28.0% vs 11.5%; aPR, 2.45; 95% CI, 2.40-2.50), current depression (36.9% vs 17.4%; aPR, 2.25; 95% CI, 2.13-2.38), and current anxiety (38.4% vs 16.9%; aPR, 2.48; 95% CI, 2.35-2.66) compared with those without these diagnoses. Medical debt was associated with forgone health care among adults with lifetime depression (29.4% vs 10.6%; aPR, 2.66; 95% CI, 2.61-2.71), lifetime anxiety (28.2% vs 10.7%; aPR, 2.63; 95% CI, 2.57-2.68), current depression (38.0% vs 17.2%; aPR, 2.35; 95% CI, 2.23-2.48), and current anxiety (40.8% vs 17.1%; aPR, 2.57; 95% CI, 2.43-2.75) compared with those without the diagnoses.

Conclusions and Relevance

Medical debt is prevalent among adults with depression and anxiety and may contribute to the mental health treatment gap. In the absence of structural reform, new policies are warranted to protect against this financial barrier to mental health care.

Diabetes and Financial Well-Being: Differential Hardship Among Vulnerable Populations

PURPOSE

The purpose of the study was to examine financial well-being among a diverse population of individuals with and without diabetes.

METHODS

Data from the Understanding America Survey, a nationally representative, longitudinal panel, were utilized to identify adults with self-reported diabetes diagnoses between 2014 and 2020. We used longitudinal mixed effects regression models to assess the association between diabetes and financial well-being score (FWBS) among racial and ethnic population subgroups. Models included sex, age, marital status, household size, income, education, race/ethnicity, insurance, body mass index, employment, and health insurance, incorporating individual- and household-level fixed effects. Racial and ethnic differentials were captured using group-condition interactions.

RESULTS

Black participants (17.06%) had the highest prevalence of diabetes, followed by White participants (12.2%), "other" racial groups (10.7%), and Hispanic participants (10.0%). In contrast, White participants (M = 67.66, SD = 22.63) and other racial groups (M = 67.99, SD = 18.45) had the highest FWBSs, followed by Hispanic participants (M = 59.31, SD = 22.78) and Black participants (M = 55.86, SD = 25.67). Compared to White participants, Black participants (β = -5.49, SE = 0.71) and Hispanic participants (β = -2.06, SE = 0.63) have significantly lower FWBSs. Compared to males, females (β = -3.25, SE = 0.41) had lower FWBSs among individuals with diabetes. FWBSs of individuals with diabetes was 2.71 points lower (SE = 0.52), on average, than those without diabetes. Education, household size, age, marital status, and income were also significantly associated with FWBSs.

CONCLUSIONS

Findings suggest potential disparities in the financial ramifications of diabetes among socially marginalized populations.

When the economy falters, hearts suffer: Economic recessions as a social determinant of health in cardiovascular emergencies

INTRODUCTION

While the relationships between cardiovascular disease (CVD), stress, and financial strain are well studied, the association between recessionary periods and macroeconomic conditions on incidence of disease-specific CVD emergency department (ED) visits is not well established.

OBJECTIVES

This retrospective observational study aimed to assess the relationship between macroeconomic trends and CVD ED visits.

METHODS

This study uses data from the National Hospital Ambulatory Care Survey (NHAMCS), Federal Reserve Economic Database (FRED), National Bureau of Economic Research (NBER), and CVD groupings from National Vital Statistics (NVS) and Center for Medicare and Medicaid Services (CMS) from 1999 to 2020 to analyze ED visits in relation to macroeconomic indicators and NBER defined recessions and expansions.

RESULTS

CVD ED visits grew by 79.7% from 1999 to 2020, significantly more than total ED visits (27.8%, p < 0.001). A national estimate of 213.2 million CVD ED visits, with 22.9 million visits in economic recessions were analyzed. A secondary group including a 6-month period before and after each recession (defined as a "broadened recession") was also analyzed to account for potential leading and lagging effects of the recession, with a total of 50.0 million visits. A significantly higher proportion of CVD ED visits related to heart failure (HF) and other acute ischemic heart diseases (IHD) was observed during recessionary time periods both directly and with a 6-month lead and lag (p < 0.05). The proportion of aortic aneurysm and dissection (AAA) and atherosclerosis (ASVD) ED visits was significantly higher (p = 0.024) in the recession period with a 6-month lead and lag. When controlled for common demographic factors, economic approximations of recession such as the CPI, federal funds rate, and real disposable income were significantly associated with increased CVD ED visits.

CONCLUSION

Macroeconomic trends have a significant relationship with the overall mix of CVD ED visits and represent an understudied social determinant of health.

Postpartum healthcare expenditures for commercially insured deliveries with and without severe maternal morbidity

BACKGROUND

Although severe maternal morbidity is associated with adverse health outcomes in the year after delivery, patterns of healthcare use beyond the 6-week postpartum period have not been well documented.

OBJECTIVE

This study aimed to estimate healthcare utilization and expenditures for deliveries with and without severe maternal morbidity in the 12 months following delivery among commercially insured patients.

STUDY DESIGN

Using data from the 2016 to 2018 IBM Marketscan Commercial Claims and Encounters Research Databases, we identified deliveries to individuals 15 to 49 years of age who were continuously enrolled in noncapitated health plans for 12 months after delivery discharge. We used multivariable generalized linear models to estimate adjusted mean 12-month medical expenditures and 95% confidence intervals for deliveries with and without severe maternal morbidity, accounting for region, health plan type, delivery method, and obstetrical comorbidities. We estimated expenditures associated with inpatient admissions, nonemergency outpatient visits, outpatient emergency department visits, and outpatient pharmaceutical claims.

RESULTS

We identified 366,282 deliveries without severe maternal morbidity and 3976 deliveries (10.7 per 1000) with severe maternal morbidity. Adjusted mean total medical expenditures for deliveries with severe maternal morbidity were 43% higher in the 12 months after discharge than deliveries without severe maternal morbidity ($5320 vs $3041; difference $2278; 95% confidence interval, $1591-$2965). Adjusted mean expenditures for readmissions and nonemergency outpatient visits during the 12-month postpartum period were 61% and 39% higher, respectively, for deliveries with severe maternal morbidity compared with deliveries without severe maternal morbidity. Among deliveries with severe maternal morbidity, adjusted mean total costs were highest for patients living in the western region ($7831; 95% confidence interval, $5518-$10,144) and those having a primary cesarean ($7647; 95% confidence interval, $6323-$8970).

CONCLUSION

Severe maternal morbidity at delivery is associated with increased healthcare use and expenditures in the year after delivery. These estimates can inform planning of severe maternal morbidity prevention efforts.

Financial Impact of Imaging Examination Site of Service in the Medicare Population

PURPOSE

The financial sustainability of the US healthcare system is a growing concern in an environment of declining reimbursement and rising costs. Variable Centers for Medicare and Medicaid (CMS) reimbursement and denial rates for specific imaging examinations exist across sites of service, adding complexity to financial planning for healthcare organizations. Understanding the financial implications of site of service in existing CMS reimbursement for imaging may be of strategic importance for organizations going forward.

MATERIALS AND METHODS

Current Procedural Terminology (CPT) codes were obtained for common cross-sectional imaging examinations using the 2022 CMS Medicare Physician Fee Schedule. Using reimbursement rates with historical volumes and denial rates, a simulation was created to estimate the overall reimbursement of paired hospital outpatient departments (HOPD) and free-standing office (FSO) sites. A baseline simulation was performed with random allocation of imaging examinations between sites of service, and an optimized simulation was performed to estimate the maximum financial impact of targeted allocation between sites. These simulations were performed for paired CT and MR scanners separately.

RESULTS

For CT, the baseline simulation estimated annual average reimbursement for combined HOPD and FSO was $3.25M. Reimbursement increased to $3.51M after optimized reallocation of studies between sites of service, resulting in an expected gain of $260,162 for a set of paired HOPD and FSO scanners. For MR, the same approach resulted in baseline reimbursement of $2.51M, increasing to $2.60M upon reallocation between sites for an expected gain of $87,532. Assuming a stable cost of service delivery, this approach would result in improved margins of 8% for CT and 3.5% for MR. There were 28 CT and 19 MRI daily patient imaging appointments at each respective HOPD and FSO scanners, unchanged between baseline and optimized cases. Differences in reimbursement rates between sites were the dominant driver of increased margins at low denial rates, although denial rates became dominant at values greater than 50%.

CONCLUSION

Given CMS payment and denial rate variability, optimally allocating imaging studies between sites of service may improve reimbursement for the same services delivered. Although financial incentives exist for site allocation, such decisions should require physician input to assess safety and appropriate level of care. This work contributes to an understanding of financial incentives of existing reimbursement policy and may guide future policy design towards high value care.

The Association of Childbirth with Medical Debt in the USA, 2019-2020

BACKGROUND

Medical debt affects one in five adults in the USA and may disproportionately burden postpartum women due to pregnancy-related medical costs.

OBJECTIVE

To evaluate the association between childbirth and medical debt, and the correlates of medical debt among postpartum women, in the USA.

DESIGN

Cross-sectional.

PARTICIPANTS

We analyzed female "sample adults" 18-49 years old in the 2019-2020 National Health Interview Survey, a nationally representative household survey.

MAIN MEASURES

Our primary exposure was whether the subject gave birth in the past year. We had two family-level debt outcomes: problems paying medical bills and inability to pay medical bills. We examined the association between live birth and medical debt outcomes, unadjusted and adjusted for potential confounders in multivariable logistic regressions. Among postpartum women, we also examined the association between medical debt with maternal asthma, hypertension, and gestational diabetes and several sociodemographic factors.

KEY RESULTS

Our sample included n = 12,163 women, n = 645 with a live birth in the past year. Postpartum women were younger, more likely to have Medicaid, and lived in larger families than those not postpartum. 19.8% of postpartum women faced difficulty with medical bills versus 15.1% who were not; in multivariable regression, postpartum women had 48% higher adjusted odds of medical debt problems (95% CI 1.13, 1.92). Results were similar when examining inability to pay medical bills, and similar differences were seen for privately insured women. Among postpartum women, those with lower incomes and with asthma or gestational diabetes, but not hypertension, had significantly higher adjusted odds of medical debt problems.

CONCLUSIONS

Postpartum women experience higher levels of medical debt than other women; poorer women and those with common chronic diseases may have an even higher burden. Policies to expand and improve health coverage for this population are needed to improve maternal health and the welfare of young families.

Patient adverse financial outcomes before and after COVID-19 infection

Adverse financial outcomes after COVID-19 infection and hospitalization have not been assessed with appropriate comparators to account for other financial disruptions of 2020-2021. Using credit report data from 132,109 commercially insured COVID-19 survivors, we compared the rates of adverse financial outcomes for two cohorts of individuals with credit outcomes measured before and after COVID-19 infection, using an interaction term between cohort and hospitalization to test whether adverse credit outcomes changed more for hospitalized than nonhospitalized COVID-19 patients. Covariates included age group, gender, and several area-level social determinants of health. Adverse financial outcomes were significantly more common after COVID-19 infection than before COVID-19 infection, with greater increases among those hospitalized with COVID-19 (5-8 percentage points) than among nonhospitalized patients (1-3 percentage points). Future work examining longitudinal financial outcomes before and after COVID-19 infection is needed to determine the causal mechanisms of this association to reduce financial hardship from COVID-19 and other conditions.

Cost communication in cosmetic and reconstructive breast surgery: Public perceptions in the United States

BACKGROUND

There is a need to better understand the financial toxicity of surgery on patients. Recent data demonstrated that plastic surgeons seldom discuss out-of-pocket costs with patients. Not much is known regarding the public perceptions of out-of-pocket cost communication in reconstructive and cosmetic breast surgery.

METHODS

A cross-sectional survey was administered to adult women in the United States from November 2021 to December 2021 using Amazon Mechanical Turk. Perceptions regarding cost communication in plastic surgery were gathered. Incomplete responses were excluded. Multivariable models were used to identify predictors of responses.

RESULTS

There were 512 complete responses. Respondents had a mean age of 37.4 years. The majority strongly agreed or agreed that plastic surgeons should discuss out-of-pocket costs with patients undergoing implant-based breast reconstruction (85%), plastic surgeons should know the impact of surgery on patients' financial well-being (78%), and discussing costs was the most important aspect of the appointment (70%). Respondents who were unsure of their insurance status had lower odds of strongly agreeing or agreeing that surgeons should discuss out-of-pocket costs for autologous reconstruction (OR 0.12, CI 0.02-0.58, p = 0.01) and cosmetic breast augmentation (OR 0.14, CI 0.03-0.65, p = 0.01). Privately insured respondents had greater odds of strongly agreeing or agreeing to both, respectively (OR 2.21, CI 1.32-3.82, p < 0.01; OR 1.94, CI 1.17-3.31, p = 0.01) CONCLUSION: Many laywomen support the cost communication in plastic surgery and believe that plastic surgeons should know the impact of surgery on the patients' financial well-being, with variability among the sociodemographic groups. Plastic surgeons should strongly consider discussing costs with patients undergoing breast surgery.

Fintech and medical expenses: What social workers should know

Individuals who cannot afford out of pocket medical expenses may reduce health care use, resulting in poorer health outcomes. To ease the situation, employers turn to financial technology ("fintech") health care credit applications. We examine whether an employer-sponsored credit fintech application (MedPut) helps employees manage medical expenses. Results of the analysis of variance (ANOVA) and probit regression models reveal MedPut users did worse financially and delayed health care due to cost more often than employees who did not use MedPut. Results may inform social work policy and direct practice perspectives on fin-tech and medical expenses.

Student loans, physical and mental health, and health care use and delay in college

Objective: Determine relationships between college students' student loan presence and self-rated physical and mental health, major medical problems, mental health conditions, physical, dental, and mental health care visits and delays, and medication use and reductions. Participants: A total of 3,248 undergraduates at two regional public U.S. universities, surveyed Spring 2017. Methods: OLS and Logistic regression. Results: Loan presence was related to significantly worse self-rated physical and mental health and more major medical problems, but not to mental health conditions, or physical or mental health medication use. Respondents with loans were less likely to visit the dentist and more likely to report delaying medical, dental, and mental health care, and reducing medication use to save money. Conclusions: Results provide evidence of health and health care use divides among college students by loan presence.

Disease and debt: Findings from the 2019 Panel Study of Income Dynamics in the United States

Medical debt has grown dramatically over the past few decades. While cancer and diabetes are known to be associated with medical debt, little is known about the impact of other medical conditions and health behaviors on medical debt. We analyzed cross-sectional data on 9174 households - spanning lower-income, middle-income, and higher-income based on the Census poverty threshold - participating in the 2019 wave of the nationally representative United States Panel Study of Income Dynamics (PSID). The outcomes were presence of any medical debt and presence of medical debt≥ $2000. Respondents reported on medical conditions (diabetes, cancer, heart disease, chronic lung disease, asthma, arthritis, anxiety disorders, mood disorders) and on health behaviors (smoking, heavy drinking). Medical debt was observed in lower-income households with heart disease (OR = 2.64, p-value = 0.006) and anxiety disorders (OR = 2.16, p-value = 0.02); middle-income households with chronic lung disease (OR = 1.73, p-value = 0.03) and mood disorders (OR = 1.53, p-value = 0.04); and higher-income households with a current smoker (OR = 2.99, p-value<0.001). Additionally, medical debt ≥$2000 was observed in lower-income households with asthma (OR = 2.16, p-value = 0.009) and a current smoker (OR = 1.62, p-value = 0.04); middle income households with hypertension (OR = 1.65, p-value = 0.05). These novel findings suggest that the harms of medical debt extend beyond cancer, diabetes and beyond lower-income households. There is an urgent need for policy and health services interventions to address medical debt in a wider range of disease contexts than heretofore envisioned. Intervention development would benefit from novel conceptual frameworks on the causal relationships between health behaviors, health conditions, and medical debt that center social-ecological influences on all three of these domains.

Association of Chronic Disease With Patient Financial Outcomes Among Commercially Insured Adults

Importance

The bidirectional association between health and financial stability is increasingly recognized.

Objective

To describe the association between chronic disease burden and patients' adverse financial outcomes.

Design, Setting, and Participants

This cross-sectional study analyzed insurance claims data from January 2019 to January 2021 linked to commercial credit data in January 2021 for adults 21 years and older enrolled in a commercial preferred provider organization in Michigan.

Exposures

Thirteen common chronic conditions (cancer, congestive heart failure, chronic kidney disease, dementia, depression and anxiety, diabetes, hypertension, ischemic heart disease, liver disease, chronic obstructive pulmonary disease and asthma, serious mental illness, stroke, and substance use disorders).

Main Outcomes and Measures

Adjusted probability of having medical debt in collections, nonmedical debt in collections, any delinquent debt, a low credit score, or recent bankruptcy, adjusted for age group and sex. Secondary outcomes included the amount of medical, nonmedical, and total debt among individuals with nonzero debt.

Results

The study population included 2 854 481 adults (38.4% male, 43.3% female, 12.9% unknown sex, and 5.4% missing sex), 61.4% with no chronic conditions, 17.7% with 1 chronic condition, 14.8% with 2 to 3 chronic conditions, 5.4% with 4 to 6 chronic conditions, and 0.7% with 7 to 13 chronic conditions. Among the cohort, 9.6% had medical debt in collections, 8.3% had nonmedical debt in collections, 16.3% had delinquent debt, 19.3% had a low credit score, and 0.6% had recent bankruptcy. Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition. Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) (all P < .001). In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions.

Conclusions and Relevance

This cross-sectional study of commercially insured adults linked to patient credit report outcomes shows an association between increasing burden of chronic disease and adverse financial outcomes.

Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US

IMPORTANCE

Cost barriers discourage many US residents from seeking medical care and many who obtain it experience financial hardship. However, little is known about the association between medical debt and social determinants of health (SDOH).

OBJECTIVE

To determine the prevalence of and risk factors associated with medical debt and the association of medical debt with subsequent changes in the key SDOH of food and housing security.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analyses using multivariable logistic regression models controlled for demographic, financial, insurance, and health-related factors, and prospective cohort analyses assessing changes over time using the 2018, 2019, and 2020 Surveys of Income and Program Participation. Participants were nationally representative samples of US adults surveyed for 1 to 3 years.

EXPOSURES

Insurance-related and health-related characteristics as risk factors for medical debt; Newly incurred medical debt as a risk factor for deterioration in SDOHs.

MAIN OUTCOMES AND MEASURES

Prevalence and amounts of medical debt; 4 SDOHs: inability to pay rent or mortgage or utilities; eviction or foreclosure; and food insecurity.

RESULTS

Among 51 872 adults surveyed regarding 2017, 40 784 regarding 2018 and 43 220 regarding 2019, 51.6% were female, 16.8% Hispanic, 6.0% were non-Hispanic Asian, 11.9% non-Hispanic Black, 62.6% non-Hispanic White, and 2.18% other non-Hispanic. A total of 10.8% (95% CI, 10.6-11.0) of individuals and approximately 18.1% of households carried medical debt. Persons with low and middle incomes had similar rates: 15.3%; (95% CI,14.4-16.2) of uninsured persons had debt, as did 10.5% (95% CI, 10.2-18.8) of the privately-insured. In 2018 the mean medical debt was $21 687/debtor (median $2000 [IQR, $597-$5000]). In cross-sectional analyses, hospitalization, disability, and having private high-deductible, Medicare Advantage, or no coverage were risk factors associated with medical indebtedness; residing in a Medicaid-expansion state was protective (2019 odds ratio [OR], 0.76; 95% CI, 0.70-0.83). Prospective findings were similar, eg, losing insurance coverage between 2017 and 2019 was associated with acquiring medical debt by 2019 (OR, 1.63; 95% CI, 1.23-2.14), as was becoming newly disabled (OR, 2.42; 95% CI, 1.95-3.00) or newly hospitalized (OR, 2.95; 95% CI, 2.40-3.62). Acquiring medical debt between 2017 and 2019 was a risk factor associated with worsening SDOHs, with ORs of 2.20 (95% CI,1.58-3.05) for becoming food insecure; 2.29 (95% CI, 1.73-3.03) for losing ability to pay rent or mortgage; 2.37 (95% CI, 1.75-3.23) for losing ability to pay utilities; and 2.95 (95% CI, 1.38-6.31) for eviction or foreclosure in 2019.

CONCLUSIONS AND RELEVANCE

In this cross-sectional and cohort study, medical indebtedness was common, even among insured individuals. Acquiring such debt may worsen SDOHs. Expanded and improved health coverage could ameliorate financial distress, and improve housing and food security.

Student Debt and Cardiovascular Disease Risk Among U.S. Adults in Early Mid-Life

INTRODUCTION

Student loan debt has become common for young adults in the U.S. and is correlated with poor physical and mental health. It is unclear how the accumulation or repayment of student debt is associated with longer-term cardiovascular risks and chronic inflammation.

METHODS

Nationally representative data collected between 1994 and 2018 from >4,000 participants of a U.S. cohort study were analyzed in 2021 to assess the associations among change in student debt between young adulthood and early mid-life, 30-year Framingham cardiovascular disease risk scores, and C-reactive protein levels.

RESULTS

Ordinary least squares regression revealed higher cardiovascular disease and C-reactive protein risks among those in households who became indebted or were consistently in debt between young adulthood and early mid-life than among those in households who were either never in debt or repaid their loans. This pattern persisted after adjustments for degree completion, socioeconomic measures, and other sources of debt.

CONCLUSIONS

These findings provide a benchmark for widening health inequalities among a cohort bearing more student debt than any other in U.S.

HISTORY

As student debt accumulates, within-cohort disparities in cardiovascular disease and related morbidities may undermine the health benefits of postsecondary education.

Dynamics of Financial Hardship in the United States: Health and Retirement Study 2006-2016

The purpose of this study was to examine the temporal trends and dynamics of financial hardship among older adults in the U.S. between 2006 and 2016 using the Health and Retirement Study. Sample included a total of 13,537 eligible person observations with a median age of 68 years. Financial hardship included measures of difficulty paying bills, food insecurity, taking less medication due to cost, and ongoing financial strain. Regression analyses were performed using a three-wave quadrennial model to estimate the prevalence of financial hardship over time, to explore temporal patterns and identify persistent hardship. Findings reveal that 51% of respondents who experienced food insecurity at one or more waves were transient. This pattern was similar to respondents who experienced ongoing financial strain (52% transient). Respondents who reported difficulty paying bills (68%) and reduced medications due to cost (62%) were also transient. Significant predictors across all four domains of financial hardship include age, years of education, marital status, self-rated health. Being African American was positively associated with reduced medication use and food insecurity. This study provides insight into the temporal dynamics of financial hardship in later life. It also highlights the contiguous, intermediate and transient nature of financial hardship among older adult populations.

The inequalities and determinants of Households' Distress Financing on Out-off-Pocket Health expenditure in Malaysia

Background

Out-of-pocket (OOP) payments for healthcare services potentially have severe consequences on households, especially among the poor. Under certain circumstances, healthcare payments are financed through selling household assets, or borrowings. This certainly could influence households’ decision, which likely resorts to forgoing healthcare services. Thus, the focal point of this study is aimed to identify the inequalities and determinants of distress financing among households in Malaysia.

Methods

This study used secondary data from the National Health and Morbidity Survey (NHMS) 2019, a national cross-sectional household survey that used a two-stage stratified random sampling design involving 5,146 households. The concentration curve and concentration index were used to determine the economic inequalities in distress financing. Whereas, the determinants of distress financing were identified using the modified Poisson regression model.

Results

The prevalence of borrowing without interest was the highest (13.86%), followed by borrowing with interest (1.03%) while selling off assets was the lowest (0.87%). Borrowing without interest was highest among rural (16.21%) and poor economic status (23.34%). The distribution of distress financing was higher among the poor, with a concentration index of -0.245. The modified Poisson regression analysis revealed that the poor, middle, rich, and richest had 0.57, 0.58, 0.40 and 0.36 times the risk to develop distress financing than the poorest socio-economic group. Whereas, the presence of one and two or more elderly were associated with a 1.94 and 1.59 times risk of experiencing distress financing than households with no elderly members. The risk of developing distress financing was also 1.28 and 1.58 times higher among households with one and two members receiving inpatient care in the past 12 months compared to none.

Conclusions

The findings implied that the improvement of health coverage should be emphasized to curtail the prevalence of distress financing, especially among those caring for the elderly, requiring admission to hospitals, and poor socio-economic groups. This study could be of interest to policymakers to help achieve and sustain health coverage for all.

Landfall After the Perfect Storm: Cohort Differences in the Relationship Between Debt and Risk of Heart Attack

Analyses of the Health and Retirement Study (HRS) between 1992 and 2014 compare the relationship between different levels and forms of debt and heart attack risk trajectories across four cohorts. Although all cohorts experienced growing household debt, including the increase of both secured and unsecured debt, they nevertheless encountered different economic opportunity structures and crises at sensitive times in their life courses, with implications for heart attack risk trajectories. Results from frailty hazards models reveal that unsecured debt is associated with increased risk of heart attack across all cohorts. Higher levels of housing debt, however, predict higher rates of heart attack among only the earlier cohorts. Heart attack risk trajectories for Baby Boomers with high levels of housing debt are lower than those of same-aged peers with no housing debt. Thus, the relationship between debt and heart attack varies by level and form of debt across cohorts but distinguishes Baby Boomer cohorts based on their diverse exposures to volatile housing market conditions over the sensitive household formation period of the life course.

Medical Debt in the US, 2009-2020

IMPORTANCE

Medical debt is an increasing concern in the US, yet there is limited understanding of the amount and distribution of medical debt, and its association with health care policies.

OBJECTIVE

To measure the amount of medical debt nationally and by geographic region and income group and its association with Medicaid expansion under the Affordable Care Act.

DESIGN, SETTING, AND PARTICIPANTS

Data on medical debt in collections were obtained from a nationally representative 10% panel of consumer credit reports between January 2009 and June 2020 (reflecting care provided prior to the COVID-19 pandemic). Income data were obtained from the 2014-2018 American Community Survey. The sample consisted of 4.1 billion person-month observations (nearly 40 million unique individuals). These data were used to estimate the amount of medical debt (nationally and by geographic region and zip code income decile) and to examine the association between Medicaid expansion and medical debt (overall and by income group).

EXPOSURES

Geographic region (US Census region), income group (zip code income decile), and state Medicaid expansion status.

MAIN OUTCOMES AND MEASURES

The stock (all unpaid debt listed on credit reports) and flow (new debt listed on credit reports during the preceding 12 months) of medical debt in collections that can be collected on by debt collectors.

RESULTS

In June 2020, an estimated 17.8% of individuals had medical debt (13.0% accrued debt during the prior year), and the mean amount was $429 ($311 accrued during the prior year). The mean stock of medical debt was highest in the South and lowest in the Northeast ($616 vs $167; difference, $448 [95% CI, $435-$462]) and higher in poor than in rich zip code income deciles ($677 vs $126; difference, $551 [95% CI, $520-$581]). Between 2013 and 2020, the states that expanded Medicaid in 2014 experienced a decline in the mean flow of medical debt that was 34.0 percentage points (95% CI, 18.5-49.4 percentage points) greater (from $330 to $175) than the states that did not expand Medicaid (from $613 to $550). In the expansion states, the gap in the mean flow of medical debt between the lowest and highest zip code income deciles decreased by $145 (95% CI, $95-$194) while the gap increased by $218 (95% CI, $163-$273) in the nonexpansion states.

CONCLUSIONS AND RELEVANCE

This study provides an estimate of the amount of medical debt in collections in the US based on consumer credit reports from January 2009 to June 2020, reflecting care delivered prior to the COVID-19 pandemic, and suggests that the amount of medical debt was highest among individuals living in the South and in lower-income communities. However, further study is needed regarding debt related to COVID-19.

The price of mental well-being in later life: the role of financial hardship and debt

OBJECTIVE

This study investigated the associations between various financial hardship and debt indicators and mental health status among older adults.

METHODS

Using data from the Health and Retirement Study (HRS), we considered the association between different forms of financial hardship and debt of those who were identified as having high levels of depressive symptoms (N = 7678) and anxiety (N = 8079). Financial hardship indicators: difficulty paying bills, food insecurity, and medication need; debt indicators: credit card and medical debt. Associations were tested using multiple logistic regression analyses and are reported as relative risk (RR) ratios and 95% confidence intervals (CIs).

RESULTS

Participants who had difficulty paying bills were more likely to have high levels of depressive symptoms (RR = 2.06, CI = 1.75-2.42, p < 0.001) and anxiety (RR = 1.46, CI = 1.02-2.05, p < 0.001) compared to those who did not have financial difficulty. Similarly, medical debt was associated with depressive symptoms (RR = 1.43, CI = 1.14-1.74, p < 0.01) and anxiety (RR = 1.20, CI = 0.96-1.50, p < 0.01). Credit card debt was not significantly associated with either mental health outcome.

CONCLUSION

Indicators of financial hardship and medical debt were associated with depressive symptoms and anxiety in a cohort of older adults. In contrast, the influence of credit card debt appeared to be more complex and vary by individual. These findings indicate that doing without meeting personal salient needs has a particularly adverse effect on psychological well-being.

Varieties of Financial Stressors and Midlife Health Problems

OBJECTIVES

Financial stressors such as wealth loss, indebtedness, and bankruptcy have gained the attention of public health scholars since the Great Recession. In this study, we extend this area of research by comparing the mental and physical impact of multiple financial stressors during midlife, a pivotal period in the life course for wealth accumulation and disease onset.

METHODS

With data from the National Longitudinal Survey of Youth 1979 (www.nlsinfo.org), an ongoing survey of adult men and women in the U.S., we used logistic regression to estimate the associations between financial stressors and the risk of a psychiatric disorder or high blood pressure diagnosis from ages 31-39 in 1996 to ages 50-59 in 2016 (N = 7,143). Financial stressors include multiple types of wealth loss, debt, and bankruptcy.

RESULTS

Even after adjusting for a comprehensive set of confounders, many of the financial stressors we considered had similar associations with the risk of a psychiatric disorder, whereas only debt and bankruptcy were associated with the risk of high blood pressure. The best fitting models for both health outcomes included a simple indicator of indebtedness. Stock losses were not significantly associated with either health outcome.

DISCUSSION

Given the recent volatility in the U.S. economy, our results highlight the potential loss of health that may occur if nothing is done to prevent economically vulnerable populations from sliding into financial crisis. Our results also emphasize the need for additional research to develop individual-level interventions to improve health among those already experiencing financial difficulties.

Contact by Collection Agencies for Medical Debt: Rural-Urban Differences Among Older and Younger Medicare Beneficiaries

Geographic disparities in health and health care are increasingly well-documented, as are financial barriers to accessing care. Still, less is known about whether Medicare beneficiaries differ in their ability to pay for care by rurality. Using data from the 2016 Medicare Current Beneficiary Survey (n = 12,688 U.S. community-dwelling beneficiaries), we analyzed rural-urban differences in rates of collection agency contact for unpaid medical bills using chi-square tests and multivariable logistic regression for the full sample and by age (65+ and <65). Nearly 10% of Medicare beneficiaries had been contacted by a collection agency for medical debt in the previous year, with higher percentages among rural beneficiaries (8% for urban vs 10% for rural micropolitan and 11% for rural noncore, p < .05). This difference attenuated after adjusting for educational attainment and income, suggesting that attention to socio-economic status among rural Medicare beneficiaries would help to address financial barriers to care and decrease medical debt.

Is less more? Examining the relationship between food assistance benefit levels and childhood weight

BACKGROUND

The Supplementary Nutrition Assistance Program (SNAP) is a critical lifeline for millions of low-income US families, but some studies suggests that it may inadvertently increase obesity risk. Building on research contesting the SNAP-obesity link, we examine the effect of SNAP participation on BMI among multiyear participants at varying levels of SNAP benefit levels to provide some of the first evidence on the relationship between SNAP participation, state-level SNAP resources, and body weight. We focus on children given the strong links between early-life obesity and later-life health.

METHODS

Linking state-level data on SNAP benefit levels with three waves of longitudinal individual-level data from the Child Development Supplement of the Panel Study of Income Dynamics, we use child- and state-level fixed effects to examine whether exogenous differences in SNAP benefit allotments influence the relationship between SNAP participation and weight gain.

RESULTS

Lower SNAP benefit levels were associated with only modest increases in BMI among children; higher benefit levels showed no association with BMI.

CONCLUSIONS

Although concerns that more food assistance promotes obesity have spurred calls for cuts in the SNAP program, we find the opposite - that SNAP participation is associated with an increase in childhood BMI only when benefit levels are low. This study adds to the mounting evidence suggesting that SNAP does not cause obesity. It also contributes to the literature on the political economy of health, especially that pertaining to social policy variation across US states.

What contributes to medical debt? Evidence from patients in rural China

BACKGROUND

Rural households in developing countries usually have severe medical debt due to high out-of-pocket (OOP) payments, which contributes to bankruptcy. China implemented the critical illness insurance (CII) in 2012 to decrease patients' medical expenditure. This paper aimed to explore the medical debt of rural Chinese patients and its influencing factors.

METHODS

A questionnaire survey of health expenditures and medical debt was conducted in two counties of Central and Western China in 2017. Patients who received CII were used as the sample on the basis of multi-stage stratified cluster sampling. Descriptive statistics and multivariate analysis of variance were used in all data. A two-part model was used to evaluate the occurrence and extent of medical debt.

RESULTS

A total of 826 rural patients with CII were surveyed. The percentages of patients incurring medical debt exceeded 50% and the median debt load was 20,000 Chinese yuan (CNY, 650 CNY = US$100). Financial assistance from kin (P < 0.001) decreased the likelihood of medical debt. High inpatient expenses (IEs, P < 0.01), CII reimbursement ratio (P < 0.001), and non-direct medical costs (P < 0.001) resulted in increased medical debt load.

CONCLUSIONS

Medical debt is still one of the biggest problems in rural China. High IEs, CII reimbursement ratio, municipal or high-level hospitals were the risk determinants of medical debt load. Financial assistance from kin and household income were the protective factors. Increasing service capability of hospitals in counties could leave more patiemts in county-level and township hospitals. Improving CII with increased reimbursement rate may also be issues of concern.

Trajectories of Unsecured Debt across the Life Course and Mental Health at Midlife

In this paper, we contribute to a growing literature on debt and mental health and ask whether patterns of unsecured debt accumulation and repayment over two decades are associated with depressive symptoms at age 50. Using data from the National Longitudinal Study of Youth 1979 Cohort and group trajectory models, we have three key findings. First, we find substantial heterogeneity in debt trajectories across the life course. Second, respondents who report consistently high debt levels across the life course or who cycle in and out of high debt report significantly more depressive symptoms than respondents who hold consistently low levels of debt. These findings hold for both absolute and relative (debt-to-income) debt. Third, we find that the association between debt and depressive symptoms is strongest among respondents with less than a college degree, but we find less evidence for heterogeneity by race in this cohort.

Cost-related medication nonadherence among over-indebted individuals enrolled in statutory health insurance in Germany: a cross-sectional population study

Background

Millions of citizens in high-income countries face over-indebtedness that implies being unable to cover payment obligations with available income and assets on an ongoing basis. Studies have shown an association between over-indebtedness and health outcomes, independent of standard socioeconomic status measures. Patterns of cost-related medication nonadherence (CRN) among over-indebted individuals are yet unclear. The aim of this study was to examine the frequency of nonadherence to prescribed medications due to cost, and to identify risk factors for CRN among over-indebted individuals in Germany.

Methods

In 2017, we conducted a cross-sectional survey among over-indebted individuals recruited in 70 debt advice agencies in North Rhine-Westphalia, Germany. Data on CRN in the last 12 months (i.e. not filling prescriptions, skipping or decreasing doses of prescribed medication due to financial problems) were collected by a survey using a self-administered written questionnaire that was returned by 699 individuals with a response rate of 50.2%. Prevalence of CRN was assessed using descriptive statistics. Multiple logistic regression analysis was performed to examine risk factors of CRN, including participants enrolled in statutory health insurance with complete data (n = 521).

Results

The prevalence of CRN was 33.6%. The chronically ill had significantly greater odds of cost-related medication nonadherence (aOR 1.96; 95% CI 1.27–3.03) than individuals without a chronic illness. CRN was more likely to occur in individuals who had discussed financial problems with their general practitioner (aOR 1.58; 95% CI 1.01–2.47). There was no association between CRN and other sociodemographic factors or socioeconomic status.

Conclusions

Medication nonadherence due to financial pressures is common among over-indebted citizens enrolled in statutory health insurance in Germany. Stakeholders in social policy, research and health care need to address over-indebtedness to develop strategies to safeguard access to relevant medications, especially among those with high morbidity.

Trial registration

Arzneimittelkonsum, insbesondere Selbstmedikation bei überschuldeten Bürgerinnen und Bürgern in Nordrhein-Westfalen (ArSemü), (engl. ‘Medication use, particularly self-medication among over-indebted citizens in North Rhine-Westphalia’), German Clinical Trials Register: DRKS00013100. Date of registration: 23.10.2017. Date of enrolment of the first participant: 18.07.2017, retrospectively registered.

Short-term lending: Payday loans as risk factors for anxiety, inflammation and poor health

While research now consistently links consumer financial debt with adverse emotional health outcomes, specific forms of debt and their impact on measures of physical health are underexplored. This gap in knowledge is significant because different forms of loans and debt may have different experiential qualities. In this paper, we focus on a type of unsecured debt - short-term/payday loan borrowing – that has risen dramatically in recent decades in the United States and is characterized by predatory, discriminatory, and poorly regulated lending practices. Using data from a study of debt and health among adults in Boston, MA (n=286), we test whether short-term borrowing is associated with a range of emotional and physical health indicators. We find that short-term loans are associated with higher body mass index, waist circumference, C-reactive protein levels, and self-reported symptoms of physical health, sexual health, and anxiety, after controlling for several socio-demographic covariates. We discuss these findings within the contexts of regulatory shortcomings, psychosocial stress, and racial and economic credit disparities. We suggest that within the broader context of financial debt and health, short-term loans should be considered a specific risk to population health.

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Short-term loans (STL) are associated with multiple indicators of poor health

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Prior research has explored general debt as a health determinant

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Specific types of debt, like STL, are understudied

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STL’s predatory lending practices raise concerns for population health

Early-life Medicaid Coverage and Intergenerational Economic Mobility

New data reveal significant variation in economic mobility outcomes across U.S. localities. This suggests that social structures, institutions, and public policies-particularly those that influence critical early-life environments-play an important role in shaping mobility processes. Using new county-level estimates of intergenerational economic mobility for children born between 1980 and 1986, we exploit the uneven expansions of Medicaid eligibility across states to isolate the causal effect of this specific policy change on mobility outcomes. Instrumental-variable regression models reveal that increasing the proportion of low-income pregnant women eligible for Medicaid improved the mobility outcomes of their children in adulthood. We find no evidence that Medicaid coverage in later childhood years influences mobility outcomes. This study has implications for the normative evaluation of this policy intervention as well as our understanding of mobility processes in an era of rising inequality.

Refining Our Understanding of Value-Based Insurance Design and High Cost Sharing on Children

BACKGROUND

There is significant concern about the financial burdens of new insurance plan designs on families, particularly families with children and youth with special health care needs (CYSHCN). With value-based insurance design (VBID) plans growing in popularity, this study examined the implications of selected VBID cost-sharing features on children.

METHODS

We studied children's health care spending patterns in 2 data sets that include high deductible and narrow network plans among others. Medical Expenditure Panel Survey data from 2007 to 2013 on 22 392 children were used to study out-of-pocket (OOP) costs according to CYSHCN, family income, and spending. MarketScan large employer insurance claims data from 2007 to 2014 (N = 4 263 452) were used to test for differences in mean total payments and OOP costs across various health plans.

RESULTS

Across the data sets, we found that existing health plans place significant financial burdens on families, particularly lower income households and families with CYSHCN; individuals among the top 10% of OOP spending averaged more than $2000 per child. Although high deductible and consumer-driven plans impose substantial OOP costs on children, they do not significantly reduce spending, whereas health maintenance organizations that use network restrictions and tighter management do.

CONCLUSIONS

Our results do not support the conclusion that high cost-sharing features that are common in VBID plans will significantly reduce health care spending on children.

Seeking relief: Bankruptcy and health outcomes of adult women

This study examined the impact of declaring consumer bankruptcy on the physical and mental health of adult women and if outcomes differed depending on whether the filer received automatic debt discharge under Chapter 7 compared to a debt repayment plan with Chapter 13. Sample data consisted of women from the NLSY79 cohort who completed the age 40 and 50 health modules as of the most recent wave. Results indicated a negative effect of bankruptcy on self-assessed health, whereas prior health history explained its negative relationship with depressive symptoms. Debt liquidation under Chapter 7 was associated with poor physical health relative to those who did not file and with depressive symptoms relative to Chapter 13 repayment plan filers. Poor health is an unintended consequence for women who seek financial relief through bankruptcy.

Demographic and service-use profiles of individuals using the CarePayment program for hospital-related medical debt: results from a nationwide survey of guarantors

Background

Many Americans find themselves with problems paying medical bills, and medical debt can lead to numerous negative financial, social and access to healthcare outcomes. One potential market-based solution to these challenges is to provide financing options that have patient-friendly terms while complying with increasingly complex federal lending regulations. CarePayment (CP) is one entity that provides zero interest financing to individuals from participating medical facilities. An independent, initial outcome study was undertaken to understand the demographic and medical debt-related outcomes of CP users. This information is integral to understanding whether and how this program can ameliorate the negative consequences of medical debt.

Methods

A nationwide telephone survey was conducted with a random sample of 8122 guarantors who were paying off CarePayment debt as of January 1, 2015. Respondents were asked about their demographic characteristics as well as self-report of negative outcomes typically associated with medical debt. Analyses included descriptive statistics along with logistic regression models comparing first-time CP users and those with higher amounts of CP debt to others.

Results

The most commonly reported financial challenge related to medical bills was problems paying or being unable to pay medical bills (59.5 %). The most commonly reported access-to-care challenges were skipping a medical test or treatment recommended by a doctor (32.9 %) and having a medical problem but not going to the doctor/clinic (30.3 %). Comparisons between first-time and repeat CP users suggest that first-time users were significantly more likely to report several negative outcomes and those with both CP and non-CP debt were significantly more likely to report nearly all of the undesirable financial and access outcomes that were assessed compared to those with only CP debt.

Conclusions

The results suggest that CP use, especially repeat CP use, may be associated with a reduction in many negative outcomes of medical debt. In addition, while we found that individuals with only CP debt fared better than those with both CP debt and other medical debt, 60 % of our sample had more than one source of medical debt. This suggests that the beneficial impact of CP could be increased by expanding access to the program.

Mortgage worries: young adults and the US housing crisis

The 2008 housing crisis and the changes in lending practices that led up to it shook the status of home loans as secure debt in the United States. The crisis hit during a time when many young adults had recently bought their first home, making it a particularly consequential moment in their homeownership career. We investigate the effects of the housing crisis on the mental health of young homeowners using longitudinal data. We model levels of anxiety among young homeowners carrying mortgage debt before and after the recession as an early indicator of how the crisis affected the experience of home loans. The positive effects of being a mortgaged homeowner before the recession declined significantly after the housing crisis. We discuss whether this shift may portend a longer-term shift in American beliefs in the value of investing in housing, with significant implications for financial well-being and wealth stratification.

The Louisiana Family Opportunity Act Medicaid Buy-in Program

OBJECTIVES

The Family Opportunity Act Medicaid Buy-In Program (FOA) allows states to expand Medicaid coverage to children who meet selected disability and income eligibility criteria. FOA programs may help address family financial hardship as a result of underinsurance. We provide specific information about the FOA program and report the first results of a survey of parents or guardians of children with disabilities who were enrolled in Louisiana's FOA program.

METHODS

A convenience sample of families enrolled in the program (N = 52) responded to questions derived from the National Survey of Children with Special Health Care Needs (CSHCN). These results were compared to two groups of Louisiana families of CSHCN that had responded to the 2009/10 national survey.

RESULTS

Data suggest that children enrolled in the Louisiana FOA are younger than those enrolled in Supplemental Security Income, are more likely to have functional losses, and, perhaps due to their age, are less likely to have difficulty with anxiety, depression, or behavior problems. FOA families are less likely than families in either group to report receiving help with care coordination, and more likely to report financial problems due to their child's health. Respondents were also more likely to report that they received all the therapy services and specialty care they needed.

CONCLUSIONS

The FOA program thus appears to be filling a niche in coverage needs among families of children with disabilities in Louisiana.

Credit Card Blues: The Middle Class and the Hidden Costs of Easy Credit

In an era of increased access to credit, it becomes increasingly important to understand the consequences of taking on unsecured consumer debt. We argue that credit can have both positive and negative consequences resulting from its ability to smooth life transitions and difficulties but that this occurs simultaneously with increased financial risks and stress resulting from carrying unsecured debt. We find that those in the middle of the income distribution suffer the greatest disruptions to mental health from carrying debt. Affluent borrowers are relatively unmoved by debt, suggesting the use of short-term debt as a convenience strategy for the financially well-heeled. The least advantaged borrowers are also suffer emotionally less from debt, possibly because securing spendable funds for necessities remains their most pressing concern. The onset of the Great Recession, however, produced increased emotional distress for all classes.

Tough Choices in Tough Times

Debt is a ubiquitous component of households’ financial portfolios. Yet we have scant understanding of how household debt constrains spending on needed health care. Diverse types of debt have different financial properties and recent work has shown that they may have varying implications for spending on needed health care. In this article, we explore the associations between indebtedness and medication nonadherence. First, we consider overall debt levels and then we disaggregate debt into types. We use a population-based sample of 434 residents of southeast Michigan who had been prescribed medications, collected in 2009-2010, the wake of the Great Recession. We find no association between medication nonadherence and total indebtedness. However, when we assess each type of debt separately, we find that having medical or credit card debt is positively associated with medication nonadherence, even net of household income, net worth, and other characteristics. Furthermore, patients with greater amounts of medical or credit card debt are more likely to be nonadherent than those with less. Our results suggest that credit card debt and medical debt may have serious implications for the relative affordability of prescription medications. These associations have been overlooked in past research and deserve further examination.