Medical debt is associated with population health and increased mortality

Published

2 years ago

March 7, 2024

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By Dr. Sushama R. Chaphalkar, PhD. Mar 7 2024 Reviewed by Lily Ramsey, LLM

In a recent cross-sectional study published in JAMA Network Open, researchers from the United States of America (US) investigated, at the county level, the association between medical debt and population health outcomes in the US.

They found that medical debt is associated with worsened health status and increased premature deaths and mortality in the population.

Study: Associations of Medical Debt With Health Status, Premature Death, and Mortality in the US . Image Credit: Pormezz/Shutterstock.com Background

Increasing economic burden and out-of-pocket costs for healthcare in the US have led to a concerning rise in medical debt, affecting 17.8% of individuals in 2020.

Certain vulnerable populations, including racial and ethnic minorities, females, younger individuals, and those with chronic diseases face a higher risk of incurring medical debt.

This debt is linked to adverse impacts on well-being, such as delayed healthcare, prescription nonadherence, and increased food and housing insecurity. Despite these individual-level associations, the county-level impact of medical debt on health outcomes remains poorly understood.

The present study aimed to address this gap by examining the relationships between medical debt and health status, mortality, and premature death at the county level in the US, using data from the Urban Institute Debt in America project. About the study

In the present study, debt data was obtained from a 2% nationally representative panel of deidentified records from a credit bureau. A total of 2,943 US counties were included, of which 39.2% were in metropolitan regions. The counties had a median 18.3% of residents above 65 years of age.

The median racial breakdown of residents was as follows: 0.4% American Indian/Alaska Native, 0.8% Asian/Pacific Islander, 3.0% Black, 4.3% Hispanic, and 84.5% White.

The excluded counties were predominantly non-metropolitan and had a smaller population size and a reduced socio-demographic diversity. Related StoriesDaily aspirin linked to higher mortality in older adults, study findsStudy suggests high levels of vitamin B3 breakdown products are linked to higher risk of mortality, heart attacks, and strokeCirculatory cholesterol levels are inversely linked to mortality of patients with sepsis and critical illness

The study investigated three health outcome sets from public data sources, including self-reported health status, premature death measured by years of potential life lost, and age-adjusted all-cause mortality rates and cause-specific mortality rates for leading causes such as cancers, heart disease, Alzheimer's, diabetes, and suicide, at the county level in the US.

Furthermore, the study considered county-level sociodemographic factors from the US Census data, including racial distribution, educational attainment, uninsured status, unemployment, and metropolitan status, as potential confounders.

The analysis considered two medical debt measures: the primary measure assessed the percentage of individuals with medical debt in collections, while the secondary measure focused on the median amount of medical debt (in 2018 US dollars).

Overall debt, including medical and other kinds of debt, were also included in the supplementary analyses.

Statistical analysis involved the use of descriptive analysis as well as bivariate and multivariable linear models, incorporating random state-level intercepts and weighted by county population size. Results and discussion

An average of 19.8% of the studied population had medical debt. Counties with fewer White and more Black residents, lower education levels, increased poverty, lack of insurance, and unemployment appeared to have higher medical debt rates.

It was 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 in 30 days.

The percent-increase in medical debt-holders was also found to be associated with 1.12 years of life lost per 1,000 people and a rise of 7.51 per 100,000 person-years in 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 the median amount of medical debt and the selected health outcomes. Supplemental analyses showed similar association patterns between medical debt and health outcomes.

This nationwide study reaffirms that medical debt remains a significant social determinant of public health.

However, the study is limited by the potential underrepresentation of medical debt in less populous 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 on the impact of coronavirus disease 2019 (COVID-19)-related policies on medical debt and population health.

Additionally, a broader focus on overall debt suggested that policies addressing various debts, like student loans, may impact population health. Conclusion

In conclusion, the study revealed associations between medical debt and adverse health outcomes, such as increased unhealthy days, premature deaths, and elevated mortality rates.

The results highlight the need for collaborative efforts among various stakeholders, including government entities, healthcare systems, hospitals, and employers, to mitigate medical debt with paid sick leave, clear financial assistance policies, and improved cost-related communication with patients.

Further, enhancing access to affordable healthcare through policies like expanding health insurance coverage may improve the overall health of the US population. Journal reference:

X. et al., (2024) Associations of Medical Debt with Health Status, Premature Death, and Mortality in the US. Han JAMA Network Open, 7(3):e2354766. doi: 10.1001/jamanetworkopen.2023.54766.https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2815530

Sports

Sources: Rangers, Mets to swap Semien, Nimmo

Published

59 mins ago

November 23, 2025

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Sources: Rangers, Mets to swap Semien, Nimmo

The New York Mets and Texas Rangers have agreed to a trade that would send second baseman Marcus Semien to the Mets and outfielder Brandon Nimmo to the Rangers, sources told ESPN on Sunday.

Nimmo agreed to waive his no-trade clause, sources said, allowing the deal to be consummated, pending MLB approval. His tenure with the Mets started when they chose him with the 13th overall pick in the 2011 draft.

Semien, a three-time All-Star, joined the Rangers in 2022 and won a World Series with them the next season.

Texas entered the offseason looking for areas to save money, with its payroll being cut and four players — Semien, shortstop Corey Seager, and right-handers Jacob deGrom and Nathan Eovaldi — set to make in excess of $25 million next year. While the Rangers will actually take on more long-term money in Nimmo, who is owed $101.25 million over the next five seasons, the per-year sum is lower, with Semien set to make $72 million for the next three seasons.

The trade is the first move in what’s expected to be a busy winter for both teams — particularly the Mets. As a result of the team’s slow collapse over the season’s final 3½ months, New York missed the postseason and eventually underwent significant turnover in its coaching staff. The acquisition of Semien — who won a Gold Glove this year — aligns with president of baseball operations David Stearns’ primary goal this winter of improving run prevention.

World

US hails ‘tremendous progress’ on Ukraine peace plan – but says negotiators ‘need more time’

Published

4 hours ago

November 23, 2025

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US hails 'tremendous progress' on Ukraine peace plan - but says negotiators 'need more time'

The US secretary of state has hailed a “tremendous amount of progress” on peace talks after the US and Ukraine delegations met in Geneva – but said that negotiators would “need more time”.

Marco Rubio said the meetings in Switzerland on Sunday have been “the most productive and meaningful” of the peace process so far.

He said the US was making “some changes” to the peace plan, seemingly based on Ukrainian suggestions, “in the hopes of further narrowing the differences and getting closer to something that both Ukraine and obviously the United States are very comfortable with”.

Mr Rubio struck an optimistic tone talking to the media after discussions but was light on the details, saying there was still work to be done.

“I don’t want to declare victory or finality here. There’s still some work to be done, but we are much further ahead today at this time than we were when we began this morning and where we were a week ago for certain,” Mr Rubio said.

He also stressed: “We just need more time than what we have today. I honestly believe we’ll get there.”

Sky News’ defence analyst Michael Clarke said on the initial US-Russian 28-point peace plan that it was Donald Trump against the world, with maybe only Moscow on his side.

Mr Rubio praised the Ukrainian attitude towards the talks and said Mr Trump was “quite pleased” after he previously said in a social media post that Ukraine’s leaders had expressed “ZERO GRATITUDE” for US efforts.

Ukrainian President Volodymyr Zelenskyy said in his nightly address on Sunday that there are signs that “President Trump’s team hears us”.

In a news release on Sunday evening, the White House said the day “marked a significant step forward”.

“Ukrainian representatives stated that, based on the revisions and clarifications presented today, they believe the current draft reflects their national interests and provides credible and enforceable mechanisms to safeguard Ukraine’s security in both the near and long term,” it claimed.

Despite diplomatic progress in Geneva the finish line remains a long way off

John Sparks

International correspondent

@sparkomat

We’ve witnessed a day of determined and decidedly frantic diplomacy in this well-heeled city.

Camera crews were perched on street corners and long convoys of black vehicles swept down Geneva’s throughfares as the Ukrainians worked hard to keep the Americans on side.

Secretary of state Marco Rubio did not want to go into details at a press “gaggle” held at the US Mission this evening, but he seemed to think they had made more progress in the last 96 hours than the previous 10 months combined.

The Ukrainian leader Volodymyr Zelenskyy also seemed satisfied enough, posting on Telegram that there were “signals President Trump’s team is hearing us” after a day of “numerous meetings and negotiations”.

That said, we are a long way from the finish line here – something Rubio acknowledged when he said that any proposal agreed here would have to be handed over to the Russians.

At that point, negotiations to stop the war would surely get tougher.

President Putin has shown little or no inclination to stop the conflict thus far.

This, then, is the most important reason the Ukrainians seem determined to keep the Americans on side.

European leaders have presented a counter proposal to the widely criticised US-Russian peace plan, with suggestions including a cap on Ukraine’s peacetime army and readmitting Moscow into the G8.

This will only take place if the plan is agreed to by the US, Russia and Ukraine, and the G7 signs off on the move. Russia was expelled after annexing Crimea in 2014.

The counter proposal also includes US guarantees to Ukraine that mirror NATO’s Article 5 – the idea that “an armed attack against one NATO member shall be considered an attack against them all”.

The initial peace plan was worked up by the White House and Kremlin without Ukraine’s involvement, and it acquiesces to many of Russia’s previous demands.

It covers a range of issues – from territorial concessions to reconstruction programmes, the future Ukrainian relationship with NATO and the EU, and educational reforms in both Ukraine and Russia.