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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 

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UK

VE Day: Veterans to join King for tea party as Keir Starmer praises ‘selfless dedication’

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VE Day: Veterans to join King for tea party as Keir Starmer praises 'selfless dedication'

Veterans are set to join the King for a VE Day tea party today as the prime minister has paid tribute to the “selfless dedication” of the war generation.

Among them will be a 99-year-old who took part in the D-Day landings and a 100-year-old woman who worked in the Special Operations Executive, known as Churchill’s Secret Army.

Director general of the Royal British Legion, Mark Atkinson, said the charity was “proud” to be taking a place “at the heart of these national celebrations and commemorations” on the 80th anniversary of the end of the Second World War.

He said it would be “one of our last opportunities as a nation to pay tribute to those veterans still with us today”.

Evacuees from World War Two and veterans who were still in active conflict after VE Day are among the other guests set to attend the tea party, which will take place in the presence of the King and other members of the Royal Family.

The Royal Family will watch a millitary procession and flypast on Monday. File pic: PA
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The Royal Family will watch a military procession and flypast on Monday. File pic: PA

At 12pm, the Royal Family will observe a military procession, followed by a flypast.

It will be the first major VE Day anniversary without any of the royals who stood on the balcony of Buckingham Palace on the day victory in Europe was declared, after the death of the late Queen Elizabeth II in 2022.

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‘Not just for Britain’

The celebrations come as Prime Minister Sir Keir Starmer praised veterans for their “selfless dedication” and thanked them for a “debt that can never fully be repaid” in an open letter ahead of VE Day.

He said the stories which will be heard this week from those who fought in the Second World War would be a reminder that the victory “was not just for Britain” but was also “a victory for good against the assembled forces of hatred, tyranny and evil”.

Sir Keir said the WW2 veterans “represent the best of who we are” and that without their service “the freedom, peace and joy that these celebrations embody, would not be possible”.

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VE Day veteran tells Sky News what the atmosphere was like when WWII was finally declared over in Europe

Personnel from NATO allies the US, France and Germany will be among those taking part in the procession in London.

The commemorations will begin with the words of Sir Winston Churchill‘s 1945 victory speech, spoken by actor Timothy Spall.

Thousands of people are expected to line the streets of the capital to witness the celebrations.

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Codebreaker’s ‘special’ encounter with Churchill

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What’s happening to mark the 80th anniversary of VE Day?
When and where to watch VE Day flypast
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On the anniversary itself on Thursday, marking exactly 80 years since the Allies formally accepted Germany’s surrender, a service of commemoration will be held at Westminster Abbey, to include a national two minutes’ silence.

Pubs across England and Wales, which usually close at 11pm, will also stay open for an extra two hours to allow punters more time to celebrate.

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Sports

Logano gets 1st win this season in OT at Texas

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Logano gets 1st win this season in OT at Texas

FORT WORTH, Texas — Reigning NASCAR Cup champion Joey Logano overcame a lot to get his first victory this season.

It came a week after Team Penske teammate Austin Cindric‘s win at Talladega, where Logano had a fifth-place finish that became 39th after a postrace inspection found an issue with the spoiler on his No. 22 Ford. There was also Logano’s expletive-laden rant on the radio toward his teammate in the middle of that race that the two smoothed out during the week. Oh, and he started 27th at Texas after a bad qualifying effort on the 1½-mile track.

But Logano surged ahead on the restart in overtime Sunday to win in the 11th race this year. He led only seven of the 271 laps, four more than scheduled.

“After what happened last week, to be able to rebound and come right back, it’s a total ’22’ way of doing things. So proud of the team,” Logano said.

On the final restart after the 12th caution, Logano was on the inside of his other teammate, Ryan Blaney. But Logano pulled away on the backstretch and stayed easily in front for the final 1½ laps, while Ross Chastain then passed Blaney to finish second ahead of him.

“Just slowly, methodically,” Logano said of his progression to the front. “Just kept grinding, a couple here and a couple there and eventually get a win here.”

Logano got his 37th career victory, getting the lead for the first time on Lap 264. He went low to complete a pass of Michael McDowell.

“I mean, there’s always a story next week, right?” Logano said. “So I told my wife last week before we left, I said, ‘Watch me go win this one.’ It’s just how we do stuff.”

On a caution with 47 laps left, McDowell took only two tires and moved up 15 spots to second. He ended up leading 19 laps, but got loose a few laps after getting passed by Logano and crashed to bring out the caution that sent the race to overtime. He finished 26th.

“We were giving it everything we had there to try to keep track position,” McDowell said. “Joey got a run there, and I tried to block it. I went as far as I think you could probably go. When Blaney slid in front of me, it just took the air off of it and I just lost the back of it. I still had the fight in me, but I probably should have conceded at that point.”

Odds and Ends

William Byron, Kyle Larson, Denny Hamlin and Chase Elliott remained the top four in season points. … Elliott left Texas last spring with his first victory after 42 races and 18 months without one. He hasn’t won since, and now has another long winless drought — this one 38 races and nearly 13 months after finishing 16th. … A crew member for Christopher Bell crawled in through the passenger side of the No. 20 Joe Gibbs Racing Toyota and was fully in the car to reconnect an air hose to the driver’s helmet during a caution in the second stage. It took two stops during that caution, and twice climbing into the car, to resolve the issue.

Fiery end to Hamlin streak

Hamlin had finished on the lead lap in 21 consecutive races, but a fiery finish on Lap 75 ended that streak that had matched the eighth longest in NASCAR history. He was the first car out of the race.

After the No. 11 Joe Gibbs Racing Toyota lost power, something blew up when Hamlin recycled the engine. Flames were coming from under the car and it was engulfed in smoke when it rolled to a stop on the inside of the track, and Hamlin climbed out unharmed.

Youngest pole sitter

Carson Hocevar, the 22-year-old driver who is McDowell’s teammate with Spire Motorsports, was the youngest pole sitter in Texas. He led only the first 22 laps of the race, losing it while pitting during the first caution. He finished 24th after a late accident.

Stage cautions

Both in-race stages finished under caution. Cindric won Stage 1 after Hamlin’s issues, and Kyle Larson took the second after a yellow flag came out because of debris on the track after the right rear tire on Chris Buescher‘s car came apart.

Larson got his 68th overall stage win and his sixth at Texas, with both marks being records. He has won a stage in each of the past five Cup races at Texas, starting in his 2021 win there.

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US

Trump calls for reopening of Alcatraz to house ‘most ruthless and violent offenders’

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Trump calls for reopening of Alcatraz to house 'most ruthless and violent offenders'

US President Donald Trump has called for the reopening of notorious prison Alcatraz.

In a post on his social media site Truth Social, Mr Trump said America had been “plagued by vicious, violent, and repeat criminal offenders”.

He added that when the United States was “a more serious nation” it “did not hesitate to lock up the most dangerous criminals”.

“That is why, today, I am directing the Bureau of Prisons, together with the Department of Justice, FBI, and Homeland Security, to reopen a substantially enlarged and rebuilt Alcatraz, to house America’s most ruthless and violent offenders,” he wrote.

Mr Trump said the reopening of the San Francisco prison would “serve as a symbol of law, order, and justice”.

The US president’s latest policy announcement comes after he fired national security adviser Mike Waltz last week in the first major change to his administration.

US President Donald Trump. Pic: AP
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US President Donald Trump speaking to reporters on Sunday. Pic: AP

Alcatraz was infamously inescapable and in the 29 years it was open, 36 men attempted 14 separate escapes, according to the FBI.

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Nearly all of them were caught or did not survive the attempt at escaping.

The prison housed some of America’s most notorious criminals, including Al Capone and George Kelly.

It has also been the subject of a number of films, including The Rock, starring Sean Connery and Nicolas Cage.

Alcatraz Island. File pic: AP
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Alcatraz Island. File pic: AP

Alcatraz Island, which is surrounded by strong ocean currents and cold Pacific waters, is now a major tourist site, operated by the National Park Service.

The prison’s closure in 1963 was attributed to crumbling infrastructure and high repair costs.

A spokesperson for the Bureau of Prisons said it would “comply with all presidential orders”.

The Bureau of Prisons currently has 16 high-security prisons, including its maximum-security facility in Florence, Colorado, and a facility in Terre Haute, Indiana, which is home to the federal death chamber.

The United States’ federal law enforcement agency has been the subject of increased scrutiny in recent years after Jeffrey Epstein‘s suicide at a federal jail in New York City in 2019.

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