Disclosures: The authors report no relevant financial disclosures.
July 20, 2021
2 min read

About 1 in 6 American adults had medical debt prior to COVID-19

Disclosures: The authors report no relevant financial disclosures.
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An estimated 17.8% of United States adults had debt that stemmed from medical care before the COVID-19 pandemic, an analysis of consumer credit reports showed.

Despite “widespread concern” surrounding medical debt, there has been little research into recent trends in medical debt, its distribution across the population and how health policy has affected the distribution, Raymond P. Kluender, PhD, an assistant professor of business administration at Harvard Business School, and colleagues wrote in JAMA.

The vector image is of several piles of money. The text is  As of June, 2020, 17.8% of American adults had medical debt
Reference: Kluender RP, et al. JAMA. 2021;doi:10.1001/jama.2021.8694.

The researchers analyzed data from a nationally representative 10% sample of TransUnion’s consumer credit reports between January 2009 and June 2020 — reflecting care that was provided before the COVID-19 pandemic, according to the researchers — as well as income and geographical data from the 2014 to 2018 American Community Survey. This yielded information from nearly 40 million unique individuals. The link between Medicaid expansion and medical debt (overall and by income group) was also analyzed.

The main outcome measures were stock — which the researchers defined as all unpaid debt on credit reports — and flow — which was new debt on credit reports during the preceding 12 months — of medical debt in collections.

Kluender and colleagues reported that as of June 2020, 17.8% of the studied cohort had medical debt and 13% had accrued debt in the previous year. Among geographic regions, the mean amount of stock was highest in the South ($616) and lowest in the Northeast ($167), for a difference of $448 (95% CI, 435-462). Among ZIP code income deciles, stock was higher in poor ZIP codes ($677) compared with rich ZIP codes ($126), for a difference of $551 (95% CI, 520-581).

In addition, and only between 2013 and 2020, states that expanded Medicaid in 2014 experienced a decline in mean flow of medical debt that was 34 percentage points (95% CI, 18.5-49.4) greater (from $330 to $175) than states that did not expand Medicaid (from $613 to $550). In the expansion states, the interval in the mean flow of medical debt between the lowest and highest ZIP code income deciles dropped by $145 (95% CI, 95-194), while the gap rose by $218 (95% CI, 163-273) in nonexpansion states.

“Although the study design does not allow for causal interpretation, the absence of a meaningful association between Medicaid expansion and changes in nonmedical debt, and the stability of the estimates, controlling for economic and policy factors reduce concerns about possible confounders,” Kluender and colleagues wrote.

The estimates are also “consistent” with previous studies that utilized experimental methods to demonstrate a causal link between Medicaid coverage and medical debt reductions, according to the researchers.

In an accompanying editorial, University of Michigan School of Public Health epidemiology professor Carlos F. Mendes de Leon, PhD, and health management and policy professor Jennifer J. Griggs, MD, MPH, wrote that addressing medical debt “must be a high priority” since those with medical debt may postpone receiving health care.

De Leon and Griggs also wrote that Kluender and colleagues’ findings suggest that the Affordable Care Act needs some tweaking if the law is to live up to its name.

“The current version of the ACA continues to provide challenges for many individual patients and their families related to deductibles, rising out-of-pocket expenses and inadequate coverage,” they wrote. “Based on data from the early years of ACA implementation, the coverage does not seem to have produced a noticeable decline in bankruptcies due to medical debt.”


de Leon CFM, Griggs JJ. JAMA, 2021;doi:10.1001/jama.2021.9011.

Kluender RP, et al. JAMA. 2021;doi:10.1001/jama.2021.8694.