Is There a Correlation Between Medical Debt and Health Status?


With out-of-pocket healthcare costs resulting in financial issues for patients, a cross-sectional study closely examines whether they are linked to more premature deaths.

Image Credit: Adobe Stock Images/

Image Credit: Adobe Stock Images/

Many would agree that when it comes to healthcare in the United States, high out-of-pocket costs are a significant challenge to achieving optimal outcomes in patients. Associated with these costs is medical debt and issues paying medical bills. In fact, a study estimated that approximately 17.8% of people had medical debt in collections in 2020.1

Which populations are more susceptible to incurring this debt? It often includes racial and ethnic minorities, younger patients, females, those living in rural areas, individuals with multiple chronic diseases or serious psychological distress, uninsured individuals, those with high-deductible insurance plans, and those in US states that do not have expanded Medicaid income eligibility under the Patient Protection and Affordable Care Act (ACA).

Being that there is limited information regarding the associations of medical debt with population health, a cross-sectional study published in JAMA Network Open2 sought to connect medical debt information from the Urban Institute Debt in America project with health surveillance data. From there, investigators analyzed the associations of medical debt with health status, premature death, and mortality at the county level in the United States.

Medical debt in collections from the Debt in America project is defined as medical debt that is either assigned to a creditors’ internal collections department or sent to a third-party collector, where the debt is not only 180 days or more past due, but the creditor was also unsuccessful in their efforts to collect this debt. The original creditor must be a healthcare institution or medical practitioner in order for collections to be considered medical.

During their analysis, the investigators analyzed two medical debt measures, including the primary measure, which was the percentage of individuals with a credit bureau record who may have any medical debt in collections. The secondary measure was the median amount of medical debt in 2018 in dollars among people with any medical debt in collections.

The public data was broken down into three sets of health outcomes:

  1. The average amount of mentally and physically and mentally unhealthy days in the past 30 days per 1,000 people.
  2. The average number of premature deaths, which measured as years of life lost before the age of 75 years per 1,000 people.
  3. The age-adjusted all-cause and 18 cause-specific mortality rates, including heart disease, malignant cancers, and suicide, per 100,000 person-years.

In order to predict the correlation between medical debt and health outcomes, multivariable linear models were used.

In total, 2,943 counties were included as part of this analysis. The median percentage of the county population aged 65 years or older was 18.3% (IQR, 15.8%-20.9%). Across counties, a median 3.0% (IQR, 1.2%-11.9%) of the population were Black residents, 4.3% (IQR, 2.3%-9.7%) were Hispanic residents, and 84.5% (IQR, 65.7%-93.3%) were White inhabitants. An average of 19.8% (range, 0%-53.6%) of the total studied population had medical debt.

After adjusting for county-level sociodemographic characteristics, a 1–percentage point increase in the population with medical debt was attributed to 18.3 (95% CI, 16.3-20.2) more physically unhealthy days and 17.9 (95% CI, 16.1-19.8) more mentally unhealthy days per every 1,000 people during the past month, 1.12 (95% CI, 1.03-1.21) years of life lost per 1,000 people, along with an increase of 7.51 (95% CI, 6.99-8.04) per 100,000 person-years in age-adjusted all-cause mortality rate.

There were also consistent associations of elevated mortality rates and medical debt for all leading causes of death, including cancer (1.12 [95% CI, 1.02-1.22]), heart disease (1.39 [95% CI, 1.21-1.57]), and suicide (0.09 [95% CI, 0.06-0.11]) per 100,000 person-years.

As a result, the authors concluded that “By linking recent nationwide county-level medical debt data with health surveillance data in this cross-sectional study, we observed associations between medical debt and worse health outcomes, including more unhealthy days, more premature deaths, and higher mortality rates. These findings suggest that efforts from multiple stakeholders, including federal, state, hospital and healthcare systems, and employers, to address medical debt may also improve population health in the US.”


1. Kluender R, Mahoney N, Wong F, Yin W. Medical debt in the US, 2009-2020. JAMA. 2021;326(3):250-256. doi:10.1001/jama.2021.8694

2. Han X, Hu X, Zheng Z, Shi KS, Yabroff KR. Associations of Medical Debt With Health Status, Premature Death, and Mortality in the US. JAMA Netw Open. 2024;7(3):e2354766. doi:10.1001/jamanetworkopen.2023.54766

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