Medical Debt Persists, but Declines in the United States

The percentage of Americans who report inability to pay medical bills has decreased slightly in recent years, to 10.8%, down from 14% in 2019, based on data from the 2019, 2020, and 2021 National Health Interview Surveys.

Medical expenses for one family member can have a significant impact on family finances, and medical debt may lead to other financial problems such as the inability to pay for food, clothing, or housing, write authors Robin A. Cohen, PhD, and Amy E. Cha, PhD, of the Centers for Disease Control and Prevention, Atlanta.

“Previous findings from NHIS indicated that adults under age 65 who were living with incomes at or near the federal poverty level (FPL) were over three times as likely to have medical bills that they were unable to pay at all compared with those with incomes at or above 200% FPL,” they say.

In the current report, “Problems Paying Medical Bills, United States, 2021,” the authors reviewed data from the Sample Child and Sample Adult modules of the 2019-2021 NHIS. The process involved an interview with one sample adult and one sample child (if applicable) per household. Traditionally, the interviews are conducted in person, but the current study included a mix of telephone and in-person interviews in the wake of the COVID-19 pandemic, the researchers noted. The 2019, 2020, and 2021 estimates included 42,331, 37,358, and 37,743 individuals, respectively. The response rates for the 3 years were 59.1%, 48.9%, and 50.9%, respectively, for adults, and 59.1%, 47.8%, and 49.9%, respectively, for children.

Overall, the percentage of individuals in families struggling to pay medical bills in the past 12 months was 10.8% vs 14% in 2019, which translated to 35 million families having trouble with medical bills in 2021 vs 45.5 million in 2019.

In 2021, females were more likely than males to be in families struggling to pay medical bills (11.8% vs 9.7%). In terms of age, more young children and adolescents aged 0-17 years and adults aged 18-64 years were likely to be in families with trouble paying medical bills compared to adults aged 65 years and older (11.5%, 11.3%, and 7.7%, respectively). 

The percentage for adults aged 65 and older in families with problems paying medical bills was lower among those with private insurance (4.8%) vs those with Medicare and Medicaid (11.3%). Similarly, the percentage of adults aged 18-64 in families with problems paying medical bills was lower for those with private insurance compared to those with Medicare/Medicaid and CHIP (9% vs 13.1%). In addition, 20.3% of uninsured adults aged 18-64 were in families struggling to pay medical bills.

When examined by race, the percentage of individuals in families with trouble paying medical bills was highest among non-Hispanic Blacks (15.8%) compared with Hispanic (12.8%), non-Hispanic White (9.4%), and non-Hispanic Asian (6.1%) populations. The percentages for non-Hispanic American Indian or Alaska Native, and non-Hispanic other/multiple races were 11.5% and 15.1% respectively.

The findings of the report were limited by the use of self-reports and the potential for bias, but the NHIS is strengthened by the low item nonresponse rate, the researchers said.

The decline in the number of families struggling to pay medical bills was likely impacted by the COVID-19 pandemic, the researchers noted.

The CARES Act and other legislation “provided direct monetary payments, flexibility with payments to creditors, additional unemployment assistance, subsidized payroll for affected small businesses, and improvements in paid sick leave,” as well as expanding Medicaid benefits and increasing coverage, the authors write.

“This may be supported in part in that people living in Medicaid expansion states were less likely than those living in non-expansion states to have problems paying medical bills for all age groups including adults aged 65 and over,” the researchers say. A decreased use in medical services during the pandemic may have decreased the potential for medical debt as well.

However, “Despite the decreasing trend in the percentage of people with problems paying medical bills, the burden associated with unpaid medical bills remains a public health concern,” they caution, and monitoring these problems through surveys continues to be important to track this burden, especially as healthcare costs continue to rise.

National Health Statistics Reports. “Problems Paying Medical Bills: United States, 2021.” US Department of Health and Human Services. January 18, 2023. Report

Heidi Splete is a freelance medical journalist with 20 years of experience.

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