Disease and debt: Findings from the 2019 Panel Study of Income Dynamics in the United States

The Association Between Medical Debt and Food Insecurity among US Families with Children

OBJECTIVES

To characterize the association between medical debt and food insecurity in a recent, nationally representative sample of US families with children, and to assess whether family income or health insurance type modifies this association.

STUDY DESIGN

We conducted a cross-sectional study of US parents using the 2019-2023 National Health Interview Survey. Multivariable logistic regression models, adjusted for sociodemographic characteristics and survey year, assessed the association between medical debt, defined as self-reported inability to pay medical bills, and food insecurity. We tested for effect modification and conducted stratified analyses by the ratio of family income to the poverty threshold and by health insurance type.

RESULTS

Among 29,260 parents, 7.9% experienced family medical debt and 8.8% reported family food insecurity. Families with medical debt had 4.04-fold odds of food insecurity (95% CI: 3.49, 4.67, p<0.001) compared with families without medical debt. This association was present across all income groups (p<0.001) and was modified by family income (p-interaction <0.001), with middle-income families (200-399% federal poverty level) experiencing the strongest association (aOR: 6.91, 95% CI: 5.28, 9.05, p<0.001). Similarly, insurance type modified the association between medical debt and food insecurity (p-interaction 0.002), with families with a privately insured parent experiencing the strongest association (aOR 5.71, 95% CI 4.57, 7.13, p<0.001) CONCLUSION: Medical debt is associated with increased odds of food insecurity among families with children. These consequences disproportionately impact middle-income and privately insured families, highlighting the importance of comprehensive policies to prevent and mitigate medical debt and food insecurity in pediatric settings.

Household income and county income inequality are associated with financial hardship among cancer survivors in New Jersey

PURPOSE

To examine how household income and county income inequality are linked to financial hardship among cancer survivors.

METHODS

Cancer survivors (n = 864) identified through the New Jersey State Cancer Registry were surveyed from August 2018 to January 2022. Local area income inequality was reflected by the Gini index a measure of income inequality at the county level. Multivariable logistic regression analyses were performed, and the average marginal effect (AME) was calculated.

RESULTS

Compared to survivors residing in households with income of $90,000 or more (higher income), those with household incomes between $50,000 and $89,999 (middle income) had a significantly higher risk of ever being unable to cover their share of the cost of cancer-related medical care (AME = .104, p = .001), higher risk of foregoing care in the past 12 months because of cost, including dental care (AME = .124, p < .001), eye care (AME = .082, p = .005), and mental health care or counseling (AME = .067, p = .002). An increase in the Gini index from the 25th to 75th percentile was associated with an increased risk of unmet needs in paying for follow-up care or medications related to cancer (AME = .021, p = .014) and an increased risk of foregoing doctor visits (AME = .017, p = .02) and eye care (AME = .03, p = .002) because of cost in the past 12 months.

CONCLUSIONS

Local area income inequality was associated with certain aspects of cancer survivors' experience of financial hardship.

IMPLICATIONS FOR CANCER SURVIVORS

It is important to consider refining and extending financial navigation programs to survivors residing in areas with high income inequality.

Medical Debt and the Mental Health Treatment Gap Among US Adults

Importance

Medical debt is common in the US and may hinder timely access to care for mental disorders.

Objective

To estimate the prevalence of medical debt among US adults with depression and anxiety and its association with delayed and forgone mental health care.

Design, Setting, and Participants

Cross-sectional, nationally representative survey study of US adult participants in the 2022 National Health Interview Survey who had current or lifetime diagnoses of depression or anxiety.

Exposures

Self-reported lifetime clinical diagnoses of depression and anxiety; moderate to severe symptoms of current depression (Patient Health Questionnaire-8 score ≥10) and anxiety (Generalized Anxiety Disorder-7 score ≥10) irrespective of lifetime diagnoses; and past-year medical debt.

Main Outcomes and Measures

Self-reported delaying and forgoing mental health care because of cost in the past year.

Results

Among 27 651 adults (15 050 [54.4%] female; mean [SD] age, 52.9 [18.4] years), 5186 (18.2%) reported lifetime depression, 1948 (7.3%) reported current depression, 4834 (17.7%) reported lifetime anxiety, and 1689 (6.6%) reported current anxiety. Medical debt was more common among adults with lifetime depression (19.9% vs 8.6%; adjusted prevalence ratio [aPR], 1.97; 95% CI, 1.96-1.98), lifetime anxiety (19.4% vs 8.8%; aPR, 1.91; 95% CI, 1.91-1.92), current depression (27.3% vs 9.4%; aPR, 2.34; 95% CI, 2.34-2.36), and current anxiety (26.2% vs 9.6%; aPR, 2.24; 95% CI, 2.24-2.26) compared with adults without the respective mental disorders. Medical debt was associated with delayed health care among adults with lifetime depression (29.0% vs 11.6%; aPR, 2.68; 95% CI, 2.62-2.74), lifetime anxiety (28.0% vs 11.5%; aPR, 2.45; 95% CI, 2.40-2.50), current depression (36.9% vs 17.4%; aPR, 2.25; 95% CI, 2.13-2.38), and current anxiety (38.4% vs 16.9%; aPR, 2.48; 95% CI, 2.35-2.66) compared with those without these diagnoses. Medical debt was associated with forgone health care among adults with lifetime depression (29.4% vs 10.6%; aPR, 2.66; 95% CI, 2.61-2.71), lifetime anxiety (28.2% vs 10.7%; aPR, 2.63; 95% CI, 2.57-2.68), current depression (38.0% vs 17.2%; aPR, 2.35; 95% CI, 2.23-2.48), and current anxiety (40.8% vs 17.1%; aPR, 2.57; 95% CI, 2.43-2.75) compared with those without the diagnoses.

Conclusions and Relevance

Medical debt is prevalent among adults with depression and anxiety and may contribute to the mental health treatment gap. In the absence of structural reform, new policies are warranted to protect against this financial barrier to mental health care.

Associations of Medical Debt With Health Status, Premature Death, and Mortality in the US

Importance

Medical debt is increasingly common in the US. Little is known regarding its association with population health.

Objective

To examine the associations of medical debt with health status, premature death, and mortality at the county level in the US.

Design, Setting, and Participants

This cross-sectional study was conducted at the US county level using 2018 medical debt data from the Urban Institute Debt in America project linked with 2018 data on self-reported health status and premature death from the County Health Rankings & Roadmaps and with 2015 to 2019 mortality data from the National Center for Health Statistics. Data analysis was performed from August 2022 to May 2023.

Exposure

Share of population with any medical debt in collections and median amount of medical debt.

Main Outcomes and Measures

Health status was measured as (1) the mean number of physically and mentally unhealthy days in the past 30 days per 1000 people, (2) the mean number of premature deaths measured as years of life lost before age 75 years per 1000 people, and (3) age-adjusted all-cause and 18 cause-specific mortality rates (eg, malignant cancers, heart disease, and suicide) per 100 000 person-years. Multivariable linear models were fitted to estimate the associations between medical debt and health outcomes.

Results

A total of 2943 counties were included in 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 residents. On average, 19.8% (range, 0%-53.6%) of the population had medical debt. After adjusting for county-level sociodemographic characteristics, a 1-percentage point increase in the population with medical debt was associated with 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 1000 people during the past month, 1.12 (95% CI, 1.03-1.21) years of life lost per 1000 people, and an increase of 7.51 (95% CI, 6.99-8.04) per 100 000 person-years in age-adjusted all-cause mortality rate. Associations of medical debt and elevated mortality rates were consistent 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. Similar patterns were observed for associations between the median amount of medical debt and the aforementioned health outcomes.

Conclusions and Relevance

These findings suggest that medical debt is associated with worse health status, more premature deaths, and higher mortality rates at the county level in the US. Therefore, policies increasing access to affordable health care, such as expanding health insurance coverage, may improve population health.

Trends in Suicidal Mortality and Motives among Working-Ages Individuals in Japan during 2007-2022

Suicides in Japan consistently decreased from 2009-2019, but increased during the COVID-19 pandemic. To identify causes of increasing suicides, age-dependent and temporal fluctuations of suicide mortality rate per 100,000 (SMRP) in working-age generations (20-59 years) disaggregated by suicidal motives (7-categories; 52-subcategories) and sex from 2007 to 2022, were analyzed by analysis of variance and joinpoint regression, respectively, using the government suicide database "Suicide Statistics". The SMRP of 20-29 year-old males and 20-49 year-old females began to increase in the late 2010s. SMRPs of these high-risk groups for suicides caused by depression (the leading suicidal motive for all groups) began increasing in the late 2010s. Economic-related, employment-related, and romance-related problems contributed to the increasing SMRPs in 20-29 males in the late 2010s. Romance-related and family-related problems contributed to the increasing SMRPs of 20-29 females in the late 2010s. Increasing SMRPs caused by child-raising stress in 20-39 year-old females from the late 2010s was a remarkable finding. In contrast, SMRPs of 30-59 year-old males consistently decreased until 2021; however, in these groups, SMRPs for suicides caused by various motives sharply increased in 2022. The consistent increase in SMRPs of high-risk groups from the late 2010s to the pandemic suggest recent socioeconomic and psychosocial problems in Japan possibly contributed to the increasing SMRPs in these high-risk groups independently of pandemic-associated factors, whereas the SMRPs of males of 30-59 years were probably associated with the ending of the pandemic rather than pandemic-associated factors.

Functional impairment is associated with medical debt in male cancer survivors and credit card debt in female cancer survivors

PURPOSE

To examine the associations of functional limitations with medical and credit card debt among cancer survivor families and explore sex differences in these associations.

METHODS

This cross-sectional study used data from the 2019 wave of the Panel Study of Income Dynamics, a nationally representative, population-based survey of individuals and households in the US administered in both English and Spanish and includes all households where either the head of household or spouse/partner reported having been diagnosed with cancer. Participants reported on functional limitations in six instrumental activities of daily living (IADL) and seven activities of daily living (ADL). Functional impairment was categorized as 0, 1-2 and ≥ 3 limitations. Medical debt was defined as self-reported unpaid medical bills. Credit card debt was defined as revolving credit card debt. Multivariable logistic regression analyses were performed.

RESULTS

Credit card debt was more common than medical debt (39.8% vs. 7.6% of cancer survivor families). Families of male cancer survivors were 7.3 percentage points more likely to have medical debt and 16.0 percentage points less likely to have credit card debt compared to families of female cancer survivors. Whereas male cancer survivors with increasing levels of impairment were 24.7 percentage point (p-value = 0.006) more likely to have medical debt, female survivors with more functional impairment were 13.6 percentage points (p-value = 0.010) more likely to have credit card debt.

CONCLUSIONS

More research on medical and credit card debt burden among cancer survivors with functional limitations is needed.