Introduction
While hospitals are interested in the effect of social determinants of health on patient care, medical debt from these same institutions negatively affects patient care.1 Amongst US residents with medical debt, the average amount is $2424, concentrated amongst low-income communities.2,3 Reports estimate 8% of Washtenaw residents have medical debt in collections4; however, there is no data on the impact of debt on low-income residents. This study explores this knowledge gap to inform policies to mitigate medical debt, including hospital Financial Assistance Programs (FAPs).
Methods
Survey questions were modeled after the 2022 Kaiser Family Foundation healthcare debt survey5 and administered to Washtenaw adult residents using Qualtrics software at events serving lower-income populations. Participants were given a $10 gift card upon completion. Statistical analysis was performed using R Statistical Software (v4.1.2; R Core Team 2021).
Results
123 participants completed the survey, all with income <300% federal poverty level (FPL) (Table 1). 69 people (56%) had medical debt with a median range of $1000-2499. Lack of insurance was associated with debt >$1,000 (p=0.03). 66% of participants with debt >$1000 had income ≤100% FPL compared to 53% of individuals with debt <$1000. Although this difference was not significant, this mirrors national trends.70% of debt came from major health systems in the area, which have FAPs. 58% of debtors were never informed of FAPs (Table 2); of these, 81% would qualify based on income guidelines.Common debt management strategies were negotiating with hospitals (29%), not paying the bill (30%), and conversion to other unsecured debt (18%). Consequences of debt included decreased spending on necessities (59%) and delayed health care (57%). 46% of debtors used all or most of their savings, and 22% reported being denied care.
Conclusions
Low-income populations in Washtenaw County have a 7-fold greater prevalence of medical debt compared to existing estimates for the general county. The median debt amongst debtors is similar to the national mean, and higher debt is associated with lack of insurance. Further, local institutions can improve FAP implementation for low-income patients to mitigate the consequences of medical debt.
References
1. Himmelstein DU, Dickman SL, McCormick D, Bor DH, Gaffney A, Woolhandler S. Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US. JAMA Netw Open. 2022;5(9):e2231898. doi:10.1001/jamanetworkopen.2022.318982.
2. 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.2021.86943.
3. Rae, Matthew, Claxton, Gary, Amin, Krutika, Wager, Emma, Ortaliza, Jared, Cox, Cynthia. The burden of medical debt in the United States. Peterson-KFF Health System Tracker. Published March 10, 2022. Accessed August 20, 2023. https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/
4. Debt in America: An Interactive Map. Accessed August 20, 2023. http://urbn.is/2AnVzHa
5. KFF Health Care Debt Survey - March 2022. Published online 2022.