4 Reasons Why Unaffordable Medical Bills Are an Important Social Determinant of Health


Medical debt can send people into “a spiral of economic disadvantage,” including a lack of stability and security in personal life, housing and work.

Traditionally, social determinants of health (SDOH) have been conceived of as the conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes, according to the U.S. Centers for Disease Control and Prevention (CDC). This includes factors such as housing, food and nutrition, transportation, social and economic mobility, education, and environmental conditions.



However, a recent study in JAMA Network Open identifies a new a type of SDOH that exacerbates patients’ problems with traditional SDOH factors. The study shows how unpaid medical bills can lead to a cascade of worsening SDOH and suggests that unaffordable medical bills are themselves an SDOH.

The researchers concluded that medical care inflicts debt on nearly one-fifth of U.S. households, including many with seemingly good health insurance and middle-class incomes.

“Incurring medical debt leaves many unable to pay for utilities, and worsens housing and food security, key SDOH associated with adverse health outcomes, including frailty at birth,” wrote lead author David Himmelstein, M.D., of the City University of New York at Hunter College, and his colleagues. “Hence, unaffordable medical bills may constitute an SDoH in their own right and contribute to a downward spiral of ill-health and financial precarity.”

SDOH’s contribution to health outcomes

It is estimated that clinical care impacts only 20% of county-level variation in health outcomes, while SDOH affect as much as 50%, with socioeconomic factors such as poverty, employment and education delivering the largest impact on health outcomes, according to the U.S. Department of Health and Human Services (HHS).

SDOH play a significant role in driving the numerous health inequities in the U.S. that persist by race, ethnicity, sexual orientation, gender identity and disability. There are also economic and community-level factors, such as geographic location, poverty status and employment.

For example, Black, Latino, American Indian and Alaska Native, Asian American, Native Hawaiian, and Pacific Islanders, and LGBTQ+, individuals, people who live in rural areas, and people with disabilities fare worse than their white, heterosexual and urban counterparts and people without disabilities. These disparities exist for many health outcomes, including infant and maternal mortality, heart disease, diabetes, hypertension, chronic illness, disability, cancer, mental illness, substance use and overall life expectancy, according to HHS.

Medical debt’s heavy burden

One in 11 American men, 1 in 8 women, and nearly 1 in 5 households carry medical debt, with only the highest-income and most educated segments of society relatively spared, according to the findings reported by Himmelstein and hiscolleagues.

Across the entire population, mean medical debt was $2,306 per U.S. adult and approximately $4,671 per household in 2018. Among racial and ethnic groups, non-Hispanic Black adults had the highest rate of medical indebtedness (16.5%), while non-Hispanic Asian adults had the lowest (4.5%). Adults with medical debt reported approximately twice as much out-of-pocket medical spending as others, and medical debtors also paid modestly more toward premiums.

In addition to the research by Himmelstein, numerous other researchers have established the connection between medical debt and SDOH. In an editorial in JAMA last year, University of Michigan researchers Carlos Mendes de Leon, Ph.D., and Jennifer Griggs, M.D., M.P.H., discussed medical debt and its “substantial adverse health effects” as well as significant financial and economic consequences.

Mendes de Leon and Griggs point to research that found that, in 2014, medical debt overtook all other forms of debt in the U.S, and that the greatest amounts of medical debt tended to be associated with ZIP codes where people have the lowest average income levels.

Drawing on this research, the following are four reasons that unaffordable medical bills are themselves an SDOHH:

Additional burden on those with poor health

Not surprisingly, those who have experienced poor and worsening health, and particularly hospitalization, are at heightened risk of incurring medical debt. For example, patients with cancer appear at especially high risk of financial problems stemming from both medical bills and employment loss.

Health insurance often isn’t enough

For those who became disabled or newly experienced hospitalization, health insurance offers only partial protection, with high-deductible plans and Medicare Advantage appearing to leave enrollees particularly exposed to debt risk.

Diversion from needed care

Researchers have concluded that medical debt can prevent people from seeking or receiving needed care, which often leads to either delayed diagnosis or exacerbation of pre-existing conditions. The reluctance to seek care has also been linked to premature mortality.

Worsens other SDOH

Medical debt is the largest overall contributor to personal debt, which may send people into “a spiral of economic disadvantage,” including a lack of stability and security in personal life, housing and work, and social stigma.

Medical debt is a widespread problem in the U.S. that contributes to care avoidance, stres, and worsening health outcomes as patients forgo spending on necessities such as food, heat, and electricity to pay unaffordable bills. Because incurring medical debt often causes so many downstream problems for patients, medical debt itself should be regarded as social determinant of health and treated by the healthcare industry as such.

Ryne Natzke is SVP of Growth and Strategy at Sphere.

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