US adults with medical debt more likely to forgo mental health care

Key takeaways:

• Of U.S. adults surveyed, 15.3% reported having medical debt in 2023.
• Approximately 1/3 of adults with past-year medical debt had forgone mental health care.

In a nationally representative cohort, adults with any previous medical debt were more likely to forgo mental health care due to cost, according to a research letter published in JAMA Health Forum.

“Given the high prevalence of medical debt (roughly one in seven people), this should raise concern about how medical debt may contribute to, or even exacerbate, the mental health treatment gap,” Kyle J. Moon, BS, PhD student trainee in the Center for Mental Health and Addiction Policy at the Johns Hopkins Bloomberg School of Public Health, told Healio.

Moon and colleagues described medical debt as one of the biggest challenges facing U.S. health care.

Specifically, according to a 2021 poll conducted by KFF and Peterson Center on Healthcare, approximately 6% of adults in the U.S. owe over $1,000 in medical debt and 1% of adults owe more than $10,000.

With less than half of adults receiving care for any mental disorder, prior research suggests that medical debt may exacerbate this gap by eroding patient trust in the system or raising the threshold for care, Moon and colleagues wrote.

This inspired the researchers to perform a cohort study to investigate the relationship between medical debt and forgone mental health care due to cost concerns in the subsequent year.

The analysis included 1,821 participants (mean age, 51.6 years; standard deviation [SD], 16.7 years; 50.5% women) surveyed from 2023 to 2024 as part of the nationally representative cohort of U.S. adults in the COVID-19 Life Stressors Impact on Mental Health and Well-Being (CLIMB) study.

The researchers used medical debt reported in 2023 and mental health care forgone in 2024 to account for the temporality of exposure and outcome.

Of the total cohort, Moon and colleagues found that 276 (15.3%) adults reported having medical debt in 2023. Most (n = 121) had less than $1,000 in debt or between $1,000 and $4,999 in debt (n = 107) whereas the remaining (n = 48) had $5,000 in debt or more.

Compared with adults without past-year medical debt, the researchers found that significantly more adults with debt refrained from receiving mental health care due to cost in 2024 (33.8% vs. 6.3% weighted).

According to a survey-weighted logistic regression model adjusted for sex, age, race and ethnicity and other factors, any medical debt was associated with increased likelihood of forgone medical care due to cost, as demonstrated by the average marginal effect (17.3 percentage points; 95% CI, 11.8-22.8). Further, as medical debt increased, so did the probability of forgoing mental health care (less than $1,000: 11.7 percentage points; 95% CI, 4.4-19 vs. $5,000 or more: 28.1 percentage points; 95% CI, 15.6-40.6).

The researchers noted several limitations to this study, including that medical debt was self-reported, introducing possible recall bias.

“While the results align with prior work on debt and forgone care, it is striking that one-third of people with medical debt reported forgoing wanted mental health care in the subsequent year due to cost,” Moon told Healio.

“Future studies will need to consider the full suite of assets that people have access to, or the lack thereof, and how they contribute to ability to access health care. While traditional measures of economic status in research may include income or education, they do not typically include monies owed, such as debt,” he said, adding that future research should also investigate strategies to protect against medical debt and their impact on care-seeking behavior.

For more information:

Kyle J. Moon, BS, can be reached at kmoon19@jh.edu.

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