Most physicians have sworn an oath to “abstain from whatever is deleterious” to our patients. Yet our medical institutions harm patients daily. They dun them for medical bills they can’t afford, often leaving them unable to pay their rent or mortgage, or buy enough to eat.
That accusation isn’t hyperbole, it’s a finding from our analysis — published this month in JAMA Network Open — of Census Bureau surveys on medical indebtedness. We found that more than one in 10 U.S. adults — and nearly one in five households — incurred a medical debt they couldn’t pay. And it wasn’t just the poor or uninsured who were at risk. Adults who had gone to college were just as likely to have medical debts as those who hadn’t finished high school, and middle-income individuals had the same risk as the poor. While the uninsured had the highest rate (15.3%) of medical indebtedness, 10.5% of individuals with private coverage had medical debts — presumably due to high copayments, deductibles, and coverage denials — with Medicare Advantage enrollees having a particularly high rate. And the debts weren’t trivial: they averaged $21,687 per debtor in 2018.
Our findings add to a growing litany of studies showing that medical bills are a huge problem for Americans. Back in 2001, we (together with then-Harvard law professor Elizabeth Warren and sociologist Deborah Thorne) found that illness and medical bills contributed to more than half of all personal bankruptcies, a figure that climbed to 62% in 2007. A Kaiser/NPR survey this year suggests that our estimates of medical indebtedness (based on 2017-2019 surveys) may be too conservative; Kaiser/NPR estimates that 100 million Americans are dealing with medical debt.
But whatever the number, the consequences are often grave. Because the Census Bureau repeatedly surveyed the same individuals over 3 years, we, unlike previous analysts (who used one-time surveys), could assess the consequences of newly acquiring medical debt. Among individuals with no medical debts in 2017, those who newly incurred such debt in subsequent years were more than twice as likely to newly become food insecure or unable to pay their rent, mortgage, or utility bill, and to be evicted or suffer foreclosure in subsequent years.
Moreover, the detailed income and asset data that the Census Bureau collected enabled us to isolate the effects of medical bills. It was medical bills, not lost income due to illness or depleted assets from non-medical bills, that drove people from their homes and left them struggling to afford groceries. In policy parlance, medical bills often worsened patients’ Social Determinants of Health — non-medical factors that affect health outcomes.
Medical leaders and policy makers like to blame those non-medical factors for the yawning disparities in health outcomes in our nation, and our life-expectancy that lags 3 to 4 years behind other wealthy nations. They’re right. Poverty and all of the woes that come with it undermine health. But while in 80% of hospitals the “leadership is committed to establishing and developing processes to systematically address social needs as part of clinical care,” they studiously avoid acknowledging that they’re part of the problem. The bills they send often contribute to a downward spiral of worsening poverty that we know causes deteriorating health.
That leaves doctors trying to clean up the mess that our healthcare system creates. Our patients get sick and their medical bills too often make them sicker, or add to their trauma (as we found in another recent study led by Sam Dickman, MD).
The Dickman study examined the ED records of sexual assault victims across the nation. More than 17,000 of those survivors were uninsured; the charges for their ED care averaged $3,600. Moreover, even rape victims with private insurance are stuck paying (on average) 14% of the costs for their rape-related care — nearly $1,000. That’s a particularly steep price for the lower-income women and girls who face the greatest risk of a sexual assault. Fear of the cost is undoubtedly part of the reason that only one in five rape victims seeks medical care.
Doctors can take some small steps that might reduce patients’ financial risks. We can remind veterans to check if they’re eligible for VA services, help our poor patients enroll in Medicaid, or connect them to hospitals’ financial assistance programs. In some practice settings, physicians can forgive copayments and deductibles that cause hardships. But those measures would still leave millions of Americans, insured and uninsured, submerged in debt once they get sick.
The hard truth is that unless you’re Elon Musk, you could be only one serious illness away from financial disaster, even if you have coverage, because health insurance is a defective product.
Our healthcare system’s infliction of financial (and hence medical) harm is a uniquely American policy choice. In most wealthy nations, national health insurance or a national health service protects patients from that harm; taxpayers foot the bill for everyone’s care so the sick don’t suffer doubly. That’s an approach — generally known as Medicare for All — that more than half of American voters and about half of all doctors support. It would let doctors do good without worrying that they’re doing harm.
David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH, are both distinguished professors at CUNY’s Hunter College in New York City, lecturers in medicine at Harvard Medical School in Boston, and research associates for Public Citizen’s Health Research Group.
Source: MedicalNewsToday.com
