Nearly one-third of working-age Americans struggle to pay their medical
bills, according to a recent report, with African Americans and women the most
A recently released analysis of the 2003 Commonwealth Fund Biennial Health
Insurance Survey concluded that an estimated 77 million adult
Americans—both insured and uninsured—have difficulty paying
medical bills, have accrued medical debt, or both. The latest findings support
the conclusions of earlier studies that have found medical debt to be a
significant problem, even for those with health insurance (Psychiatric
News, March 18).
"Medical bill and debt problems not only create financial hardship
but can deter people from seeking further health care," said Michelle
McEvoy Doty, Ph.D., a study author and senior analyst at the Commonwealth
Fund. "In the long run that situation puts a bigger burden on the health
care system because you are missing out on preventive medicine and not
managing chronic conditions."
Working-age adults are much more likely to face medical bill problems than
Americans aged 65 and older, since pensions and Medicare offer protections for
older Americans. The survey found that nearly one-third of the working-age
respondents (32 percent) reported struggles with medical bills, while just 14
percent of elderly respondents reported the same. Medical debt was reported by
16 percent of working-age adults compared with 4 percent among adults over 64
Doty said the larger impact of medical bills on working-age adults stems
from private insurers' "much more fragmented" approach to
coverage, compared with Medicare's "very reliable" assistance in
paying medical bills.
The challenge for working adults trying to pay for health care was even
greater than for seniors among those with low incomes. The report found that
48 percent of low-income, working-age adults reported medical bill problems in
the 12 months prior to the survey, while only 20 percent of low-income seniors
reported such problems.
Working-age women were strongly impacted by the cost of medical care, and
39 percent reported medical bill problems, compared with 25 percent of
The survey found that 52 percent of African Americans reported medical bill
problems, in contrast to 34 percent of Hispanics and 28 percent of whites,
according to the report.
The data stem from a national telephone survey conducted from September 3,
2003, through January 4, 2004, among a random, nationally representative
sample of 4,052 U.S. adults. The survey had a 50 percent response rate.
Health care reform advocates, such as Physicians for a National Health
Program (PNHP), said the data support long-held beliefs that the rising cost
of health care reduces access to that care, especially among working-age
Americans, who lack the Medicare or pension coverage that buffers costs for
"Though some protection for the retired is afforded by pension funds,
the much larger incomes of the workforce are not adequate to compensate for
the deficiencies of private coverage," according to a statement on the
results issued by PNHP, which advocates a national, single-payer health
system. "Obviously a universal Medicare program with expanded benefits
would be much more effective in preventing medical debt."
Those without health insurance coverage during the study period had
significantly higher rates of medical bill problems and debt (60 percent) than
did the continuously insured (35 percent).
Rates of medical bill problems for the uninsured were more than twice those
of the insured, with 35 percent of those without insurance at some point in
the year contacted by collection agents compared with 15 percent of the
However, the possession of health insurance was not enough to prevent large
numbers of Americans from incurring a large burden of medical debt.
Researchers found that 57 percent of adults with medical bill problems and 70
percent with medical debt were insured at the time their financial obligation
"As employers continue to pass on health care costs to their
employees, you are going to see more people struggling with their medical
bills and accruing debt," Doty said.
A survey of 1,800 firms released in September by Mercer Human Resources
Consulting found more employers are struggling with ways to cover what is
expected to be a nearly 10 percent increase in health insurance costs for 2006
and plan to shift more of the burden of paying for medical care to their
employees. Despite the expected 10 percent increase, employers polled plan to
increase their spending by only 6.4 percent and have their employees make up
Medical bill problems and inadequate insurance, said the Commonwealth
survey analysis, were also linked by inadequate or absent prescription drug
coverage. Nearly half of working-age adults without prescription coverage in
their insurance plan had problems covering the medical costs, compared with
one-third who did have prescription drug benefits.
The study also found that medical bill burdens and medical debt reduced
Americans' access to health care, with 63 percent of adults with medical debt
problems forgoing needed care within the preceding year due to cost. Only 19
percent of adults without medical bill challenges avoided seeking needed
The study found 43 percent of workingage adults experiencing medical bill
or debt problems failed to fill a prescription because of cost, compared with
just 9 percent of adults not enduring such problems.
Even after adjusting for insurance coverage, income, health status, and
other variables, the researchers found that Americans with problems paying
health care bills were much more likely to leave a prescription unfilled,
forgo a needed physician's visit, or skip recommended tests or follow-up
visits than were adults less challenged by medical costs.
The study found as well that 23 percent of those struggling to pay medical
bills did not see a specialist when needed, compared with 6 percent without
such bill-paying challenges. Thirty-seven percent with medical bill problems
skipped medical tests, treatment, or follow-up, while only 6 percent of those
without bill problems did so. Additionally, 42 percent of those with daunting
medical bills had a medical problem but did not visit a physician or clinic
for treatment, far more than the 8 percent without difficult medical bills and
did not seek needed assistance.
"People who have bills and debt are more likely to have health care
access problems," Doty said.
"Seeing Red: Americans Driven Into Debt by Medical
Bills" is posted at<www.cmwf.org/usr_doc/837_Doty_seeing_red_medical_debt.pdf>.▪