Prevalence and Correlates of Medical Financial Hardship in the USA

Abstract

Background: High patient out-of-pocket (OOP) spending for medical care is associated with medical debt, distress about household finances, and forgoing medical care because of cost in the USA.

Objective: To examine the national prevalence of medical financial hardship domains: (1) material conditions from increased OOP expenses (e.g., medical debt), (2) psychological responses (e.g., distress), and (3) coping behaviors (e.g., forgoing care); and factors associated with financial hardship.

Design and participants: We identified adults aged 18-64 years (N = 68,828) and ≥ 65 years (N = 24,614) from the 2015-2017 National Health Interview Survey. Multivariable analyses of nationally representative cross-sectional survey data were stratified by age group, 18-64 years and ≥ 65 years.

Main measures: Prevalence of material, psychological, and behavioral hardship and hardship intensity.

Key results: Approximately 137.1 million (95% CI 132.7-141.5) adults reported any medical financial hardship in the past year. Hardship is more common for material, psychological and behavioral domains in adults aged 18-64 years (28.9%, 46.9%, and 21.2%, respectively) than in adults aged ≥ 65 years (15.3%, 28.4%, and 12.7%, respectively; all p < .001). Lower educational attainment and more health conditions were strongly associated with hardship intensity in multivariable analyses in both age groups (p < .001). In the younger group, the uninsured were more likely to report multiple domains of hardship (52.8%), compared to those with some public (26.5%) or private insurance (23.2%) (p < .001). In the older group, individuals with Medicare only were more likely to report hardship in multiple domains (17.1%) compared to those with Medicare and public (12.1%) or Medicare and private coverage (10.1%) (p < .001).

Conclusions: Medical financial hardship is common in the USA, especially in adults aged 18-64 years and those without health insurance coverage. With trends towards higher patient cost-sharing and increasing health care costs, risks of hardship may increase in the future.

Keywords: National Health Interview Survey; access to care; health insurance; medical debt; medical financial hardship; out-of-pocket spending; prescription drug nonadherence.

Figure 1

Any material, psychological, or behavioral medical financial hardship by age group. All p < 0.001. Data from 2015 to 2017 National Health Interview Survey.

Figure 2

Any medical financial hardship by age group by age and type of health insurance coverage. a Material hardship. b Psychological hardship. c Behavioral hardship. Multivariable logistic regression models controlled for the effects of age, sex, race/ethnicity, marital status, educational attainment, and number of health conditions and results are presented as adjusted predicted margins. All p < 0.001. Data from 2015 to 2017 National Health Interview Survey.

Figure 3

Medical financial hardship and medication prescribed status in the past 12 months. a Aged 18–64 years. b Aged 65+ years. The medication prescribed status was measured by the yes/no question: During the past 12 months, were you prescribed medication by a doctor or other health professional? Age, sex, race/ethnicity, marital status, educational attainment, insurance status, condition count, and survey year were adjusted in the regression. All p < 0.001. Data from 2015 to 2017 National Health Interview Survey.