Rural-Urban Differences in Health Care Unaffordability during the Postpartum Period

Background and Purpose

In the United States, rising health care costs and high needs for health care services have left millions with medical debt. Rural residents on average have lower incomes and are more likely to report significant medical debt. In addition, the postpartum period is associated with high out of pocket spending due to rising deductibles and maternal morbidities requiring expensive health care encounters. However, there is limited information on rural/urban differences in health care unaffordability by postpartum status. In this study, we used National Health Interview Study (NHIS) to examine differences in three measures of health care unaffordability by postpartum status and rural/urban location.

Methods

Study Design

We used cross-sectional survey data from the 2019-2021 NHIS to assess differences in health care unaffordability defined by three measures: worry about medical bills, problems paying medical bills, and being unable to pay medical bills by postpartum status and rurality. Survey weighted chi-squared tests were used to determine bivariate differences. Survey weighted multivariate logistic regression models including year fixed effects were used to determine the association between health care unaffordability, postpartum status, and rurality after adjusting for relevant sociodemographic covariates.

Population Studied

Our sample consisted of 17,800 female-identifying NHIS respondents, weighted to represent 57,927,729 individuals ages 18-44 at the time of the survey for years 2019, 2020, and 2021.

Results

Bivariate analyses showed postpartum people reported statistically significantly higher rates of being unable to pay medical bills and having problems medical paying bills, as compared to non-postpartum people. Rural residents also reported statistically significantly higher rates of being unable to pay medical bills and having problems paying medical bills as compared to urban residents. In adjusted models, the predicted probability of being unable to pay medical bills among postpartum respondents was 12.8 percent (CI: 10.1-15.5), which was statistically significantly higher than among non-postpartum respondents. Similarly, postpartum respondents had statistically significantly higher predicted probabilities of reporting problems paying medical bills (18.4 percent, CI: 15.4-21.4) as compared to non-postpartum respondents. Rural residency was not significantly associated with the health care unaffordability outcome measures in adjusted models.

Conclusions and Implications

Both postpartum and rural respondents reported higher rates of being unable to pay medical bills and having problems paying medical bills, however after adjusting for covariates, only postpartum respondents reported significantly higher rates of being unable to pay medical bills and having problems paying medical bills. These results suggest that postpartum status may present challenges to health care unaffordability that span geographic context.

Health care unaffordability and medical debt are demonstrated to have deleterious effects on multiple facets of life including health, mental health, and social determinants of health. The fact that rural and postpartum respondents report being unable to pay medical bills and having problems paying medical bills at higher rates calls for policies and programs designed to alleviate financial stress for postpartum people and rural residents. Social workers should advocate for policies that expand affordable health insurance coverage and financial assistance options in the postpartum period especially in rural areas.