Caring While in Crisis: The Mental Health Toll of Medical Debt Among Healthcare Workers

Background and Purpose: Medical debt is a widespread and inequitable burden in the U.S., linked to financial insecurity, housing instability, and poor mental health outcomes such as depression, anxiety, and suicidal ideation (Collins et al., 2023; Han et al., 2024; Kluender et al., 2024; Wiltshire et al., 2020). While existing research has focused primarily on patients, less attention has been given to healthcare workers, many of whom ironically experience medical debt despite working in healthcare themselves and having employer-provided insurance (Himmelstein & Tsai, 2024; Kim et al., 2024). This study examines the extent of medical debt among hospital workers in Southwest Pennsylvania and investigates how the presence of debt is associated with mental health outcomes.

Methods: Data were collected from 1,466 nurses, service, and technical workers employed in hospitals in Southwest Pennsylvania, through an online survey administered via Qualtrics in March 2022. The purposive sample included unionized and non-unionized workers, recruited through union outreach. The explanatory variable was medical debt status (having medical debt or not). Outcome variables included mental health outcomes (e.g., depression, anxiety, suicidal ideation, PTSD, professional quality of life (PROQOL)—burnout, secondary traumatic stress, and compassion satisfaction). Covariates used in propensity score matching (PSM) included sociodemographic characteristics (e.g., age, gender, education, race, marital status), material hardship variables, general health. PSM was applied to match workers with and without medical debt on these covariates to reduce potential biases. To examine the effects of medical debt on the outcomes, multivariate regression models were applied, incorporating the matching weights and all covariates.

Results: One-third of the 1,466 hospital workers surveyed reported medical debt, most owing between $100 and $5,000 and carrying it for less than two years. Those with medical debt were more likely to be women, people of color, parents, and lower-income earners. They also reported greater material hardship and worse mental health outcomes, including higher rates of depression, anxiety, suicidal ideation, burnout, and secondary traumatic stress. Propensity score matching (PSM) achieved covariate balance between groups, reducing bias and eliminating significant baseline differences. Multivariate models using matching weights and covariates showed that medical debt was significantly associated with suicidal ideation (ATT=.070, 95% CI: [0.019, 0.121], p=.007), PTSD (ATT=.090, 95% CI: [0.017, 0.163], p=.015), and higher levels of burnout (ATT=.029, 95% CI: [0.001, 0.057], p=.043) and secondary traumatic stress (ATT=.070, 95% CI: [0.011, 0.130], p=.021).

Conclusions and Implications: This study highlights the widespread and persistent nature of medical debt among hospital workers and its strong association with poor mental health outcomes, including suicidal ideation, PTSD, burnout, and secondary traumatic stress. The findings point to the urgent need for targeted policy reforms and workplace interventions that address both the financial and psychological toll of medical debt. Key steps include expanding access to affordable healthcare, improving the quality of employer-sponsored insurance, and providing timely, confidential mental health and financial support within hospital systems. Future research should examine the long-term effects of medical debt and evaluate the effectiveness of interventions aimed at preventing its accumulation and mitigating its consequences.