Examining Associations between Past-Due Unpaid Medical Bills and Healthcare Utilization

Background and Objective. Nearly 1 in 12 adults owe medical debt in the US, which is about $220 billion, despite over 90% of the population having some form of health insurance. Having unpaid bills from a healthcare provider has been associated not only with adverse physical and mental health conditions, but also with decrease in credit scores and bankruptcy. Anderson’s model for health services utilization suggests that healthcare costs limit access to and utilization of healthcare services. While previous research has examined the general impact of financial barriers on healthcare access, limited attention has been given to the specific role of past-due unpaid medical bills in predicting healthcare utilization. Thus, we examine whether past-due unpaid medical bills predict healthcare utilization, such as not filling prescriptions for medicine, skipping medical tests, treatments, or follow-ups, and forgoing doctor or clinic visits.

Methods. Using 2021 National Financial Capability Study data, we examined the associations between having past-due unpaid medical bills and the likelihood of not filling a prescription, skipping a medical test, and not visiting a doctor, while controlling for health insurance access, gender, ethnicity, age, employment, income, and dependents. First, we performed chi-squared tests to explore these associations. Significant associations warranted further analyses. As the dependent variables were dichotomous, three separate binary logistic regressions were performed to test these associations.

Results. Our sample consisted of 54% female, 28% aged 18-35, 26% Non-Whites, 46% had a college degree, and over half of the participants (55%) were employed. Additionally, 22% reported having unpaid medical bills, and 88% had health insurance. Across all three models, several factors were consistently associated with the likelihood of avoiding healthcare due to cost. In Model 1, females (OR=1.199, p<0.01) and individuals aged 18-35 (OR=1.425, p<0.01) were more likely to not fill a prescription. Non-White individuals were less likely (OR=0.892, p<0.01), while unpaid medical bills were the strongest predictor, significantly increasing the odds (OR=5.645, p<0.01). Health insurance decreased the likelihood (OR=0.578, p<0.01). In Model 2, females (OR=1.291, p<0.01) and individuals aged 18-35 (OR=1.424, p<0.01) were again more likely to skip a test, while non-Whites were less likely (OR=0.828, p<0.01). Unpaid medical bills increased the odds (OR=5.540, p<0.01), and having health insurance reduced the likelihood (OR=0.461, p<0.01). In Model 3, individuals aged 18-35 (OR=1.671, p<0.01) were more likely to avoid seeing a doctor, and unpaid medical bills increased the odds significantly (OR=5.290, p<0.01). Non-White individuals were less likely to avoid care (OR=0.807, p<0.01), and health insurance again reduced the likelihood (OR=0.370, p<0.01).

Implications. Results highlight the importance of addressing the financial burden of healthcare, particularly for vulnerable populations. Policies aimed at reducing financial barriers could help improve healthcare access and utilization, particularly among younger adults, females, and those facing financial hardship. Findings have implications for social workers, as forgoing necessary care will lead to increased emergency care, productivity loss, and long-term healthcare costs, which will place additional strain on the healthcare system and economy.