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Estimates have suggested that identify and improve health dis- S. Tuminello conducted data analyses. 3. Moreno G, Walker KO, Grumbach K. fl primary care physicians treat from parities in the . Their R. Flores and E. Taioli conceptualized the Self-reported uency in non-English lan- study design. All authors contributed to guages among physicians practicing in 1200 to 2300 patients per year, intent to practice and work with manuscript preparation. California. Fam Med. 2010;42(6):414–420. and the reported average for underserved populations can al- 4. Association of American Medical specialists in the years 2009 to leviate current and projected ACKNOWLEDGMENTS Colleges. Diversity in medical education fi 2010 was 2704 patients per year. health care demand in these We thank the participants of the study. facts & gures 2016. Available at: http:// www.aamcdiversityfactsandfigures2016. Even under a conservative esti- groups, especially in primary care. org/index.html. Accessed August 14, mate for this sample, each DACA The medical establishment must CONFLICTS OF 2018. The authors have no conflicts of interest. physician could treat 1000 pa- devote critical effort to resolving 5. Association of American Medical tients per year, with a likely focus the status of DACA recipients and Colleges. Diversity of US medical students 7 HUMAN PARTICIPANT by parental income. Available at: https:// on the underserved. Over a realize the social and economic PROTECTION www.aamc.org/download/102338/ 10-year period, a DACA physi- benefits that DACA physicians Approval for this study was granted by the data/aibvol8no1.pdf. Accessed August 11, cian could treat 10 000 patients in provide to US health care. institutional review board of the Icahn 2018. populations that currently face School of Medicine at Mount Sinai. As the 6. Association of American Medical survey wasanonymouslyadministered,the Colleges. The complexities of physician inequity in health care and are Julio C. Ramos, BS study was deemed exempt. supply and demand: projections from projected to have increased de- Wil Lieberman-Cribbin, MPH 2016 to 2030 final report. Available at: mand for physicians. Christina Gillezeau, MPH REFERENCES https://aamc-black.global.ssl.fastly. fi net/production/media/filer_public/ This work emphasizes the Naomi Alpert, MS 1. Migration Policy Institute. A pro le of current DACA recipients by education, 85/d7/85d7b689-f417-4ef0-97fb- distinct contributions of DACA Maaike van Gerwen, MD industry, and occupation. 2017. Available ecc129836829/aamc_2018_workforce_ medical students to US health Stephanie Tuminello, MPH at: https://www.migrationpolicy.org/ projections_update_april_11_2018.pdf. fi Accessed August 14, 2018. care. Given the current and Raja Flores, MD research/pro le-current-daca-recipients- education-industry-and-occupation. 7. Xierali IM, Nivet MA. The racial and expanding need for socioeco- Emanuela Taioli, MD, PhD Accessed August 8, 2018. ethnic composition and distribution of nomic, cultural, and linguistic 2. Association of American Medical primary care physicians. J Health Care Poor – diversity in the medical profession CONTRIBUTORS Colleges. Supporting medical students Underserved. 2018;29(1):556 570. to match patients’ backgrounds, J. Ramos, C. Gillezeau, and M. van and residents with DACA status. Available at: Gerwen developed the questionnaire in- https://news.aamc.org/diversity/article/ the diversity of this sample pro- strument and performed study outreach. supporting-medical-students-residents- vides a unique perspective to W. Lieberman-Cribbin, N. Alpert, and daca-status. Accessed August 10, 2018.

filers from 2013 to Medical Bankruptcy: Still Common 2016, we randomly sampled 200 each quarter, abstracted Despite the their court record data, and (with institutional review board Myriad anecdotes—of a public and stigmatizing confession bankruptcy, increasing medical approval) mailed them a ques- Nobel laureate who sold his of impoverishment. In surveys costsandstagnantincomescould tionnaire closely modeled on medal to pay medical bills,1 conducted by researchers with the have the opposite effect. the questionnaires used in those or the more than 250 000 Consumer Bankruptcy Project in We sought to assess the in- earlier studies.5,6 GoFundMe medical campaigns 20015 and 2007,6 a majority of cidence of medical bankruptcy in Of the 3200 surveys we last year2—attest to the financial recently bankrupt debtors impli- the current era using methods mailed, the postal service toll of illness on American fam- cated medical bills or illness- similar to those employed by the returned 108 as undeliverable ilies. National surveys confirm related work loss as causes of their Consumer Bankruptcy Project and 910 debtors responded, that medical bills frequently bankruptcy, findings that Presi- in its 2001 and 2007 surveys. for a response rate of 29.4%. 3 From court records of all US Court records indicated that cause financial hardship, and dent Obama used to argue for the US Consumer Financial passage of the Affordable Care Act Protection Bureau reported that (ACA). The ACA both expanded ABOUT THE AUTHORS David U. Himmelstein and Steffie Woolhandler are with Hunter College, City University of they were by far the most andupgradedhealthinsurance , New York, NY, and Harvard Medical School, Boston, MA. Robert M. Lawless common cause of unpaid bills coverage, banning preexisting ill- is with the University of Illinois College of Law, Champaign. Deborah Thorne is with the sent to collection agencies in ness exclusions, imposing a cap on Department of Sociology & Anthropology, University of Idaho, Moscow. Pamela Foohey is with the Maurer School of Law, Indiana University, Bloomington. 2014, accounting for more than out-of-pocket spending, and Correspondence should be sent to David U. Himmelstein, MD, 255 West 90th St, New half of all such .4 mandating coverage for essential York, NY 10024 (e-mail: [email protected]). Reprints can be ordered at http:// fi www.ajph.org by clicking the “Reprints” link. Less evidence is available on the bene ts. Although these reforms This editorial was accepted November 27, 2018. medical causes of bankruptcy, a might attenuate the risk of medical doi: 10.2105/AJPH.2018.304901

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nonrespondents’ financial char- states that did versus did not ac- Even if the medical bankruptcy assumption that every bank- acteristics mostly resembled those cept the ACA’s Medicaid ex- rate among nonrespondents were rupting illness starts at the mo- of respondents; their median net pansion (P = .76). The responses half that of respondents, the ment of an initial hospitalization worth was similar (–$32 947 regarding individual items in the overall rate would exceed 40%. is contradicted by its cohort’s vs –$30 409; P = .17), as were current survey are also similar Our findings contrast with upsloping rate of bankruptcy their assets, debts, and ongoing to those in 2007, when 57.1% those of a recent study analyzing filings in the baseline period medical expenses (P > .05 for all of debtors cited medical bills as the financial sequelae of hospi- prior to hospitalization. Because comparisons), although non- contributors to their bankruptcy talization in California from 2003 bankruptcy rates do not rise respondents had slightly higher and 40.3% cited income loss due to 2007.7 That study found that with age, this suggests that fi- monthly incomes ($2750 vs to illness.6 hospitalization increased medical nancial distress from illness $2489; P < .001). Among those we surveyed debts and decreased employment frequently predated hospitali- Table 1 displays debtors’ re- from 2013 to 2016, medical and income, but it suggested zation. Because the study esti- sponses regarding the (often debtors were more likely than that medical were mated medical bankruptcies multiple) contributors to their other respondents to live with a uncommon. However, its eco- from changes in filing trends bankruptcy. The majority spouse or partner but were similar nometric approach rests on before versus after hospitaliza- (58.5%) “very much” or in age, gender, and likelihood of four assumptions likely to un- tion, failure to account for the “somewhat” agreed that medi- being uninsured. Medical debtors derestimate the medical bank- upsloping baseline probably cal expenses contributed, and more frequently self-reported fair ruptcy rate. First, its cohort introduced a substantial down- 44.3% cited illness-related work or poor health (odds ratio [OR] = excluded most persons with fre- ward bias. loss; 66.5% cited at least 2.88; P < .001), major disability quent hospitalizations, a group at The California study’s authors one of these two medical (OR = 2.52; P < .001), foregoing high risk of medical bankruptcy. argued that survey-based ascer- contributors—equivalent to about needed medical attention in the Second, it assumed that only tainment of the causes of bank- 530 000 medical bankruptcies two years prior to the bankruptcy hospitalized patients can suffer a ruptcy is unreliable, because annually. filing (OR = 1.77; P < .001), and medical bankruptcy, although debtors cannot know the true The share of debtors reporting foregoing needed patients hospitalized in the course cause of their financial pre- a medical contributor before the (OR = 2.65; P < .001). of a year account for only 18.2% dicament—just as heart attack ACA’s January 1, 2014 imple- Like all surveys, ours relies on of out-of-pocket costs paid by patients cannot know what caused mentation (65.5%) and after respondents’ candor. Moreover, US households (Himmelstein their illness.7 Yetinour(D.U.H. implementation (67.5%) was the modest response rate—17.1% and Woolhandler, unpublished and S. W.) clinical experience, similar (P = .37). Both of these lower than the response rate in analysis of data from the 2015 most such patients can accurately figures are close to the 62.1% the 2007 study—mandates cau- Medical Expenditure Panel identify the smoking, dietary estimate from the 2007 survey, tious interpretation of our cur- Survey). Third, it assumed that a habits, and family history that put and in a difference-in-differences rent findings. However, the child’s, elderly parent’s, or other them at risk. Moreover, debtors analysis we found no evidence similarities between respondents relative’s illness never causes a are peculiarly well positioned to that trends differed between and nonrespondents is reassuring. bankruptcy. Finally, the study’s identify the contributors to the

TABLE 1—Share of Debtors Citing Specific Contributors to Their Bankruptcy: United States, 2013–2016

Reasons Cited as Contributors to Bankruptcy (A) Very Much Agree, % (B) Somewhat Agree, % (A) + (B) Very Much or Somewhat Agree, % Medical-related reasons Medical expenses 37.0 21.5 58.5 Medical problems causing work loss 27.9 16.5 44.3 Either of above 44.2 22.3 66.5 Change in family size such as birth or death 13.7 7.9 21.6 Any of above 50.1 21.4 71.5 Other reasons Income loss (including persons with medically related work loss) 61.5 16.3 77.8 Unaffordable mortgage or foreclosure 29.2 15.8 45.0 Spending/living beyond means 17.2 27.2 44.4 Student 14.3 11.1 25.4 Divorce/separation 18.5 5.9 24.4 Tried to help friends/relatives 12.7 15.7 28.4

Note. The sample size of the survey was n = 910.

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bankruptcy. As part of their preexisting condition coverage 4. Consumer Financial Protection bankruptcy proceedings, all of our mandate. Bureau. Consumer reports: a study of medical and non-medical collec- respondents had recently prepared The results of the midterm tions. 2014. Available at: http://files. detailed documentation of their election—in which health consumerfinance.gov/f/201412_cfpb_ assets, debts, and current finances, care was the most prominent reports_consumer-credit-medical-and- non-medical-collections.pdf. Accessed and had sworn to its accuracy. issue—stand as a rebuke to these September 30, 2018. Medical bankruptcy has gar- retrograde steps. Instead, policy- 5. Himmelstein DU, Warren E, Thorne nered public attention because makers should move forward D, Woolhandler S. Illness and injury as it resonates with the abuse that from the ACA and implement contributors to bankruptcy. Health Aff — (Millwood). 2005;24(suppl Web exclu- Americans including many programs that guarantee coverage sives):W5-63–W5-73. — middle-class Americans that is not just universal but also 6. Himmelstein DU, Thorne D, Warren suffer at the hands of our comprehensive, as well as sick E, Woolhandler S. Medical bankruptcy in health care finance system. leave and disability coverage that the United States, 2007: results of a na- tional study. Am J Med. 2009;122(8): Despite gains in coverage and replaces income during illness. 741–746. access to care from the ACA, Although death is inevitable, 7. Dobkin C, Finkelstein A, Kluender R, our findings suggest that it good public policy can ensure Notowidigdo MJ. Myth and measure- did not change the proportion that financial suffering from ill- ment—the case of medical bankruptcies. N Engl J Med. 2018;378(12):1076–1078. of bankruptcies with medical ness is not. causes. That’s not surprising because the chronically poor— David U. Himmelstein, MD the group most affected by the Robert M. Lawless, JD ACA’s coverage expansion— Deborah Thorne, PhD have reduced access to credit, Pamela Foohey, JD have few assets (such as a home) Steffie Woolhandler, MD, MPH to protect, and face particular difficulty in securing the legal CONTRIBUTORS help needed to navigate formal D. U. Himmelstein, R. M. Lawless, and S. Woolhandler performed data analyses. bankruptcy proceedings. D. U. Himmelstein and S. Woolhandler Moreover, medical costs drafted the initial version of the manu- continue to outpace incomes, 29 script. R. M. Lawless, D. Thorne, and P. Foohey were responsible for data col- million remain uninsured, and lection. All authors reviewed and revised many of those with health in- the final version of the manuscript. surance face unpredictable and CONFLICTS OF INTEREST unaffordable out-of-pocket costs The authors had no conflicts of interest. as copayments and deductibles REFERENCES ratchet up. And few Americans 1. Kliff S. A Nobel Prize–winning have adequate disability cover- physicist sold his medal for $765,000 to age, leaving them vulnerable to pay medical bills: only in America. Vox, illness-related income loss that October 4, 2018. Available at: https:// www.vox.com/health-care/2018/10/ amplifies the financial distress 4/17936626/leon-lederman-nobel-prize- caused by medical bills. medical-bills. Accessed October 15, 2018. Rather than acting to make 2. GoFundMe. Get help with medical health care more affordable, the fundraising: with a free GoFundMe, you can get immediate help with medical bills. current administration seems Available at: https://www.gofundme. intent on further hollowing com/start/medical-fundraising. Accessed out coverage: encouraging a October 15, 2018. migration to bare-bones, short- 3. Hamel L, Norton M, Pollitz K, Levitt L, Claxton G, Brodie M. The burden of term insurance policies that medical : results from the Kaiser leave enrollees largely un- Family Foundation/New York Times protected; allowing states to Medical Bills Survey. Kaiser Family Foundation, 2016. Available at: impose Medicaid work re- https://www.kff.org/health-costs/ quirements that threaten to report/the-burden-of-medical-debt- swell the ranks of the uninsured; results-from-the-kaiser-family- foundationnew-york-times-medical- and joining a suit that would bills-survey/view/print. Accessed end enforcement of the ACA’s September 30, 2018.

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