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Past-Due Medical Debt Among Nonelderly Adults, 2012–15

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Past-Due Medical Debt Among Nonelderly Adults, 2012–15 HEALTH POLICY CENTER AND OPPORTUNITY AND OWNERSHIP INITIATIVE Past-Due Medical Debt among Nonelderly Adults, 2012–15 Michael Karpman and Kyle J. Caswell March 2017 Medical bills contribute to financial insecurity for many Americans. In this brief, we use survey data to examine the prevalence of past-due medical debt among nonelderly adults—specifically, how it varies across states, and how it has changed over time. We find that states differ substantially in the share of nonelderly adults reporting that they have unpaid medical bills that are past due. Many Americans carry past-due medical debt balances. A recent Consumer Financial Protection Bureau report found that unpaid debt in collections owed to hospitals and other medical providers made up about half of all debt in collections, and that 19 percent of consumers with a credit file had some form of medical debt in collections (CFPB 2014). Families with medical debt report that it reduces their ability to save and to afford basic household needs, increases their reliance on credit cards and other forms of debt, damages their credit, and induces them to forgo needed health care (Hamel et al. 2016; Pollitz et al. 2014). In extreme cases, medical debt may contribute to personal bankruptcy, although the extent to which medical bills cause bankruptcy is debated (Dobkin et al. 2016; Dranove and Millenson 2006; Gross and Notowidigdo 2011; Himmelstein et al. 2005). A fundamental function of health insurance is to protect people against the risk of unexpected medical bills, and several studies have found that health insurance reduces medical debt as well as other forms of debt. For example, expansions of health insurance coverage that occurred before the Affordable Care Act (ACA) lowered the share of individuals with medical debt in collections, personal bankruptcy rates, and total debt past due (Finkelstein et al. 2011; Gross and Notowidigdo 2011; Mazumder and Miller 2016). More recently, the ACA’s Medicaid expansion has been shown to reduce nonmedical debt in collections in communities with high shares of low-income and uninsured people (Hu et al. 2016). However, health insurance may not fully offset the costs of medical care received and does not necessarily eliminate the risk of acquiring medical debt. One study suggests that most patients who incur medical debt do so when they are covered by health insurance (Karpman and Long 2015). For those with coverage, the risk of accumulating medical debt may depend on their health plan’s benefit design and cost sharing requirements, their understanding of their plan’s benefits, and their state’s insurance regulations. The patient’s family income, savings, need for and use of medical care, and financial knowledge could also affect the likelihood of incurring medical debt. Although health insurance coverage rates and other potential determinants of medical debt differ across states and have changed over time, we found no published studies examining geographic variation in the prevalence of medical debt and how it has changed across states in recent years. This brief provides the first available state-level estimates on past-due medical debt. It draws on data from the 2012 and 2015 iterations of the National Financial Capability Study (NFCS) to estimate the share of nonelderly adults (ages 18 to 64) nationally and in each state with medical bills that are past due (see the Data and Approach section on page 10 for more information about the NFCS and limitations of this analysis). Our focus on the nonelderly population is motivated by the different risk factors this group faces compared with elderly adults. In particular, most people ages 65 and older have health insurance coverage through Medicare, and most are not working.1 Consequently, recent trends that may affect levels of medical debt—for example, improving economic conditions, expansion of health insurance coverage under the ACA, and the ongoing shift toward high-deductible employer- based health plans (Claxton et al. 2016)—are much more relevant to nonelderly adults. This work is part of a larger Urban Institute project to produce research that can be used to improve family financial health and capability as it relates to the risk of accumulating medical debt. We address the following questions: What share of nonelderly adults had past-due medical debt in 2012 and in 2015? Which states have the highest and lowest prevalence of past-due medical debt among nonelderly residents? How did the prevalence of past-due medical debt among nonelderly adults change, nationally and in individual states, between 2012 and 2015? How much did the prevalence of past-due medical debt change over time for nonelderly adults of different demographic and socioeconomic backgrounds? How does the prevalence of past-due medical debt vary by health insurance coverage status? The NFCS data indicate that past-due medical debt is common and that reported past-due medical debt varies considerably across states.2 2 PAST- DUE MEDICAL DEBT AMO NG NONELDERLY ADULTS, 2 012–15 Results Past-Due Medical Debt Affects Many Nonelderly Adults and Is Most Prevalent in the South Nearly one-quarter (23.8 percent) of nonelderly adults reported past-due medical debt in 2015, with the highest prevalence found in the South (figure 1).3 The share of adults who reported past-due medical debt varies substantially across states, ranging from 5.9 percent in Hawaii to 37.4 percent in Mississippi. Eight of the 10 states with the highest rates of past-due medical debt rates are in the South (Mississippi, Arkansas, West Virginia, South Carolina, Kentucky, Oklahoma, Alabama, and Georgia) and two are in the Midwest (Indiana and Missouri). The 10 states with the lowest prevalence of past-due medical debt are more geographically dispersed: three are located in the Northeast (Massachusetts, Connecticut, and New York), one in the Midwest (Minnesota), four in the West (Hawaii, California, Utah, and Nevada), and two in the South (the District of Columbia and Maryland).4 Overall, state past-due medical debt rates correlate strongly with state uninsured rates (figure 2). PAST- DUE MEDICAL DEBT AMO NG NONELDERLY ADULTS , 2 0 1 2 –15 3 FIGURE 1 Share of Adults Ages 18 to 64 Reporting Past-Due Medical Debt, 2015 MS 37.4% AR WV IN SC KY MO OK AL GA NC FL ME TN MT KS LA NM AK VA DE TX NE WY AZ US 23.8% NH WA WI ID IA SD CO OR PA OH NJ IL VT MI RI ND NV NY MD UT DC CT MA CA MN HI 5.9% 0% 5% 10% 15% 20% 25% 30% 35% 40% Source: National Financial Capability Study, 2015. Note: Adults reporting that they don't know if they have past-due medical debt or who refuse to report whether they have past- due medical debt are excluded from the denominator when calculating the share of adults reporting past-due medical debt. 4 PAST- DUE MEDICAL DEBT AMO NG NONELDERLY ADULTS, 2 012–15 FIGURE 2 Past-Due Medical Debt and Uninsured Rates among Adults Ages 18 to 64, by State, 2015 Share with past-due medical debt 40% MS AR 35% WV IN SC KY MO 30% OK AL NC GA FL ME TN MT NM KS LA VAAK 25% DE NE TX WY AZ NH WA WI OR ID IA PA SD CO OH 20% MI NJ VT RI ND IL NY NV MD UT DC MA CT CA 15% MN 10% HI 5% 0% 0% 5% 10% 15% 20% 25% 30% Share uninsured Source: National Financial Capability Study, 2015. Note: The correlation between state-level estimates of past-due medical debt and uninsurance (0.62) is weighted by census projections of state population size in 2015. Reported Past-Due Medical Debt Declined across States between 2012 and 2015 The national share of nonelderly adults reporting past-due medical debt fell 5.8 percentage points between 2012 and 2015, from 29.6 percent to 23.8 percent (table 1). During this period, the share of adults reporting past-due medical debt declined across all states. The largest percentage-point reductions occurred in Nevada, North Carolina, Minnesota, Mississippi, and Kentucky. The largest relative changes (i.e., percentage change) were in Hawaii, Minnesota, Nevada, Connecticut, and Vermont. Nationally, the share of adults who reported past-due medical bills fell by 19.5 percent from 2012 levels. PAST- DUE MEDICAL DEBT AMO NG NONELDERLY ADULTS , 2 0 1 2 –15 5 With some notable exceptions (e.g., Nevada, Ohio), states that had a relatively high prevalence of past-due medical debt in 2012 also had a high prevalence in 2015. In addition, there was no correlation between the change in a state’s share of nonelderly adults with past-due medical debt and the change in the state’s uninsured rate as reported in the NFCS (data not shown).5 TABLE 1 Share of Adults Ages 18 to 64 Reporting Past-Due Medical Debt, 2012 and 2015 Percentage-point Share in 2012 Share in 2015 difference Percent change Alabama 33.3% 30.0% -3.3 -10.0% Alaska 30.1% 26.2% -3.8 -12.8% Arizona 31.4% 24.3% -7.2 -22.8% Arkansas 40.3% 36.3% -3.9 -9.8% California 16.4% 16.0% -0.4 -2.6% Colorado 30.0% 22.2% -7.8 -26.1% Connecticut 26.4% 16.3% -10.1 -38.4% Delaware 34.2% 25.5% -8.7 -25.3% District of Columbia 22.1% 18.1% -4.0 -18.2% Florida 28.6% 28.1% -0.5 -1.8% Georgia 31.0% 29.2% -1.8 -5.9% Hawaii 14.6% 5.9% -8.8 -59.9% Idaho 31.5% 22.7% -8.8 -27.9% Illinois 28.0% 19.9% -8.1 -28.8% Indiana 32.7% 32.5% -0.2 -0.6% Iowa 29.2% 22.3% -6.9 -23.5% Kansas 31.1% 27.0% -4.1 -13.2% Kentucky 42.1% 30.9% -11.2 -26.7% Louisiana 32.8% 26.9% -5.9 -18.0% Maine 29.1% 27.7% -1.4 -5.0% Maryland 24.8% 18.6% -6.2 -25.0% Massachusetts 20.2% 16.1% -4.1 -20.2% Michigan 28.2% 19.7% -8.5 -30.0% Minnesota 25.0% 13.3% -11.7 -46.8% Mississippi 49.0% 37.4% -11.7 -23.8% Missouri 34.5% 30.6% -3.9 -11.3% Montana 36.7%
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