AHCJ – Association of Health Care Journalists

14/08/2024 | News release | Distributed by Public on 15/08/2024 04:40

Covering medical debt? You’ll need these resources

An audience member talks during the HJ24 panel "Reporting on America's medical debt crisis" in June. Photo by Zachary Linhares

One of the little-known angles when covering medical debt is its effect on low-income communities, the under- and uninsured and people of color. Another under-covered angle is that having medical debt in collections is common among consumers with chronic conditions.

Health care journalists can find a wealth of data on these and other issues related to medical debt in a robust series of reports the Urban Institute has published since the spring of 2022. In that series, researchers document the biggest factors driving up health care debt and the multiple reasons that cause consumers to acquire such debt.

The Urban Institute's reports are important because medical debt - rather than fighting disease - is now a defining feature of the United State's health care system, as a KFF Health News investigation with NPR and CBS News has shown. "More than 100 million people in America - a startling 41% of adults - are saddled with medical bills they cannot pay," that investigation showed.

A nonprofit research organization in Washington, D.C., the Urban Institute published the latest report in its series, "The Changing Medical Debt Landscape in the United States," last month (July 10). For journalists, this report may be the most useful place to begin covering America's medical debt crisis.

"It's not a report per se," researcher Fredric Blavin said of the July 10 report. "It's more like a user-friendly data tool that you can use to look at medical debt in any county or state." Blavin is a principal research associate in the institute's Health Policy Center.

For the 100 million Americans who have health care debt in collections, all financial challenges become more pressing than they would be otherwise and can affect health care access and potentially worsen health outcomes, Blavin added in an email. Other researchers have shown a link between medical debt, worsening health status and mortality. In March, JAMA Network Open published an article showing that in 2,943 U.S counties, a higher share of the population with health care debt was associated with worse health status, more premature deaths, and higher mortality rates, as we reported in May.

Medical debt trends in states and counties

While the Urban Institute researchers did not examine the link between medical debt and mortality risk, the work is a deep and nuanced collection of data that health care reporters can use to assess health care debt trends in specific regions, states and counties, Blavin said. Using data from one region, journalists can compare those numbers with data from other counties or states, he added.

Reporters also can use the data to identify the factors that drive up medical debt, such as changes in average income in a population, the share of the population who are uninsured or have disabilities, and the percentage of people of color in certain areas, he explained.

The most recent report also is useful for identifying factors in individual communities that drive up medical debt, such as the concentration of hospitals, recent hospital closures or mergers with other hospitals. Other factors include average household income and the number of uninsured and disabled consumers in a state, county or ZIP code.

How hospital care drives up debt

In March 2023, for example, the institute published a report showing 72.9% of adults in the United States who have past-due health care debt owe at least some of that amount to hospitals. In that report, "Most Adults with Past-Due Medical Debt Owe Money to Hospitals," researchers noted that among adults with medical debt, 27.9% owe that money only to hospitals while 45.1% owe both hospitals and other providers.

Also in that report, the researchers identified how journalists could report on whether hospitals in their area were offering charity care to patients in need. Just over one-third of adults (35.7%) with past-due hospital bills reported that they had a payment plan and that only about one-fifth of adults (21.7%) received discounted care, the report showed.

In addition, adults who had annual income below 250% of the Federal Poverty Level ($31,200 for a family of four) were as likely as those with higher incomes to have debt collectors inquire about hospital bills and to have received discounted care, the report showed.

Here's a story to pursue: The concentration of past-due medical debt among families with low incomes and the large share who owe a portion of that debt to hospitals suggests that hospitals could provide more charity care to consumers in need, the researchers wrote.

A strong example from Colorado

For an article on medical debt collections in Colorado, we recently highlighted reporting by Rae Ellen Bichell and Lindsey Toomer who used Urban Institute data to supplement their reporting about how low-income consumers struggled to pay their hospital bills. In April, KFF Health News and several Colorado news sites published their article, "Medical Debt Affects Much of America, but Colorado Immigrants Are Hit Especially Hard." We reported on their work here: "Colorado journalists show power of collaboration in UCHealth debt collection exposé."

"The state's overall medical debt burden is lower than most. But racial and ethnic disparities are wider," Bichell and Toomer wrote. They showed that the largely Hispanic and low-income Westwood neighborhood in Denver (ZIP code 80219) had among the highest levels of health care debt in the state, according to Urban Institute data.

County-level data on debt

Using data from credit bureaus on more than 10 million consumers, Urban Institute researchers showed where people are more likely to have health care debt in collections and which county-level socioeconomic and health characteristics predict medical debt. "We find that 79 out of the 100 counties with highest levels of medical debt in collections are in states that have not expanded Medicaid under the Affordable Care Act," they wrote in this report, "Which County Characteristics Predict Medical Debt?"

These counties are concentrated mostly in Georgia, North Carolina and Texas, the researchers added. None of those states had expanded Medicaid when the report was published in June 2022. Since then, only North Carolina has done so, effective Dec. 1, 2023. Two months later, more than 346,400 residents had enrolled, according to reporting by Jaymie Baxley for North Carolina Health News.

Another story to cover is the effect of changes the three largest credit bureaus made when they started removing paid medical debt from consumers' credit reports two years ago. Then in 2023, they stopped including outstanding balances under $500, CNBC reported in July. In June, the federal Consumer Financial Protection Bureau proposed a ban on including medical bills on credit reports.

Documenting changes over time

One of the strengths of the Urban Institute reports is that they show the effect of the changes the credit bureaus made over time. Removing paid debt from credit reports helped to cut the number of Americans with medical debt in collections by half, Blavin noted in an email. Still,15 million Americans have health care debt in collections, and most debt balances remain on credit reports, he added.

The changes in reporting of health care debt are concentrated in the South, he added. The following states had the largest declines in the share of consumers who have medical debt in collections from 2021 to 2023: West Virginia (a decline from 25.8% to 6.7%); South Carolina (24.4% to 9.1%), Oklahoma (23.7% to 10.1%); Louisiana (21.3% to 8.1%); and Mississippi (18.5% to 6.1%).

In 2023, Blavin added, the states with the lowest levels of medical debt in collections were Colorado (0%), Minnesota (0.7%), Hawaii (1.2%), Vermont (1.2%), and Washington (1.4%). As of August 2023, Colorado prohibited credit bureaus from including medical debt to consumers' credit reports.

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