Thread by @nealemahoney

New publication: Medical Debt in the US, 2009-2020 (joint with @ray_kluender, @francisawong, and @wesyin) in @JAMA_current

Link to the paper: jamanetwork.com/journals/jama/…

The 4 of us have been studying medical debt for 5+ years, including an exciting debt forgiveness experiment with @RIPMedicalDebt. Our initial goal with this paper was to establish a set of facts on medical debt that could inform policy and lay a foundation for future research.

We’re grateful to the editors who pushed us to be ambitious and write a paper that tries to paint a more comprehensive picture of the evolution of medical debt over the last decade. Here are some key takeaways:

1. Over 2009-2020, medical debt (as listed on credit reports) has grown to account for more than half of debt in collections, measured both as the stock of debt in collections (left) and the flow of debt in collections accrued in the last year (right).

That is, while financial distress has declined over the last decade due to the recovery from the Great Recession, medical debt has grown relative to non-medical debt and is now greater in total than debt in collections from all other sources combined.

If you have a debt collector calling you up or knocking on your door, it’s more often than not because of an unpaid medical bill. I've been studying medical debt for years and I still find this fact jarring.

2. Medical debt is disproportionately concentrated in the South and in low-income communities. The avg amount of medical debt is 3x higher in the South than in the Northeast (left). The avg amount of medical debt is 5x higher in poor communities than rich ones (right).

3. The ACA Medicaid expansions led to a (huge) 34 pp decline in medical debt in collections in expansion states vs non-expansion states (left). Non-medical debt did not trend differentially in expansion vs non-expansion states (right), reducing concerns about confounding factors.

4. Medical debt has historically been highest in the South. Because most states in the South have not expanded Medicaid, medical debt has increased the most in the places with the highest amounts of medical debt (a “poor gets poorer” type of result)

In expansion states, the gap btw the richest and poorest communities fell (left). In non-expansion states, the gap btw the richest and poorest communities grew (right). Strikingly, communities with the most medical debt in 2009 saw the largest increases over the last decade.

There’s more in the paper, including an estimate of the total amount of medical debt and a discussion of the limitations of measuring medical debt with credit reports.

And check out this fantastic summary in the @UpshotNYT by @sarahkliff and @sangerkatz

nytimes.com/2021/07/20/ups…