Association of medical debt and cancer mortality in the US.

Abstract

6505 Background: Medical debt is associated with non-medical and medical financial hardship, such as food and housing insecurity, as well as delaying or forgoing recommended health care. This study examines county level associations between medical debt and cancer mortality in the US. Methods: We conducted a county level ecological study, using 2018 medical debt data from the Urban Institute linked with 2015-2019 mortality data from the National Centers for Health Statistics. All US counties with non-missing information on medical debt and other covariates were included. Primary outcomes were age-adjusted mortality rates per 100,000 person-years for all malignant cancers and by cancer type. Multivariable linear mixed models were used to estimate the association of percent of population with medical debt with cancer mortality, adjusting for county level sociodemographic characteristics. Additional analyses examined the association between median amount of medical debt per person and cancer mortality for the subset of counties with these data. Models were weighted by county level population size, with standard errors clustered at the state level. Results: Among 2,943 counties, an average of 19.8% of the population had medical debt, ranging from 0% to 53.6% across counties. Higher percentages of the population with medical debt were observed in non-metro areas, counties with higher percentages of non-Hispanic Black people, adults without high school education, living below poverty level, uninsured, or unemployed. One percentage point increase in the population with medical debt was associated with a 1.12 (95% CI=1.02-1.22) increase in age-adjusted mortality rate (per 100,000 person-years) for all malignant cancers, a 0.47 (95% CI=0.43-0.52) increase for lung cancer, a 0.09 (95% CI=0.07-0.11) increase for colorectal cancer, and a 0.06 (95% CI=0.04-0.07) increase for female breast cancer. Among 1,949 counties with the amount of medical debt available, each $100 increase in median medical debt was associated with a 0.86 (95% CI=0.52-1.21) increase in age-adjusted mortality rate for all malignant cancers. Associations between increases in median medical debt and increased mortality rates were statistically significant for major cancer types. Conclusions: Medical debt is associated with significantly higher cancer mortality at the county level. Policies increasing access to affordable health care may improve cancer outcomes. [Table: see text]