Medical debt linked to increased likelihood of forgoing mental health care

People with medical debt in 2023 were about five times more likely to forgo mental health care treatment in the following year due to cost, compared to those without medical debt, according to a study led by researchers at the Johns Hopkins Bloomberg School of Public Health.

For their study, the researchers analyzed 2023 and 2024 data from a nationwide survey related to mental health. The researchers found that 33.8% of respondents who reported having had medical debt in 2023 also reported forgoing mental health care for cost-related reasons in 2024, compared to 6.3% of respondents who reported not having medical debt in 2023 and forgoing care the following year.

The peer-reviewed research letter was published online April 18 in JAMA Health Forum.

Almost half of Americans with mental health disorders don't receive treatment, and our findings reinforce the view that medical debt contributes to that treatment gap."

Kyle Moon, study first author, doctoral student, Bloomberg School's Department of Mental Health

The study's senior author is Catherine Ettman, PhD, an assistant professor in the Bloomberg School's Department of Health Policy and Management.

Nearly one in four U.S. adults was living with a mental illness in 2022, and only about half were being treated, according to the National Institute of Mental Health. The large mental health treatment gap is thought to be, in part, due to costs of mental health care and the burden of existing medical debt-which about 20 million Americans are estimated to carry.

The results are similar to those from a study published last year by Bloomberg School researchers. The new study covered a different population and employed a "longitudinal" design in which debt preceded forgone care to strengthen the likelihood that the former causes the latter.

In the study, the researchers analyzed data from the COVID-19 Life Stressors Impact on Mental Health and Well-Being (CLIMB) study co-led by Ettman. Their analysis focused on the 1,821 CLIMB respondents who participated in 2023 and 2024 and answered the relevant questions about medical debt and needing mental health care, including the question "Was there a time in the past 12 months when you wanted to see a health provider about your mental health but could not because you could not afford it?"

A minority of respondents-15.3%-reported having medical debt in 2023. Of these, about a third-33.8%-reported forgoing mental health care in 2024 due to the cost. In contrast, 84.7% reported not having medical debt in 2023. Of these, only 6.3% reported forgoing mental health care in 2024. When adjusting for other variables, including demographics and assets, the authors still found a 17.3 percentage point increase in the probability of forgoing care for adults with medical debt relative to no medical debt.

The researchers also analyzed respondents' medical debt as reported in the CLIMB study and found the lowest rate of forgone care (28.9%) in the lowest of three debt categories (<$1,000) and the highest rate of forgone care (46.3%) in the highest debt category (≥$5,000). 

The researchers note that the differences between the respondents across the three medical debt categories were not statistically significant, probably due to the small sample size. 

Moon considers the findings troubling, given that mental health disorders are a major cause of disability and yet are likely to go untreated.

Moon hopes that the findings will lead to larger studies that can better quantify the debt-care relationship and interventions to address the burden of medical debt.

"Medical Debt and Forgone Mental Health Care Due to Cost Among Adults" was co-authored by Kyle Moon, Katherine Miller, Sandro Galea, and Catherine Ettman.

The COVID-19 and Life Stressors Impact on Mental Health and Well-Being (CLIMB) study was funded by a grant from the de Beaumont Foundation.