National Prevalence of Problems Paying Medical Bills and Cost‐Related Delays in Care Among Medicare Enrollees
Authors: Madden J. , Bayapureddy S. , Briesacher B. , Zhang F. , Ross‐Degnan D. , Soumerai S. , Gurwitz J. , Galbraith A. 
Published: August 2020

Research ObjectiveOlder adults and disabled individuals in Medicare often have limited financial resources and high levels of health care needs. When out‐of‐pocket costs are not affordable, treatment may be delayed or forgone, potentially leading to worse health outcomes. We examined newly available survey data to produce the first national prevalence estimates of problems paying medical bills and delaying care due to costs among Medicare enrollees.Study DesignThe Medicare Current Beneficiary Survey (MCBS) has enhanced the measurement of health care affordability with new questionnaire items. These include whether enrollees experienced problems paying or were unable to pay any medical bills in the past year, and, if so, whether they currently have medical bills that are being paid off over time and whether they have been contacted by a collection agency in the last year due to problems paying. A separate MCBS question asks whether enrollees have delayed seeking medical care in the past year because of cost worries. Our survey‐weighted analyses estimated the prevalence of payment problems and cost‐related delays among the overall Medicare population and groups defined by demographic and health‐related factors. We further tested predictors using multivariate logistic regression.Population StudiedWe included community‐dwelling participants in the nationally representative 2017 MCBS: 10,974 older adults aged 65+ years and 2197 adults aged 18‐64 years with long‐term disability status, together representing 53.0 million Medicare enrollees.Principal FindingsOverall, the prevalence of problems paying medical bills was 7.4% among older enrollees and 29.8% among disabled enrollees. Among seniors who had problems paying, 48.2% were paying off bills over time, and 44.3% had been contacted by a collection agency; these proportions were higher for disabled individuals (50.5% and 62.2%, respectively). Delayed care due to costs was similarly common (8.3% among those ≥65, 25.2% among <65 years). Among seniors, 12.2% reported either problems paying medical bills or cost‐related delays, and 3.4% reported both. Health status was strongly predictive: 24.6% of seniors in fair‐to‐poor health had either payment problems or cost‐related delays, compared to 9.7% for those with good‐to‐excellent health. Among disabled people in fair‐to‐poor health, 45.0% had either payment problems or cost‐related delays vs 29.6% for those with good‐to‐excellent health. Income was also predictive: 21.3% of seniors with annual incomes less than $25,000 had either payment problems or cost‐related delays, versus 8.2% of seniors with more than $25,000.ConclusionsWe present the first national statistics on problems paying medical bills and delayed care due to costs within Medicare, including specific concerns such as ongoing medical debt and contact by collectors. The modest overlap between payment problems and delayed care suggests that cost pressures have differential impacts, pushing people to choose between putting off needed care and getting care for which they cannot pay. Substantial disparities by health status and income were observed.Implications for Policy or PracticeCost sharing in Medicare can be substantial and places a greater burden on sicker and lower‐income enrollees. Faced with high out‐of‐pocket spending, enrollees take on medical debt and/or delay needed care. Further research is needed on the specific services driving debt, and the impacts of delayed care on health outcomes.Primary Funding SourceNational Institutes of Health.