US county medical debt linked to late-stage cancer, research finds

Patients living in U.S. counties with the highest levels of medical debt face a 7% increased risk of death compared to those in counties with the lowest debt, according to research published in the JAMA Network Open and the Journal of the National Comprehensive Cancer Network.

The data indicates a clear link between community-level financial hardship and cancer outcomes. Patients in the lowest medical debt quartile saw a 5-year survival rate of 66.3%, while that figure dropped to 63.4% for the second quartile, 61.2% for the third, and 58.6% for those in the highest debt quartile. This association remained consistent across various subgroups, including metropolitan status, insurance status, age, race, and ethnicity.

Medical Debt Correlates with Late-Stage Cancer Diagnoses

Researchers found that higher county-level medical debt is associated with increased incidence rates of both all-stage and late-stage cancers. The most significant correlation was observed in lung and bronchus cancer; for every 10-percentage-point increase in county-level medical debt, late-stage incidence rose by 5.15 cases per 100,000 person-years.

Significant increases in late-stage diagnoses were also found for the following cancers:

• Melanoma (0.59 increase)
• Head and neck (0.92 increase)
• Bladder (0.24 increase)
• Kidney and renal pelvis (0.38 increase)
• Cervical (0.39 increase)
• Colorectal (0.69 increase)

Community Factors and Barriers to Care

The studies utilized data from 2,958 U.S. counties, noting that medical debt prevalence averaged 21.1%. This burden was higher in rural counties, as well as in the South and Southwest. Higher prevalence was also linked to counties with greater social vulnerability and higher proportions of uninsured or unemployed residents. Counties with larger proportions of non-Hispanic White residents reported lower medical debt prevalence.

Researchers suggest that medical debt serves as an area-level indicator of structural and financial barriers. Because people with medical debt are more likely to delay or forgo healthcare, they may miss critical opportunities for early detection and screening. This is particularly consequential since survival rates are substantially lower for patients diagnosed at advanced stages.

Study Methodology

One analysis included 6,841,646 patients after applying inclusion criteria. Researchers used the Urban Institute Credit Bureau Panel to gather county-level medical debt data from 2011 to 2019. Medical debt in collections was defined as unpaid debt, typically at least 180 days past due, that had been assigned to a third-party collector or a creditor’s internal collections department.

The researchers examined nine common cancers amenable to screening. They utilized 2016 medical debt data and combined it with cancer incidence rates from 2017 to 2021. The study population included 1,804 rural counties (61%) and 1,154 urban counties (39%). The mean density of primary care physicians was 0.54 per 1,000 residents.

Study Limitations

The ecological, county-level design of the research limits the ability to draw causal inferences. Specifically, the study could not confirm if the individual residents diagnosed with cancer were the same individuals carrying the medical debt. The researchers also noted missing data regarding the specific amount of debt relative to income and within-county heterogeneity.