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Original Investigation
August 22, 2022

Association of Chronic Disease With Patient Financial Outcomes Among Commercially Insured Adults

Author Affiliations
  • 1Division of General Medicine, University of Michigan Medical School, Ann Arbor
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 3Department of Surgery, University of Michigan Medical School, Ann Arbor
  • 4Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor
  • 5Division of Pediatric Critical Care Medicine, University of Michigan Medical School, Ann Arbor
  • 6Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
JAMA Intern Med. Published online August 22, 2022. doi:10.1001/jamainternmed.2022.3687
Key Points

Question  What is the association between chronic disease diagnoses and adverse financial outcomes among commercially insured adults?

Findings  In this cross-sectional study of 2 854 481 adults, the likelihood of adverse financial outcomes was substantially higher with a greater number of chronic conditions.

Meaning  Patients with chronic disease experience a significantly greater burden of adverse financial outcomes compared with healthier patients; research to understand the mechanisms behind this association is critically needed to design policies to improve financial outcomes for patients with chronic conditions.


Importance  The bidirectional association between health and financial stability is increasingly recognized.

Objective  To describe the association between chronic disease burden and patients’ adverse financial outcomes.

Design, Setting, and Participants  This cross-sectional study analyzed insurance claims data from January 2019 to January 2021 linked to commercial credit data in January 2021 for adults 21 years and older enrolled in a commercial preferred provider organization in Michigan.

Exposures  Thirteen common chronic conditions (cancer, congestive heart failure, chronic kidney disease, dementia, depression and anxiety, diabetes, hypertension, ischemic heart disease, liver disease, chronic obstructive pulmonary disease and asthma, serious mental illness, stroke, and substance use disorders).

Main Outcomes and Measures  Adjusted probability of having medical debt in collections, nonmedical debt in collections, any delinquent debt, a low credit score, or recent bankruptcy, adjusted for age group and sex. Secondary outcomes included the amount of medical, nonmedical, and total debt among individuals with nonzero debt.

Results  The study population included 2 854 481 adults (38.4% male, 43.3% female, 12.9% unknown sex, and 5.4% missing sex), 61.4% with no chronic conditions, 17.7% with 1 chronic condition, 14.8% with 2 to 3 chronic conditions, 5.4% with 4 to 6 chronic conditions, and 0.7% with 7 to 13 chronic conditions. Among the cohort, 9.6% had medical debt in collections, 8.3% had nonmedical debt in collections, 16.3% had delinquent debt, 19.3% had a low credit score, and 0.6% had recent bankruptcy. Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition. Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) (all P < .001). In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions.

Conclusions and Relevance  This cross-sectional study of commercially insured adults linked to patient credit report outcomes shows an association between increasing burden of chronic disease and adverse financial outcomes.

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