KFF’s Kaiser Health News (KHN) and NPR today launched a yearlong investigative project that explores the scale, impact, and causes of the health care debt crisis in the United States.

Drawing upon a special KFF poll conducted for the project, original data analysis, and hundreds of interviews, the investigation reveals a problem far more pervasive than previously reported. That’s because much of the medical debt is hidden as monthly installments paid via credit card, loans from family, and payment plans arranged directly with hospital and doctor’s offices.

About 4 in 10 adults report having medical or dental debt, the KFF poll finds, a share that roughly translates into an estimated 100 million adults. Many expect repaying the debt to take years, and about 1 in 5 say they do not expect to ever pay it all off.

The problem drives millions of Americans from their homes or into bankruptcy, but the consequences are not just financial. About 1 in 7 people with health care debt say they have been denied access to a hospital, doctor, or other provider because of unpaid bills. The toll of medical debt tends to fall most severely on the poor, the sick, and people of color, the investigation reveals.

Diagnosis: Debt is a multimedia series featuring KHN senior correspondent Noam N. Levey and NPR correspondent Yuki Noguchi. The first installment will run today on khn.org and npr.org and air on NPR’s Morning Edition, which can be found at participating member stations. It represents a fusion of the investigative power of KHN and NPR, the public opinion survey expertise of the KFF polling team, and original data analysis.

The project will feature a series of digital and audio stories to be published and aired over the rest of this year, as well as an NPR podcast and profiles of Americans whose lives have been upended by health care debt. In addition to the poll and other research, KHN and NPR reporters conducted hundreds of interviews with patients, physicians, health industry leaders, consumer advocates, and researchers.

The first installment spotlights the plight of people like Elizabeth Woodruff, of Binghamton, New York., who spent through her retirement account and worked three jobs after she and her husband were sued for nearly $10,000 by the hospital where his infected leg was amputated. There is Ariane Buck of Peoria, Arizona, near Phoenix, who was unable to get an appointment with his doctor for an intestinal infection because the office said he had outstanding bills. Nurse practitioner Allyson Ward of Chicago worked extra shifts and she and her husband loaded up credit cards, borrowed from relatives, and delayed repaying student loans after the premature birth of their twins left them $80,000 in debt.

Forthcoming stories will examine U.S. hospital billing and collections practices as well as the flourishing medical debt industry that is now an integral part of American health care.

“From our joint Bill of the Month series with NPR, we knew that debt was a major byproduct of the American medical system. But in this investigation, we sought to quantify the scale of the problem and detail its impact on families’ financial health,” said KHN Editor-in-Chief Elisabeth Rosenthal. “It was a huge task, pulling in the reporting muscle of both our teams, outside data help, and an important survey performed by our colleagues at the KFF polling team.”

“This series represents the culmination of months of investigations and reporting by NPR and KHN, said Andrea Kissack, NPR’s Chief Science and Health Editor. “In addition to some of these stunning findings, the project will explore some of the little-known ways to avoid debt traps and how the mental health and substance abuse crisis is impacting debt and how the pandemic may influence racial disparities.”

A novel poll

In the national poll conducted for the project, KFF survey researchers found that about 1 in 4 four adults with health care debt (translating to 1 in 10 adults overall) owes at least $5,000, including about 1 in 8 who owe $10,000 or more (1 in 20 adults overall). Those who are uninsured, with low incomes, and Black and Hispanic adults are among the groups most likely to carry health care debt.

The survey used a broad lens to measure health care debt, including medical and dental bills people are unable to pay as well as different forms of debt accruing from health care bills such as payment plans, credit cards, bank loans, and borrowing from family and friends. About 1 in 5 adults (21%) say they are paying off health care bills through an installment plan with a hospital or other provider. One in 10 say they owe money to a friend or family member who covered their medical or dental bills.

Most people with health care debt (63%) say they or a household member had to cut spending on food, clothing, and basic household items as a result. Nearly half (48%) say they used up nearly all their savings. About 4 in 10 increased their credit card debt (41%), took on an extra job or worked more hours (40%), or skipped or delayed paying other bills (37%).

Having insurance is not a panacea. While 62% of working-age uninsured adults report having health care debt, so do 44% of working-age adults with health coverage, according to the poll.

A link between medical debt and chronic illness

Also published today is an interactive graphic showing where debt is concentrated in the U.S., based on original research the Urban Institute conducted for this project analyzing credit report data. The graphic features county and state maps as well as charts comparing counties and showing the link between medical debt and chronic illness.

Researchers find that chronic illness is a strong predictor of debt. In the 100 U.S. counties with the highest levels of chronic disease, nearly a quarter of adults have medical debt on their credit records, compared with fewer than 1 in 10 in the healthiest counties.

Patient debt is growing despite increased access to insurance through the Affordable Care Act, the investigation finds. Over the past decade the medical industry has posted record profits as hospitals, physicians, and other providers steadily raised prices, while health insurers have shifted costs onto patients through higher deductibles.

KHN is KFF’s award-winning news service with a national newsroom in Washington, D.C., and a rapidly growing network of regional bureaus in California, the Midwest, the Mountain States, and the South. Earlier this year KHN established a Rural Health Desk to produce and distribute stories on health care issues relevant to rural communities.

NPR and KHN have partnered for over a decade to bring important health stories from NPR member stations around the country to NPR and KHN’s audiences and to improve and expand health reporting at these stations. They also maintain a long-standing collaborative investigative project entitled “Bill of the Month,” which examines surprising medical bills and what they tell us about the U.S. health care system.

KHN works with many editorial partners, and media outlets can publish KHN stories at no charge. KHN also will publish the stories on khn.org and promote them through its social media platforms. KHN journalists also are available for interviews about their stories. News organizations interested in working with KHN should contact the news service at [email protected], and those interested in helping to expand and improve health journalism around the country should contact KFF at [email protected].

About KFF

KHN (Kaiser Health News) is one of the four major operating programs at KFF (Kaiser Family Foundation), together with Policy Analysis, Polling and Survey Research, and Social Impact Media. KFF is an endowed nonprofit organization providing information on health issues to the nation. It has no connection to Kaiser Permanente.

About NPR

NPR’s rigorous reporting and unsurpassed storytelling connects with millions of Americans every day — on the air, online, and in person. NPR strives to create a more informed public — one challenged and invigorated by a deeper understanding and appreciation of events, ideas, and cultures. With a nationwide network of award-winning journalists and 17 international bureaus, NPR and its member stations are never far from where a story is unfolding. Listeners can find NPR by tuning in to their local member stations (npr.org/stations), and now it’s easy to listen to NPR stories on smart-speaker devices. Ask your smart speaker to “Play NPR,” and you’ll be tuned in to your local member station’s livestream. Your speaker can also access NPR podcasts, NPR One, and NPR News Now, and the Visual Newscast is available for screened speakers. Get more information at npr.org/about and by following NPR Extra on Facebook, Twitter, and Instagram.

About the KFF Survey

The KFF Health Care Debt Survey was designed and analyzed by public opinion researchers at KFF in collaboration with KHN journalists and editors. The survey was conducted online and via telephone Feb. 25-March 20, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.