By Don Tracy, Associate Editor

JAMA study aims to determine whether financial barriers impact access to mental health services.In the United States, a number of low-income adults struggle to gain access to appropriate mental health care. Despite efforts such as new legislations aimed at extending both private and public insurance through the Affordable Care Act (ACA), financial barriers are still an issue.
In a study published in JAMA Psychiatry, researchers aimed to discover whether there was an association between medical debt and delayed or forgone mental health care among adults in the United States. The study included data from the 2022 National Health Interview Survey, which measured responses from 27,651 adults with current or lifetime diagnoses of depression or anxiety. Additionally, Asian, Black, and Hispanic households were oversampled to improve precision of estimates for these groups.
To provide accurate results, mental health status was assessed for depression and anxiety, measured by lifetime diagnosis and current status. In the case of lifetime depression, participants were queried, “In the past 12 months, did you have problems paying or were unable to pay medical bills?”
They were also asked, ““During the past 12 months, have you delayed getting counseling or therapy from a mental health professional because of the cost?” and “During the past 12 months, was there any time when you needed counseling or therapy from a mental health professional, but did not get it because of the cost?”
Sociodemographic characteristics included age, sex, race, ethnicity, employment status, income, marital status, health insurance status, geographic region, prescribed medication for anxiety, prescribed medication for depression, and physical comorbidities. The results show a considerable prevalence of medical debt among adults with mental health disorders.
According to the researchers, approximately one in five adults with lifetime depression or anxiety reported having medical debt, with these numbers increasing to one in four among those with current depression or anxiety. Further, debt was associated with a more than two-fold increase in the likelihood of delaying or forgoing mental health care. Overall, 29.0% of adults with lifetime depression and medical debt delayed care, compared to 11.6% without debt, whereas 36.9% of adults with current depression and debt delayed care, compared to 17.4% without debt.
“Medical debt has become an increasing concern in the US over the last decade, as it has become a leading source of debt collections and contributes to approximately half of all bankruptcies,” reports the authors of the study.
“This mounting burden stems from increasing health care costs and inadequate insurance coverage, causing patients to bear high out-of-pocket costs. At the same time, health systems have adopted more aggressive tactics in debt collection, engaging in lawsuits, property liens, and foreclosures against patients. Emerging scholarship has linked medical debt to food insecurity, housing instability, and homelessness, underscoring medical debt as a key social determinant of health that can potentially be addressed through policy change.”
The researchers also explained that policy interventions, such as the ACA, have supported low-income individuals in terms of gaining health insurance and reductions in medical debt. However, these issues remain due to differences in service use or whether a patient is still uninsured, which leads to high out-of-pocket costs and subsequent debt. This suggests that debt not only limits access to mental health services but also exacerbates financial stress, potentially worsening mental health conditions.
“Medical debt appears to contribute to the mental health treatment gap, suggesting that aggressive debt collection practices have negative consequences for population mental health. In the absence of structural health care reform, many states have enacted laws to protect patients from medical debt, but regulations have been heterogeneous across states. Further studies are needed to evaluate policies to inform protections against medical debt at the federal level. Such protections may aid in addressing barriers to treatment for individuals with mental and behavioral disorders,” the authors of the study concluded.