Medical Debt and Entry of Satellite Freestanding Emergency Departments

Existing evidence suggests the growth of freestanding emergency departments (EDs) is associated with net increases in health care spending and inefficient use of emergency services; however, empirical research examining how these facilities are associated with patients' financial well-being is lacking.

To examine whether the entry of hospital-owned satellite freestanding EDs was associated with changes in county-level medical debt in collections.

This cross-sectional study examined the association of the entry of hospital-owned satellite freestanding EDs with medical debt between January 1, 2014, and December 31, 2021, using a difference-in-differences design comparing counties with a freestanding ED opening with counties that did not experience an opening (unexposed). The sample was restricted to counties consistently observed in the Urban Institute Credit Bureau Panel between 2011 and 2021; counties with an existing freestanding ED on or before 2014 were excluded from analysis. Data analysis was conducted between August 2024 and April 2025.

Entry of freestanding EDs between 2015 and 2021.

The median medical debt in collections (among individuals with medical debt in collections) was the main outcome measure. Freestanding ED entry and medical debt outcomes were measured on the county-year level. County-by-year data on medical debt came from the Urban Institute Credit Bureau Panel, and data on freestanding ED openings came from the Centers for Medicare & Medicaid Services Provider of Services File.

The study sample included 1368 counties (48 exposed, 1320 unexposed) observed between 2011 and 2021. The baseline characteristics of exposed and unexposed counties suggested that counties exposed to freestanding EDs, on average, had a larger proportion of younger residents (≤17 years, 23.9% vs 22.8%; P = .01; ≥65 years, 15.0% vs 16.5%; P = .007), had a higher median household income ($53 284 vs $46 535; P < .001), and were more likely to be designated as urban (75.0% vs 35.1%; P < .001). Freestanding ED entry was associated with an increase of $98.20 (95% CI, $17.60-$178.81) in county-level median medical debt in collections and a 2.0-percentage point increase (95% CI, 0.7-3.2 percentage points) in the proportion of the population with medical debt in collections.

In this cross-sectional study, freestanding ED entry was associated with increased medical debt. Additional research is needed to better understand the mechanisms to aid the development of policies aimed at protecting patients' financial health.