Medical Debt Among Insured Adults: The Impact of Insurance and Transportation Barriers by Metropolitan Status

Medical debt is a significant barrier to health equity in the United States, disproportionately affecting rural populations. Understanding how insurance and transportation barriers contribute to this burden is critical for informing interventions.

Using 2022 Health Reform Monitoring Survey data (N = 7761), we applied generalized linear models (GLMs) to examine associations of insurance-related and transportation barriers with medical debt among insured adults. Analyses assessed whether these relationships varied by metropolitan statistical area (MSA) status.

Overall, 18.2% of respondents had medical debt, with prevalence higher among nonmetropolitan than metropolitan residents (24.2% vs. 17.4%, p < 0.001). Insurance-related barriers were prevalent: 10.4% could not get authorization for care, 9.5% could not find providers accepting their insurance, and 8.0% did not receive health plan information. Transportation difficulties affected 3.7% of respondents and were more common among nonmetropolitan residents (4.9% vs. 3.6%, p = 0.049). In adjusted models, nonmetropolitan residents had a 17% higher risk of medical debt than metropolitan residents (RR = 1.17, 95% CI: 1.01-1.35, p = 0.037, where RR stands for risk ratio). Insurance authorization, provider acceptance, and health plan information barriers were associated with greater medical debt (RR range: 1.34-1.46, all p < 0.01). Insurance authorization and transportation barriers were associated with medical debt among nonmetropolitan residents, with no significant interaction by MSA status.

Medical debt among insured adults is more prevalent among nonmetropolitan residents and is associated with insurance-related access barriers. Policies that streamline insurance procedures and improve transportation may help reduce financial hardship and advance rural health equity.