Functional limitations and medical bill payment problems among US adults: A national study, 2014-2023

To quantify the association between functional limitations and household medical bill payment problems among US adults, to decompose this association into components mediated by health status and insurance coverage, and to examine whether the residual association is explained by individual cost barriers.

Repeated cross-sectional analysis of a nationally representative survey.

Medical Expenditure Panel Survey Household Component data were pooled across seven survey years between 2014 and 2023 (N = 155,064 adults aged ≥18 years) with complete responses to all six limitation items. Functional limitations were measured using six items (hearing, vision, cognition, mobility, self-care, errands) summed into an index (range 0-6). The outcome was self-reported difficulty paying family medical bills. Survey-weighted sequential logistic regression and Karlson-Holm-Breen decomposition were used.

The weighted prevalence of payment problems rose monotonically from 7.6% (no limitations) to 19.8% (three or more). The fully adjusted odds ratio for any functional limitation was aOR 1.58 (95% CI 1.46 to 1.70), with an adjusted risk difference of 3.8 percentage points. Health status and insurance coverage mediated 53% of the total association. The association was robust to SF-12 adjustment (aOR 1.46), stable across pre-COVID and COVID-era periods, and observed in every insurance stratum. Adding individual cost barriers attenuated the association only modestly (aOR 1.64 vs. 1.76 in the 2019-2023 subsample; both p < 0.001), which is consistent with mechanisms that extend beyond individual care-seeking but does not exclude them.

Functional limitations are associated with a substantial household financial burden. Approximately half of this burden operates through health and insurance pathways that existing policy levers can address; the remainder is consistent with household financial strain that insurance alone does not eliminate. Policy responses should combine insurance expansion with direct financial protection.