National Health Statistics Reports, Number 180, January 18, 2023

National Health Statistics Reports

Number 180  January 18, 2023

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

NCHS reports can be downloaded from: https://www.cdc.gov/nchs/products/index.htm.

Problems Paying Medical Bills: United States, 2021

by Robin A. Cohen, Ph.D., and Amy E. Cha, Ph.D., M.P.H.

Abstract

Objectives—This report presents national estimates of people living in families

having problems paying medical bills by selected sociodemographic and geographic

characteristics, including sex, race and Hispanic origin, family income, health

insurance coverage status, education level, urbanization level, region, and state

Medicaid expansion status.

Methods—Data from the 2019, 2020, and 2021 National Health Interview Survey

(NHIS) were used to estimate short-term trends in problems paying medical bills in

the past 12 months. Data from the 2021 NHIS were used to describe estimates of

people who were in families who have problems paying medical bills by selected

sociodemographic and geographic characteristics.

Results— Overall, the percentage of people who were in families having problems

paying medical bills in the past 12 months decreased from 14.0% in 2019 to 10.8% in

2021. In 2021, males (9.7%) were less likely than females (11.8%) to have problems

paying medical bills. The percentage of people who were in families having problems

paying medical bills was higher among children aged 0–17 years (11.5%) and adults

aged 18–64 (11.3%) than adults aged 65 and over (7.7%). Among people under age

65 and those aged 65 and over, the percentage who were in families having problems

paying medical bills varied by health insurance coverage status, family income, and

state Medicaid expansion status.

Keywords: financial burden • medical debt • National Health Interview Survey

Introduction

Previously published data from the

National Health Interview Survey (NHIS)

found that in 2018 about 14% of people

were in families that had problems paying

medical bills in the past 12 months (1).

This was a significant trend downwards

from 2011, when nearly 20% of people

were in families having problems paying

medical bills (1). More recently, estimates

from the Health Reform Monitoring

Survey found that problems paying

medical bills among adults aged 18–64

decreased from 23.6% in March 2019 to

16.8% in April 2021 (2).

Financial stability has been associated

with one’s ability to pay medical expenses

(3,4). Significant expenses for one family

member may adversely affect the whole

family financially (5). People who have

medical debt may pay off these bills by

taking on other forms of debt, including

credit cards and bank loans, or negotiate

payment plans with healthcare providers,

or just fail to pay them (6–8). However,

medical debt continues to be the major

form of debt in the United States (9).

People who are in families with problems

paying medical bills or have medical

debt may experience serious financial

consequences, such as having problems

paying for food, clothing, or housing

(rent, mortgage, or utilities), and filing

for bankruptcy (3,6,8,10,11). In addition,

adults with medical debt are more likely to

forgo needed health care due to cost (12).

The inability to pay medical bills

and accrued medical expenses can

leave families in financial struggle and

debt, especially in families with low or

moderate incomes. For example, previous

findings from NHIS indicated that adults

under age 65 who were living with

incomes at or near the federal poverty

level (FPL) were over three times as

likely to have medical bills that they

were unable to pay at all compared with

those with incomes at or above 200%

FPL (4). Health insurance coverage status

(that is, uninsured, public coverage, or

private coverage) may also impact the

ability to afford healthcare costs (1,13).

Among people under age 65, those who

Page 2 National Health Statistics Reports  Number 180  January 18, 2023

were uninsured were more likely than

those with Medicaid or private coverage

to be in families having problems paying

medical bills (1). Among older adults,

the percentages of those who were in

families having problems paying medical

bills were higher among those with

Medicare and Medicaid and Medicare-

only coverage than those with Medicare

Advantage or private coverage (1).

A recent study found that adults

aged 19–64 who were impacted by the

COVID-19 pandemic due to illness or

testing positive, decreased income, or loss

of job-based healthcare coverage were

more likely to have higher rates of medical

bills and debt problems than adults aged

19–64 who had not experienced these

three pandemic effects (6). However,

another study using county-level data

from 2018 to 2020 found no significant

association between medical debt and

the COVID-19 pandemic across counties

with different income levels and pandemic

severity (14).

This report presents estimates of the

percentage of people who are in families

having problems paying medical bills in

the past 12 months. Short-term trends

from 2019 through 2021 in problems

paying medical bills are shown by

age group in Table 1. To understand

current sociodemographic differences in

problems paying medical bills, estimates

for 2021 are also presented by age group

and selected sociodemographic and

geographic characteristics, including sex,

race and Hispanic origin, family income,

health insurance coverage, family

education level, urbanization level,

region, and state Medicaid expansion

status in Table 2. Selected highlights from

these tables are presented in the Results

section of this report.

Methods

Data source

The estimates in this report are

based on data from the Sample Adult

and Sample Child modules of the

2019–2021 NHIS. NHIS is a nationally

representative household survey of

the U.S. civilian noninstitutionalized

population. It is conducted continuously

throughout the year by the National

Center for Health Statistics (NCHS).

From each household, one sample adult

is randomly selected to answer detailed

questions about their health. One sample

child, if present, is also randomly selected

from each household, and an adult who

is knowledgeable and responsible for the

child’s health answers questions on the

child’s behalf. Interviews are typically

conducted in respondents’ homes, but

follow-ups to complete interviews may

be conducted over the telephone when

necessary.

Impact of the COVID-19

pandemic on data collection

Due to the COVID-19 pandemic,

NHIS data collection shifted from

in-person interviews in the home to

a telephone-only mode beginning on

March 19, 2020 (15). Personal visits to

households resumed in selected areas in

July 2020 and in all areas of the country

in September 2020. However, cases

were still attempted by telephone first,

and most were completed by telephone.

For more information about the impact

of these changes on the 2020 data and

general information about NHIS, visit

https://www.cdc.gov/nchs/nhis/2020nhis.

htm.

In 2021, due to ongoing data

collection difficulties posed by the

COVID-19 pandemic, NHIS cases

continued to be attempted by telephone

first from January to April 2021

(16). Personal visits were used only

to followup on nonresponse, deliver

recruitment materials, and conduct

interviews when telephone numbers

were unknown. Starting in May 2021,

interviewers were instructed to return to

regular survey interviewing procedures,

whereby first contact attempts to

households were made in person,

with follow-up allowed by telephone.

Interviewers were given flexibility to

continue using telephone-first contact

attempts based on local COVID-19

conditions.

Problems paying medical

bills

Problems paying medical bills is

a family-level measure that may be

collected as part of the Sample Adult

interview or as part of the Sample Child

interview or both, depending upon the

circumstance (16). The respondent is

asked, “In the past 12 months, did you

or anyone in the family have problems

paying or were unable to pay any

medical bills? Include bills for doctors,

dentists, hospitals, therapists, medication,

equipment, nursing home, or home care.”

When the sample adult and sample child

belong to the same family, the question is

asked only during the first interview. This

helps to minimize respondent burden by

eliminating repetition. In turn, the data

are replicated during data processing.

When the sample adult and sample child

are in different families within the same

household, both respondents will be

asked the family-level questions about

their respective families. Therefore, to

study problems paying medical bills, the

Sample Adult and Sample Child files can

be combined to create a file that contains

people of all ages.

Sample sizes and response

rates

For 2019, estimates were based

on a combined file containing 42,331

people (9,193 sample children and 33,138

sample adults). For 2020, estimates were

based on a combined file containing

37,358 people (5,790 sample children

and 31,568 sample adults). For 2021,

estimates were based on a combined file

containing 37,743 people (8,261 sample

children and 29,482 sample adults).

The 2019 response rate for the Sample

Adult module was 59.1% and for the

Sample Child module was 59.1% (17).

The 2020 NHIS Sample Adult (excluding

reinterviewed Sample Adults) and

Sample Child response rates were 48.9%

and 47.8%, respectively (15). For 2021

NHIS, Sample Adult and Sample Child

response rates were 50.9% and 49.9%,

respectively (15).

Selected sociodemographic

and geographic

characteristics

Family education level—Based on

years of school completed or the highest

degree obtained among all adults within a

family. The high school diploma category

includes those who obtained a GED.

National Health Statistics Reports  Number 180  January 18, 2023 Page 3

Family income—Based on the ratio

of the family’s income in the previous

calendar year to the appropriate threshold

(given the family’s size and number of

children) defined by the U.S. Census

Bureau (18). People were classified into

four groups based on their family income:

less than 100% FPL, 100% to less than

200% FPL, 200% to less than or equal to

400% FPL, and greater than 400% FPL.

Family income in NHIS was imputed for

about 22% of people (19).

Health insurance coverage—

Collected at the time of interview. Sample

adults and sample child respondents

reported whether they or the sample

child were covered by private insurance,

Medicare (including Medicare Advantage

plans), Medigap (supplemental Medicare

coverage), Medicaid, Children’s Health

Insurance Program (CHIP), Indian

Health Service (IHS), military coverage

(including VA, TRICARE, or CHAMP-

VA), a state-sponsored health plan, or

another government program.

For people under age 65, a health

insurance hierarchy of four mutually

exclusive categories was used (20).

People with more than one type of health

insurance were assigned to the first

appropriate category in the following

hierarchy: private, Medicaid and CHIP,

other coverage, and uninsured.

For adults aged 65 and over, a health

insurance hierarchy of six mutually

exclusive categories was developed. This

hierarchy eliminates duplicate responses

for both private health insurance and

Medicare Advantage, giving preference

to the report of Medicare Advantage.

Medicare Advantage is another way for

people covered by Medicare to get their

Medicare Part A and Medicare Part B

coverage. Medicare Advantage plans

are sometimes called “Part C” and are

offered by Medicare-approved companies

that must follow rules set by Medicare

(21). Older adults with more than one

type of health insurance were assigned

to the first appropriate category in the

following hierarchy: private, Medicare

and Medicaid (dual-eligible), Medicare

Advantage, traditional Medicare only,

other coverage, and uninsured (22).

Race and Hispanic origin—Based on

responses to two questions that determine

Hispanic or Latino origin and race.

People categorized as Hispanic may be of

any race or combination of races. People

categorized as non-Hispanic White,

non-Hispanic Black, non-Hispanic Asian,

and non-Hispanic American Indian or

Alaska Native indicated one race only.

Non-Hispanic people of multiple or other

races (includes those who did not identify

as White, Black, Asian, American Indian

or Alaska Native, or Hispanic, or who

identified as more than one race) are

combined into the non-Hispanic other

and multiple races category.

Region—Based on four regions

used by the U.S. Census Bureau.

Northeast includes Connecticut, Maine,

Massachusetts, New Hampshire,

New Jersey, New York, Pennsylvania,

Rhode Island, and Vermont. Midwest

includes Illinois, Indiana, Iowa, Kansas,

Michigan, Minnesota, Missouri,

Nebraska, North Dakota, Ohio,

South Dakota, and Wisconsin. South

includes Alabama, Arkansas, Delaware,

District of Columbia, Florida, Georgia,

Kentucky, Louisiana, Maryland,

Mississippi, North Carolina, Oklahoma,

South Carolina, Tennessee, Texas,

Virginia, and West Virginia. West

includes Alaska, Arizona, California,

Colorado, Hawaii, Idaho, Montana,

Nevada, New Mexico, Oregon, Utah,

Washington, and Wyoming.

State Medicaid expansion status—

Under provisions of the Affordable Care

Act of 2010 (23), states have the option

to expand Medicaid eligibility to cover

adults who have family incomes up

to and including 138% of FPL. There

is no deadline for states to choose to

implement the Medicaid expansion,

and they may do so at any time. As of

January 1, 2021, 36 states and the District

of Columbia had expanded Medicaid.

Medicaid expansion states include

Alaska, Arizona, Arkansas, California,

Colorado, Connecticut, Delaware,

Hawaii, Idaho, Illinois, Indiana, Iowa,

Kentucky, Louisiana, Maine, Maryland,

Massachusetts, Michigan, Minnesota,

Montana, Nebraska, Nevada, New

Hampshire, New Jersey, New Mexico,

New York, North Dakota, Ohio, Oregon,

Pennsylvania, Rhode Island, Utah,

Vermont, Virginia, Washington, and West

Virginia. The District of Columbia also

has expanded Medicaid. States without

expanded Medicaid include Alabama,

Florida, Georgia, Kansas, Mississippi,

Missouri, North Carolina, Oklahoma,

South Carolina, South Dakota, Tennessee,

Texas, Wisconsin, and Wyoming.

Urbanization level—Categorized by

collapsing the “2013 NCHS Urban–Rural

Classification Scheme for Counties”

(24,25). The NCHS urban–rural

classification is based on metropolitan

statistical area (MSA) status defined by

the Office of Management and Budget

according to published standards that are

applied to U.S. Census Bureau data.

This report condenses the NCHS

urban–rural classification into four

categories: large central metropolitan

(similar to inner cities), large fringe

metropolitan (similar to suburbs),

medium and small metropolitan,

and nonmetropolitan (25,26). Large

metropolitan areas have populations of

1 million or more. Metropolitan

areas with populations of less than

1 million were classified as medium

(250,000–999,999 population) or small

(less than 250,000 population) (25).

Statistical analysis

Percentages are presented for

prevalence estimates of problems paying

medical bills, and 95% confidence intervals

(CI) were generated using the Korn–

Graubard method for complex surveys (27).

Estimates were calculated using the NHIS

survey weights and are representative

of the U.S. civilian noninstitutionalized

population. The weighting adjustment

method incorporates robust multilevel

models predictive of response propensity.

Nonresponse-adjusted weights were

further calibrated to U.S. Census Bureau

population projections and American

Community Survey (ACS) 1-year estimates

for age, sex, race and ethnicity, education

level, housing tenure, census division,

and MSA status (15,17). For the 2021

survey year, the U.S. Census Bureau did

not release single-year ACS estimates

by housing tenure, education level, and

MSA by division. Therefore, substitute

calibration totals for these variables were

obtained from the 2021 Current Population

Survey March Annual Social and Economic

Supplement (16).

Point estimates and their

corresponding variances were calculated

using SUDAAN software version

Page 4 National Health Statistics Reports  Number 180  January 18, 2023

11.0.0, a software package designed

to account for the complex sampling

design of NHIS. Respondents with

missing data or unknown information

were generally excluded from the

analysis unless specifically noted.

All estimates presented in this report

met NCHS standards of reliability as

specified in “National Center for Health

Statistics Data Presentation Standards for

Proportions” (28).

Differences in percentages between

subgroup characteristics were evaluated

using two-sided significance tests at the

0.05 level. Trends by family income (as

a percentage of FPL), education level,

and urbanization level were evaluated

using orthogonal polynomials in logistic

regression. Terms such as “more likely”

and “less likely” indicate a statistically

significant difference. Lack of comment

regarding the difference between any two

estimates does not necessarily mean that

the difference was tested and not found to

be significant.

Results

Trends from 2019 through

2021

Overall, the percentage of people

who were in families having problems

paying medical bills in the past 12

months decreased 3.2 percentage points

from 2019 (14.0%) to 2021 (10.8%)

(Figure 1, Table 1). In 2021, 10.5 million

fewer people (35.0 million) were in

families having problems paying medical

bills than in 2019 (45.5 million).

Selected sociodemographic

results for 2021

Sex, age group, and race and

Hispanic origin

In 2021, among people of all ages,

females (11.8%) were more likely than

males (9.7%) to be in families having

problems paying medical bills in the

past 12 months (Figure 2, Table 2). The

percentage of people who were in families

having problems paying medical bills was

higher among children aged 0–17 years

(11.5%) and adults aged 18–64 (11.3%)

than adults aged 65 and over (7.7%).

The percentage of people who were in

families having problems paying medical

bills was higher among non-Hispanic

Black people (15.8%) compared with

Hispanic (12.8%), non-Hispanic White

(9.4%), and non-Hispanic Asian (6.1%)

people. Estimates for people who are

non-Hispanic American Indian or Alaska

Native (11.5%) and non-Hispanic other

and multiple races (15.1%) were not

significantly different from estimates for

non-Hispanic Black people (15.8%).

Non-Hispanic Asian people were less

likely than all other race and ethnicity

groups to be in families having problems

paying medical bills.

Health insurance

In 2021, among children aged 0–17

years, those with Medicaid and CHIP

coverage (15.5%) were as likely as those

who were uninsured (14.8%) to be in

families having problems paying medical

bills in the past 12 months (Figure 3,

Table 2). Children with Medicaid and

CHIP coverage or those who were

uninsured were more likely than children

with private coverage (8.7%) to be in

families having problems paying medical

bills. Among adults aged 18–64, 20.3%

of those who were uninsured, followed

by 13.1% of those with Medicaid and

CHIP and 9.0% of those with private

coverage were in families having

problems paying medical bills.

In 2021, among adults aged 65 and

over, those with private coverage (4.8%)

were less likely than those with Medicare

and Medicaid (11.3%), Medicare

Advantage (8.9%), traditional Medicare

only (9.8%), and other coverage (9.1%)

to be in families having problems paying

medical bills (Figure 4). No significant

differences were observed among older

adults with Medicare and Medicaid,

Medicare Advantage, traditional

Medicare only, and other coverage.

Family income

In 2021, among people under age

65, the percentage who were in families

having problems paying medical bills in

the past 12 months decreased from those

with family incomes less than 100% FPL

(17.6%) and incomes 100% to less than

200% FPL (18.8%) to those with family

incomes 200% to less than or equal to

400% FPL (13.7%) to those with incomes

greater than 400% FPL (4.5%)

(Figure 5, Table 2). Among adults

aged 65 and over, a decreasing trend

in problems paying medical bills was

Figure 1. Percentage and number of people of all ages who were in families having

problems paying medical bills in the past 12 months, by year: United States, 2019–2021

Significant linear decrease from 2019 through 2021 (p < 0.05).

NOTES: Problems paying medical bills is based on a positive response to the question, “In the past 12 months, did you or

anyone in the family have problems paying or were unable to pay any medical bills? Include bills for doctors, dentists,

hospitals, therapists, medication, equipment, nursing home, or home care.” Estimates are based on household interviews

of a sample of the U.S. civilian noninstitutionalized population.

SOURCE: National Center for Health Statistics, National Health Interview Survey, 2019–2021.

Percent

Number (millions)

202120202019

45.5

40.5

35.0

National Health Statistics Reports  Number 180  January 18, 2023 Page 5

observed with increasing levels of

income, from 15.5% among those with

family incomes less than 100% FPL to

2.8% among those with family incomes

greater than 400% FPL.

State Medicaid expansion status

In 2021, people living in Medicaid

expansion states (9.3%) were less likely

than those living in states that did not

expand Medicaid (13.5%) to be in

families having problems paying medical

bills in the past 12 months (Figure 6,

Table 2). Significant differences in the

percentage with problems paying medical

bills between Medicaid expansion states

and nonexpansion states were observed

for children aged 0–17 years (9.9%

compared with 14.7%), adults aged

18–64 (9.8% compared with 14.4%), and

adults aged 65 and over (7.0% compared

with 9.0%).

Figure 2. Percentage of people who were in families having problems paying medical bills in the past 12 months, by sex, age group, and

race and Hispanic origin: United States, 2021

Significantly different from females (p < 0.05).

Significantly different from people aged 65 and over (p < 0.05).

Significantly different from non-Hispanic White people (p < 0.05).

Significantly different from non-Hispanic Black people (p < 0.05).

Significantly different from non-Hispanic Asian people (p < 0.05).

Significantly different from non-Hispanic people of other or multiple races (p < 0.05).

Significantly different from non-Hispanic American Indian or Alaska Native people (p < 0.05).

NOTES: Problems paying medical bills is based on a positive response to the question, “In the past 12 months, did you or anyone in the family have problems paying or were unable to pay

any medical bills? Include bills for doctors, dentists, hospitals, therapists, medication, equipment, nursing home, or home care.” Estimates are based on household interviews of a sample of

the U.S. civilian noninstitutionalized population.

SOURCE: National Center for Health Statistics, National Health Interview Survey, 2021.

Percent

11.8

11.5

11.3

15.8

6,7

6.1

3–5

12.8

4–6

9.4

10.8

7.7

11.5

15.1

9.7

0 5 10 15 20

Non-Hispanic other and multiple races

Non-Hispanic American Indian or Alaska Native

Non-Hispanic Asian

Non-Hispanic Black

Non-Hipanic White

Hispanic

65 years and over

18–64 years

0–17 years

Female

Male

Total

Figure 3. Percentage of people under age 65 who were in families having problems paying

medical bills in the past 12 months, by age group and health insurance status:

United States, 2021

Significantly different from those with Medicaid coverage (p < 0.05).

Significantly different from those who are uninsured (p < 0.05).

NOTES: Problems paying medical bills is based on a positive response to the question, “In the past 12 months, did you or

anyone in the family have problems paying or were unable to pay any medical bills? Include bills for doctors, dentists,

hospitals, therapists, medication, equipment, nursing home, or home care.” People with more than one type of health

insurance were assigned to the first appropriate category in the following hierarchy: private, Medicaid, other coverage,

and uninsured. People with other coverage are not shown. Estimates are based on household interviews of a sample of

the U.S. civilian noninstitutionalized population.

SOURCE: National Center for Health Statistics, National Health Interview Survey, 2021.

Percent

Age (years)

Medicaid and CHIP

Private Uninsured

1,2

8.7

1,2

9.0

13.1

20.3

14.8

15.5

18–640–17

Page 6 National Health Statistics Reports  Number 180  January 18, 2023

Figure 4. Percentage of adults aged 65 and over who were in families having problems paying medical bills in the past 12 months, by

health insurance status: United States, 2021

Significantly different from those with Medicare and Medicaid, Medicare Advantage, traditional Medicare only, and other coverage (p < 0.05).

NOTES: Problems paying medical bills is based on a positive response to the question, “In the past 12 months, did you or anyone in the family have problems paying or were unable to pay

any medical bills? Include bills for doctors, dentists, hospitals, therapists, medication, equipment, nursing home, or home care.” Adults with more than one type of health insurance were

assigned to the first appropriate category in the following hierarchy: private, Medicare and Medicaid, Medicare Advantage, Medicare only (no Advantage), and other coverage. Adults who are

uninsured are not shown. Estimates are based on household interviews of a sample of the U.S. civilian noninstitutionalized population.

SOURCE: National Center for Health Statistics, National Health Interview Survey, 2021.

Percent

4.5

9.9

0 2 4 6 8 10 12

9.1Other coverage

9.8Traditional Medicare only

8.9Medicare Advantage

11.3Medicare and Medicaid

4.8

Private

Figure 5. Percentage of people who were in families having problems paying medical bills

in the past 12 months, by age group and family income as a percentage of the federal

poverty level: United States, 2021

Significant quadratic trend by family income (p < 0.05).

NOTES: Problems paying medical bills is based on a positive response to the question, “In the past 12 months, did you or

anyone in the family have problems paying or were unable to pay any medical bills? Include bills for doctors, dentists,

hospitals, therapists, medication, equipment, nursing home, or home care.” Estimates are based on household interviews

of a sample of the U.S. civilian noninstitutionalized population.

SOURCE: National Center for Health Statistics, National Health Interview Survey, 2021.

Percent

Age (years)

100% to less than

200% FPL

Less than

100% FPL

200% to less than or

equal to 400% FPL

Greater than

400% FPL

18.8

13.7

13.1

8.6

4.5

2.8

17.6

15.5

65 and overUnder age 65

Discussion

In 2021, the percentage of people

who were in families having problems

paying medical bills in the past 12

months decreased 3.2 percentage points

from 14.0% in 2019 to 10.8% in 2021.

This corresponded to 10.5 million fewer

people who were in families having

problems paying medical bills in 2021

(35.0 million) than in 2019 (45.5 million).

more likely to have problems paying

medical bills if they had low family

income, were uninsured, or resided in

non-Medicaid expansion states. These

sociodemographic differences were

similar to those reported previously

(1,7). People who are in families with

problems paying medical bills not only

face financial consequences (3,8,10,11),

but also may forgo medical care and

prescription drugs (12,40). Despite the

decreasing trend in the percentage of

people with problems paying medical

bills, the burden associated with unpaid

medical bills remains a public health

concern.

One strength of NHIS is that it

has a low item nonresponse rate on

the questions about problems paying

medical bills (less than 1%). In addition,

problems paying medical bills can be

analyzed in combination with other

measures available on NHIS, including

forgone care, worry about healthcare

costs, healthcare access and use, chronic

conditions, and health behaviors.

However, NHIS responses are self-

reported and so, they may be subject

to recall bias. Additionally, although

respondents are asked to confine their

responses to those family members that

they live with, they may have either

thought only about their own difficulty

with paying for medical care or may

have thought about medical care they are

paying for on behalf of a member not

living in their household, such as a parent

living in a long-term care facility.

Medical debt is a major contributor

to overall debt in the United States (9).

Monitoring problems paying medical

bills continues to be an important

measure for assessing the financial

burden of medical care and medical debt

as rising healthcare costs are a dominant

concern in the United States (7). NHIS

continues to be a national resource for

monitoring financial burden for medical

care in the United States.

References

1. Cha AE, Cohen RA. Problems

paying medical bills, 2018. NCHS

Data Brief, no 357. Hyattsville, MD:

National Center for Health Statistics.

2020.

2. Karpman M, Martinchek K, Braga

B. Medical debt fell during the

pandemic. How can the decline be

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Available from: https://www.urban.

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during%20the%20Pandemic%20

How%20Can%20the%20Decline%20

Be%20Sustained.pdf.

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Kriss JL. Losing ground: How the

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https://www.commonwealthfund.org/

publications/fund-reports/2008/aug/

losing-ground-how-loss-adequate-

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2011–June 2015. National Center

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Page 10 National Health Statistics Reports  Number 180  January 18, 2023

Table 1. Percentage and number of people who were in families having problems paying

medical bills in the past 12 months, by year and age group: United States, 2019–2021

Age group (years) 2019 2020 2021

Percent (95% condence interval)

All ages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.0 (13.5–14.6) 12.5 (11.9–13.1) 10.8 (10.3–11.2)

Under 65 . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.9 (14.3–15.6) 13.3 (12.6–14.0) 11.4 (10.9–11.9)

0–17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.0 (14.1–15.9) 13.7 (12.5–15.0) 11.5 (10.7–12.4)

18–64. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.9 (14.3–15.6) 13.1 (12.5–13.8) 11.3 (10.8–11.9)

65 and over . . . . . . . . . . . . . . . . . . . . . . . . . 9.4 (8.6–10.3) 8.4 (7.7–9.2) 7.7 (7.0–8.5)

Number (millions)

All ages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.5 40.5 35.0

Under 65 . . . . . . . . . . . . . . . . . . . . . . . . . . . 40.5 35.9 30.7

0–17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.0 10.0 8.3

18–64. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29.5 25.9 22.3

65 and over . . . . . . . . . . . . . . . . . . . . . . . . . 5.0 4.6 4.3

NOTES: Problems paying medical bills is based on a positive response to the question, “In the past 12 months, did you or anyone

in the family have problems paying or were unable to pay any medical bills? Include bills for doctors, dentists, hospitals, therapists,

medication, equipment, nursing home, or home care.” Estimates may not add up to the total number in millions due to rounding.

Estimates are based on household interviews of a sample of the U.S. civilian noninstitutionalized population.

SOURCE: National Center for Health Statistics, National Health Interview Survey, 2019–2021.

National Health Statistics Reports  Number 180  January 18, 2023 Page 11

Table 2. Percentage of people who were in families having problems paying medical bills in the past 12 months, by age group and selected

characteristics: United States, 2021

Selected characteristic

Age group (years)

All ages Under 65 0–17 18–64 65 and over

Percent (95% condence interval)

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.8 (10.3–11.2) 11.4 (10.9–11.9) 11.5 (10.7–12.4) 11.3 (10.8–11.9) 7.7 (7.0–8.5)

Sex

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.7 (9.1–10.3) 10.3 (9.6–10.9) 11.7 (10.6–13.0) 9.7 (9.1–10.4) 6.7 (5.7–7.8)

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.8 (11.1–12.4) 12.5 (11.8–13.2) 11.3 (10.2–12.6) 12.9 (12.1–13.7) 8.6 (7.5–9.7)

Race and Hispanic origin

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.8 (11.6–14.1) 12.8 (11.5–14.1) 12.6 (10.9–14.4) 12.8 (11.5–14.3) 13.1 (9.6–17.2)

Non-Hispanic White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4 (8.8–9.9) 10.2 (9.5–10.9) 10.2 (9.1–11.4) 10.2 (9.5–10.8) 6.4 (5.7–7.1)

Non-Hispanic Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.8 (14.2–17.5) 16.1 (14.4–18.0) 14.8 (12.0–17.9) 16.6 (14.8–18.6) 13.7 (10.9–17.0)

Non-Hispanic Asian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 (4.7–7.6) 6.1 (4.7–7.9) 6.2 (4.0–9.1) 6.1 (4.6–7.9) 5.8 (3.0–9.8)

Non-Hispanic American Indian or Alaska Native . . . . . . . . 11.5 (7.4–16.8) 12.5 (7.8–18.7) * 13.9 (7.6–22.7) *

Non-Hispanic other and multiple races. . . . . . . . . . . . . . . . 15.1 (12.2–18.4) 15.4 (12.3–18.9) 16.5 (12.4–21.2) 14.5 (11.0–18.5) *

Family income as a percentage of FPL

Less than 100% FPL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.4 (15.6–19.3) 17.6 (15.6–19.7) 15.9 (13.3–18.7) 18.6 (16.5–20.9) 15.5 (12.1–19.4)

100% to less than 200% FPL . . . . . . . . . . . . . . . . . . . . . . . 17.7 (16.4–19.1) 18.8 (17.2–20.4) 17.9 (15.8–20.3) 19.2 (17.6–20.9) 13.1 (11.0–15.5)

200% to less than or equal to 400% FPL . . . . . . . . . . . . . . 12.7 (11.9–13.7) 13.7 (12.7–14.8) 12.6 (11.0–14.2) 14.1 (13.0–15.3) 8.6 (7.2–10.2)

Greater than 400% FPL . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 (3.8–4.7) 4.5 (4.1–5.0) 3.6 (2.8–4.4) 4.8 (4.3–5.3) 2.8 (2.1–3.6)

Health insurance coverage

People under age 65

Private. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … 8.9 (8.4–9.5) 8.7 (7.8–9.7) 9.0 (8.5–9.6) …

Medicaid and CHIP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . … 14.3 (13.1–15.6) 15.5 (14.0–17.2) 13.1 (11.5–14.7) …

Other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … 15.0 (12.2–18.2) * 17.1 (14.1–20.5) …

Uninsured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … 19.7 (17.8–21.8) 14.8 (10.6–19.9) 20.3 (18.3–22.5) …

Adults aged 65 and over

Private. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … … … … 4.8 (3.9–5.8)

Dual-eligible (Medicare and Medicaid) . . . . . . . . . . . . . . … … … … 11.3 (7.8–15.5)

Medicare Advantage . . . . . . . . . . . . . . . . . . . . . . . . . . . .

… … … … 8.9 (7.7–10.3)

Traditional Medicare only . . . . . . . . . . . . . . . . . . . . . . . . … … … … 9.8 (7.6–12.3)

Other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … … … … 9.1 (6.3–12.6)

Uninsured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … … … … *

Family education level

Less than high school. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1 (12.0–16.4) 14.9 (12.3–17.9) 12.7 (9.1–17.2) 16.0 (13.4–19.0) 11.8 (9.1–14.9)

High school diploma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.4 (13.3–15.6) 16.0 (14.6–17.5) 14.7 (12.5–17.0) 16.5 (15.1–18.0) 8.1 (6.7–9.6)

Some college . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.4 (13.4–15.4) 15.3 (14.2–16.5) 17.0 (15.1–18.9) 14.7 (13.7–15.9) 9.6 (8.1–11.2)

Bachelor's degree or more . . . . . . . . . . . . . . . . . . . . . . . . . 6.9 (6.4–7.4) 7.1 (6.5–7.7) 7.1 (6.2–8.1) 7.1 (6.5–7.7) 5.7 (4.6–6.8)

Urbanization level

Large central metropolitan . . . . . . . . . . . . . . . . . . . . . . . . . 9.8 (9.0–10.6) 10.0 (9.1–11.0) 10.3 (8.9–11.9) 9.9 (9.1–10.8) 8.4 (6.7–10.3)

Large fringe metropolitan . . . . . . . . . . . . . . . . . . . . . . . . . . 9.5 (8.7–10.5) 10.1 (9.1–11.2) 10.0 (8.5–11.7) 10.1 (9.1–11.3) 6.9 (5.7–8.3)

Medium and small metropolitan . . . . . . . . . . . . . . . . . . . . . 11.6 (10.7–12.5) 12.6 (11.5–13.6) 13.1 (11.5–14.8) 12.4 (11.4–13.4) 7.3 (6.1–8.7)

Nonmetropolitan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.3 (11.9–14.9) 14.5 (12.9–16.4) 13.6 (11.2–16.3) 14.9 (13.2–16.7) 8.6 (7.1–10.4)

Region

Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.5 (6.6–8.4) 7.5 (6.4–8.6) 5.7 (4.3–7.4) 8.1 (6.9–9.3) 7.5 (5.6–9.6)

Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.7 (9.8–11.8) 11.5 (10.4–12.7) 12.7 (10.8–14.8) 11.1 (10.0–12.2) 7.0 (5.7–8.5)

South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.2 (12.4–14.1) 14.1 (13.1–15.1) 13.7 (12.3–15.2) 14.2 (13.2–15.2) 9.3 (8.0–10.8)

West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.2 (8.3–10.0) 9.8 (8.8–10.8) 10.7 (9.1–12.4) 9.5 (8.5–10.5) 5.8 (4.7–7.1)

State Medicaid expansion status

Medicaid expansion states

. . . . . . . . . . . . . . . . . . . . . . . . 9.3 (8.8–9.9) 9.8 (9.2–10.4) 9.9 (8.9–10.9) 9.8 (9.2–10.4) 7.0 (6.2–7.9)

Non-Medicaid expansion states

. . . . . . . . . . . . . . . . . . . . 13.5 (12.6–14.4) 14.5 (13.5–15.5) 14.7 (13.1–16.3) 14.4 (13.4–15.5) 9.0 (7.6–10.6)

See footnotes at end of table.

Page 12 National Health Statistics Reports  Number 180  January 18, 2023

Table 2. Percentage of people who were in families having problems paying medical bills in the past 12 months, by age group and selected

characteristics: United States, 2021—Con.

* Estimate does not meet National Center for Health Statistics standards of reliability.

… Category not applicable.

People categorized as Hispanic may be of any race or combination of races. People categorized as non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and non-Hispanic American Indian

or Alaska Native indicated one race only. Non-Hispanic people of multiple or other races are combined into the non-Hispanic other and multiple races category.

FPL is federal poverty level and was calculated using the U.S. Census Bureau’s poverty thresholds for the previous calendar year, which consider family size and age.

At the time of interview, respondents reported their type(s) of coverage. This information was used to form two health insurance hierarchies: one for people under age 65 and another for adults aged

65 and over. For people under age 65, a hierarchy of four mutually exclusive categories was developed. People with more than one type of health insurance were assigned to the rst appropriate

category in the following hierarchy: private coverage, Medicaid (includes state-sponsored health plans including the Children’s Health Insurance Program [CHIP]), other coverage (includes Medicare,

other government, and military coverage), and uninsured.

For adults aged 65 and over, a health insurance hierarchy of six mutually exclusive categories was developed. This hierarchy eliminates duplicate responses for both private health insurance and

Medicare Advantage, giving preference to the report of Medicare Advantage. Adults aged 65 and over with more than one type of health insurance were assigned to the rst appropriate category in the

following hierarchy: private coverage, Medicare and Medicaid, Medicare Advantage, traditional Medicare only (excluding Medicare Advantage), other coverage, and uninsured.

Educational level is based on the highest level of education within a family.

Urbanization level is measured using metropolitan statistical area (MSA) status. The Office of Management and Budget denes MSAs according to published standards that are applied to U.S. Census

Bureau data. Generally, an MSA consists of a county or group of counties containing at least one urbanized area with a population of 50,000 or more (see reference 24 in this report). See Methods section

in this report for more detail. The large central MSA category has a population of 1 million or more and is similar to an inner city. The large fringe MSA category has a population of 1 million or more and is

similar to a suburb. The medium and small MSA category has a population of less than 1 million. The nonmetropolitan category includes those not living in an MSA.

In the geographic classication of the U.S. population, states are grouped into four regions used by the U.S. Census Bureau. Northeast includes: Connecticut, Maine, Massachusetts, New Hampshire,

New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest includes: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, Oklahoma,

South Dakota, and Wisconsin. South includes: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina,

Tennessee, Texas, Virginia, and West Virginia. West includes: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

Under provisions of the Affordable Care Act of 2010 (Pub L No 111–48, Pub L No 111–152), states have the option to expand Medicaid eligibility to cover adults who have incomes up to and including

138% of FPL. There is no deadline for states to choose to implement the Medicaid expansion, and they may do so at any time. As of January 1, 2021, 36 states and the District of Columbia have

moved forward with Medicaid expansion.

For 2021, states that had expanded Medicaid included: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine,

Maryland, Massachusetts, Michigan, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, Utah,

Vermont, Virginia, Washington, and West Virginia. The District of Columbia also moved forward with Medicaid expansion.

For 2021, states that had not expanded Medicaid included: Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas,

Wisconsin, and Wyoming.

NOTES: Problems paying medical bills is based on a positive response to the question, “In the past 12 months, did you or anyone in the family have problems paying or were unable to pay any

medical bills? Include bills for doctors, dentists, hospitals, therapists, medication, equipment, nursing home, or home care.” Estimates are based on household interviews of a sample of the U.S. civilian

noninstitutionalized population.

SOURCE: National Center for Health Statistics, National Health Interview Survey, 2021.

National Health Statistics Reports  Number 180  January 18, 2023

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Suggested citation

Cohen RA, Cha AE. Problems paying medical

bills: United States, 2021. National Health

Statistics Reports; no 180. Hyattsville, MD:

National Center for Health Statistics. 2023.

DOI: https://dx.doi.org/10.15620/cdc:122191.

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Brian C. Moyer, Ph.D., Director

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