Trends in charges and association with defaults on medical payments in uninsured Americans: a disproportionate burden in ethnic minorities - a retrospective observational study

BMJ Open. 2022 May 25;12(5):e054494. doi: 10.1136/bmjopen-2021-054494.


Objective: To evaluate whether medical event charges are associated with uninsured patients' probability of medical payment default and whether there exist racial/ethnic disparity gaps in medical payment defaults.

Design: We use logistic regression models to analyse medical payment defaults. Our adjusted estimates further control for a rich set of patient and medical visit characteristics, region and time fixed effects.

Setting: Uninsured US adult (non-elderly) population from 2002 to 2017.

Participants: We use four nationally representative samples of uninsured patients from the Medical Expenditure Panel Survey across office-based (n=39 967), emergency (n=3269), outpatient (n=1739) and inpatient (n=340) events.

Primary and secondary outcome measures: Payment default, medical event charges and medical event payments.

Results: Relative to uninsured non-Hispanic white (NHW) patients, uninsured non-Hispanic black (NHB) patients are 142% (p<0.01) more likely to default on medical payments for office-based visits, 27% (p<0.05) more likely to default on emergency department visit payments and 82% (p<0.1) more likely to default on an outpatient visit bill. Hispanic patients are 46% (p<0.01) more likely to default on an office-based visit, but 25% less likely to default on emergency department visit payments than NHW patients. Within our fully adjusted model, we find that racial/ethnic disparities persist for office-based visits. Our results further suggest that the probabilities of payment defaults for office-based, emergency and outpatient visits are all significantly (p<0.01) and positively associated with the medical event charges billed.

Conclusions: Medical event charges are found to be broadly associated with payment defaults, and we further note disproportionate payment default disparities among NHB patients.

Keywords: Chargemaster Rates; Charges; Medical Payment Defaults; Racial Disparities; Structural Inequity; Structural Racism; Uninsured.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Ethnic and Racial Minorities*
  • Hispanic or Latino
  • Humans
  • Medically Uninsured*
  • Middle Aged
  • Office Visits
  • Retrospective Studies
  • United States