Conference Report: Debt and Health Disparities in the U.S.

As a health disparities researcher interested in socioeconomic conditions, I felt both captivated and deficient while listening to the IAPHS 2018 conference session and the discussion that ensued on debt and its place in understanding health. A key question emerged during the session from my outsider perspective: should debt be a more central variable in health disparities work?

Debt is a disparity-setting condition
As Jason Houle explained as he eloquently led off the discussion, debt is a key disparity-setting condition. That is, it opens up possibilities for some people, while having far-reaching negative consequences for others. Think about it: nearly everyone has debt. We have debt because we purchase homes in neighborhoods with good schools. We have debt because we spend more than we should on a four-wheel-drive vehicle with top-of- the-line features like traction control (who knows what that actually is, but it must be important) because it snows twice a year where we live. Those sources of debt provide status, safety perhaps, and opportunities for our children to receive an impressive early education. Most of us can handle those debts. We make our monthly payments and keep up on our mortgages with reasonable interest rates.

Help…and harm from debt
But some families, too often families of color, strive to live in those  neighborhoods and purchase safer cars, but in doing so, they incur large debts. Subprime lenders can set families on an unstable financial course of insecurity that has long-term consequences for parents and children. Some families, as Katrina Walsemann pointed out, strive for social mobility for their children by borrowing larger and larger sums of money to pay for a  college education. If parents borrow and help their children climb the social ladder, such as giving them access to educational opportunities that improve their long-term economic and physical health, there are certainly some positives there. The positives for the children may come at the cost of the parents. As it turns out, the more fathers borrowed to pay for their children’s education, the worse the father’s mental health.

Medical debt and harm
But if we are to focus on debt, we need to get more specific. Kyle Caswell of the Urban Institute has studied the link between medical debt and public health insurance. His findings are compelling and provide some real teeth to the notion that public health insurance has far- reaching impacts. Going onto public insurance, such as starting Medicare at age 65, stops the accumulation of new medical debts and, by association, this reduces something that the medical industry has been concerned about forever — uncompensated care. In fact, medical debt is a unique and particularly problematic form of unsecured debt, as Mackenzie Brewer’s research is revealing. No insurance equals more medical debt, a key ingredient to whether or not families with children experience food insecurity. And  food insecurity is associated with a host of problems for children, from lower academic achievement to suicide ideation.

Based on these important papers and the discussion of the panel, I think the answer to the key question of whether we should be paying more attention to debt as a key contributor to health disparities is a resounding yes.   

For more information on the presenters’ work, visit…

• Houle: http://pediatrics.aappublications.org/content/early/2016/01/20/peds.2015-3059 
• Walsemann: https://academic.oup.com/psychsocgerontology/article/72/6/1084/2645641
• Caswell: http://journals.sagepub.com/doi/abs/10.1177/1077558717725164
• Brewer: https://www.mackenziebellebrewer.com/current-projects/