Medical Debt Makes Americans Skip Dental Care at 2.4 Times the Normal Rate

Published in Journal of General Internal Medicine. Senior author Catherine Ettman, Johns Hopkins Bloomberg School of Public Health.

Medical debt does not just sit on a balance sheet. It changes behavior. Americans carrying medical debt are 2.4 times more likely to delay dental care, 4.3 times more likely to delay medical care, and nearly 3 times more likely to delay mental health care compared to those without medical debt. And having insurance does not erase the effect.

Those figures come from a study published in the Journal of General Internal Medicine, drawing on data from nearly 30,000 adults in the 2023 National Health Interview Survey. The research, led by investigators at the Johns Hopkins Bloomberg School of Public Health, provides the first systematic comparison of which types of care are most affected by medical debt.

The numbers across care types

Among people with medical debt, 42.3% reported delaying dental care, compared with 17.7% of those without debt. For medical care, the gap was 23.0% versus 5.3%. For mental health care, 14% versus 5%.

These are not small differences. The dental care gap is the most pronounced in absolute terms, which the researchers attribute partly to the structure of dental insurance in the United States. Dental coverage is often separate from medical insurance, typically carries limited benefits, and many insurance plans do not include it at all. For someone already burdened by medical bills, out-of-pocket dental costs may be the first expense to get cut.

More than 10% of the nearly 30,000 adults surveyed reported medical debt, defined as experiencing problems paying or being unable to pay medical bills in the past 12 months. The bills could be for doctors, dentists, hospitals, therapists, medication, equipment, or home care.

Insurance does not fully protect

One of the study's most important findings is that medical debt's association with deferred care persists across insurance types. Having health insurance reduces the likelihood of medical debt -- uninsured adults reported debt at roughly twice the rate of commercially insured adults -- but it does not eliminate the behavioral effect of debt on care-seeking.

Among insured adults with medical debt, the rates of deferred dental and mental health care were comparable to those of uninsured adults with debt. The one area where insurance made a larger difference was medical care: uninsured adults with debt were significantly more likely to defer medical care than commercially insured adults with debt.

The breakdown by insurance type showed that more than 19% of uninsured adults, 13% with Medicaid, 9% with commercial insurance, and 8% with Medicare reported medical debt. The gradient follows predictable economic lines, but the fact that substantial portions of insured populations carry medical debt underscores the limits of coverage as a shield against financial hardship.

The downstream costs of deferred care

Skipping preventive and routine care is not just a personal health decision; it is an economic one with system-wide consequences. People who defer care miss prevention opportunities and recommended monitoring. Conditions that could be managed cheaply if caught early become expensive emergencies when they are not.

The dental connection illustrates this clearly. Poor dental health is linked to heart disease, cognitive decline, and other serious conditions. A patient who skips dental cleanings because of medical debt may end up with a cardiovascular event that costs far more to treat than the dental care would have. The cycle compounds: more medical costs, more debt, more deferred care.

Senior author Catherine Ettman of the Bloomberg School's Department of Health Policy and Management noted that avoiding routine or preventive care can worsen health conditions, making them more costly for patients, insurers, and taxpayers who subsidize much of the medical care in the U.S.

Policy context and timing

The findings arrive during a period of active policy debate over healthcare affordability. First author Kyle Moon, a PhD candidate at the Bloomberg School, pointed to recent developments including cuts to insurance coverage in the 2025 Budget Reconciliation Act, which may exacerbate both medical debt and deferred care. Moon argued that policies addressing affordability and the cascading toll of medical debt are critical to mitigating the health and economic impact of deferred care.

The study does not evaluate specific policy interventions, but its data provide a baseline against which future policy changes could be measured. If coverage cuts increase the proportion of Americans with medical debt, the model predicts corresponding increases in deferred care across all three categories -- dental, medical, and mental health.

What the data cannot show

The study uses self-reported measures of both medical debt and deferred care. People may underreport debt due to stigma or may not accurately recall when and whether they delayed seeking care. The cross-sectional design captures a snapshot rather than a trajectory, meaning the study cannot determine whether medical debt causes people to defer care or whether both are consequences of a shared underlying factor, such as chronic illness or poverty.

The survey also does not capture the severity of medical debt or the duration of deferral. A patient who delays a dental cleaning by one month is counted the same as one who goes years without care. The health consequences of these two scenarios differ enormously, but the survey data cannot distinguish between them.

The study population is limited to non-institutionalized adults with fixed household addresses, which excludes homeless individuals, incarcerated populations, and nursing home residents -- all groups likely to have high rates of both medical debt and unmet healthcare needs.

Despite these limitations, the data make a clear case: medical debt is associated with a broad pattern of deferred care that crosses insurance boundaries and affects dental, medical, and mental health services. The policy question is whether that pattern will be addressed through systemic reform or allowed to compound through inaction.