Medical Debt Is Linked to Deferred Dental Care in US Survey

US adults who reported problems paying medical bills were much more likely to say they had delayed or gone without needed dental care because of cost, according to an analysis of the 2023 National Health Interview Survey. Dental care showed the largest association with debt among the three categories the researchers compared.

The finding is substantial, but it is not a demonstration that debt forced a particular person to skip a procedure. The study was cross-sectional: debt and deferred care were reported for the same past-year period. It can describe a national association after statistical adjustment, but it cannot prove that debt came first or isolate the effect of one bill.

The Study Used 28,699 Adult Responses

The researchers analyzed responses from 28,699 civilian, noninstitutionalized US adults with complete information on medical debt and deferred care. Survey weights were used to generate nationally representative estimates. People without fixed household addresses, those in long-term care, active-duty military personnel and incarcerated people were outside the survey's sampling frame.

“Medical debt” was measured with a question asking whether the respondent had problems paying, or was unable to pay, medical bills in the past 12 months. The wording included bills from doctors, dentists, hospitals, therapists, medication, equipment, nursing homes and home care. It did not measure a verified balance or distinguish debt created by dental care from debt created elsewhere.

Deferred care combined two self-reported outcomes: delaying needed care because of cost and going without needed care because of cost. The researchers examined medical, mental-health and dental needs separately.

Dental Care Had the Largest Association

The weighted prevalence of past-year medical debt was 10.7%. It was highest among uninsured adults at 19.5%, followed by adults with Medicaid at 12.6%, commercial insurance at 9.3% and Medicare at 8.1%.

Before adjustment, 53.2% of adults with medical debt reported deferred dental care, compared with 17.3% of adults without debt. For medical care, the corresponding figures were 33.3% and 5.3%. Deferred mental-health care was reported by 20.3% of adults with debt and 5.1% of those without it.

After adjusting for demographic and socioeconomic characteristics, medical debt was associated with a 24.6 percentage-point increase in the probability of deferred dental care. The estimated increases were 17.6 points for medical care and 9.3 points for mental-health care. Confidence intervals around all three estimates excluded zero.

The pattern was largely consistent across insurance categories. The association between debt and deferred medical care was stronger for uninsured adults than for those with commercial insurance, while differences by insurance category were not statistically significant for mental-health or dental care under the study's tests.

The Data Do Not Establish a Causal Chain

Several limitations narrow the conclusion. Both the exposure and outcomes depended on memory and self-report. The debt measure was binary, so the analysis could not compare small and large balances. It could not distinguish new debt from obligations carried for years, and the survey did not ask whether each respondent believed they currently needed every category of care.

Most importantly, the design could not establish timing. A person may have deferred dental care after accumulating hospital bills, but someone could also have incurred dental debt while seeking treatment and then deferred further care. Low income, chronic illness, weak coverage and other factors may contribute to both debt and delayed treatment even after measured characteristics are adjusted.

The authors performed sensitivity analyses using complete cases, separate delay and forgone-care outcomes, additional adjustment for dental coverage and tests for unmeasured confounding. The core associations remained. Robustness strengthens confidence that the pattern is not a simple modeling accident; it does not convert an observational survey into an experiment.

Insurance Did Not Remove the Affordability Signal

Dental benefits are often separate from commercial medical insurance, excluded from traditional Medicare and variable in Medicare Advantage and state Medicaid programs. The study found that dental needs remained the most sensitive to medical debt even after dental insurance was added to a sensitivity model.

That does not prove that the separation of dental and medical coverage caused the result. It does show that an insurance label alone did not erase the association. People with Medicaid, Medicare and commercial coverage all reported medical debt, and debt remained linked to deferred care across those groups.

The study did not measure root-canal prices, credit-card interest, emergency-department costs, rural hospitalization trends, productivity losses or later disease. Those claims require other evidence. Its verified message is narrower and still severe: financial hardship associated with past care travels forward into decisions about current care. A system has not solved access when it issues an insurance card but leaves yesterday's bill powerful enough to close tomorrow's dental chair.