Bankruptcies and Medical Illness: Which 'Causes' Which?

Did you know that baldness is a risk factor for heart attacks? That’s right. Armed with that insight, health policy makers could argue that treatments for baldness, such as hair transplants and creams, should be promoted, since that would reduce the incidence of heart attacks, right?

That’s an extreme example of an important risk when it comes to over-interpreting medical studies: there is a difference between the association of two events versus one event causing the other event. Even association may be tricky: it can be methodologically spurious (something about the way the research was done detected an excess of baldness or heart attacks in the study population), accidental (a statistical fluke that just happened to show up) or due to an underlying confounding factor that is causing both at the same time (a concordant sensitivity to androgens in hair follicles and coronary arteries?).

But let's say it is causal. We still don’t technically know if developing coronary artery disease ‘causes’ baldness or vice versa. While that may seem silly, it's an important reason to pause... and think. As a very brief example of the conundrum over the direction of causality, the Disease Management Care Blog has occasionally watched tennis phenom Rafael Nadal. It couldn’t help but notice how larger his left arm is compared to the right. While it’s easy to conclude that being a lefty when it comes to using a tennis racket for hours at a time ‘caused’ the muscle hypertrophy, is it also possible that a genetic predisposition to a unilaterally larger arm enabled the lefty Mr. Nadal to play better tennis for longer periods of a time - and win.

So, with that has background, let’s ask if medical problems ‘cause’ personal bankruptcy and if increasing health insurance will keep people out of Chapter 7. According to much of the media, a recent high profile publication says they do. Too bad they don't read the DMCB.

In an on-line release from the American Journal of Medicine (known among docs as the ‘Green Journal’), David Himmelstein, Deborah Thorne, Elizabeth Warren and Steffie Woolhandler report on the link between health problems and financial bankruptcy. Using public records, they asked 5252 randomly selected filers for bankruptcy to complete a survey and participate in a telephone interview. 2314 (46.5%) completed the survey. If the questionnaire indicated that a) a medical problem prompted the filing or, b) the medical bills were excessive or c) there was a loss of work for medical problems or d) the house was mortgaged to pay the medical bills, the bankruptcy was considered medically related. Court records were also pulled. 1032 participants agreed to be interviewed.

The bottom line was remarkable: illness or medical bills contributed to 62.1% of the bankruptcies in the study, which could be extrapolated to all bankruptcies in the entire United States. Most were normal folks: middle aged, had attended some college and were home owners. ¾ had health insurance at the time they filed. Review of the records showed a mean medical debt of $4988 vs. $256 in the non-medical filers. These are our friends and neighbors.

Compelling data, but what does this study really tell us? Does it say Medical Bills Leading Cause of Bankruptcy? Does it say medical bills ‘contributed,’ ‘played a role,’ or ‘underlie?’ The implication is also that reducing the burden of medical bills would lead to fewer bankruptcies.

To the author’s credit, wayyyyy deep in the discussion of the findings, they point out that ‘teasing causation’ from these kind of data is ‘challenging.’ Indeed. That’s because it is well known that poor socioeconomic status is closely tied to low health status, but it’s never been clear which ‘causes’ which. It is very possible that as socioeconomic status declines, thanks to decreasing income, health status decreases also - not vice versa. In other words, it’s just as possible that looming bankruptcy contributes, plays a role or underlies and yes, causes, increasing health care consumption and unpaid medical bills.

When it was in clinical practice, the DMCB was witness to the struggles of many families dealing with financial disasters: unpaid electric bills, looming foreclosures, past due rent and loss of jobs. The stress was considerable and whatever chronic condition was present usually got worse.

Is the DMCB being a curmudgeon? A heartless heel in the fight to help the chronically ill overcome the unfairness of economic status when it comes to access to healthcare? Are the activist Physicians for a National Health Program going to noisily disrupt the proceedings of the DMCB? Maybe, but the fact is, based on the science behind this study, the direction of the causality between health status and bankruptcies is not clear (even the authors agree with that) and we don’t know if prevention of one will lead to betterment of the other.