When Medical Bills Put Health at Risk: Evidence from California’s Pre-Retirement Adults

Intro. Older Americans are increasingly entering retirement with debt, yet the consequences of medical debt for pre-retirees remain understudied. Uncollateralized debt, including medical debt, is common among adults approaching retirement, with pre-retirees more likely than younger adults to carry unpaid medical bills and credit card debt. Medical debt may be especially harmful because it can generate financial strain, delay or deter needed care, and compromise the ability to afford basic necessities such as food and housing. Prior research has focused largely on mortgage and credit card debt in later life, with less attention to medical debt and its implications for health and well-being. This gap is important because financial and health distress during the pre-retirement years may shape preparedness for retirement. To address this, this cross-sectional study examined the association between medical debt and self-rated health among pre-retirees.

Methods. We analyzed adults ages 50–64 using pooled 2021–2024 California Health Interview Survey (CHIS) data and estimated survey-weighted ordinal logistic regression models with jackknife replicate weights. Primary subpopulation models among pre-retirement adults (unweighted n = 28,677; weighted N ≈ 6.94 million statewide) examined the association between medical bill problems and self-rated health. Secondary analyses were restricted to respondents with medical bill problems who completed follow-up hardship items (unweighted n = 3,129; weighted N ≈ 729,512), and estimated separate models for each hardship indicator: unpaid medical bill amount, inability to pay for basic necessities due to medical bills, and taking on credit card debt due to medical bills. In this subgroup, most reported unpaid medical bills of $2,000 or more and taking on credit card debt, while 38.3% reported being unable to pay for necessities. All models adjusted for survey year, race/ethnicity, nativity, self-reported sex, education, marital status, and insurance status.

Results. Among adults ages 50–64, reporting problems paying one’s own or family medical bills was associated with higher odds of worse self-rated health (OR = 1.93, 95% CI: 1.76–2.11, p < .001). Among respondents with medical bill problems, inability to pay for basic necessities due to medical bills was also associated with worse self-rated health after adjustment (OR = 1.53, 95% CI: 1.24–1.87, p < .001), whereas unpaid medical bill amount and taking on credit card debt due to medical bills were not statistically significant.

Discussion. Our findings highlight the negative associations between medical debt and health rating, as well as the further financial hardship of inability to pay for basic necessities. Together, these results suggest that high out-of-pocket health care costs may push pre-retirees into financially precarious circumstances that compound health vulnerability. In particular, pre-retirees with medical debt were more likely to report difficulty meeting basic needs such as food, housing, and health care, conditions that may further debilitate physical and mental health. Being unable to meet these needs due to medical debt may itself have mediating effects on health. Future research is needed to examine this and other pathways linking medical debt to poorer health to inform more actionable policy and practice responses.