Medical Debt Among Insured Adults: The Impact of Insurance and Transportation Barriers by Metropolitan Status.

PURPOSE: Medical debt is a significant barrier to health equity in the United States, disproportionately affecting rural populations. Understanding how insurance and transportation barriers contribute to this burden is critical for informing interventions. METHODS: Using 2022 Health Reform Monitoring Survey data (N = 7761), we applied generalized linear models (GLMs) to examine associations of insurance-related and transportation barriers with medical debt among insured adults. Analyses assessed whether these relationships varied by metropolitan statistical area (MSA) status. FINDINGS: Overall, 18.2% of respondents had medical debt, with prevalence higher among nonmetropolitan than metropolitan residents (24.2% vs. 17.4%, p < 0.001). Insurance-related barriers were prevalent: 10.4% could not get authorization for care, 9.5% could not find providers accepting their insurance, and 8.0% did not receive health plan information. Transportation difficulties affected 3.7% of respondents and were more common among nonmetropolitan residents (4.9% vs. 3.6%, p = 0.049). In adjusted models, nonmetropolitan residents had a 17% higher risk of medical debt than metropolitan residents (RR = 1.17, 95% CI: 1.01-1.35, p = 0.037, where RR stands for risk ratio). Insurance authorization, provider acceptance, and health plan information barriers were associated with greater medical debt (RR range: 1.34-1.46, all p < 0.01). Insurance authorization and transportation barriers were associated with medical debt among nonmetropolitan residents, with no significant interaction by MSA status. CONCLUSIONS: Medical debt among insured adults is more prevalent among nonmetropolitan residents and is associated with insurance-related access barriers. Policies that streamline insurance procedures and improve transportation may help reduce financial hardship and advance rural health equity.