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Financial instability limits access to medical care and is associated with poor health outcomes, potentially burdensome medical bills, and lower earnings.^1,2 Financial health also plays a role in housing access, stable employment, and good credit, which are key social determinants of health.³ Physical health disparities among Medicaid beneficiaries are well documented,^4,5 but less is known about financial disparities in this population. This study used novel data to describe the financial health of Medicaid enrollees in Louisiana, specifically Hispanic, non-Hispanic Black (hereafter, Black), and non-Hispanic White (hereafter, White) beneficiaries.

We obtained Medicaid enrollment data for March 2018 through December 2019 from the Louisiana Department of Health, which were linked to deidentified credit report data from Equifax Information Services. The sample comprised adults aged 18 to 64 years with continuous Medicaid enrollment for at least 24 months (July 2016-December 2019). The Tulane University and Louisiana Department of Health Institutional Review Boards approved this cohort study and waived informed consent because deidentified data were used. We followed the reporting guideline.

We constructed 3 primary person–level credit outcomes: average credit score, average monthly balance of unpaid medical debt in collections, and average monthly balance of nonmedical debt in collections. Average monthly balances of medical and nonmedical debt in collections included observations with no debt in collections. We defined poor credit as an average credit score below 580 and assessed proportions of enrollees with any medical or nonmedical debt in collections.⁶ We weighted all analyses to be representative of adults younger than 65 years enrolled in Louisiana Medicaid.

Enrollment data included age, sex, self-reported race and ethnicity, and parish of residence. We reported weighted, unadjusted outcomes and demographic characteristics for Black, Hispanic (all races), and White enrollees. We used linear regression to compare mean values of outcome variables between race and ethnicity subgroups, adjusting for age, sex, and parish of residence.

Two-sided P < .05 indicated statistical significance. Analyses were performed between February 2023 and July 2024 using R 4.1.1 (R Core Team). The eMethods in Supplement 1 provides more details.

The weighted sample included 265 258 individuals, of whom 173 337 were females (65%), 91 920 males (35%) with a mean (SD) age of 37 (14) years. Hispanic enrollees had a younger mean age (34 vs 38 years) and were more likely to be female (73% vs 64%) than White enrollees (Table 1).

Average credit score was 547 for Black enrollees and 571 for Hispanic enrollees, both are significantly lower than 588 for White enrollees (P &±ô³Ù; .001). Proportion of Black and Hispanic enrollees with poor credit was significantly higher than the proportion of White enrollees (61% and 50% vs 44%; P < .001) (Table 2).

The proportion of enrollees with medical debt in collections was slightly higher among Black and Hispanic enrollees than White enrollees (47% and 45% vs 45%; P &±ô³Ù; .001). Average balance of medical debt in collections did not differ significantly across enrollees.

Average balances of nonmedical debt in collections were higher among Black and Hispanic enrollees than White enrollees ($680 and $648 vs $550; P &±ô³Ù; .001). Proportion of any nonmedical debt in collections was also higher for Black and Hispanic enrollees than White enrollees (50% and 42% vs 36%; P &±ô³Ù; .001).

We found racial disparities in credit scores and nonmedical debt in collections among Louisiana Medicaid enrollees. Black and Hispanic enrollees had significantly worse credit scores and higher burdens of nonmedical debt in collections than White enrollees. Differences in the prevalence and balance of medical debt in collections were either small or not significant.

These findings suggest Medicaid coverage may play a protective role that ameliorates race- and ethnicity-based disparities in financial outcomes associated with medical care. A study limitation was our inability to observe whether Medicaid directly affected credit and debt outcomes or whether disparities in financial health preceded enrollment in Medicaid.

Accepted for Publication: July 24, 2024.

Published: October 11, 2024. doi:10.1001/jamahealthforum.2024.3028

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Frenier C et al. JAMA Health Forum.

Corresponding Author: Chris Frenier, PhD, Yale School of Public Health, 60 College St, New Haven, CT 06510 (chris.frenier@abtglobal.com).

Author Contributions: Dr Frenier had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Frenier, Wallace, Anderson, Callison, Walker.

Acquisition, analysis, or interpretation of data: Frenier, Green, Siebert, Anderson, Callison, Walker.

Drafting of the manuscript: Frenier, Callison, Walker.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Frenier, Green, Siebert, Walker.

Obtained funding: Anderson, Callison, Walker.

Administrative, technical, or material support: Wallace, Callison, Walker.

Supervision: Frenier, Wallace, Callison, Walker.

Conflict of Interest Disclosures: Dr Frenier reported receiving grants from the Agency for Healthcare Research and Quality (postdoctoral training grant T32HS017589) and employment by Abt Global Inc (outside of the submitted work) during the conduct of the study. Dr Wallace reported spouse employment with Manatt Phelps and Phillips. Dr Callison reported receiving grants from The Commonwealth Fund during the conduct of the study and grants from the National Cancer Institute, Louisiana Department of Health, and W.K. Kellogg Foundation outside the submitted work. Dr Walker reported receiving grants from The Commonwealth Fund during the conduct of the study and personal fees from ConcertAI LLC and Ontada LLC outside the submitted work. No other disclosures were reported.

Funding/Support: This research was supported by grant 559886G1 from The Commonwealth Fund (Dr Walker).

Role of the Funder/Sponsor: The Commonwealth Fund provided feedback during the review of the manuscript. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

Additional Contributions: Akeiisa Coleman, MSW, The Commonwealth Fund, provided thoughtful feedback throughout the research process. Staff at Equifax Information Services reviewed the manuscript to verify the description of data but did not have editorial input on the contents of the manuscript. These individuals received no additional compensation, outside of their usual salary, for their contributions.