Medical debt and insufficient sleep among U.S. adults

Background Medical debt is a rising public health concern in the United States. This study aims to examine whether family-level medical indebtedness, defined as inability to pay medical bills, was associated with insufficient sleep (≤ 6 hours) among US adults of different generations (boomers, generation X, and millennials) during pre- and post- Affordable Care Act (ACA) and after the COVID-19 pandemic. Methods Nationally representative data from 2011-2013, 2015-2018, and 2022 and 2024 waves of the National Health Interview Survey (NHIS) were used. Since both medical debt and sleep health are tied with socioeconomic positions, separate investigations across disaggregated income levels were performed, followed by random effect meta-analyses, to obtain an overall estimate of the relationship for respective generations across periods. Robustness-check analyses were performed for sub-samples stratified by sex. Results For all generations and periods, the prevalence of insufficient sleep was higher among those with medical indebtedness. During pre-ACA period, boomers, gen Xers and millennials with medical indebtedness were 1.52, 1.57 and 1.41 times more likely to have insufficient sleep. The odds were 1.51, 1.56, and 1.47 in post-ACA period; and 1.46, 1.33, and 1.51after COVID-19, respectively. The estimates were robust for both male and female sub-groups. Conclusions Our findings that U.S. adults with medical indebtedness are more likely to have insufficient sleep, add to the larger literature of public health consequences of medical debt and may facilitate dialogues on medical financial hardship and sleep health.