Over a quarter of people in the United States aged 18–64 years had difficulties paying their medical bills in the past 12 months (Liz Hamel, 2016). Of those, 31%- and 32% identified as Black and Hispanic, respectively. Twenty-four percent identified as White. However, race was not associated with difficulties paying medical bills when other factors were controlled for, indicating other issues, such as differences in earnings, are at play. (Liz Hamel, 2016). Problems paying medical bills are associated with socioeconomic status and access to healthcare insurance (Bennett, 2021; Liz Hamel, 2016). People with problems paying their medical bills are more likely to forego or delay necessary medical care or medications, which could exacerbate medical problems (Liz Hamel, 2016).

People with HIV (PWH) are more likely to experience socioeconomic challenges than the general population (Centers for Disease Control and Prevention, 2021; Semega, 2020). However, to our knowledge there are no studies assessing the prevalence of problems paying medical bills among PWH. Problems paying medical bills may differ among certain groups. If PWH have problems paying their medical bills, they may miss regular care visits and/or be less adherent to antiretroviral therapy (ART), which is essential for maintaining viral suppression and thus, reduces forward HIV transmission and improves health outcomes (Mugavero et al., 2013). Safety net programs, such as the Ryan White HIV/AIDS Program (RWHAP) and Medicaid, provide coverage for essential medical care services for PWH who are uninsured or underinsured. In addition, the program provides access to support services for PWH, including those for mental health, home health, and oral health.

The availability of care resources for PWH may depend on available funding, income requirements, and needs of the local population in individual jurisdictions. Estimates of problems paying medical bills among PWH could help align support programs to the needs of PWH. Financial issues related to paying medical bills could be a barrier to achieving national HIV prevention goals, and thus, ending the HIV epidemic in the United States (U.S. Department of Health and Human Services, 2021).

Using representative data from CDC’s Medical Monitoring Project (MMP), we assessed differences in problems paying medical bills by selected sociodemographic characteristics and social determinants of health, as well as associations between problems paying medical bills and clinical outcomes, among adults with diagnosed HIV in the United States.

Nearly one in five adults with diagnosed HIV had problems paying their medical bills during the past 12 months. Problems paying medical bills varied by certain demographic characteristics and social determinants of health. Persons who lived in households <400% of the FPL were more likely to have problems paying their medical bills than those who lived in households ≥400% of the FPL (<100% FPL: 16.8%; 100%–138% FPL: 26.4%; 139%–399% FPL: 22.8%; ≥400% FPL: 8.1%; Table 1). The prevalence of problems paying medical bills were 1.47 times as high in persons that experienced homelessness as those that did not (95% CI: 1.24–1.75). Differences in problems paying medical bills were also seen by health care coverage. Compared with persons with any private health care coverage, those whose only source of coverage was Ryan White were more likely to have problems paying their medical bills (PR: 1.55; 95% CI: 1.35–1.78). However, persons that only had public insurance were less likely than those with private health care coverage to have problems paying their medical bills (PR: 0.78; 95% CI: 0.70–0.87). Problems paying medical bills were also associated with suboptimal clinical outcomes. After adjusting for age and race/ethnicity, persons who had problems paying their medical bills were less likely to be retained in HIV care (PR: 0.93; 95% CI: 0.90–0.97), be 100% ART dose adherent (PR: 0.82; 95% CI: 0.76–0.87) and have sustained viral suppression (PR: 0.88; PR: 0.83–0.93; Table 2). Persons who had problems paying their medical bills were also more likely to miss ≥1 HIV care appointment (PR: 1.35; 95% CI: 1.22–1.50), have ≥1 emergency room visit (PR:1.59; 95% CI: 1.51–1.68) or be hospitalized (PR: 1.72; 95% CI 1.55–1.91).

Nearly one in five adults with diagnosed HIV report problems paying their medical bills during the previous 12 months. Persons with certain demographic characteristics and social determinants of health—including those who experienced homelessness, lived in households at <400% of the FPL, and relying solely on the RWAP for health coverage—were more likely to report having problems paying their medical bills. Our results are consistent with those of the total United States population, among which over a quarter of adults have problems paying their medical bills and those most affected were people with lower household incomes (Liz Hamel, 2016). PWH who had problems paying their medical bills were more likely to have adverse clinical outcomes, including lower prevalence of sustained viral suppression, retention in care and 100% ART dose adherence.

Although the prevalence of problems paying medical bills were high across all health care coverage types, people who received coverage only through the RWHAP were more likely than those with any private insurance to report problems paying their medical bills, likely reflecting lower socio-economic status (SES) in this population. Persons with lower SES are more likely to make difficult decisions regarding their health and health care (e.g., medication rationing), which can be detrimental to a person’s health (Beer, Tie, et al., 2019; Liz Hamel, 2016). This is consistent with our study’s finding that PWH living in households at <100% of the FPL and those between 100%–399% of the FPL were more likely to have problems paying their medical bills than those living at ≥400% of the FPL. For context, a family of four living 100%–399% of the FPL might have an annual household income between $25,100–$100,399 (U.S. Department of Health and Human Services, 2018). Being unable to pay medical bills is not isolated to PWH living below the FPL. The wide range in household income indicates that many other PWH can experience financial barriers, even if they live above the FPL.

Compared with those with any private healthcare coverage, persons with public insurance were less likely to have problems paying their medical bills. This finding indicates that publicly funded programs, such as Medicaid and Medicare, for which many people qualify based on low income, robustly cover essential medical care services for PWH, and are essential for their health and well-being. However, eligibility criteria for these programs may preclude those who may not qualify for services but still need financial support, given their medical needs. For instance, PWH that live in states that did not expand Medicaid under the Affordable Care Act, generally qualify for Medicaid if their household income is <=138% of the FPL and they meet criteria for living with a disability. Although many PWH qualify for disability benefits, not all do. PWH that live in states that expanded Medicaid must meet the low-income requirement but are not required to meet the criteria for living with a disability. This results in increased access to benefits for PWH. Most states that did not expand Medicaid are in the Southern region of the United States (Kaiser Family Foundation, 2022). This region is also disproportionately affected by HIV (Centers for Disease Control and Prevention, 2022). It is important to also note that RWHAP will cover medical and support services for people with HIV, but it is a payer of last resort. However, expanding public programs like Medicaid, could help address some financial barriers experienced by PWH in the South.

These findings indicate that although people relying on publicly funded insurance may be less likely to experience financial obstacles in paying for medical bills, there may be other lower income PWH who do not qualify for these safety net programs that may be falling through the gaps. It is also important to note that not all health care plans are created equal. Persons with private health insurance qualify for health care services in different ways, with variable deductibles and coverage costs

People who have problems paying their medical bills might experience greater challenges in having their medical needs met, which for PWH, may lead to adverse HIV clinical outcomes (Dasgupta et al., 2021). Because problems paying medical bills is associated with adverse HIV outcomes, expansion of safety net programs could help PWH receive the care they need to live long, healthy lives, and achieve national HIV prevention and care goals. For instance, expansion of Medicaid could increase the number of PWH who qualify for Medicaid benefits, which could help address financial burdens related to paying medical bills and improve clinical outcomes among PWH (Dawson, 2020).

Our analysis is subject to limitations. Our data are self-reported and may result in misclassification (e.g., recall bias) of variables included in this study, including problems paying for medical bills. In addition, our response rates were 45%. However, results were adjusted for nonresponse and post-stratified to known population totals by age, race/ethnicity, and sex from NHSS using established, standard methodology. People with HIV may also have comorbidities that increase their need to seek medical care, and thus, increase their medical bills and lead to suboptimal outcomes. Our analysis does not describe specific mechanisms through which problems paying medical bills affects HIV outcomes. The purpose of analysis was to examine bivariate associations between problems paying medical bills and clinical outcomes. Lastly, we did not assess differences by jurisdiction, region or with respect to Medicaid expansion or differences in local public health care programs. Assessing these differences in the future might help direct efforts where PWH need the most support.

One in five PWH reported problems paying their medical bills, with a disproportionate impact among those with lower SES, including those living in households at <400% of the FPL and homeless persons. People who have problems paying their medical bills were more likely to have adverse HIV outcomes, which could deter progress in achieving national HIV prevention and care goals. State and local health departments may engage with stakeholders to identify and provide additional assistance to PWH experiencing financial burden. In addition, increasing access to safety net programs, including through Medicaid expansion, would help a larger percentage of PWH and allow them to receive the care they need to achieve viral suppression, live a healthy life, and allow the nation to reach its HIV prevention goals.