The killing late last year of Brian Thompson, CEO of the Minnesota-based insurance company UnitedHealthcare – and subsequent reactions – sparked renewed discussion surrounding American frustration with the high cost of health care and unaffordable medical bills. 

High health care costs and associated medical debt in the U.S. are pressing social problems with an estimated 100 million Americans having some medical debt. The effects of medical debt can be numerous, including financial and household budget strain as well as delaying or forgoing seeking health care, with repercussions for health, mental health and well-being.

Looking across the U.S., rural residents are more likely to have medical debt in collections, and we find this is also true in Minnesota. According to our analysis of the Urban Institute’s Medical Debt in America data from 2022, across Minnesota, an average of 2.8% of residents have medical debt that has been sent to collections. For rural counties in Minnesota, the average is 2.9%, compared with an average of 2.6% in urban counties. There is wide variation across counties as well. Roseau County has the highest share of residents with medical debt in the state at 8.3% while Lake County has the lowest share at less than one percent. There is wider variation among rural Minnesotan counties, which range from 1.1% to 8.3% of residents with medical debt than among urban Minnesotan counties, which range from 0.97% to 5.5% residents with medical debt.

Several policies have been enacted to help ease medical debt; for instance some states, counties, and municipalities have initiated medical debt forgiveness using funds from the American Rescue Plan Act and have partnered with the non-profit, Undue Medical Debt (formerly RIP Medical Debt). Yet, these have been primarily enacted in urban areas, including St. Paul, leaving disproportionately impacted rural areas without similar relief policies. 

Minnesota has been successful in enacting statewide legislation to address this issue. The Minnesota Debt Fairness Act, which aims to help with the problems surrounding medical debt accrual, became effective in Minnesota on Oct. 1. Protections include not denying care due to unpaid bills, not transferring medical debt to one’s spouse, not reporting medical debt to credit agencies, and the establishment of several new medical debt collection rights. However, more may need to be done to ensure that rural Minnesotans do not continue to experience disproportionate impacts of health care costs.

To prevent medical debt in the first place, policy should also focus on making health care more accessible and affordable. Additional policies focusing on reducing income and economic inequality across all locations would help alleviate problems with medical debt and help people to afford needed health care. This is especially true for rural areas that have lower household incomes on average and whose residents face inequities in health, including higher rates of underlying health problems and chronic conditions. In addition, promoting access to affordable health insurance is key as rural residents have higher rates of uninsurance.

Rural residents also face unique health care access barriers, including limited public transportation, longer distances to medical facilities, shortages of medical providers, and facility closures. Improving rural access to health care is one avenue to reduce medical debt and promote equitable health outcomes for all. Minnesota has a long and proud history of promoting good health and health care, but work remains to ensure that no one is left out.

Alexis Swendener is a postdoctoral associate at the University of Minnesota School of Public Health within the Rural Health Research Center. Hannah MacDougall is an assistant professor at the University of Minnesota School of Social Work. Carrie Henning-Smith is an associate professor in the University of Minnesota School of Public Health Division of Health Policy and Management and co-director of the University of Minnesota Rural Health Research Center.

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Imagine owing hundreds of dollars in medical debt and then having it suddenly erased. This scenario is becoming more common in the United States thanks to American Rescue Plan Act funds and a nonprofit called RIP Medical Debt.

Currently, nearly 1 in 10 adults owe more than $250 in medical bills and 6% of U.S. adults owe more than $1,000. Medical debt — debt from unpaid medical bills — often results from unexpected health care expenses, such as an emergency hospital stay following a health crisis or accident. While lack of health insurance is a key risk factor in having medical debt, nearly half of adults with insurance have incurred it too.

Medical debt can be devastating to one’s health and well-being. Negative effects of owing medical debt include cutting spending on food, clothing or other basic needs, being unable to access needed health care services, and being forced to change living situations. Medical debt is so commonplace in the U.S. that in 2022, credit bureaus removed paid medical collections from credit reports and in 2023, medical collections under $500 will no longer appear on consumer credit reports. These changes amount to an admission by credit agencies that owing medical debt is not a reflection of financial responsibility in the U.S. Instead, it is an all-too-common experience for users of our opaque health care system. It doesn’t need to be this way, though.

To combat medical debt, the nonprofit, RIP Medical Debt, has been using private donations to pay off medical debt since 2014. By purchasing debt for cents on the dollar, RIP Medical Debt uses the same model private sector companies have used to buy up debt — but arguably with better intent. More recently, RIP Medical Debt has started to use public dollars to cancel medical debt, contracting with more than 30 states, counties, and cities to cancel medical debt for hundreds of thousands of individuals using COVID-19 funds from the American Rescue Plan Act (ARPA).

Minnesota is not immune to the effects of medical debt. In February, state lawmakers proposed “The Minnesota Debt Fairness Act,” which would, among other things, ban medical debt from being reported to credit agencies, reduce interest on medical debt, and ban the withholding of medical services due to unpaid debt. Withholding medical services due to unpaid medical debt is on the minds of many Minnesotans after the New York Times reported that Allina Health was rejecting patients who were in medical debt from receiving care. This legislation is of critical importance but stops short of erasing medical debt for individual Minnesotans.

There have been efforts at the municipal level, though, to eliminate medical debt for Minnesotans. For example, in December of 2023, Mayor Melvin Carter of St. Paul announced the city would be investing $1 million of ARPA funds with RIP Medical Debt to pay off $100 million in medical debt for approximately 45,000 St. Paul residents. Other cities around the U.S. have taken similar action, including New York City, Washington, D.C., New Orleans, Chicago (Cook County), and Detroit (Wayne County).

We applaud the efforts by St. Paul and these other cities to cancel medical debt. So far, however, most efforts to address medical debt around the country have focused on large urban areas. While such efforts are urgent and important, they ignore the disproportionate impact of medical debt on rural residents. In the U.S., rural residents are more likely than urban residents to experience medical debt (11% vs. 8%). In addition to shouldering a disproportionate share of medical debt, rural residents are more likely to be uninsured, have worse overall health and mental health, and have more barriers to health care services, including recent closures of obstetric units in Minnesota. Ensuring the continued vitality of rural Minnesota requires addressing the crisis of medical debt there, which is made worse by these other systemic failures.

We heartily support the cancellation of medical debt, and we encourage lawmakers in Minnesota to add statewide medical debt cancellation to its legislative agenda. Other states such as Arizona and Connecticut have contracted with RIP Medical Debt to cancel debt throughout their states, and we encourage Governor Walz to do the same in Minnesota. Rural residents should receive the same benefit as their urban St. Paul counterparts.

Hannah MacDougall is an assistant professor at the University of Minnesota School of Social Work. Mariana Tuttle is a research fellow at the University of Minnesota Rural Health Research Center. Carrie Henning-Smith is an associate professor in the University of Minnesota School of Public Health Division of Health Policy and Management and deputy director of the University of Minnesota Rural Health Research Center.

The authors would like to acknowledge collaborators Katie Rydberg, MPH, Ingrid Jacobson, MPH, and Alexis Swendener, Ph.D., for their input.

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Social well-being is essential to good health. Yet, as the COVID-19 pandemic roiled the country and upended social routines, supporting social well-being became even more challenging, including in rural areas. Social well-being was impacted most directly by the need to socially distance and isolate, and many people moved some or all their social activity online. However, this proved more challenging in rural areas, where broadband connectivity is less available and devices are less omnipresent, and for older adults, who generally report lower use of online technology than their younger counterparts.

In an April, 2022 report released by AP and NORC at the University of Chicago, rural adults age 50 and older reported the lowest level of satisfaction with available social activities in their community (only 38% thought the area they lived in was doing a good job at providing social activities, compared with 52% in urban areas and 55% in suburban areas, despite the fact that older adults make up a disproportionate share of rural residents). The survey also showed that rural residents reported lower satisfaction with transportation and availability of services to help them age in their own homes, compared with their urban and suburban counterparts.

Clearly, while rural older adults may have strong relationships and desire for social connection, there are barriers to good social health. That said, rural areas have long boasted a rich social tapestry, and as we stumble our way toward a new social normal more than two years into the pandemic, we must find ways to support community and connection.

We researched social opportunities in all 60 non-metropolitan counties in Minnesota, focusing most on those geared toward older adults. We found ample opportunities, but also variation between counties. Most – but not all – counties offer some combination of social infrastructure, including public libraries, senior centers, farmer’s markets, faith-based organizations (notably mostly Christian churches), American Legions and/or VFWs, and public parks. For some, there were community arts centers and hobby groups (e.g., quilting, fitness classes, bee keeping, cards, gardening, community theater, movie nights, bingo, photography, fishing, art classes, wine tasting, book clubs).

Some counties and communities made it easy to find opportunities online. For example, the Todd County website listed a variety of opportunities and social infrastructure resources in an accessible, user-friendly fashion. This is good for residents looking for new ways to connect with each other, but is also important for loved ones who live out of town and are trying to find opportunities for those they care about. Many counties also have local news sources through which activities and events can be shared, although the availability and independence of those has decreased nationally in recent years, potentially making it more difficult to share local social opportunities.

Some counties had more inclusive messaging than others. For example, Crow Wing County provides a list of LGBT-specific resources in its county resources guide, including one organization geared toward older adults. Chippewa County features a Restorative Justice program on its website, including volunteer mentoring opportunities for adults. Within Goodhue County, Red Wing has a webpage focused on racial equity, including a community strategic action plan.

Although our exploration of social infrastructure in rural Minnesota was limited to what’s advertised online, we found a wealth of opportunities for social connection. Not all rural communities have adequate capacity for website maintenance, though, and a lot of social activity happens in less formal ways. Not to mention, online advertising doesn’t work for people who can’t get online.

Rural older adults report lower satisfaction with social activities available to them, and the pandemic has highlighted the urgent need to strengthen social connection to improve health. Going forward, we need investment in social infrastructure – that is, accessible and inclusive places and opportunities for people to meet, gather, and socialize – to make sure that existing opportunities to connect are supported, expanded, and sustained.

Dr. Carrie Henning-Smith is an associate professor in the Division of Health Policy and Management, School of Public Health, 2021-2022 Fesler-Lampert chair in Aging Studies, and deputy director of the University of Minnesota Rural Health Research Center. Mary Anne Powell is a graduate research assistant and master’s in public health student at the University of Minnesota School of Public Health. 

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