Massachusetts is routinely cited as proof that universal health coverage can work in America. The Commonwealth boasts among the nation’s lowest uninsured rates, a robust Medicaid program through MassHealth, and a reform legacy predating the Affordable Care Act. On paper, Massachusetts solved the access problem.
Beneath that achievement lies a quieter and more troubling reality, one that falls with force on older adults and people with disabilities.
Medical debt persists even among the insured. It shapes whether people seek care, maintain housing, remain in their communities, or exhaust the savings they spent decades accumulating. And it does not fall evenly. It concentrates precisely among those with the greatest medical needs and the fewest financial protections: the populations this publication exists to serve.
The Scale of the Problem
Nationally, the Kaiser Family Foundation estimates that roughly 100 million Americans carry some form of healthcare debt, totaling at least $220 billion according to the Consumer Financial Protection Bureau. Medical collections have historically appeared on tens of millions of credit reports, affecting access to housing, employment, and loans. But aggregate numbers obscure the human geography of this crisis.
For older adults, Medicare substantially reduces exposure to catastrophic hospital costs but leaves enormous gaps. Medicare does not cover extended custodial nursing home care, most dental services, hearing aids, vision care, or the long-term home- and community-based supports that make independent living possible. Even with supplemental insurance, older adults face accumulating deductibles, copayments, prescription costs, and uncovered long-term care expenses.
Nationally, the Kaiser Family Foundation estimates that roughly 100 million Americans carry some form of healthcare debt, totaling at least $220 billion according to the Consumer Financial Protection Bureau.
The result is a paradox at the center of aging policy: the period of highest healthcare utilization coincides with reduced earning capacity, fixed incomes, and diminished financial flexibility. A 2024 CFPB analysis found that approximately 4.5 million Americans age 65 and older carried medical debt before the pandemic. Those affected were disproportionately likely to report lower incomes, poorer health, and broader financial insecurity particularly those living just above Medicaid eligibility thresholds, financially precarious enough to struggle with costs but not poor enough to qualify for comprehensive public assistance.
The situation is even more severe for people with disabilities. Disability frequently entails recurring medical expenses, durable equipment costs, home modifications, personal care supports, and transportation needs — all layered onto interrupted employment histories, reduced lifetime earnings, and dependence on fragmented public benefit systems. According to KFF research on medical debt and health, people carrying healthcare debt are significantly more likely to skip medications, delay treatment, and experience food insecurity consequences that fall hardest on those whose medical needs are continuous rather than episodic. For many disabled individuals, medical debt is not episodic. It is cumulative. It emerges not from a single catastrophic illness but from continuous friction between human need and inadequate financing.
Massachusetts: A Cautionary Case
The Commonwealth illustrates this contradiction with unusual clarity. A 2025 study by the Massachusetts Center for Health Information and Analysis found that more than 12% of Massachusetts residents carried medical debt. Most were insured. Deductibles, copayments, and underinsurance, not lack of coverage were the primary drivers. CHIA Executive Director Lauren Peters called this outcome “a hollow victory.” Massachusetts largely solved access to insurance. It did not solve financial exposure to illness.
Reporting by the Boston Globe documented that medical debt in Massachusetts contributes to food insecurity, housing instability, and delayed care even within one of the nation’s most insured healthcare systems. When people delay care because of debt, they worsen the very conditions that generated the debt. Medical debt becomes recursive: illness produces debt, debt creates barriers to care, barriers worsen illness. The cycle reinforces itself.
Massachusetts further illustrates this dynamic through its Medicaid estate recovery practices. The Globe documented how the state has maintained one of the nation’s most aggressive programs, seeking repayment for certain MassHealth expenditures from the estates of deceased beneficiaries. In practice, older adults and disabled individuals who relied on Medicaid-funded long-term care could lose family homes or leave diminished inheritances to surviving relatives. Disability advocates described the policy as punitive toward vulnerable populations and destructive to intergenerational stability. Estate recovery reveals something important about the moral architecture of American healthcare financing: the system frequently treats illness and dependency not merely as conditions requiring support, but as opportunities for downstream financial extraction.
Credit Reporting Reform: Necessary but Insufficient
Recent efforts to remove medical debt from consumer credit reports represent an important acknowledgment that healthcare debt differs fundamentally from ordinary consumer debt. Illness is not a discretionary purchase. Beginning in 2022 and 2023, the three major credit reporting agencies announced removal of many medical collections from credit reports. The CFPB has argued that medical debt is a poor predictor of creditworthiness and reflects failures in healthcare financing more than individual irresponsibility.
These reforms matter, particularly for older adults and disabled individuals whose damaged credit scores affect housing access, transportation, and borrowing costs. But removing medical debt from credit reports addresses one downstream consequence while leaving intact the structures that keep producing debt. An older adult who spends down retirement savings for assisted living may avoid formal credit damage while still losing long-term security. A disabled individual facing recurring uncovered costs may avoid collections while living under chronic economic precarity. The central policy question is not whether medical debt should appear on credit reports. It is why healthcare systems continue generating large-scale debt among medically vulnerable populations in the first place.
The United States built a healthcare financing system oriented primarily around acute medical treatment rather than the long-term social realities of aging, disability, and chronic illness.
The Deeper Architectural Problem
The United States built a healthcare financing system oriented primarily around acute medical treatment rather than the long-term social realities of aging, disability, and chronic illness. Modern demographics have rendered that architecture obsolete. The aging of the population, longer survival with chronic disease, rising disability prevalence, and escalating long-term care needs are colliding with financing structures designed for episodic illness rather than sustained human dependency.
Medical debt is therefore not a peripheral consumer finance issue. It is an aging policy issue, a disability rights issue, a housing stability issue, and a governance failure. It shapes whether people seek care early, remain independent, avoid institutionalization, preserve family assets, and participate fully in community life.
The Massachusetts experience is instructive nationally. The Commonwealth demonstrates that expanding insurance coverage, while critically important, is insufficient by itself. Coverage without long-term care reform still generates household collapse. Access without affordability still destabilizes lives.
A society reveals its ethical priorities not only by whom it treats, but by whom it protects from ruin while seeking treatment. The persistence of medical debt among older adults and disabled people — even in Massachusetts — suggests that American healthcare continues to confuse access to medicine with genuine security in illness.
They are not the same thing.
James A. Lomastro, PhD, brings more than 40 years of experience in long-term care administration, healthcare policy, and disability advocacy, including his work with Dignity Alliance Massachusetts, which has secured more than $200 million in policy victories for older adults and people with disabilities.
Photo credit: Shutterstock/Valeri Luzina
