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If you get sick in America, there’s a good chance you’ll end up in debt. Four in 10 U.S. adults have some form of health-care debt, .

One surprising risk: living in a community where hospitals have consolidated — an increasingly common development as health systems merge or large systems gobble up smaller hospitals.

That’s according to a  shared exclusively with �鶹Ů�� Health News by the Urban Institute, a nonprofit that has been tracking medical debt across the United States for years and worked with �鶹Ů�� Health News on our .

It’s already well-documented that hospitals  when they gain market power, which can happen when systems get bigger or competitors close.

So researchers at Urban wondered if market concentration could also leave more patients in debt.

“With fewer alternatives and higher prices, patients may have limited options to seek more affordable care,” the report’s authors hypothesized. “They might delay seeking treatment, potentially leading to worse outcomes and even higher medical debt in the future.”

Making such a direct link is tricky, in part because many factors influence how much medical debt there is in a community.

Urban researchers have already established, for example, that medical debt is higher in counties with larger shares of uninsured residents and  such as cancer or diabetes.

To explore the impact of consolidation, researchers first looked at  in every U.S. county.

They then looked at credit bureau data to see the share of county residents with an unpaid medical bill on a credit report, which is one measure of medical debt in a community.

Nationally, the share of people with a medical bill on a credit report . But the researchers noticed that the declines were less pronounced in counties where hospitals had become more consolidated, even after accounting for other factors.

“While medical debt on credit reports declined across most U.S. counties between 2012 and 2022, increases in hospital market concentration prevented such improvements in many areas of the country,” they wrote.

Perhaps not surprisingly, the report drew criticism from the American Hospital Association (AHA), the industry’s largest trade group. Molly Smith, group vice president for public policy at the AHA, called it a “thin analysis” that didn’t account for more important factors driving medical debt such as the rise of high-deductible health plans.

“Until policymakers account for the real drivers in medical debt,” she said, “our country won’t be able to develop public policies that address this significant problem.”

The Urban Institute’s Breno Braga, one of the report’s authors, acknowledged that factors such as chronic illness remain stronger predictors of medical debt than market consolidation. But, he said, the new research should give policymakers another reason to scrutinize the growing market power of health systems across the country.

“Limiting hospital consolidation could be beneficial for consumers in limiting medical debt,” he said.

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