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Canceling people’s debt from unpaid medical bills does not lead to improvements in their health or finances, according to a new study. | Getty Images The US leaves millions of people with outstanding medical bills. How do we help them? Four in 10 Americans carry some kind of medical debt, an affliction that is unique to the United States among wealthy nations. The country does not guarantee medical insurance to everyone, and the costs even to people who carry coverage are much higher on average than they are for patients in the rest of the developed world. It’s a fundamental flaw in the design of the US health care system. Those debts weigh on the people who carry them: Research has found that people who incur substantial medical bills (after a cancer diagnosis, for example) report cutting back on everyday spending, depleting their savings, and even downsizing their homes. Medical debt is associated with poorer general health, as well as higher rates of cancer, heart disease, and overall mortality. People end up sicker because they can’t afford their health care. In the absence of politically difficult health care reform, activists and some state and local governments have set up medical debt relief programs, purchasing the debts of people in difficult financial circumstances for much less than face value and wiping them out at no cost to the patient. But a new study of medical debt relief by a group of top economists has called its value into question. Participants who had their debt erased did not see their mental or physical health or their access to credit improve much after debt relief. There was even evidence that some people felt more depressed. “It would be great if we could improve people’s mental health, we could ease their finances, we could get them to go to the doctor more often by buying debt for less than a penny on a dollar,” Francis Wong, a University of Munich economist who co-authored the study, told me. “But it just didn’t work.” The findings stunned the researchers. While it might still be premature to discard medical debt relief based on one study, the research raises important questions about the limits of debt relief, and about how to use finite government and philanthropic resources to alleviate high health care costs. One lesson of the paper may be that relieving debt long after it’s accrued is ultimately a Band-Aid on the structural problems within US health care. Many people with medical debt are contending with other financial problems compounded by their health expenses, which are not easily undone by eliminating hospital bills. Preventing medical debt in the first place may be more effective. “The punchline for me is that you really need to tackle the root cause that created all of these issues in the first place, that created the financial distress and poor mental health,” Wong said. “That’s a matter of addressing the holes in the American health care system.” Medical debt relief didn’t do much to improve people’s finances The research team — including Wong, Harvard’s Raymond Kluender, Stanford’s Neale Mahoney, and UCLA’s Wesley Yin — was commissioned to study a group of 83,400 people who collectively had $169 million in medical debt relieved through the organization RIP Medical Debt (recently renamed Undue Medical Debt). The study analyzed two groups of patients: one had held their debts for seven years on average, the other for a little more than a year. Using surveys and financial data, the experiment tracked most patients for about a year after they received debt relief. Compared to patients who did not have their debt wiped out, the researchers found, the relief had negligible effects on participants’ access to credit and other measures of financial well-being. Credit scores increased by a marginal 3.6 points on average, though for people whose only debt had been medical debt, there was a more sizable 13.4-point increase. The average increase in credit limits was just $342. Participants whose debt was relieved actually became less likely to pay future medical bills, the study found. The results showed no improvements in objective and subjective measures of financial distress. One reason may be that although participants had an average of $2,167 in debt relieved, they had plenty of other, non-medical debt. The group averaged $28,000 in debts including things like credit card balances and car loans. An average of $4,000 in bills had already reached collections. “The most striking thing to me was just how much financial distress that folks with medical debt are experiencing broadly,” Kluender said. “The debt relief that we were able to execute through the experiment was insufficient to address their financial deprivation.” People in medical debt are often pestered by collectors and forced into even more debt to pay their bills and cut their spending on necessities such as food and rent. People did not report feeling happier or healthier after debt relief The study also found that measures of depression, stress, anxiety, subjective feelings of well-being, and general health barely budged after debt was wiped out. One finding is especially telling. Before the experiment began, the authors asked a panel of 45 experts what they expected the study to find. Panelists anticipated on average a 7 percentage point reduction in the number of patients reporting moderate or worse depression. Instead, the study showed a 3.2-percentage point increase in patients reporting that they were depressed. That’s on top of the 45 percent of participants who reported having at least moderate depression before the experiment began. The worst mental health effects were found among the 25 percent of participants with the most medical debt: They experienced a 12.4-percent increase in depression along with “worsening of anxiety, stress, general health, and subjective well-being” after debt relief. “That’s just staggeringly high rates of poor mental health,” Wong said. How can that be? One possibility is that the relief came too late to undo the severe mental health burden of carrying debt for months or years. Such patients have “already been scarred by the collection process,” Mahoney told me, and will continue to struggle with non-medical debts. “That’s the sort of person who on a weekly basis is getting hounded by debt collectors, not just sort of the medical debt collectors that we study, but debt collectors of all sorts,” Wong said. Medical debt relief “really doesn’t do anything to alleviate any of those other conditions, not to mention whatever health condition led them to incur medical debt in the first place.” The researchers identified another plausible theory through a sub-experiment included in the study, which tested the reactions of patients based on how they were informed of their debt relief, either by phone call or by letter. Among the people who received a direct phone call to let them know, the negative mental health effects were greater. Prior research has found that Americans tend to feel shame and stigma when receiving charitable or government aid to pay their bills. Participants had not requested debt relief, the study noted, but rather had it purchased and wiped out by RIP Medical Debt without their prior knowledge (this is often how medical debt relief programs work). It’s possible that the very act of filling out the study’s surveys may have affected how the respondents perceived their own situation. “We’re reminding people of this unpleasant experience that they had,” Kluender told me. “And maybe they were going through some unpleasant negotiations with their insurer or they feel a lot of guilt and shame about being unable to pay the bill.” What do we do with this information? The disappointing findings are especially surprising in light of research on relief programs for other types of debt, like credit card debt and student loan debt, that has found improvements in financial health and job prospects. Medical debt, like those other types of debt, has been associated with worse health and a weaker financial situation. But medical debt has some distinct characteristics. Repayment rates are much lower than they are for student loans or mortgages. Once a medical bill reaches collections, it’s often resolved with a negotiated settlement, which can result in much lower payments than what the patient originally owed. So the study participants, who had carried their debt for more than a year at a minimum, may have already been subconsciously writing off the medical debt by the time relief came, the authors said. That limits the impact they may feel when it’s wiped out. Some experts not involved in the study think the findings may understate the benefits of medical debt relief, especially on people’s finances, based on earlier studies of medical debt relief that had found larger benefits for people’s credit scores and credit access. The effect on credit scores is increasingly a moot point, however. Credit agencies have agreed to stop reporting most medical debt on people’s credit reports, after urging from the Biden administration, a step taken in the midst of the experiment. (The study relied on a subset of people whose debt was relieved prior to that announcement.) Amy Finkelstein, a leading researcher on health care costs at MIT whose nonprofit J-PAL North America helped fund the study, said she was shocked by the results but grateful to have them. Part of the difficult work of policymaking is to soberly assess the results of what you are doing. “Yes, it’s disappointing. But another way of saying it is: This was true whether or not we had done the study,” Finkelstein told me. “So it’s good to know so that we can try to learn from it and move on.” Everybody I spoke to agreed on one thing: Preventing people from accruing medical debt in the first place would likely be more effective in improving their finances and health than relieving debts after the fact. One-time debt relief may not make it any easier or less stressful to access health care in the future, but providing people with health coverage that eliminates the risk of debt does. That hypothesis is supported by existing evidence. The Oregon Health Insurance Experiment, a totemic work in health care research, found that low-income adults who received Medicaid saw a 9 percent reduction in depression. They were also less likely to end up in debt because of a medical bill and less likely to take out loans or skip payments on their other necessities to cover their health care balance. Experts I spoke to named more robust interventions that could lead to less medical debt and better health and financial outcomes, including more generous insurance benefits for people already covered. Covering the 26 million Americans who remain uninsured would be another step. Most states in the Deep South still haven’t expanded Medicaid under the Affordable Care Act (ACA), leaving millions of low-income people without coverage. Other proposals, such as more public insurance options, have gained increasing support among Democrats. “As a consumer advocate, the best solution would be single-payer, Medicare for all,” Chi Chi Wu, an attorney with the National Consumer Law Center, said. But major overhauls are easier said than done. The history of US health care reform is one of a country inching toward universal health coverage: Medicare and Medicaid passed in the 1960s, and the ACA didn’t come along until 2010. Our byzantine insurance system with weak cost controls persists, with a massive health care industry invested in maintaining the status quo. In the meantime, experts said, policymakers could focus on making sure that hospital financial assistance programs are accessible to more people. Many patients are eligible for aid that would significantly reduce what they owe — but they often have no idea it’s available. The New York Times reported in 2022 that some hospitals were making it extremely difficult for eligible patients to find out about and use assistance programs, while aggressively seeking payment even from patients who should qualify for aid. The long-term project of universal health care continues. The debt relief study, disappointing as its results might be, may spur some fresh thinking about how to better help people.

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Nude images shared without consent can be traumatic, whether they’re real or not. | Getty Images/iStockphoto How do you stop deepfake nudes? There’s a lot of debate about the role of technology in kids’ lives, but sometimes we come across something unequivocally bad. That’s the case with AI “nudification” apps, which teenagers are using to generate and share fake naked photos of their classmates. At Issaquah High School in Washington state, boys used an app to “strip” photos of girls who attended last fall’s homecoming dance, according to the New York Times. At Westfield High School in New Jersey, 10th grade boys created fabricated explicit images of some of their female classmates and shared them around school. Students from California to Illinois have had deepfake nudes shared without their consent, in what experts call a form of “image-based sexual abuse.” Now advocates — including some teens — are backing laws that impose penalties for creating and sharing deepfake nudes. Legislation has passed in Washington, South Dakota, and Louisiana, and is in the works in California and elsewhere. Meanwhile, Rep. Joseph Morelle (D-NY) has reintroduced a bill that would make sharing the images a federal crime. Francesca Mani, a 15-year-old Westfield student whose deepfaked image was shared, started pushing for legislative and policy change after she saw her male classmates making fun of girls over the images. “I got super angry, and, like, enough was enough,” she told Vox in an email sent via her mother. “I stopped crying and decided to stand up for myself.” Supporters say the laws are necessary to keep students safe. But some experts who study technology and sexual abuse argue that they’re likely to be insufficient, since the criminal justice system has been so inefficient at rooting out other sex crimes. “It just feels like it’s going to be a symbolic gesture,” said Amy Hasinoff, a communications professor at the University of Colorado Denver who has studied image-based sexual abuse. She and others recommend tighter regulation of the apps themselves so the tools people use to make deepfake nudes are less accessible in the first place. “I am struggling to imagine a reason why these apps should exist’’ without some form of consent verification, Hasinoff said. Deepfake nudes are a new kind of sexual abuse So-called revenge porn — nude photos or videos shared without consent — has been a problem for years. But with deepfake technology, “anybody can just put a face into this app and get an image of somebody — friends, classmates, coworkers, whomever — completely without clothes,” said Britt Paris, an assistant professor of library and information science at Rutgers who has studied deepfakes. There’s no hard data on how many American high school students have experienced deepfake nude abuse, but one 2021 study conducted in the UK, New Zealand, and Australia found that 14 percent of respondents ages 16 to 64 had been victimized with deepfake imagery. Nude images shared without consent can be traumatic, whether they’re real or not. When she first found out about the deepfakes at her school, “I was in the counselor’s office, emotional and crying,” Mani said. “I couldn’t believe I was one of the victims.” When sexual images of students are shared around school, they can experience “shaming and blaming and stigmatization,” thanks to stereotypes that denigrate girls and women, especially, for being or appearing to be sexually active, Hasinoff said. That’s the case even if the images are fake because other students may not be able to tell the difference. Moreover, fake images can follow people throughout their lives, causing real harm. “These images put these young women at risk of being barred from future employment opportunities and also make them vulnerable to physical violence if they are recognized,” Yeshi Milner, founder of the nonprofit Data for Black Lives, told Vox in an email. Stopping deepfake abuse may require reckoning with AI To combat the problem, at least nine states have passed or updated laws targeting deepfake nude images in some way, and many others are considering them. In Louisiana, for example, anyone who creates or distributes deepfakes of minors can be sentenced to five or more years in prison. Washington’s new law, which takes effect in June, treats a first offense as a misdemeanor. The federal bill, first introduced in 2023, would give victims or parents the ability to sue perpetrators for damages, in addition to imposing criminal penalties. It has not yet received a vote in Congress but has attracted bipartisan support. However, some experts worry that the laws, while potentially helpful as a statement of values, won’t do much to fix the problem. “We don’t have a legal system that can handle sexual abuse,” Hasinoff said, noting that only a small percentage of people who commit sexual violence are ever charged. “There’s no reason to think that this image-based abuse stuff is any different.” Some states have tried to address the problem by updating their existing laws on child sexual abuse images and videos to include deepfakes. While this might not eliminate the images, it would close some loopholes. (In one recent New Jersey lawsuit, lawyers for a male high school student argued he should not be barred from sharing deepfaked photos of a classmate because federal laws were not designed to apply “to computer-generated synthetic images.”) Meanwhile, some lawyers and legal scholars say that the way to really stop deepfake abuse is to target the apps that make it possible. Lawmakers could regulate app stores to bar them from carrying nudification apps without clear consent provisions, Hasinoff said. Apple and Google have already removed several apps that offered deepfake nudes from the App Store and Google Play. However, users don’t need a specific app to make nonconsensual nude images; many AI image generators could potentially be used in this way. Legislators could require developers to put guardrails in place to make it harder for users to generate nonconsensual nude images, Paris said. But that would require challenging the “unchecked ethos” of AI today, in which developers are allowed to release products to the public first and figure out the consequences later, she said. “Until companies can be held accountable for the types of harms they produce,” Paris said, “I don’t see a whole lot changing.” This story appeared originally in Today, Explained, Vox’s flagship daily newsletter. Sign up here for future editions.

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