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Value Health. 2018 Jan;21(1):95-104. doi: 10.1016/j.jval.2017.07.006. Epub 2017 Sep 1.

Trading Bankruptcy for Health: A Discrete-Choice Experiment.

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Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA. Electronic address:
Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA, USA.
Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA.
Department of Medicine, Stanford Medical School, Stanford, CA, USA.



Although nearly two-third of bankruptcy in the United States is medical in origin, a common assumption is that individuals facing a potentially lethal disease opt for cure at any cost. This assumption has never been tested, and knowledge of how the American population values a trade-off between cure and bankruptcy is unknown.


To determine the relative importance among the general American population of improved health versus improved financial risk protection, and to determine the impact of demographics on these preferences.


A discrete-choice experiment was performed with 2359 members of the US population. Respondents were asked to value treatments with varying chances of cure and bankruptcy in the presence of a lethal disease. Latent class analysis with concomitant variables was performed, weighted for national representativeness. Sensitivity analyses were undertaken to test the robustness of the results.


It was found that 31.3% of the American population values cure at all costs. Nevertheless, for 8.5% of the US population, financial solvency dominates concerns for health in medical decision making. Individuals who value cure at all costs are more likely to have had experience with serious disease and to be women. No demographic characteristics significantly predicted individuals who value solvency over cure.


Although the average American values cure more than financial solvency, a cure-at-all-costs rubric describes the preferences of a minority of the population, and 1 in 12 value financial protection over any chances of cure. This study provides empirical evidence for how the US population values a trade-off between avoiding adverse health outcomes and facing bankruptcy. These findings bring to the fore the decision making that individuals face in balancing the acute financial burden of health care access.


discrete-choice analysis; health care costs; medical bankruptcy

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