Introduction
Mixed method study designs that combine qualitative and quantitative approaches can be a powerful tool in research. Surveys are designed to provide robust estimates of population-level findings but can miss the nuance of personal experience. Qualitative methods like focus groups and in-depth interviews uncover stories, depth, and context, but are typically not designed to produce population estimates. When qualitative and quantitative methods are combined, however, we benefit from both the breadth and depth of measurement that helps us to more fully understand a topic or a population.
These two approaches can work in tandem in a variety of ways. In cases where researchers have well-defined research questions and hypotheses that easily lend themselves to traditional surveys, follow-up qualitative interviews with survey respondents can help us to gather a deeper understanding of the experiences underlying their responses. In other cases, qualitative research helps us learn how to ask about topics and areas of study that are not yet well-defined by previous research, or to help us better understand the cultural nuances of a population before surveying them.
In this whitepaper, we present a case study demonstrating the power of mixed-methods research to tell a story and inform action.
The Need
Missouri Foundation for Health (MFH), an independent philanthropic foundation, was interested in understanding the effects of medical debt on individuals and families in order to explore potential policy interventions to help Missourians avoid and deal with medical debt. MFH sought to both paint a vivid picture of the profound effects of medical debt on Missourians’ lives and to gather statistics that could help them to produce accurate estimates of the prevalence and impact of medical debt.
To meet MFH’s goals, SSRS carried out a mixed-mode study: the study began with a series of focus groups that shed light on individual experiences, and supported the development of a questionnaire that was fielded in a statewide, representative survey. Together, these two methods produced comprehensive and wide-reaching insights.
Qualitative Phase (Focus Groups)
SSRS began by conducting eight focus groups with Missouri residents. The focus groups were designed to explore the varying impacts of medical debt among different segments of the population. This included low-income Missourians (living below 250% of the federal poverty line) who may struggle to pay regular medical bills, those living in rural areas who may have more difficulty accessing high quality care, individuals with disabilities who may have larger medical needs, and Spanish-speaking communities who may face challenges in advocating for their health needs.
Whether totaling hundreds, thousands, or tens of thousands of dollars, participants across the focus groups conveyed that their medical debt has imposed significant financial burdens on them and their families. Many shared stories of taking on multiple jobs, downsizing living arrangements, postponing retirement, depleting savings, and struggling to meet routine expenses. Furthermore, the detrimental impact on credit scores emerged as a prominent concern, affecting people’s ability to secure housing, transportation, and employment opportunities. The repercussions extend beyond financial hardships, with deeply troubling consequences for health and well-being. Participants described the relentless stress of grappling with debt, compounded by aggressive debt collection practices and the shame associated with seeking assistance from friends and family. Several shared that they were forced to forgo or delay necessary medical care to avoid accruing additional debt, while others recounted instances of being coerced into settling debts before receiving essential treatment.
In exploring potential solutions, participants called for policy interventions aimed at streamlining health care costs, enhancing transparency in pricing, expanding financial assistance programs, and improving insurance coverage while reducing out-of-pocket expenses. Of particular importance were suggestions to provide targeted support for individuals hovering just above the federal poverty line and those grappling with income loss due to disability or unemployment.
Quantitative Phase (Survey)
Informed by the focus groups, seven areas of interest emerged as main topics to be covered in a quantitative survey:
- Prevalence of medical debt and its circumstances
- Impacts of medical debt on personal finances and employment
- Impacts of medical debt on accessing healthcare
- Emotional impact of medical debt
- Impact of medical debt on relationships with family and friends
- Strategies for dealing with medical debt
- Policy solutions to the burdens of medical debt
A Multi-Mode Hybrid Survey:
The survey was fielded online and by phone with a representative sample of more than 2,000 Missourians, including more than 300 Black adults, 130 Hispanic adults, and 650 adults living in rural parts of the state. More than half of the respondents reported having medical debt.[1] Respondents were reached through two probability-based panels, the SSRS Opinion Panel[2] and the Ipsos Knowledge Panel[3], along with a random digit dial sample of prepaid cell phone numbers, and an online opt-in panel.
Final survey data were weighted using SSRS’s Hybrid Encipher™ calibration solution[4] to address issues of selection bias in opt-in samples and were matched to US Census benchmarks to reflect the Missouri adult population on key demographics.
What We Found
Results from the survey echoed the deeply personal experiences that emerged in the focus groups, adding robust results that quantify the challenges of medical debt on a statewide scale. Below, we provide examples from each topical area, showcasing how the focus group and survey data effectively complement each other.
Medical Debt Circumstances



Impact on Personal Finances



Impact on Accessing Healthcare



Emotional Impact of Medical Debt



Impact on Relationships with Family and Friends



Strategies for Dealing with Medical Debt



Policies for Addressing Medical Debt



Conclusion
Through this mixed method approach, SSRS helped MFH to gather a full understanding of the profound impact of medical debt on people’s lives. The survey provided statistical evidence on the scope and impact of medical debt, both statewide and among specific segments of Missourians. The focus groups elicited actual stories and narratives of how medical debt has affected people’s lives, especially among population segments that tend to be more deeply affected by medical debt and whose voices are often not fully represented in surveys. Put together, this study demonstrates the power of mixed methods research in holistically understanding social phenomena and the findings illustrate how individual stories bring statistical data to life.
[1] “Recent medical debt” was defined as anyone who currently has or in the past five years has had any medical or dental bills that are past due or that they have been unable to pay; medical or dental bills they are paying off over time directly to a provider; debt they owe to a bank, collection agency, or other lender that includes debt or loans used to pay medical or dental bills; medical or dental bills they have put on a credit card, and they are paying off over time; or debt they owe to a family member or friend for money borrowed to pay medical or dental bills
[2] https://ssrs.com/ssrs-solutions/ssrs-opinion-panel/
[3] https://www.ipsos.com/en-us/solutions/public-affairs/knowledgepanel
[4] https://ssrs.com/ssrs-solutions/encipher/
Authors
Jazmyne Sutton, Ph.D. | Research Director
Nashay Lowe, Ph.D. | Qualitative Associate Research Director
Darby Steiger | Vice President of Innovation and Solutions >>
Eran Ben-Porath, Ph.D. | EVP & Chief Research Officer >>