manifests as medical debt. As with any type of debt, medical debt can lead to an array of personal and financial problems—including having to go without food and heat plus a reluctance to seek further medical treatment. Aggressive debt collecting has been highlighted as an aggravating factor. A study has found about 63% of adults with medical debt avoided further medical treatment, compared with only 19% of adults who had no such debt. In the United States, one of the largest concerns of medical debt stems from high medical costs. For example, in a 2011 study of fees paid to physicians for office visits and hip replacement procedures across the United States and several other wealthy countries, the patients in the United States paid 27% more for office visits and 70% more for hip replacement procedures. Similarly, the United States charges an average of $75,345 for a heart bypass operation whereas the same operation in other wealthy countries, such as the Netherlands and Switzerland, costs $15,000 to $36,000 on average. In general, data has shown that individuals in the United States pay nearly double the amount of money on healthcare in their lifetime than those in other wealthy countries. As these healthcare costs continue to rise, a lack of insurance or insurance that does not cover all fees causes a rise in out-of-pocket expenses. In addition, those with medical debts may increase in the future due to increasing patient cost-sharing and rising health care costs. According to a study conducted in 2012 by Demos, it was determined that among indebted households 62% cited out-of-pocket medical expenses as a contribution to their debt. As these medical fees continue to rise and out-of-pocket expenses continue to grow, Americans are at much higher risk of falling into medical debt whether insured or not. Medical debt in other countries The threat of unmanageable medical debts is largely unknown for those in Western Europe, Japan and Australia. A 2019 study of health provision carried out for the Los Angeles Times found that about 1 in 35 citizens of the United Kingdom, Sweden, France, Germany and Japan faced medical bills that were sufficiently high to threaten their economic security: in contrast, tens of millions of Americans have to balance medical expenses against other basic needs. In the same year, a World Health Organization analysis of the spending of patients in 36 countries found that only 1