Megan, who currently lives in Pittsburgh, was hospitalized in September for pneumonia. It was just a one-day stay, and she had health insurance, but even so, the bills piled up, eventually totaling $6,500.

The only thing that made paying them realistic, she said, was that she received a $4,200 tax refund this year.

“I would have put off my medical payments [without the refund],” she told me via email. “Between rent and day to day expenses, I don’t have the income to pay both. … Even with insurance the numbers seemed insurmountable until I got my refund. If it wasn’t for that I would have had to reapply for payment plans with the risk of being sent to collections.”

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Tax returns were officially due this week, which means that the roughly 80 percent of filers who receive refunds will soon have their money, if they don’t have it already. The average tax refund so far this year is $2,995, which is roughly in line with last year. For the average family that receives a refund, the amount is equal to nearly six weeks’ income. And a big proportion of the money Americans receive during refund season, like Megan’s, goes to pay for health care.

According to a report from the JP Morgan Chase and Co. Institute, families who receive a tax refund increase their out of pocket health care spending by 60 percent the following week. Spending on health care remains higher than normal for 75 days post-refund.

“The cash infusion represented by a tax refund payment allowed more people to make more purchases of healthcare goods and services, but, even more consequentially, it facilitated larger payments,” the report said. “This implies that the cash infusion generated by a tax refund payment triggered additional spending on large healthcare ticket items that consumers could have least afforded out of their pre-refund cash flow.”

“100 percent of ours is going to pay for prenatal care and the birth of our second child, due in June,” said Molly, who received a refund of around $2,000 for her family’s state and local taxes. “Our first child’s 2017 birth was uncomplicated and routine, and while I don’t remember what we paid out of pocket versus what insurance covered, the birth, the epidural anesthesiologist, the recovery, and a one-day stay in pediatrics (due to jaundice, probably the most common newborn treatment there is) was a little over $20,000. So we’re counting on the 2019 refunds going to paying off this birth as well, as we will easily hit our deductible.”

62 percent of the additional health care spending triggered by refunds went to in-person payments to health care service providers. That indicates that the higher spending isn’t limited to paying bills for past services, but that tax refunds actually led families to seek care that they had put off until they received a cash infusion. Dentists receive a disproportionate share of the additional spending: One in four adults with incomes below the poverty line skip needed dental work because of costs, and dental-related issues are responsible for about $1 billion per year in emergency room spending.

That so many Americans need a refund windfall in order to access medical care, sadly, makes sense. About one in four adults – 65 million people – reported skipping a medical treatment due to costs in the last 12 months, according to a recent West Health-Gallup survey. Last year, Americans borrowed a collective $88 billion for medical treatments, which doesn’t include the totals from the now ubiquitous medical crowdfunding campaigns that have proliferated on social media.

So tax season injects cash for those households to get the care they either would have had to delay or go into debt to obtain.

It’s worth noting that receiving a big refund means a taxpayer overpaid her taxes during the year, whether via automatic withholdings from paychecks or by paying quarterly estimated taxes (which is a requirement for the self-employed and independent contractors), thus giving the government an interest-free loan. A refund is just that overpaid amount being paid back.

However, the public doesn’t really view it that way: According to a recent New York Times poll, 77 percent of people would prefer to overpay and receive a refund come tax time, which makes sense. 40 percent of people don’t have $400 to cover an emergency cost, and the average savings amongst the poorest 20 percent of households is zero dollars, so an unexpected tax payment can deal a real blow.

One in four adults reported skipping a medical treatment due to costs.



But people also use their refund as a way to enforce savings: Paying their money to the government and then getting it back means they can’t spend it in the interim. Recent reports have shown that the Trump administration, in an attempt to inject money from its 2017 tax bill into the economy sooner, decreased withholdings so that people had less taken out of each paycheck for taxes throughout the year, meaning they were less likely to overpay their taxes and require a refund. But that ploy has backfired spectacularly. Many taxpayers were reportedly upset at getting smaller refunds than they expected come Tax Day, even if their overall bill was in many instances lower than the year before.

“We actually aren’t those types who try to have a big refund each year. We’d rather not allow the government to keep an interest-free loan all year. My husband has tweaked his withholdings so we do get more in the paycheck each week because we need it for all the copays, gas, etc,” said Lindsey Cox of Thomasville, North Carolina. Both she and her husband carry a gene for a rare disease called Van Maldergem Syndrome, which two of her three children have, while the third has severe nervous system issues. Their health care bills total hundreds of thousands of dollars annually. This year, their tax refund of $2,940 went to an array of household needs.

“Our tax return went to catch up on the house payment, electric bill, other small miscellaneous bills, and some car maintenance we had been putting off, like inspections, tire rotations, oil changes, etc.,” Cox said. “We’ve become experts at gaming our system and know for instance, we can be 60 days behind on electric before we face it being cut off. We’ve learned very well how to rob Peter to pay Paul and stay afloat in the process.”

That so many Americans need a quick injection of money in order to see a doctor or access other necessities is a problem that can be addressed by policy: Think universal health care, or the proposals to both expand the pool of those eligible for the Earned Income Tax Credit and allow low-income households to receive some of their refund early. As Bryce Covert explained, “as powerful as the EITC is, there are plenty of people who receive barely any money from it or miss out entirely.”

Tax Day should be a celebration of America’s commitment to civic responsibility and collective welfare, not a grim reminder that far too many people can’t access things that should be basic human rights. However, for too many, a tax refund isn’t just the difference between staying afloat and not, but between seeing a doctor and not, which can literally be the difference between life and death.

Editor’s note: When requested, last names have been withheld to allow people to talk freely about their finances.