J. W. Scott1,2, N. Raykar2,3, C. K. Zogg1, A. H. Haider1, J. G. Meara2,4, M. G. Shrime2,5 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Department Of Surgery,Boston, MA, USA 2Program For Global Surgery And Social Change,Harvard Medical School,Boston, MA, USA 3Beth Israel Deaconess Medical Center,Department Of Surgery,Boston, MA, USA 4Children’s Hospital Boston,Department Of Plastic And Oral Surgery,Boston, MA, USA 5Massachusetts Eye And Ear Infirmary,Department Of Otolaryngology And Office Of Global Surgery,Boston, MA, USA
Introduction:
The Affordable Care Act attempts to decrease the uninsured population in the US by extension of coverage for young adults, creation of insurance exchanges, and expansion of Medicaid eligibility. However, implementation of these programs—most notably Medicaid expansion—remains incomplete. Approximately 1/5th of US trauma patients ages 18-64y are uninsured, and lack of insurance may increase the risk of potentially impoverishing catastrophic health expenditure–previously defined as any expense exceeding 10% of annual household income. We aimed to use a nationally-representative patient sample to determine the proportion of uninsured trauma patients admitted to a hospital who incurred catastrophic medical bills.
Methods:
Uninsured patients ages 18-64y who were admitted for traumatic injury (ICD-9-CM 800-959) were abstracted from the 2007-2011 National Inpatient Sample (NIS). To provide a more detailed estimate of median household income, patients were matched to data obtained from the US census bureau, wherein zip codes were ranked by median income into quartiles and linked to states. State and median zip code household income quartiles were matched to the corresponding NIS variables to provide an estimated household income for each patient. Charges were determined by the NIS total hospital charges billed to each patient. Proportions and estimations were calculated using nationally-representative discharge scaling weights provided in the NIS.
Results:
A total of 117,497 patients (weighted to represent 579,656 patients nationwide) were included. Median estimated household income was $44,287 (IQR: $35,456-$56,646). Median total hospital charges were $26,339 (IQR: $14,575-$47,941). The proportion of uninsured trauma patients with total charges exceeding 10% of estimated household income was 95.8% (95% CI: 94.7-96.9%). The proportion of uninsured trauma patients with total charges exceeding 40% of estimated post-subsistence income was 71.6% (95%CI: 69.4-73.8%). When scaled to the total US population, these proportions imply an estimated total of 555,385 (95%CI: 496,728-614,041) uninsured trauma patients ages 18-64y incurred catastrophic medical bills between 2007-2011–equivalent to 110,077 patients per year (95%CI: 99,346-122,808) patients per year.
Conclusion:
Applying an established definition of catastrophic heath spending, estimates from a nationally representative sample suggest that over 95% of uninsured patients ages 18-64y incur catastrophic medical bills if hospitalized for a traumatic injury in the US. Surgeons should take note, especially in states in which Medicaid has not been expanded, that nearly all of their uninsured trauma patients are at risk of financial catastrophe. Whether through enhanced insurance coverage or other means of improving access to affordable care, providers and policy makers should take note and promote efforts that favor financial risk protection for patients.