Nearly 4 in 10 in report financial hardship after surgery

About 38% of people who undergo surgery in the United States report experiencing financial hardship. This is especially true with emergency procedures, new research suggests. Private insurance appears to inadequately shield lower-income patients from this hardship, the study authors reported, while Medicaid enrollees report relatively less resulting burden.    

The findings were published Nov. 19 in JAMA Surgery.  

“This paper comes at a pivotal time in health policy in our country,” said lead author Dr. Alexandra Hernandez, a surgical resident at the University of Washington School of Medicine. “We’re moving away from funding Medicaid by reducing eligibility and privatizing public insurance models like Medicare Advantage. Private insurers are raising deductibles and sharing more costs with patients. All of this points to more Americans being vulnerable to financial insecurity after surgery.” 

The researchers examined how surgical procedures affect patients' financial situations. Their source was the Medical Expenditure Panel Survey, an annual, nationally representative survey of individuals, medical providers and employers. The wide-ranging patient questionnaire includes queries about surgical care and, separately, financial hardship — that is, being unable to pay bills and forgoing recommended medical care due to cost.  

Respondents are surveyed five times in a two-year span. Adult patients ages 18 to 64 who reported undergoing surgery between 2014 and 2021 were matched to a representative control group of patients who had no surgery.  

Because the survey captured respondents' answers to questions before and after their procedure, the researchers were better able to isolate the effects of surgery on finances, Hernandez said.  

In the cohort, 37.9% reported financial hardship after undergoing surgery. Having an operation “was associated with a 16% relative increase in financial hardship and an eight-fold increase in annual out-of-pocket spending, with the greatest increases among emergency surgery patients and those privately insured or uninsured,” the study reported.  

Emergency procedures were predictably associated with worse financial outcomes than elective surgeries.  

“When you plan for surgery, you can prepare financially, go through preauthorization with insurance, and potentially save money in advance to prepare,” Hernandez said. “In an emergency, patients don't have these advantages and face whatever financial situation they're already in when the medical crisis hits.” 

Senior author Dr. John W. Scott, a trauma surgeon and associate professor at the University of Washington School of Medicine, called emergency surgery “the ultimate litmus test for health insurance.” 

“Our paper shows that Medicaid passed while private insurance, especially for low-income people, failed," he said.  

In treating emergency cases at Harborview Medical Center in Seattle, Scott described patients who voice fear about medical costs instead of their own life-threatening injuries.  

“This has been true across three hospitals in health systems in three states,” he said. “Everywhere I've worked, I have vivid memories of patients in the trauma bay saying, ‘I can't afford this.’” 

Although uninsured patients reported the highest increase in financial hardship after surgery, low-income patients with private insurance had the second highest burden. The authors attributed this to insurers’ shifting costs to policyholders, including higher out-of-pocket costs.   

“People are rightly concerned about the uninsured population in the current policy environment, but many ignore the tidal wave of under-insurance that is coming,” Scott said. “Having a so-called ‘catastrophic’ health insurance plan isn’t enough if it doesn’t actually protect you from financial hardship when you need it most.”  

Meanwhile, patients with Medicaid, the government insurance program for lower-income Americans, saw no difference in financial hardship after surgery. This was a key finding because studies often equate Medicaid insurance with financial risk, Hernandez said. 

“Our data demonstrate the protective effects of Medicaid from financial hardship. It also means that current moves to restrict Medicaid eligibility may create more hardship,” she said. That could happen if people who are forced off Medicaid become uninsured or underinsured. 

The study was supported by the National Institutes of Health (T32DK070555, R0-1DK137466) and the Agency for Healthcare Research and Quality (K08-HS028672). The authors’ conflict of interest statements are in the published paper and available to journalists upon request. 

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