By Ronnie Cohen for Reuters.

(Reuters Health) – When a badly injured patient rolls into the emergency room, Dr. John Scott doesn’t ask to see proof of insurance. Instead, he immediately begins treatment.

Hospital care frequently saves patients from gunshots, stab wounds, crushing car accidents and other traumatic injuries. But Scott found in a new study that 7 out of 10 adult uninsured trauma patients suffer another debilitating injury: financial catastrophe.

“We’re getting better at trauma, and they’re going home financially ruined,” Scott said in a phone interview.

“Everyone in America’s at risk for an accidental injury, and not everyone’s protected from the financial consequences,” said Scott, lead author of the study and a surgery resident at Brigham and Women’s Hospital in Boston.

The study, reported in Annals of Surgery, is the first to couple data on U.S. trauma admissions with Census Bureau data on income to evaluate the risks of catastrophic health expenses.

Researchers analyzed 117,502 hospital admissions for uninsured 18- to 64-year-olds admitted for trauma care from 2007 to 2011, before implementation of the Affordable Care Act.

Overall, half the patients had an estimated annual income below $40,867, and half had hospital charges of at least $27,420, not counting charges from doctors, who bill separately.

In other words, one unforeseen major injury could potentially cost well over half of someone’s annual income.

Previous studies have examined the impact of hospitalizations on so-called medical bankruptcies. But most who file for bankruptcy in the aftermath of medical crises are middle-class Americans with health insurance, the authors write, while the poorest uninsured often never declare bankruptcy.

To capture poorer uninsured Americans, Scott used the “catastrophic health expenditure” metric, which the World Health Organization uses to compare out-of-pocket expenses to income.

Scott defined catastrophic health spending as out-of-pocket health costs that were more than 40 percent of a patient’s income after they paid for food.

By that definition, nearly 71 percent of uninsured 18- to 64-year-old trauma patients – or more than 82,000 men and women – risk financial calamity every year.

Patients with the lowest incomes were at highest risk – 78 percent – of destitution. But even those with the highest incomes had a 53 percent risk of a medically induced fiscal catastrophe, the study found.

Dr. David Himmelstein, a professor at the City University of New York’s Hunter College School of Public Health, described the study as “quite sophisticated.” It “paints an extraordinarily disturbing picture of America’s vulnerability,” he said in an email.

“This study shows that someone who is in a car accident, or is mugged, or experiences sudden trauma for some other reason, risks being driven to financial ruin,” he added.

“In essence, unless you’re Bill Gates, you could be at risk of financial catastrophe if you fall seriously ill,” said Himmelstein, who was not involved with the study.

The uninsured are not the only ones suffering the consequences of catastrophic health expenditures, Scott said. When hospitals fail to collect, they pass the costs onto paying customers and health-insurance companies, he said.

“More uncompensated care leads to higher costs for everybody else,” he said.

“For clinicians, it’s important to consider the financial strain as a complication of trauma care. Survival is not the only measure of good care,” he said.

But when a patient asks him how much a CT scan will cost, he has no idea.

Scott’s message to lawmakers considering changes to the Affordable Care Act: “Financial catastrophe is a reality for tens of thousands of Americans who haven’t planned for it. They’re being cured, but being cured into destitution.”

“There’s nobody we turn away for emergency trauma care. We don’t check people’s insurance status. We don’t check their wallet,” he said. “If everybody is deserving of world-class trauma care, everybody is deserving of protection from financial catastrophe from that care.”

SOURCE: Annals of Surgery, online April 7, 2017.

Comment by Don McCanne of PNHP’s Quote of the Day:
We hear often of healthy individuals remaining uninsured because of the very high cost of health insurance, but it is a risk that they are willing to take because they have very few health care needs… though they hope nothing really bad happens. Well, bad things do happen, and this study confirms that 70 percent of those who lost the bet face destitution.
The intent leading up to health care reform was that everyone would be covered. But, as the Affordable Care Act was crafted, it became obvious that the design in putting together various public and private programs was not seamless, and could never be. Thus it was accepted that millions would remain uninsured (28.5 million under 65 as of Sep 2016 – KFF), unless we were to do single payer or something like that, but, of course, that wasn’t feasible, so they said.
More patches could be added to the system but only at higher marginal costs, requiring a major expansion of our wasteful administrative burden, and yet it would still fall short. The deficiencies of the Republican proposals have been exposed by their own rhetoric – that it’s about “access” (but not about actually financing insurance or health care). Their proposals would only increase the numbers of uninsured.
Today’s report shows that relying on current good health and hoping for the best in the future is not a satisfactory approach. As study coauthor Dr. John Rose indicates, absolutely everyone is entitled to our world-class trauma care, and yet they are not entitled to protection from financial catastrophe from that care. We have to change that.
It has become obvious that a single payer national health program is the only feasible approach for the United States that would not only guarantee access to care but would also finance it for everyone. The patchwork models just don’t work, and are too expensive anyway.

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