A recent study from the University of Washington School of Medicine reveals a national snapshot of the ways Americans are vulnerable to financial insecurity after undergoing medical procedures.
Surveys showed that about 38% of people who undergo surgery in the United States report experience financial hardship after the medical procedure — meaning they have incurred debt and have difficulty paying medical bills, or they delay medical care for fear of cost.
John Scott is a trauma surgeon and researcher who studies health policy at the University of Washington. He joins us to discuss his findings.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. A recent study found that 4 in 10 people who had surgery ended up with bills they could not afford. John Scott is a trauma surgeon and a researcher who studies health policy at the University of Washington. He is a senior author of this new paper, and he joins us now to discuss his findings. John Scott, welcome to the show.
John Scott: Thanks for having me, Dave.
Miller: I want to start with your personal experience as a trauma surgeon. How often has it happened that a patient who needs life-saving surgery says to you, “no, don’t do it,” in some way, “I can’t afford it?”
Scott: Yeah, this is increasingly common. And I’m a surgeon, I’m a researcher, and the best research questions come straight from my patients. That’s the benefit I have of doing both. And I’ve been operating for 15 years in three different states, and everywhere I’ve worked, I’ve had these haunting moments in the emergency room. I’ve had patients bleeding out after a car crash or a gunshot wound, and we’re trying to save their life and they’re trying to stop us saying, “I can’t afford this. Don’t do this.” I’ve had patients with simple things like appendicitis, who are otherwise healthy, coming in with really complicated diseases like ruptured appendix or abscess. And when we talked to them about why they waited, they said, “I was just hoping it would go away because I couldn’t afford it.”
So I’ve seen it happen everywhere I’ve worked. And the point of research is to say, well, that’s one patient at a time. What does this really look like at the national level? What do the numbers really show?
Miller: Before we get to the new study, you mentioned a ruptured appendix. Are there studies that have looked at the effects on health outcomes from people who delay care because of cost?
Scott: There are a lot of studies and in fact we’ve written a number of those studies. What’s striking is that people … The first thing, the Affordable Care Act did a lot of good here. We saw perforated appendix rates went down because a bill was passed. That’s amazing. The way people show up in a CAT scan is better, and different, and earlier, and less sick because of a policy that was passed. That’s a huge win.
Miller: I’ve never had appendicitis, happily, but from what I understand, it’s very painful. Is the thinking that people think maybe this is bad, but I’m not gonna go in because I can’t afford it, and then it ruptures? That’s what went down because more people got health insurance?
Scott: The simple answer is yes. There’s some nuance. There’s some complication here. But the thought process is things like appendicitis, gallbladder disease or colon infections like diverticulitis, the longer you wait before seeking care, the more likely you are going to present with something like an abscess or perforation. Every time we’ve looked at it, policies that expand health insurance coverage, people show up earlier. And policies that reduce health insurance coverage or make patients pay more, like being on a high deductible health plan, we see that younger, healthier, wealthier people, despite that, they are showing up with more advanced disease on these, what we call access-sensitive surgical conditions.
So yeah, this is where policy intersects with health. This is how you know policy gets into the body.
Miller: How did you actually do this study?
Scott: We used a national health survey that has been tracking Americans for decades. They enroll people two years at a time. And because they surveyed the same people multiple times over two years, we could find people that had surgery and look at their answers before and after surgery. So in this study, we looked at questions about problems paying medical bills or delaying care due to cost, and we compared them before and after surgery. And then we had a comparison group of people that didn’t have surgery, so we could really hone in and isolate the impact of surgical care.
Miller: And how, specifically, did you define financial hardship?
Scott: So this specific survey has a couple of questions that we kind of combined together. One is, do you currently have medical bills that you’re having trouble paying? It’s literally, do you have trouble paying medical bills? And another question that said, have you delayed care or skipped getting care that you know you needed because you couldn’t afford it? And if somebody said yes to one of those two questions, or they said, I have bills that I’m struggling to pay off over time … If you said yes to those, then we said that’s somebody that’s having some financial hardship.
Miller: And how big a difference was there in financial hardship among people, whatever their insurance situation, who had surgery and people who didn’t?
Scott: When we look at the attributable part just to surgery, what we see when you drop it before and after is that it went up like five percentage points, which doesn’t sound like a lot, but that’s almost a 20% increase in the proportion of patients who said, “I’m having problems paying my bills.” So it’s about a third of all Americans in the comparison group and before surgery group … about a third of them had problems paying medical bills. And then the piece that was specific to surgery was just under between five and 10 percentage points.
Miller: OK, but in the end, what stands out most from this study is not that overall number, but to me, the differences in populations based on what kind of insurance they have. You’ve actually called emergency surgery the “ultimate litmus test for health insurance.” What do you mean by that?
Scott: Yeah, it really is. You can’t plan for emergency surgery. You can’t go shop around and say, oh, is this in my network or not, or what are the rates at this place or not? You’re bleeding or you’re in sepsis, you need care now. So this is what health insurance is for. If you were going to explain to like a Martian, what is this health insurance thing, you’d say, well, if I have a health crisis right this moment and I need protection, then this is the thing that keeps me from having financial hardship. So it’s a great test to see how well did people’s health insurance really protect them in that moment.
Miller: You can explain it to a Martian, you could also explain it to a lot of people on our own planet who have a very different version of paying for health care.
Scott: Anywhere but in America.
Miller: We don’t need to get in a spaceship. [Laughs]
How did people with private insurance fare compared to those with Medicaid?
Scott: Yeah, that’s really the thing that is most interesting. Unsurprisingly, being uninsured is really bad, not having health insurance is really bad, but private insurance often fails at its one job. And we looked especially at lower income patients, so people that were eligible for these cost-sharing reductions under the Affordable Care Act. And if you look at that group of patients, half of them still had problems paying medical bills or were delaying care after surgery. So even with a little bit of government help, it didn’t really protect them.
Meanwhile, for Medicaid patients, it was incredibly protective. So we think of Medicaid as serving people with fewer economic resources, but it works really well at these kinds of health shocks, if you will. There was no change after surgery. The proportion of people having problems with medical bills and Medicaid was like 25% before surgery. It didn’t budge after surgery. So it meant they had this big, scary, expensive thing happen to them, and there was no difference, and it really protected them.
So comparing Medicaid to private insurance, we see that Medicaid did its one job. Private insurance for a lot of folks, especially lower income folks, really doesn’t.
Miller: How do you explain that?
Scott: I think we’re often pretty blind to it. So if you have means, among higher income patients, private insurance works fine because people have money set aside, they can cover that deductible. But we live in a situation where 40% of Americans say they can’t afford an unexpected $500 bill. And then we have these deductible limits that are in the $2,000 to $10,000 range. So it’s really more than people can afford. And the deductibles, the amount you pay for your care, is just related to how protective the plan is, it’s not related to how much money you have. So what I find fascinating is that you go to a company, the CEO of the company and the first day intern, their incomes may be 10x or 100x different, but they have the same exact deductible if they’re on the same health plan – and that just doesn’t make a lot of sense.
Miller: The context for your new study is really important. Millions of Americans – I’ve seen various estimates: 5 million, 7 million, 10 million Americans – are gonna lose Medicaid coverage, the version of insurance that you’re saying often does better than private insurance. They’re gonna lose that coverage in the coming years because of the One Big Beautiful Bill. Some people say not to worry, the private market will step in. What does your study say about that idea?
Scott: Things are not going in the right direction right now with federal policy. As you mentioned, Medicaid is getting cut back, private insurance is getting more expensive and less protective. I mean, that’s what this whole recent shutdown was about. It’s about how we handle these private insurance subsidies. And it gets a little wonky to get in the weeds, but the bottom line is it’s just year, over year, over year, more costs are being put on the individual patient. We have families skipping essential care because they can’t afford it, and the big national private insurance companies made $70 billion last year in profit.
So there’s not much precedent to say that private insurance companies are working real hard to make things more affordable. I just get frustrated with the idea of these “catastrophic plans.” That’s a bait and switch. They label them that way to say, oh, if there’s some terrible tragedy, then you’ll be protected, but our study shows that they don’t work at that. So I think there are some policy solutions out there, but I’m not optimistic, at least at the federal level, that we’re pursuing any of them right now.
Miller: Just briefly, how much of this is on your mind when you’re in the operating room with a scalpel in your hand?
Scott: Yeah, I work really hard to separate these two. I’m always taking care of the patient in front of me, right here and right now. The good news is I never know what insurance my patients have, that never comes into play. But it burdens me and it’s got me involved in figuring out what we can do about it. So I actually work with the people at our hospital that work on financial assistance programs and stuff, and I actually talked to a lot of other surgeons to say, “hey, all this stuff’s happening in your hospital, you can be part of it, don’t be scared of it, we’ve got to do something.”
So I think the solutions come at the big policy level, but you also have to know in the environment you work in, how you do it. But I make sure it doesn’t affect the actual care that I’m giving.
Miller: John Scott, thanks very much.
Scott: Thank you.
Miller: John Scott is a trauma surgeon and a researcher who studies health policy at the University of Washington.
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