Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Cured into Destitution

Catastrophic Health Expenditure Risk Among Uninsured Trauma Patients in the United States

Scott, John W. MD, MPH*,†; Raykar, Nakul P. MD, MPH†,‡; Rose, John A. MD, MPH*; Tsai, Thomas C. MD, MPH*,§; Zogg, Cheryl K. MSPH, MHS*,¶; Haider, Adil H. MD, MPH*,||; Salim, Ali MD*,||; Meara, John G. MD, DMD, MBA†,**; Shrime, Mark G. MD, MPH, PhD†,††

doi: 10.1097/SLA.0000000000002254

Objective: To characterize the economic hardship for uninsured patients admitted for trauma using catastrophic health expenditure (CHE) risk.

Background: Medical debts are the greatest cause of bankruptcies in the United States. Injuries are often unpredictable, expensive to treat, and disproportionally affect uninsured patients. Current measures of economic hardship are insufficient and exclude those at greatest risk.

Methods: We performed a retrospective review, using data from the 2007–2011 Nationwide Inpatient Samples of all uninsured nonelderly adults (18—64 yrs) admitted with primary diagnoses of trauma. We used US Census data to estimate annual postsubsistence income and inhospital charges for trauma-related admission. Our primary outcome measure was catastrophic health expenditure risk, defined as any charges ≥40% of annual postsubsistence income.

Results: Our sample represented 579,683 admissions for uninsured nonelderly adults over the 5-year study period. Median estimated annual income was $40,867 (interquartile range: $21,286–$71.733). Median inpatient charges were $27,420 (interquartile range: $15,196–$49,694). Overall, 70.8% (95% posterior confidence interval: 70.7%–71.1%) of patients were at risk for CHE. The risk of CHE was similar across most demographic subgroups. The greatest risk, however, was concentrated among patients from low-income communities (77.5% among patients in the lowest community income quartile) and among patients with severe injuries (81.8% among those with ISS ≥ 16).

Conclusions: Over 7 in 10 uninsured patients admitted for trauma are at risk of catastrophic health expenditures. This analysis is the first application of CHE to a US trauma population and will be an important measure to evaluate the effectiveness of health care and coverage strategies to improve financial risk protection.

*Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA

Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA

Department of Surgery, Beth Israel Deaconess Hospital, Boston, MA

§Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA

Yale School of Medicine, New Haven, CT

||Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA

**Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA

††Massachusetts Eye and Ear Infirmary, Department of Otolaryngology and Office of Global Surgery, Boston, MA.

Reprints: John W. Scott, MD MPH, Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, 1620 Tremont Street, One Brigham Circle, Suite 4-020, Boston, MA 02120. E-mail:

Disclosure: This article was presented as an Oral Presentation at the 11th Annual Academic Surgical Congress on February 2, 2016 to February 4, 2016 in Jacksonville, FL.

The authors declare no conflict of interests.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.