Cured into Destitution: Catastrophic Health Expenditure Risk among Uninsured Trauma Patients in the United States

John W. Scott, Nakul P. Raykar, John A. Rose, Thomas C. Tsai, Cheryl K. Zogg, Adil H. Haider, Ali Salim, John G. Meara, Mark G. Shrime

Research output: Contribution to journalArticlepeer-review

57 Citations (Scopus)


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.

Original languageEnglish
Pages (from-to)1093-1099
Number of pages7
JournalAnnals of Surgery
Issue number6
Publication statusPublished - 1 Jun 2018
Externally publishedYes


  • catastrophic expenditure
  • health insurance
  • health policy
  • medical debt
  • trauma


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