A Nationwide Analysis of Financial Hardship After Surgery

Background and Objectives: Affordable access to surgical remains elusive for many in the US. However, the financial hardship attributable to surgery is not well understood at the national level. Our objectives were to (1) evaluate the association between surgery and financial hardship among working age adults in the US, (2) compare changes in financial hardship after elective versus emergency surgery, and (3) examine variation by payer and income.

Methods: We performed a retrospective cohort study of the Medical Expenditure Panel Survey (MEPS), a nationally representative survey of non-institutionalized US civilians, including respondents from 2014 to 2021. We included respondents aged 18 to 64 years old who reported having surgery. This group was matched to a cohort of non-surgical control patients using coarsened exact matching on age, sex, race, ethnicity, income, payer, census region, comorbidities, and survey year. The primary exposure was surgery within the last 12 months, and secondary exposures were emergency versus elective surgery. Outcomes of interest were financial hardship, defined as problems paying medical bills or delaying needed care due to cost and family out-of-pocket spending.

Results: Our weighted sample included 40 million working-age adults who underwent surgery. Overall, 4-in-10 surgical patients experienced financial hardship in the year after surgery. On difference-in-differences analysis surgery was associated with a 6.9 percentage-point increase (95% CI: 3.2-10.6) in financial hardship, a 20% relative increase. Uninsured patients had a 25.6 percentage-point increase (95% CI: 5.1–46.2), privately insured patients had a 9.9 percentage-point increase (95% CI: 5.1–14.7), and those with Medicaid had no significant change. Out-of-pocket spending increased by $716 (95% CI: $585–$847) after surgery, with the highest increases among emergency surgeries and non-Medicaid insurance type.

Conclusions: Surgery was associated with substantial financial hardship for working age adults in the US, especially after emergency surgery and among the uninsured and privately insured. Our finding that Medicaid enrollees were protected against increases financial hardship after surgery suggests that policies that restrict Medicaid eligibility may increase financial hardship among working-age surgical patients, unless other changes are made to improve financial risk protection.