No more emergency surgeries in states without Medicaid expansion

By Rose Hoban

There is a big difference between having a knee replacement or scheduled back surgery and having an emergency gallbladder removal or cardiac catheterization.

Orthopedic surgeries tend to be elective elective procedures that are planned in advance.

On the other hand, gallbladder removals are often emergency surgeries, as patients usually experience excruciating pain. Emergency heart catheterizations are performed on patients at high risk of an impending heart attack, a condition that could often be avoided with continued cardiac care.

Yet these two emergency procedures – gallbladder removal and cardiac catheterization – are the two main surgeries performed on uninsured patients in states like North Carolina that have not decided to expand Medicaid. , according to a recent article in the journal Health Affairs.

“I imagine most people who find out that they are going to need surgery for one reason or another when they are not insured will try to get insurance first if possible,” said Duke University gynecologist Benjamin Albright, who is the first author on the paper.

Uninsured patients who undergo these emergency procedures almost always end up with a catastrophic financial burden, Albright said. This happens much more frequently for uninsured patients in states that have decided not to expand Medicaid coverage, according to Albright and colleagues at the Duke and Memorial Sloan Kettering Cancer Center in New York City.

They also found that these extremely expensive emergency surgeries often could have been avoided if the patient had access to preventive health care services.

“We see patients who are struggling financially all the time,” Albright said in an interview with NC Health News. “There are issues with not being insured and having to be patients with charity care and sort of trying to get over those issues.”

Southern residents more at risk

The policy of expansion of Medicaid, made possible by the Affordable Care Act, has been adopted by 38 states and the District of Columbia over the past decade. Twelve states – including seven in the southern part of the United States, including North Carolina – have not decided to offer health insurance to those who earn too much money to qualify for Medicaid, but do not earn enough to qualify for subsidies to purchase an insurance plan on the ACA Marketplace.

The lack of expansion likely contributed to findings recently released by the US Census Bureau that the southern United States had the highest rate of uninsured people in the country, at 16.4%, compared to 11.3% uninsured. insured in the West and 6.6% uninsured in the North East.

The South also has lowest rates of state-insured residents, as well as private policyholders.

In North Carolina, it is virtually impossible for an adult without children and without a disability to qualify for Medicaid coverage. Adults in low-income families lose coverage once they exceed an income limit of about $ 10,760 for a family of three.

This applies to about half a million people in this state.

The disparity in policies has been a wealth of information for researchers to tap into, as they examine what happens to patients in states of expansion versus states of non-expansion.

This is the story of Albright, now a medical researcher at Duke, who also did postgraduate work in health economics. He has spent the last few years researching what happens to his gynecology patients when they are uninsured.

“I have a separate article… focusing on changes in mortality with the expansion of Medicaid and on gynecologic cancers,” he said. “More precisely, we have in fact found a slight decrease in mortalities linked to gynecological cancer with the Medicaid extension [compared to] states of non-expansion.

High rates of emergency care

For this research, Albright wanted to see if people in non-expanding states were more likely to have unexpected surgeries and what types of surgeries they were. He also wanted to examine the financial implications of emergency surgery for patients without health insurance.

He used data from patients who had been devoid of identifying information and compared patients from two states that expanded Medicaid, Kentucky and Maryland, to those from two states without expansion, Florida and Carolina. North. He also used national data to create state-based analyzes of surgical patients, focusing on three groups: privately insured patients, Medicaid patients, and uninsured patients.

All three groups included people aged 19 to 64, because after 65 most Americans are eligible for Medicare.

Private insurance	Medicaid	Not insured
Knee prosthesis (9.4%)	Gallbladder removal (9%)	Gallbladder removal (13.2%)
Back / spine surgery (7.6%)	Cardiac catheterization (5.5%)	Cardiac catheterization (11.4%)
Hip replacement (6.0%)	Hysterectomy (5.2%)	Removal of the appendix (7.8%)
Hysterectomy (5.8%)	Back / spine surgery (4.2%)	Hysterectomy (3.3%)
Gallbladder removal (5.7%)	Knee replacement (3.5%)	Non-specific joint / tendon surgery (3.2%)

Albright found that seven out of ten times uninsured people were admitted to hospital due to an emergency. Meanwhile, in the privately insured group, the emergency room admission rate was only 28%, while about half of Medicaid patients went through the emergency room, often on weekends.

Private patients were nearly 79% White and 15.4% Black, while uninsured patients were 69% White and 19.5% Black. Hispanic patients were almost three times more likely to be uninsured (21 percent) than insured (7.7 percent).

Medicaid and uninsured patients were generally younger than insured patients.

“Most of the uninsured population tend to be younger and relatively healthy people to start with, but often with relatively low incomes, simply because these are the people who are most likely to decrease spending on health insurance. insurance payment, ”noted Albright. “You can be in relatively good health and suddenly have appendicitis or [a gallbladder attack]. “

The data did not include traumatic surgeries and admissions, such as car accidents, which Albright called another big source of uninsured care that ends up costing patients a bundle.

“It sort of confirms this anecdotal experience that we have clinically, that most uninsured patients who undergo surgery actually go through the [Emergency Department]”said Albright.

His calculations revealed that adopting the expansion of Medicaid in the 12 recalcitrant states would have avoided 50,000 incidences of catastrophic financial burden resulting from uninsured surgery in 2019 alone.

Low-income patients most affected

Data showed that 99 percent of those uninsured hospital stays cost patients more than 10 percent of what a typical employee in their area would bring home in a year. Fifty-eight percent of the patients had bills that exceeded the median annual income of people in their area, and many bills totaled up to two to four times the median local income.

“I think this… really just kind of a screen how ridiculously expensive the surgery is if you’re uninsured,” Albright said. “You have insurance, whether private or Medicaid, you will not be exposed to most of these costs.”

Insurance companies are negotiating with hospitals for discounts on the amount they reimburse for care, but research and countless patient experiences show that uninsured patients are routinely billed for full freight.

“While some hospitals will definitely write some of these things as charity care or that patients just don’t pay. [Then] they are somehow harassed by debt collectors or are unable to pay some of these expenses. But it’s fair […] crazy, ”he said.

“Without the protection of insurance, it will almost universally be a catastrophic expense for you.”