By Rose Hoban
There’s a big difference between getting a scheduled knee replacement surgery or back surgery and having an emergency gallbladder removal or cardiac catheterization.
The orthopedic surgeries tend to be non-emergency, elective procedures that are planned in advance.
On the other hand, gallbladder removals are often emergency surgeries, as patients are usually in excruciating pain. Emergency cardiac catheterizations are done on patients who are at high risk of imminent heart attack, a condition that often could be prevented by ongoing cardiac care.
Yet those two emergency procedures — the gallbladder removal and a heart catheterization — are the top two surgeries performed on uninsured patients in states such as North Carolina that have not moved to expand Medicaid, according to a recent paper in the journal Health Affairs.
“I would imagine that most people who learn that they are going to need a surgery for one reason or another while they’re uninsured are going to try to obtain insurance first if possible,” said Duke University gynecologist Benjamin Albright, who is the first author on the paper.
Uninsured patients who have these emergency procedures are almost always left with a catastrophic financial burden, Albright said. This occurs much more frequently for uninsured patients in states that decided not to expand Medicaid coverage, according to Albright and his colleagues from Duke and Memorial Sloan Kettering Cancer Center in New York.
They also found that these catastrophically expensive emergency surgeries often could have been avoided, if the patient had had access to preventive health care services.
“We see patients all the time who are struggling financially,” Albright said in an interview with NC Health News. “There are issues of uninsurance and having to be patients with charity care and sort of trying to overcome those issues.”
Southern residents more at risk
The Medicaid expansion policy, made possible by the Affordable Care Act, has been enacted by 38 states and the District of Columbia over the past decade. Twelve states — seven of them in the Southern tier of the U.S. including North Carolina — have not made the move to offer health insurance to those who make too much money to qualify for Medicaid, but don’t earn enough to qualify for subsidies to buy an insurance plan on the ACA marketplace.
Lack of expansion likely contributed to recently published findings by the U.S. Census Bureau that the Southern U.S. had the highest rate of uninsured people in the country at 16.4 percent, compared to 11.3 percent who are uninsured in the West and 6.6 percent uninsured in the Northeast.
The South also has the lowest rates of publicly insured residents, as well as people on private insurance.
In North Carolina, it’s virtually impossible for a childless adult without a disability to qualify for Medicaid coverage. Adults in low-income families lose their coverage once they pass an income cap of about $10,760 for a family of three.
That applies to about a half million people in this state.
The policy disparity has been a rich mine of information for researchers to tap into, as they examine what happens in patients in expansion versus non-expansion states.
That’s the story for Albright, now a medical fellow at Duke, who also has done post-graduate work in health economics. He spent the past few years doing research into what happens to his gynecology patients when they’re uninsured.
“I have a separate paper … centered around mortality changes with Medicaid expansion, and in gynecologic cancers,” he said. “Specifically, we actually found a slight dip in gynecologic cancer-related mortalities with Medicaid expansion [compared to] non-expansion states.”
High rates of emergency care
For this research, Albright wanted to see whether people in non-expansion states were more likely to have unexpected surgeries, and what types of surgeries those were. He also wanted to examine the financial implications of having emergency surgery for patients without health care insurance.
He used data about patients that had been stripped of identifying information, and compared patients in two states that expanded Medicaid, Kentucky and Maryland, to those in two non-expansion states, Florida and North Carolina. He also used some national data to create state-based analyses of surgical patients, focusing on three groups: privately insured patients, Medicaid patients and uninsured patients.
All three groups included people from 19 to 64 years old, because after 65, most Americans qualify for Medicare.
| Privately insured | Medicaid | Uninsured |
| Knee replacement (9.4%) | Gallbladder removal (9%) | Gallbladder removal (13.2%) |
| Back/ spinal surgery (7.6%) | Cardiac catheterization (5.5%) | Cardiac catheterization (11.4%) |
| Hip replacement (6.0%) | Hysterectomy (5.2%) | Appendix removal (7.8%) |
| Hysterectomy (5.8%) | Back/ spinal surgery (4.2%) | Hysterectomy (3.3%) |
| Gallbladder removal (5.7%) | Knee replacement (3.5%) | Non-specific joint/ tendon surgery (3.2%) |
Top five surgeries that occurred for each insurance type and how often they’re performed.
Albright found that seven out of 10 times, people who were uninsured were admitted to the hospital because of an emergency. Meanwhile in the privately insured group, the ER admission rate was only 28 percent, while about half of Medicaid patients came through the emergency room, often on the weekend.
Private patients were almost 79 percent white and 15.4 percent Black, while the uninsured patients were 69 percent white and 19.5 percent Black. Hispanic patients were almost three times more likely to be uninsured (21 percent) than insured (7.7 percent).
Both the Medicaid and the uninsured patients skewed younger overall than the insured patients.
“Most of the uninsured population tends to be younger, relatively healthy people at baseline, but often with relatively low incomes, just because those are the people who are most likely to decline the expense of paying for insurance,” Albright noted. “You can be relatively healthy and all of a sudden end up with appendicitis or [a gallbladder attack].”
The data didn’t include trauma surgeries and admissions, such as car accidents, which Albright called another large source of uninsured care that ends up costing patients a bundle.
“That sort of confirms that anecdotal experience that we have clinically, that most uninsured patients who are getting surgery are actually coming through the [Emergency Department],” Albright said.
His calculations found that adoption of Medicaid expansion in the 12 holdout states would have prevented 50,000 incidences of catastrophic financial burden resulting from uninsured surgery in 2019 alone.
Low income patients hit hardest
The data showed that 99 percent of these uninsured hospital stays cost the patients more than 10 percent of what a typical wage earner in their area would take home in a year. Fifty-eight percent of patients had bills that exceeded the median annual income for people in their area and many bills totalled as much as two to four times the median local income.
“I think this … really just kind of screens how ridiculously expensive surgery is if you’re uninsured,” Albright said. “You have insurance, whether it be private or Medicaid, you’re not going to be exposed to most of those charges.”
Insurance companies negotiate with hospitals to get discounts on how much they reimburse for care, but research and the experiences of countless patients show that uninsured patients routinely get charged the full freight.
“While some hospitals will certainly write some of this stuff off as charity care or patients just don’t pay. [Then] they just kind of get harassed by debt collectors or are unable to pay some of these expenses. But it’s just […] crazy,” he said.
“Without the protection of insurance, it’s almost universally going to be a catastrophic expenditure for you.”
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Even with medicaid there is both inequity and problems with access and quality.
Try find a good specialist-one that has actually done a number of surgeries who is not bottom of the barrel for complications and making appointment. Most don’t accept medicaid. And even people with top insurance have long wait so the rare MD specialist accepting would typically have very long wait (if even accepting ‘new’ patients.
One reason though why some vote against expansion is because of what is BUNDLED with expanding. This is dumping off many who do qualify for the ACA benefits , and also enjoy the narrow landing strip of best benefits/cost sharing onto Medicaid. This further aggravates the above but also takes a privately insured lower-middle income person out of getting better care. This is because in expanded states the income qualification is shifted upward several thousand dollars. So the lower enders fall off into the medicaid system.