55EMF Assessing Financial Risk among Uninsured Patients Seeking Care in the Emergency Department

Abstract

Patients who lack insurance are uniquely reliant on the emergency department (ED) as a safety-net for vital care. Though the number of uninsured Americans initially declined after the Affordable Care Act (ACA) was enacted, the uninsured rate has been on the rise since 2017. Financial risk protection for patients is critically important as nearly two-thirds of bankruptcies are attributable to medical bills, a problem that is likely to worsen as health care costs continue to increase. However, the degree to which ED bills contribute to financial strain among uninsured patients is currently unknown. To address this gap, we aim to conduct the first-known national analysis to estimate and characterize the risk of economic hardship due to ED bills among uninsured patients. The primary data source is the Nationwide Emergency Department Sample, which is the largest publicly-available, all-payer database that captures a nationally-representative sample of U.S. hospital-based ED visits from 2006 to 2017. We obtained each encounter’s insurance status, age, sex, primary diagnosis, zip code income quartile, source file (treat-and-release ED visits versus those hospitalized through the ED), and charge for ED services. The analytic sample was limited to uninsured, treat-and-release ED visits in 2017. Each encounter’s household income was estimated using zip code income quartile data as has been done in prior studies. Following prior work, a catastrophic health expenditure (CHE) was defined as health expenses (ie, the listed ED charge) that exceeded 10% of projected household income. We calculated the percentage of uninsured treat-and-release ED encounters that met criteria for receiving a CHE bill and characterized this risk by income quartile. In 2017, there were an estimated 144.8 million ED visits. Of all ED visits, 86% were treat-and-release encounters with 13% being uninsured among this group. Among the uninsured treat-and-release ED encounters, 51% were male, mean age was 34 years, and the median ED charge was $2090 (mean = $3853, range: $100-$551442). A plurality fell into the lowest income quartile (43%), while 11% were categorized in the highest income quartile. An estimated 23% of all uninsured treat-and-release ED encounters met criteria for receiving a CHE bill, which translates to a weighted estimate of over 3.58 million (95% CI, 3.57 million - 3.59 million) ED encounters in 2017. This at-risk group’s median ED charge was $8710 (mean = $11,476). Those with the lowest income had the highest risk for receiving a CHE bill for ED care (Figure 1). Using a conservative estimate for assessing financial hardship among uninsured ED patients, these findings suggest that nearly 1 in 4 uninsured visits were at risk of receiving a financially catastrophic bill for ED care in 2017. This equates to approximately 3.6 million treat-and-release ED encounters that year. Examining these trends over time will be important in light of historic declines in employment and dynamic changes in insurance coverage that disproportionately burden low-income patients.