Medical debt can be pernicious.

For those who otherwise fully recover from an ailment or injury, the debt incurred to pay for care is often the one painful burden they still cannot escape months and years later.

For those with chronic conditions and ongoing care needs, the associated debt can make everything more difficult and less accessible, standing in the way of improved health and well-being.

Yet the relationship between health and debt seems obvious, but there's so much that we still don't know about who's most likely most likely to trigger that debt.

Those are among the questions we intend to confront on today's episode.

I'm here with Doctor.

John W.

Scott, associate professor in the division of trauma, burn, and critical care surgery at the University of Washington.

Together with coauthors, he has a new study in the February issue of Health Affairs describing, quote, changes in medical debt and bankruptcy after acute traumatic injuries twenty nineteen to 2021.

I cannot wait to hear more about their findings and the implications for policymakers going forward.

Doctor, John Scott, welcome to A Health Policy.

Thanks, Rob.

It's really a pleasure to be here.

Well, let's just dive right in.

Maybe before we talk about the paper, little bit of context.

Tell us, before you conducted your study, what did we know generally about medical debt and the burden it imposes over time?

Yeah, medical debt is a huge problem.

The affordability crisis is the right word crisis.

Depending on the way you look at the estimates, it's been suggested that a hundred million people in America have medical debt.

That's like four out of ten adults.

And you know they say that a system is designed to get exactly the results it gets and our healthcare system is funded in such a way that $200,000,000,000 is the amount of debt that's on the backs of the sick and the injured, the grieving, those recovering from injury.

And it's not just the financial piece, it's the way it gets in the body.

It's the health consequences from it everywhere it's ever been looked at.

Worse financial hardship due to medical bills, medical debt associated with worse mental health, worse physical health.

People delay the care that they know they need because they can't get it.

I'm a trauma surgeon.

I've been doing this for about fifteen years.

I've worked in three states, multiple health systems, and everywhere I've ever been I've had these haunting episodes that you just can't shake.

I've had patients in the trauma bay, they're bleeding, we're doing life saving resuscitation, and they're screaming like I can't afford this, stop.

Like that only has to happen once to like stick with you for a long time.

And so that's what really motivated me to get in this in the first place is really from the lips of my patients figuring out how big a deal is this, how does this actually work, and that led us to read up as much as we can and start looking at ourselves.

Wow, you mentioned you're a trauma surgeon.

Your study focused specifically on the impact of acute traumatic injuries.

I'm hoping maybe you can tell us a little more about what exactly we're talking about when we talk about traumatic injuries.

Do you have a sense of of out of total hospitalizations, what proportion traumatic injuries represent?

Yeah, trauma is really common and it's confusing because it's kind of a bit of a catch all.

Trauma you know the big three would be car crashes, firearm injuries, and falls among older adults and people often kind of think of those three as different things but you know trauma the way we talk about as trauma surgeons anything that needs a trauma system, you know acute injury that comes from energy transfer to the body.

It's a lot of things but it's really common.

It's like forty million emergency department visits a year, it's two and a half million hospitalizations.

If you look at heart attacks or strokes those are like eight hundred thousand or something each, so it's it's three times that, for trauma admissions.

And the reason we think it's really an important tool to use to study these kind of questions is it's cross cutting across all ages.

So if you're 45 it's the number one reason to be hospitalized in America, number one cause of death from one to forty five and heading up into the 50s as well, And it affects people at sort of different economic times too, so like young workers entering the workforce, sort of people in their economic prime of the workforce, and then people after they've retired they're all subject to injuries.

Now they might be different injuries might be a car crash versus a fall, and sadly assaults and firearm injuries are all too common among younger adults, but it's really common.

It hits people across the spectrum of sort of age and economic rank.

And it's really the ultimate health shock.

Like if you want to study you know how well your insurance prepares you for the unexpected, there's no prodrome in trauma.

You woke up that morning, were driving to work, got in a car crash.

Like it's the ultimate surprise.

So I think it's important because I'm a trauma surgeon, but it's also really valuable to look at sort of unique aspects of things like financial risk protection.

Well, let's talk about your paper.

In your study, you compared financial outcomes for injured patients to those of a cohort that hadn't experienced injury, and you looked at things like medical debt in collections and bankruptcy filings for a year and a half after the injury.

What did you find?

What are the sort of top line most interesting takeaways?

Yeah, so this dataset is a really unique data opportunity that, you know, the biggest part with trauma, you only meet people after they've been injured, and so it's really hard to have pre and post data without asking them to just think back before their injury.

And by having these credit data that were linked to a sort of state of the art clinical trauma registry, we had really robust clinical data.

We had the same data points before and after injury, which solved one of the biggest problems.

But the second problem was this happened during COVID.

It was a lot happening regarding economics and finance during that time.

Actually, you know, not everybody realizes medical debt went down, bankruptcies went down because stimulus checks were coming in, people weren't spending, and so we would have confused the effects of injury with the effects of COVID, And then you need a real good comparison cohort then, and it's kind of hard to get one trauma so heterogeneous like we just said it's hard to get a perfect comparison cohort.

But the best cohort for trauma patients is trauma patients who just haven't been injured yet.

So the way our data were structured, had patients that were injured at the end of the study after the observation period, but we had their pre injury information.

So we were able to kind of look at things over time doing a, you know, event time study, we're also able to do this sort of difference in difference with a comparison group.

So that was a big opportunity, and what we found

was Sorry, just to clarify that one point.

In my question, I referred to the comparison cohort as a group that hadn't been injured.

If I'm understanding you correctly, it's a group that hadn't been injured yet.

Is that right?

Yeah, and that was the key goal.

Number one, we only had the trauma registry data linked, so we didn't have any other patients, and we were really struggling to figure out how do we get a good control group here.

And so that was that was a key that let us do the event time study but also let us do the difference in difference to have a comparison cohort.

So you know no study is perfect, it's observational, but it helped us feel better about we were really isolating the impact of injury.

And the impact of injury was profound.

Our cohort was ninety eight percent insured, almost universally insured, and yet we found about a twenty five percent relative increase in the proportion of people with medical debt.

And the amount of medical debt from before injury to we stopped our observation a year and a half after, essentially doubled.

It went up by almost $300, but that is the poll population.

So, you know, seventy plus percent of people had zero change, and so if you just look at the indebted, one in ten had $5,000 in debt.

So it doesn't affect everybody, but those it affects it can affect in a big way.

We also prior studies to this, the bankruptcy findings were really mixed and ours did have some pretty clear bankruptcy findings and it went up by about a little more than three per thousand which seems really small but but that's a really short time window to be filing for bankruptcy and and the biggest piece wasn't even the overall numbers we sort of expected to see something there but it was it was who was affected and it was very heterogeneous impact across the population.

So if you were higher income you were relatively spared.

If you were older you were relatively spared.

It was concentrated on low income patients.

It was concentrated on younger patients.

Of course the uninsured did really poorly, but what was interesting among people with insurance, those with Medicaid had almost no change, and they're in Medicaid because they're financially vulnerable.

That's how you get enrolled in Medicaid.

Had had almost no change in medical debt or no statistically significant change, certainly, in medical debt or bankruptcy, whereas lower income and younger private insured patients were the ones that, really stood out.

And it just goes to show that, you know, for some people private insurance works great, but it doesn't work great for everybody and it's increasingly so that the kind of working age, lower income, people with private insurance are really feeling the squeeze and that's what came out in our data.

Got it.

Well I want to ask you a little more about the policy implications of your findings, but first let's take a quick break.

And we're back.

I'm here with Doctor.

John Scott from the University of Washington talking about, a paper he and his colleagues have in the February issue of health affairs on changes in medical debt and bankruptcy after acute traumatic injuries.

You shared some of your findings, and I think if we sort of take a step back, there's a general belief that, obviously being in debt is not good.

Getting necessary care shouldn't put people in debt, and yet, it's the inadequacies of our approach to coverage across The United States health care system that makes such instances all too common.

If that's our baseline, what's the next step for policymakers interested in better protecting people from debt and bankruptcy?

Well, we've known this for a while.

You know, you can't do this kind of work and not go back to Carlos Dobkin and others who did similar work from data in the early 2000s before the ACA had pretty similar findings after hospitalization in California.

We were kind of hoping that after the ACA population level we'd see, you know, smaller effects.

It's not perfect comparison, but they're still there.

They haven't gone away.

And I think one of the key things that matters is how we frame this.

If we just frame it as sort of a moral argument whether or not patients should or shouldn't have to carry debt to get the care life saving care they need, I think we missed the part that this is a quality issue.

Every time it's ever been looked at having financial you know difficulty affording care leads to worse like actual physical and mental health outcomes, and so without affordability you don't really have quality, and I think there needs to be sort of an awareness that this is not just some inevitable byproduct.

But you know there's actually phrases in the cancer community they call it financial toxicity.

It's like the actual way that financial stress gets into the body and makes health worse.

We do the same thing in trauma, we call it financial hardship.

So a lot of the simple things are insure the uninsured.

Know, Medicaid really did its job.

It did its job better than any of the other health insurance groups that we looked at, and unfortunately right now things are going the other direction.

We're seeing the largest funding cuts in the history of the Medicaid program coming up over the next ten years, and so that's probably not going to get better in that regard, but some states are stepping up to the plate to do something on their own.

But I think in addition to the obvious, it's thinking about private insurance benefit design and how we can make it actually work for patients.

Like people would say, oh I, you know, I just have this small insurance plan.

It's just like in case I get hit by a bus.

It's like a catastrophic plan.

But like those are precisely the plans that don't help you if you get hit by a bus.

Those were our patients in this study.

And so you know things like pre deductible care for like real emergencies You know Mark Polly taught us that you know cost sharing exists to reduce moral hazard.

Know if you're insulated from prices then you don't you know you might use more care than you need but if you get hit by a bus and you get intubated in the field by the paramedics and taken to hospital you're not going to overuse care.

And so the fundamental rationale for cost sharing doesn't always apply and you know from a theory standpoint that would make a lot of sense.

I think another one is what people refer to as like means based deductibles.

So a lot of private insurance comes from employer sponsored insurance.

The CEO and the frontline workers may have 200 fold different in their income in The US, but if they're on the same health insurance plan by the company they pay the same exact deductible.

And you know we know that financial stress, it didn't happen among the higher income folks with private insurance.

They were insulated.

And so maybe if we could limit sort of what the patients are on the hook for, especially for emergency life saving and elastic care, if you could pin that to what their actual means are.

So you know there's a lot of changes right now that aren't really prioritizing affordability and it's pretty concerning if I'm being honest, but you know states as sort of the laboratories of democracy or laboratories of policy, a lot of states are doing a lot to protect patients, and I think that's where we're going to see a lot of innovation.

On one hand, I can see a takeaway from your findings is that we need to help injured patients navigate high costs, maybe even reduce costs or slow the growth of those costs where possible.

On the other hand, there is an argument that looks further upstream and says the best solution is to prevent injuries in the first place.

I'm curious how we should think about your research in that context.

The idea that most traumatic injuries are preventable, how preventable are they, and how much energy and attention should we be giving to those sort of upstream factors?

Yeah, on cost containment absolutely that's true everywhere in the health system.

We talk about low value care and expensive care and all that.

For injured trauma patients often this is life saving care, but it would follow the same principles that are going to improve cost containment for any other disease.

Injury prevention wise, absolutely.

We in the trauma we love love love injury prevention.

There's been some huge wins since like going back to the you know early 1900s car crashes have gone down so dramatically.

We make cars so much safer per mile driven but we drive more and we use more cars and you know automated cars are supposed to make that better.

Know seat belts, airbags, better roads, better lights, you know there's a lot of gains and millions and millions and millions of lives have been saved.

But then there's other parts that aren't going well.

Firearm deaths are going up not down, as the aging population falls are going up not down so you know we need to try to prevent these diseases just like we prevent heart disease just like we prevent diabetes but I what I'm most worried about preventing for my patients that I see every day sort of in the here and now is the you know the insult to injury, that's happening on the financial side.

And our systems are really well designed to help injured patients survive their injuries.

Inpatient mortality has never been lower but our systems aren't really calibrated to make sure that they can sort of get their lives back, thrive, avoid this financial hit.

And so I think any you know clinicians that are dealing with this sometimes it gets frustrating confusing but there's a lot to do at hospital level sort of downstream.

Earlier we talked about the upstream policy impacts I think that's where the ultimate solutions are but states and hospitals have a lot to do and so you know whether or not hospitals can even send debt to states are trying to regulate things like that, how aggressive they are about it, what they do with uncompensated care.

And then there's a lot of things that you can do for patients.

The cancer has these financial navigators in the cancer community.

In trauma we look at things like crime victim compensation, no fault auto insurance, these sort of wraparound programs for helping people, get signed up for financial assistance programs.

If you're a clinician, your hospital is doing this right now and to get to know those people kind of understand how to how to work the system here and now.

So I'm very much for prevention.

On the financial side that prevention is policy stuff that kind of needs those policy windows.

I'm not super confident that we're in one of those right now, but there's also the patient in front of me here and now there's a lot we can do and that's actually the spin off of this work has led to studies where we're trialing at my own hospital now here in Seattle What happens when we sort of do a little enhanced financial support for patients?

Can we get them back to work faster?

Can we get them the follow-up visits they need?

Can we improve their health just by addressing financial outcomes?

Great.

Well, a great note to, wrap up on and, exciting to think about, what we might learn from that future research.

Doctor John Scott, thank you so much for taking the time to chat with us today.

I really enjoyed

it.

Thanks so much.

It's really a pleasure.

Absolutely.

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