{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T12:42:05Z","timestamp":1791636125593,"version":"4.3.4"},"reference-count":46,"publisher":"American Medical Association (AMA)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Surg"],"published-print":{"date-parts":[[2026,1,1]]},"abstract":"\n Importance<\/jats:title>\n Affordable access to surgical procedures remains elusive for many in the US. However, the financial hardship attributable to surgical procedures is not well understood at the national level.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To evaluate the association between surgical procedures and financial hardship among working-aged adults in the US, compare changes in financial hardship after elective vs emergency surgery, and examine variation by payer and income.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This retrospective cohort study of the Medical Expenditure Panel Survey (MEPS) included respondents from 2014 to 2021. The MEPS is a nationally representative survey of noninstitutionalized US civilians. All adults aged 18 to 64 years old who reported undergoing a surgical procedure were matched to a cohort of nonsurgical control patients using coarsened exact matching on age, sex, race, ethnicity, income, payer, census region, comorbidities, and year. These data were analyzed from January 2025 to August 2025.<\/jats:p>\n <\/jats:sec>\n \n Exposures<\/jats:title>\n The primary exposure was surgical procedure(s) within the last 12 months; secondary exposure was emergency vs elective surgical procedures.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n The primary outcome of interest was financial hardship, defined as problems paying medical bills or delaying needed care due to cost. Secondary outcome was family out-of-pocket (OOP) spending.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The weighted sample included 40 million working-aged (18-64 years) adults (62% female and 38% male) who underwent surgical procedures. Overall, 37.9% of surgical patients experienced financial hardship in the year after surgery. On difference-in-differences analysis, surgical procedures were associated with a 5.4\u2013percentage point increase (95% CI, 1.8-9.0) in financial hardship, a 16% relative increase. Uninsured patients had a 23.7\u2013percentage point increase (95% CI, 5.1-42.2), privately insured patients had an 8.4\u2013percentage point increase (95% CI, 3.6-13.1), and those with Medicaid had no significant change. OOP spending increased by $708 (95% CI, $576-$839) after operations, with the highest increases among emergency surgeries and non-Medicaid insurance type.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n Surgical procedures were associated with substantial financial hardship for working-aged adults in the US, especially after emergency surgery and among the uninsured and privately insured. The finding that Medicaid enrollees were protected against increases in financial hardship after surgical procedures suggests that policies that restrict Medicaid eligibility may increase financial hardship among working-aged surgical patients, unless other changes are made to improve financial risk protection.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamasurg.2025.5055","type":"journal-article","created":{"date-parts":[[2025,11,19]],"date-time":"2025-11-19T16:00:27Z","timestamp":1763568027000},"page":"59","source":"Crossref","is-referenced-by-count":12,"title":["Financial Hardship After Surgical Procedures"],"prefix":"10.1001","volume":"161","author":[{"given":"Alexandra","family":"Hernandez","sequence":"first","affiliation":[{"name":"Department of Surgery, University of Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nina M.","family":"Clark","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jamie","family":"Olapo","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charles","family":"Liu","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rhea","family":"Udyavar","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan G.","family":"Sham","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ali","family":"Rowhani-Rahbar","sequence":"additional","affiliation":[{"name":"Department of Epidemiology, University of Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph L.","family":"Dieleman","sequence":"additional","affiliation":[{"name":"Institute for Health Metrics and Evaluation, University of Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John W.","family":"Scott","sequence":"additional","affiliation":[{"name":"Institute for Health Metrics and Evaluation, University of Washington, Seattle"},{"name":"Division of Trauma, Burn & Critical Care Surgery, University of Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"2","key":"soi250077r1","doi-asserted-by":"publisher","first-page":"265","DOI":"10.1097\/SLA.0000000000006586","article-title":"Trends in timely access to high-quality and affordable surgical care in the United States.","volume":"281","author":"Mullens","year":"2024","journal-title":"Ann Surg"},{"issue":"9","key":"soi250077r2","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2020.17696","article-title":"Catastrophic health expenditures across insurance types and incomes before and after the Patient Protection and Affordable Care Act.","volume":"3","author":"Liu","year":"2020","journal-title":"JAMA Netw Open"},{"key":"soi250077r3","doi-asserted-by":"publisher","DOI":"10.1001\/jamasurg.2020.1995","article-title":"Medicaid expansion and surgical care-evaluating the evidence.","author":"Scott","year":"2021","journal-title":"JAMA Surg"},{"issue":"3","key":"soi250077r4","doi-asserted-by":"publisher","first-page":"496","DOI":"10.1377\/hlthaff.2020.01106","article-title":"The Affordable Care Act\u2019s insurance marketplace subsidies were associated with reduced financial burden for US adults.","volume":"40","author":"Liu","year":"2021","journal-title":"Health Aff (Millwood)"},{"issue":"11","key":"soi250077r5","doi-asserted-by":"publisher","first-page":"1058","DOI":"10.1001\/jamasurg.2020.2959","article-title":"Association between Medicaid expansion and the use of outpatient general surgical care among US adults in multiple states.","volume":"155","author":"Lin","year":"2020","journal-title":"JAMA Surg"},{"issue":"4","key":"soi250077r6","doi-asserted-by":"publisher","first-page":"e667","DOI":"10.1097\/SLA.0000000000005819","article-title":"High deductibles are associated with severe disease, catastrophic out-of-pocket payments for emergency surgical conditions.","volume":"278","author":"Scott","year":"2023","journal-title":"Ann Surg"},{"issue":"1","key":"soi250077r7","doi-asserted-by":"publisher","first-page":"e56","DOI":"10.1097\/SLA.0000000000005382","article-title":"Financial toxicity among surgical patients varies by income and insurance: a cross-sectional analysis of the National Health Interview Survey.","volume":"276","author":"Taylor","year":"2022","journal-title":"Ann Surg"},{"issue":"5","key":"soi250077r8","doi-asserted-by":"publisher","first-page":"800","DOI":"10.1097\/TA.0000000000003979","article-title":"Financial toxicity after trauma and acute care surgery: from understanding to action.","volume":"95","author":"Scott","year":"2023","journal-title":"J Trauma Acute Care Surg"},{"key":"soi250077r9","doi-asserted-by":"publisher","DOI":"10.5888\/pcd17.200244","article-title":"Cost-related nonadherence and mortality in patients with chronic disease: a multiyear investigation, National Health Interview Survey, 2000-2014.","volume":"17","author":"Van Alsten","year":"2020","journal-title":"Prev Chronic Dis"},{"issue":"1","key":"soi250077r10","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1016\/j.amjsurg.2020.11.040","article-title":"Does health insurance protect against risk of financial catastrophe for pancreatic tumor care? A cost-based review of patients undergoing pancreatic resection at an academic institution.","volume":"222","author":"Okoroh","year":"2021","journal-title":"Am J Surg"},{"issue":"6","key":"soi250077r11","doi-asserted-by":"publisher","first-page":"538","DOI":"10.1001\/jama.2019.21463","article-title":"Out-of-network bills for privately insured patients undergoing elective surgery with in-network primary surgeons and facilities.","volume":"323","author":"Chhabra","year":"2020","journal-title":"JAMA"},{"issue":"1","key":"soi250077r12","doi-asserted-by":"publisher","first-page":"99","DOI":"10.1097\/SLA.0000000000005272","article-title":"The impact of Medicare coverage on downstream financial outcomes for adults who undergo surgery.","volume":"275","author":"Neiman","year":"2022","journal-title":"Ann Surg"},{"issue":"11","key":"soi250077r13","doi-asserted-by":"publisher","first-page":"1517","DOI":"10.1377\/hlthaff.2023.00604","article-title":"The joint distribution of high out-of-pocket burdens, medical debt, and financial barriers to needed care.","volume":"42","author":"Bernard","year":"2023","journal-title":"Health Aff (Millwood)"},{"issue":"1","key":"soi250077r14","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1093\/pan\/mpr013","article-title":"Causal inference without balance checking: coarsened exact matching.","volume":"20","author":"Iacus","year":"2012","journal-title":"Polit Anal"},{"issue":"2","key":"soi250077r15","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2020.0157","article-title":"Association of the US Affordable Care Act with out-of-pocket spending and catastrophic health expenditures among adult patients with traumatic injury.","volume":"3","author":"Liu","year":"2020","journal-title":"JAMA Netw Open"},{"issue":"5","key":"soi250077r16","doi-asserted-by":"publisher","first-page":"720","DOI":"10.1097\/TA.0000000000004545","article-title":"Pre- and postinjury financial hardship among trauma survivors: A national survey study.","volume":"98","author":"Clark","year":"2025","journal-title":"J Trauma Acute Care Surg"},{"issue":"3","key":"soi250077r19","doi-asserted-by":"publisher","first-page":"530","DOI":"10.1097\/SLA.0000000000004201","article-title":"The increasing financial burden of outpatient elective surgery for the privately insured.","volume":"272","author":"Billig","year":"2020","journal-title":"Ann Surg"},{"issue":"2","key":"soi250077r20","doi-asserted-by":"publisher","first-page":"193","DOI":"10.1097\/SLA.0000000000005689","article-title":"Unmet social health needs as a driver of inequitable outcomes after surgery: a cross-sectional analysis of the National Health Interview Survey.","volume":"278","author":"Taylor","year":"2023","journal-title":"Ann Surg"},{"issue":"3","key":"soi250077r21","doi-asserted-by":"publisher","first-page":"443","DOI":"10.1097\/SLA.0000000000006117","article-title":"Social determinants of health needs and health-related quality of life among surgical patients: a retrospective analysis of 8512 patients.","volume":"279","author":"Malapati","year":"2024","journal-title":"Ann Surg"},{"issue":"1","key":"soi250077r23","doi-asserted-by":"publisher","first-page":"28","DOI":"10.1177\/1077558720972592","article-title":"The effects of ACA Medicaid expansions on health after 5 years.","volume":"79","author":"Semprini","year":"2022","journal-title":"Med Care Res Rev"},{"issue":"5","key":"soi250077r25","doi-asserted-by":"publisher","DOI":"10.1001\/jamahealthforum.2022.1031","article-title":"Trends in medical debt during the COVID-19 pandemic.","volume":"3","author":"Guttman-Kenney","year":"2022","journal-title":"JAMA Health Forum"},{"issue":"4","key":"soi250077r26","doi-asserted-by":"publisher","first-page":"423","DOI":"10.1001\/jamasurg.2022.6356","article-title":"Variability in out-of-pocket costs and quality for common emergency general surgery conditions.","volume":"158","author":"Neiman","year":"2023","journal-title":"JAMA Surg"},{"issue":"6","key":"soi250077r27","doi-asserted-by":"publisher","first-page":"e1252","DOI":"10.1097\/SLA.0000000000003823","article-title":"Impact of the Affordable Care Act insurance marketplaces on out-of-pocket spending among surgical patients.","volume":"274","author":"Liu","year":"2021","journal-title":"Ann Surg"},{"issue":"11","key":"soi250077r28","doi-asserted-by":"publisher","DOI":"10.1001\/jamahealthforum.2022.4105","article-title":"Financial outcomes after traumatic injury among working-age US adults with commercial insurance.","volume":"3","author":"Scott","year":"2022","journal-title":"JAMA Health Forum"},{"issue":"3","key":"soi250077r29","doi-asserted-by":"publisher","first-page":"424","DOI":"10.1097\/SLA.0000000000005225","article-title":"Financial burden of traumatic injury amongst the privately insured.","volume":"275","author":"Fu","year":"2022","journal-title":"Ann Surg"},{"issue":"2","key":"soi250077r30","doi-asserted-by":"publisher","first-page":"172","DOI":"10.1097\/TA.0000000000003993","article-title":"Catastrophic health expenditure in nonneurological injury due to motor vehicle crash.","volume":"95","author":"Nishtala","year":"2023","journal-title":"J Trauma Acute Care Surg"},{"key":"soi250077r31","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.jss.2020.05.095","article-title":"Financial hardship after traumatic injury: risk factors and drivers of out-of-pocket health expenses.","volume":"256","author":"O\u2019Neill","year":"2020","journal-title":"J Surg Res"},{"issue":"14","key":"soi250077r32","doi-asserted-by":"publisher","first-page":"1245","DOI":"10.2106\/JBJS.18.01114","article-title":"The personal financial burden associated with musculoskeletal trauma.","volume":"101","author":"Bhashyam","year":"2019","journal-title":"J Bone Joint Surg Am"},{"issue":"2","key":"soi250077r33","doi-asserted-by":"publisher","first-page":"345","DOI":"10.1016\/j.surg.2014.04.039","article-title":"Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities?","volume":"156","author":"Schwartz","year":"2014","journal-title":"Surgery"},{"issue":"2","key":"soi250077r34","doi-asserted-by":"publisher","first-page":"352","DOI":"10.1097\/XCS.0000000000000468","article-title":"Cost of failure to achieve textbook outcomes: association of insurance type with outcomes and cumulative cost for inpatient surgery.","volume":"236","author":"Jacobs","year":"2023","journal-title":"J Am Coll Surg"},{"issue":"4","key":"soi250077r37","doi-asserted-by":"publisher","first-page":"321","DOI":"10.1001\/jamasurg.2021.7567","article-title":"Association between high-deductible health plans and hernia acuity.","volume":"157","author":"Yelorda","year":"2022","journal-title":"JAMA Surg"},{"issue":"9","key":"soi250077r38","doi-asserted-by":"publisher","DOI":"10.1001\/jamahealthforum.2021.2324","article-title":"Association of cost sharing with delayed and complicated presentation of acute appendicitis or diverticulitis.","volume":"2","author":"Loehrer","year":"2021","journal-title":"JAMA Health Forum"},{"issue":"9","key":"soi250077r39","doi-asserted-by":"publisher","first-page":"1136","DOI":"10.1007\/s11606-013-2354-z","article-title":"Prevalence and predictors of underinsurance among low-income adults.","volume":"28","author":"Magge","year":"2013","journal-title":"J Gen Intern Med"},{"issue":"11","key":"soi250077r40","doi-asserted-by":"publisher","first-page":"1085","DOI":"10.1001\/jama.2022.14791","article-title":"The US Medicaid program: coverage, financing, reforms, and implications for health equity.","volume":"328","author":"Donohue","year":"2022","journal-title":"JAMA"},{"issue":"1","key":"soi250077r41","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1097\/TA.0000000000002493","article-title":"Lifting the burden: state Medicaid expansion reduces financial risk for the injured.","volume":"88","author":"Scott","year":"2020","journal-title":"J Trauma Acute Care Surg"},{"key":"soi250077r44","doi-asserted-by":"publisher","DOI":"10.1007\/s11606-024-09331-3","article-title":"Changes to US hospital charity care policies between 2021 and 2023.","author":"Goodman","journal-title":"J Gen Intern Med"},{"issue":"2","key":"soi250077r45","doi-asserted-by":"publisher","first-page":"100","DOI":"10.3322\/caac.21653","article-title":"Time to add screening for financial hardship as a quality measure?","volume":"71","author":"Bradley","year":"2021","journal-title":"CA Cancer J Clin"},{"issue":"18","key":"soi250077r46","doi-asserted-by":"publisher","first-page":"3198","DOI":"10.1002\/cncr.35367","article-title":"Interventions to mitigate cancer-related medical financial hardship: a systematic review and meta-analysis.","volume":"130","author":"Rashidi","year":"2024","journal-title":"Cancer"},{"key":"soi250077r17","unstructured":"Banthin? J, Skopec? L, Ramchandani? U. Improving Affordability of Insurance for Consumers by Eliminating the Firewall Between Employer and Individual Markets. Urban Institute; 2024. Accessed August 30, 2025. https:\/\/www.urban.org\/research\/publication\/improving-affordability-insurance-consumers-eliminating-firewall-between"},{"key":"soi250077r18","unstructured":"Federal Reserve Board\u2019s Division of Consumer and Community Affairs (DCCA). Economic well-being of US households in 2022. Accessed October 17, 2025. https:\/\/www.federalreserve.gov\/publications\/2023-economic-well-being-of-us-households-in-2022-expenses.htm"},{"key":"soi250077r22","doi-asserted-by":"crossref","unstructured":"Collins? SR, Rasmussen? PW, Doty? MM, Beutel? S; The Commonwealth Fund. The rise in health care coverage and affordability since health reform took effect. Accessed October 17, 2025. https:\/\/www.commonwealthfund.org\/sites\/default\/files\/documents\/___media_files_news_news_releases_2015_jan_revised_embargoed_1800_collins_biennial_survey_brief_01142015.pdf","DOI":"10.15868\/socialsector.25023"},{"key":"soi250077r24","unstructured":"Gonzalez? D, Karpman? M, Kenney? GM, Zuckerman? S; Urban Institute. Delayed and forgone health care for nonelderly adults during the COVID-19 pandemic. Accessed October 17, 2025. https:\/\/www.urban.org\/sites\/default\/files\/publication\/103651\/delayed-and-forgone-health-care-for-nonelderly-adults-during-the-covid-19-pandemic.pdf"},{"key":"soi250077r35","unstructured":"Commonwealth Fund. US health insurance coverage in 2020: a looming crisis in affordability: findings of the Commonwealth Fund Biennial Health Insurance Survey, 2020. Accessed October 17, 2025. https:\/\/www.commonwealthfund.org\/sites\/default\/files\/2020-08\/Collins_looming_crisis_affordability_biennial_2020_sb.pdf"},{"key":"soi250077r36","unstructured":"Spiegel? J, Fronstin? P. Recent trends in patient out-of-pocket cost sharing. Accessed October 17, 2025. https:\/\/openurl.ebsco.com\/contentitem\/gcd:158250394?sid=ebsco:plink:crawler&id=ebsco:gcd:158250394"},{"key":"soi250077r42","unstructured":"Keith? K, Levitis? J. HHS Proposes To Restrict Marketplace Eligibility, Enrollment, And Affordability In First Major Rule Under Trump Administration (Part 1). Accessed October 17, 2025. https:\/\/www.healthaffairs.org\/do\/10.1377\/forefront.20250312.194932\/full\/"},{"key":"soi250077r43","unstructured":"Buettgens? M. Reducing federal support for Medicaid expansion would shift costs to states and likely result in coverage losses. October 17, 2025. https:\/\/www.urban.org\/sites\/default\/files\/2025-02\/Reducing_Federal_Support_for_Medicaid_Expansion_Would_Shift_Costs_to_States_and_Likely_Result_in_Coverage_Losses.pdf?utm_source=chatgpt.com"}],"container-title":["JAMA Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/articlepdf\/2841652\/jamasurgery_hernandez_2025_oi_250077_1767031593.23533.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,14]],"date-time":"2026-01-14T16:01:04Z","timestamp":1768406464000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/fullarticle\/2841652"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,1]]},"references-count":46,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,1,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamasurg.2025.5055","relation":{},"ISSN":["2168-6254"],"issn-type":[{"value":"2168-6254","type":"print"}],"subject":[],"published":{"date-parts":[[2026,1,1]]}}}