Financial Hardship After Surgical Procedures.

Importance: 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. Objective: 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. Design, Setting, and Participants: 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. Exposures: The primary exposure was surgical procedure(s) within the last 12 months; secondary exposure was emergency vs elective surgical procedures. Main Outcomes and Measures: 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. Results: 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-percentage point increase (95% CI, 1.8-9.0) in financial hardship, a 16% relative increase. Uninsured patients had a 23.7-percentage point increase (95% CI, 5.1-42.2), privately insured patients had an 8.4-percentage 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. Conclusions and Relevance: 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.