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Invited Critique
November 16, 2009

Trauma of the Uninsured: Comment on “Downwardly Mobile: The Accidental Cost of Being Uninsured”

Arch Surg. 2009;144(11):1011-1012. doi:10.1001/archsurg.2009.194

This article is especially relevant given the priority assigned to health care reform by the current administration. Clearly, one of the more significant problems in our current health care system is that of the uninsured and their relative lack of access to care.

However, one might assume that lack of access would be less of a problem with emergency and trauma care, since all patients entering an emergency department or a trauma center are guaranteed to receive care regardless of their ability to pay. It is the providers, hospitals and physicians, who assume the major financial risk for these uninsured patients. Our emergency departments and trauma centers are the safety net for many communities.

It is therefore disturbing to see from this study that, even with guaranteed access, the uninsured have a higher adjusted mortality rate after trauma. Several mechanisms are postulated: treatment delay, different care (receipt of fewer diagnostic tests), and decreased health literacy. The authors have acknowledged the limitations of data derived from the NTDB, but their conclusions should be taken seriously.

Elimination of this disparity in mortality rates should be fundamental to any health care reform policy and certainly the goal of any trauma center or system. ACS Trauma Center Verification site visit teams should be aware of, and look for, this potential disparity in quality of care. Inclusive trauma systems in the United States are designed to ensure that all trauma patients have expeditious transfer to the level of care commensurate with their injuries regardless of insurance status. Such systems should also guarantee the same level and quality of care to all patients

Correspondence: Dr Eastman, Scripps Memorial Hospital La Jolla, Scripps Health, 4275 Campus Point Ct, Mail Drop CP222, San Diego, CA 92121 (Eastman.Brent@scrippshealth.org).

Financial Disclosure: None reported.