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Double Jeopardy and the Individual Mandate

Trauma patients increase costs but are less likely to follow the individual mandate.

Source: Keniju (Creative Commons / Flickr)

Source: Keniju (Creative Commons / Flickr)

Although studies exist that tout the benefits of the individual mandate on health care costs, data is lacking on how it affects costs for traumatically injured patients. The national costs of treating traumatically injured patients from EMS pickup to trauma evaluation and treatment has been estimated to be as high as $163 billion dollars annually, or as high as 10% of all US health care expenditures. A recent study in the American Journal of Public Health evaluated the rates of insurance for traumatically injured patients before and after the individual mandate for health care reform in Massachusetts.

In the case of patients injured without health insurance, often times the cost of trauma care is uncompensated with the burden picked up by society via rising health care costs. Debilitated uninsured patients also tend to have longer length of stays in hospitals and missed time from work while they await charity care for services such as acute rehabilitation and skilled nursing facilities.

Double jeopardy is a concept that describes patients from a certain sociodemographic group that suffer from a higher incidence of trauma as well as a lack of compliance with the individual mandate, illustrating the blurry line that exists between policy and societal behaviors. The policy involved with an individual mandate is meant to protect the uncompensated catastrophic financial burdens of an individual’s health care from falling on the shoulders of our medical system and ultimately society. The results of health care reform in Massachusetts show that the individual mandate can reduce costs of health care nationally, but hospitals and trauma centers with a large portion of patients who fall into double jeopardy may not experience these costs savings.

As the Affordable Care Act (ACA) calls for increased funding for trauma centers nationally, the results from the individual mandate in Massachusetts and its results on trauma care costs will have large policy implications. As this study shows, the social factors that lead to higher injury incidence appear to work hand-in-hand with non-compliance with the individual mandate. A stronger effort to examine and eradicate this social disparity in combination with the individual mandate is necessary to help improve insurance rates among this sociodemographic group. Whether or not it requires federal legislation will be sure to spark national debate.


Using data from the trauma registry at the University of Massachusetts Medical Center, the authors gathered pre-injury insurance status on their patients aged 18-64 during the years of 2004-2005 and 2009-2010 (after health care reform). The Massachusetts general population’s insurance rate during the same time periods were also included to compare to the trauma cohort. Prior to health care reform, the rate of insurance among these patients was 76.7%, whereas afterwards there was an improvement to 84.3% (P<.001). In comparison, the trauma cohort lagged behind the state’s general population before and after health care reform, which was 87% and 94% respectively. In addition to increases in pre-injury insurance status, the study saw improvements in length of hospital stay as well as favorable hospital discharge dispositions such as acute rehabilitation centers and skilled nursing facilities for disabled patients. In both time periods, common characteristics of an uninsured patient consisted of being a minority, young, male, and suffering from penetrating trauma (i.e. stab wounds and gunshot/rifle wounds). PMID: 24825208

Santry, HP, et al. AJPH 2014; 104 (6) 1066-1072.


Nii Darko, DP, MBA

Nii Darko, DO, MBA
About Nii Darko, DO, MBA

Dr. Darko is a board-certified general surgeon who currently practices in Pennsylvania. He began writing for Policy Prescriptions® in 2012. Contact: Facebook | Twitter | More Posts