The idea of local government erasing debt emerged a couple of years ago in Cook County, Illinois, home to Chicago. Toni Preckwinkle, president of the county board of commissioners, says two staffers came to her with a bold proposal: The county could spend a portion of its federal pandemic rescue funds to ease a serious burden on its residents.

In 2022, Cook County became the first local government to partner with RIP Medical Debt, a nonprofit group that uses private donor funds to buy up and forgive patient debt.

RIP’s model turns debt collection on its head. Normally, debt collectors buy unpaid bills and then try to collect the money owed. RIP identifies unpaid hospital bills owed by people making up to four times the federal poverty level, then buys that debt on secondary markets or directly from hospitals at a small fraction of the original value. Instead of trying to collect, RIP forgives it — so it simply disappears for the patients.

In the Chicago area, as across the country, medical debt is an ongoing problem, causing mental and financial strain that can follow patients for years. An estimated100 million people in the U.S. carry some form of health care debt, ºÚÁϳԹÏÍø News and NPR reported in 2022.

Preckwinkle said the RIP model dovetailed nicely with Cook County’s health care mission. For nearly two centuries, the county has funded its own hospital and health system, Cook County Health, in part to provide care to all residents, regardless of income.

“We have a legacy commitment to delivering quality health care to people without regard to their ability to pay,” Preckwinkle said.

She said that health care mission eats up nearly half of the county’s $9.3 billion annual budget. It is now in the process of spending $12 million — a tiny portion of its budget — to retire $1 billion worth of hospital bills for residents.

Since Cook County announced its program, seven other local governments have followed suit, including Ohio cities Akron, Cleveland, and Toledo; New Orleans; Wayne County, Michigan; Washington, D.C.; and now New York City, which announced its commitment Jan. 22.

During his announcement, New York Mayor Eric Adams noted that medical debt disproportionately affects Black and Hispanic people, who are more likely to be uninsured or underinsured. For the city’s low-income residents, he said, “taking on medical debt isn’t a choice.”

“Working-class families often have to choose between paying their medical bills or some of the basic essentials that they need to go through life,” he said.

RIP is in talks with 30 other municipalities and states, including Connecticut, New Jersey, and Michigan.

Typically, RIP can retire at least $100 worth of debt for every $1 of government funds, so the local initiatives could end up wiping out several billion dollars in medical debt. The software selects eligible patients who remain anonymous, so it’s hard to know what the impact of eliminating that debt might be across a community, or for the families that benefit.

Allison Sesso, CEO of RIP Medical Debt, acknowledged that debt is one of many factors contributing to unequal access to health care, and as hospital costs continue to rise, new debts are also piling up perhaps faster than her group can retire it. She said RIP hopes to retire $2.5 billion worth of unpaid medical bills through various government initiatives this year, but that’s a drop in the bucket of the $195 billion estimated medical debt held by Americans.

“I’m under no illusions,” Sesso said. “I don’t think what I’m doing is the solution to getting rid of medical debt, writ large.”

An Unusual Move for Local Government

Amber Clapsaddle said having the city of Toledo eliminate a $1,500 medical bill of hers from three years ago has given her hope.

In the past, Clapsaddle said, she looked down on those who didn’t pay their bills. “I was like, ‘I’ll never do that,’ and I judged people really hard,” she said.

Then, several years ago, her entire family of five each got sick one after another, requiring numerous surgeries, ultrasounds, and diagnostic tests. She had insurance, but she and her husband, a warehouse worker, couldn’t meet the $6,000 deductible. Clapsaddle, a social worker, realized why medical debt is such a prevalent problem: “It just takes one bill, one bad insurance plan, just one extra diagnosis to have it all fall apart.”

When Toledo’s program with RIP forgave some of her family’s debt two months ago, she cried with joy and relief. She said that motivated her to negotiate with doctors’ offices and her insurance company to try to prevent herself from getting into debt again. “It’s the spark that lights the fire of getting out of medical debt,” she said.

Debt forgiveness is an unusual solution for local governments. More are taking it on, aided by access to federal pandemic rescue funds through the American Rescue Plan Act of 2021, and RIP Medical Debt offered a quick and easy fix to distribute those funds to those most burdened by medical expenses.

Nationally, medical debt is shown to disproportionately affect people of color and people who earn less. It also contributes to a vicious health cycle, discouraging patients from seeking preventive or follow-up care, leading to worse and more expensive outcomes.

Cook County’s Preckwinkle said the pandemic only deepened racial and income gaps that affect people’s access to health care.

“I always talk about the fact that medical debt is the leading cause of bankruptcy in the United States,” she said.

Getting Down to the Root Causes of Debt

Medical debt is being created at high rates, Sesso said, and stronger policies — such as protecting consumers and strengthening insurance coverage — are needed to stop it at its source.

Often that boils down to high prices charged by hospitals and providers.

As Adams, the New York City mayor, put it: “You know, not only do you hold your breath when you go into a hospital or a doctor’s office and wait for a diagnosis, you continue to hold your breath when you see the bill and what it costs, particularly for low-income New Yorkers.”

The idea of forgiving medical debt has broad political support, said Sesso, perhaps because the issue affects people of all political stripes. A recent RIP survey, she said, showed that “84% of people agreed that it is the responsibility of government to ensure health care is affordable, and that position is held by people on the left and the right.”

The enduring benefit of the recent local government initiatives is that they have helped draw more attention to the problem, raising its profile in useful ways, she said. “I think the issue of medical debt is becoming a priority, local governments are talking about it,” and that is leading to other conversations about what else they can do to get more eligible families insured through Medicaid, or through the Affordable Care Act insurance marketplace, for example.

It is also inspiring programs like one recently adopted by Milwaukee County, in which it’s urging more hospitals and health systems to use credit reports to screen and automatically enroll eligible patients in financial assistance programs. These programs already exist to help reduce medical expenses for patients making up to three times the poverty level, but often patients are unaware or not told to apply for them.

By automating the process, as many as 50% more patients may receive free or reduced-cost care, so they have a better chance of avoiding incurring medical debt in the first place, said Shawn Rolland, a member of Milwaukee County’s board of supervisors.

“Why make it more difficult than necessary to get enrolled?” he said. “Because ultimately this will make it more likely that they’ll come back for preventative care.”

About This Project

“Diagnosis: Debt” is a reporting partnership between ºÚÁϳԹÏÍø News and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country.Ìý

Additional research was , which analyzed credit bureau and other demographic data on poverty, race, and health status for ºÚÁϳԹÏÍø News to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute  from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with ºÚÁϳԹÏÍø News on a survey of its clients to explore links between medical debt and housing instability.Ìý

ºÚÁϳԹÏÍø News journalists worked with KFF public opinion researchers to design and analyze the “.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from ºÚÁϳԹÏÍø News and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Rachel and her husband adopted Marcus out of Guatemalan foster care as a 7-month-old infant and brought him home to Lansing, Michigan. With a round face framed by a full head of dark hair, Marcus was giggly and verbal — learning names of sea animals off flashcards, impressing other adults.

But in preschool, Marcus began resisting school, throwing himself on the ground, or pretending to be sick — refusals that got more intense and difficult to deal with. His parents sought therapy for him. Rachel and her husband had some savings for retirement, college, and emergencies; at first, the cost of Marcus’ therapy was not an issue. “We didn’t realize where it was going,” Rachel said.

Today, Marcus is 15 and has a younger sibling. His parents have depleted their savings and gone into debt to pay for treatments for his severe depression, anxiety, and mood disorders. Frequently agitated and increasingly violent, Marcus could not attend a regular school. Over the years, he’s needed weekly therapy, hospitalization, and specialized schooling — all of which has cost tens of thousands of dollars a month.

He required lots of medical and mental health appointments that were often many miles from the family’s home. Rachel ultimately quit her real estate broker’s job to care for her son, and with that the family took another financial hit. With no good treatment options within hours of where they live, Marcus is now in residential care out of state that specializes in therapy for children with conditions like his. That’s helped modulate his behavior, but also costs $12,500 a month.

“All of our savings is gone,” said Rachel, who spoke on condition of anonymity to protect her son’s privacy. She and her husband have taken out a second mortgage and borrowed against their retirement accounts.

“How are we going to send our kids to school?” she said. “How are we going to recover from this? I don’t know.” Just surviving the string of crises is all-consuming. “Those thoughts in your mind — there’s no space for that when you are just trying to keep your child alive.”

Untold numbers of families like Rachel’s are dealing with myriad challenges finding and paying for mental health care, and then ending up in debt. There are too few therapists and psychologists in the U.S. — and fewer still who accept insurance. That compounds the financial toll on families.

Tabulating the impact isn’t easy. Many do what Rachel did: They refinance their houses, drain college savings, or borrow from family. But that kind of borrowing often isn’t included in estimates of medical debt. As a result, it’s hard to know how much families are paying out of their pockets for mental health treatment.

A recent designed to measure the many ways people borrow to pay medical bills found that about 100 million Americans have some kind of health care debt, and 20% of those owe money for mental health services.

Those who can’t afford to borrow sometimes try to get coverage for their children under public insurance like Medicaid, which sometimes means reducing their income to qualify.

When Even Medicaid Isn’t a Safety Net

After her workplace health insurance denied coverage for her 9-year-old daughter, Colleen O’Donnell, a single mom from Providence, Rhode Island, applied for a  to qualify her daughter for Medicaid. At the time, she earned too much to get her on Medicaid without it.

But when the pandemic started, she had to stop working and stay home to care for her daughter, who suffers from, among other things,  — a condition that goes far beyond normal tween moodiness.

Treatment didn’t require just medication or visits to the doctor or hospital; the girl needed wrap-around therapy that included in-home care. The child’s unpredictable moods and violent tantrums made it impossible to send her to school, or for her mother to hire a sitter to care for her.

Once she stopped working, her income was low enough that, in fact, the whole family qualified for Medicaid, including her 9-year-old.

O’Donnell, a registered nurse, could have made lots of bonus pay caring for covid-19 patients, but she continued to stay home. She took on a second mortgage for $22,000. She estimates at least $60,000 in lost wages a year.

O’Donnell recently decided to start working again. But the added income means her family could lose Medicaid coverage, so she will have to reapply for the special waiver for her daughter. If she doesn’t qualify, she may have to cut her income back to stay on Medicaid, she worries.

“Qualifying for Medicaid means essentially you’re living right around the poverty level, which means I’m not generating any sort of wealth, I’m not saving for retirement or anything like that,” said O’Donnell.

Some desperate families go to even more extreme lengths to get mental health care covered by Medicaid. Some leave their children at hospitals, relinquishing custody, so they become wards of the state. Others simply forgo care altogether.

So, how much is this costing families across America? And how many are forgoing care? It’s hard to know.

Lack of Data Keeps Struggling Families in the Shadows

“We don’t have real data,” said Patrick Kennedy, a former member of Congress and founder of the Kennedy Forum, a mental health advocacy group. Across the board, he said, there’s a lamentable lack of data when it comes to mental illness. “We don’t track this. We have a hodgepodge of reporting that’s not standardized.”

That lack of data keeps many people in the shadows, Kennedy said. It makes it hard to hold insurers accountable for they have to pay for mental health care, or to argue for specific policy changes from regulators that oversee them. Kennedy said that problem should not fall on the shoulders of the many families who are too busy fighting to survive.

“If you’re a family or someone who has one of these illnesses, you don’t have the capacity for self-advocacy, right? And shame still factors in, in a large way,” he said.

Rachel, the mother in Lansing, estimates Marcus’ treatment costs topped a quarter-million dollars over the past two years alone. Nearly all that, Rachel said, was driven by care their insurance company declined to cover.

Over the years, Marcus underwent numerous neuropsychological tests, checking everything from intelligence and personality to trauma and motor skills to gauge the gaps in how he perceives the world. Each test cost several thousand dollars. Weekly therapy cost $120. Special schools, including a wilderness therapy program, cost thousands of dollars a month, and Rachel said insurance covered almost none of it.

The insurer cited various reasons: The wilderness therapy, even if it worked, was deemed too experimental. Other treatments weren’t in-network. Even when Marcus became increasingly violent and a danger to himself and others, insurance agents repeatedly told Rachel that various types of inpatient or residential treatment programs and specialists recommended to her weren’t covered because they were “not medically necessary” or would require reauthorization within days.

Meanwhile, Marcus’ problems at home were escalating. “There were times that I hid,” Rachel said, voice breaking. “I found hiding places so that my kid couldn’t find me. He would hurt me. He would attack me, throw things at me, push me.”

Faced with this do-or-die situation, Rachel and her husband decided to pay the costs of the care themselves and fight it out with insurance and lawyers later. For the past year, they’ve spent $150,000 to send Marcus to his out-of-state school.

What About ‘Mental Health Parity’ in Reimbursement?

That growing reliance on out-of-network care for mental health treatment is a national trend, despite various federal and state laws requiring insurers to cover services like addiction treatment on par with CT scans, surgeries, or cancer treatments. found those disparities getting markedly worse, especially among children, between 2013 and 2017 — effectively forcing more patients to seek behavioral health care outside their insurer’s network.

AHIP, a health insurer trade group, said the industry complies with existing laws and is working to expand options to meet increased demand for mental health care.

“Given the workforce and capacity shortages in [mental health and substance use disorder] care, it’s important that patients receive the appropriate level of care, helping to preserve higher levels of care for those who need it most,” David Allen, an AHIP spokesperson, said in an emailed statement. He said insurers are taking measures like adding new providers to their networks, and adding telehealth options to expand their reach into places like . But, he said, not every kind of care should qualify for coverage: “It is important to make sure that people receive high-quality care based on scientific evidence.”

Regulators Have Been Slow to Police Insurers

But Deborah Steinberg, a health policy lawyer at the Legal Action Center, which advocates for consumers, said insurers improperly deny coverage for appropriate treatments far too often. Few people know how to determine that, and end up paying the bill.

“They are actually not necessarily bills [patients and families] should be paying, because a lot of the time these are illegal practices,” Steinberg said. “There are so many complicated laws here that people don’t understand. And when people pay the bills or take it out as credit card debt, they’re not challenging those practices.”

Nor have regulators been aggressive in policing insurers, or fining them for violations.

That’s something Ali Khawar pledges to change. Khawar, an acting assistant secretary at the Labor Department’s Employee Benefits Security Administration, which oversees private insurers, said showed high levels of violations. The report also showed the insurance industry failing to keep adequate data on their compliance with parity laws.

But, Khawar said, coverage of mental health care is a problem he hears about continually, and the fact that so many families are struggling has made this a top priority for his agency. “There is a level of attention, a level of resources being put to these issues that is kind of unprecedented,” he said.

Often, it falls to attorneys general to enforce insurance rules, and the willingness and resources available to do so varies by state.

In Michigan, where attorney J.J. Conway practices, the state has not been active in investigating the industry, he said. So families must seek recourse on their own, he said, if they want to with their insurer. Conway, who represents Rachel’s family and many other parents, said he’s seeing the biggest surge in mental health disputes in his 25 years as a lawyer.

Conway said there’s a strange silver lining in the sheer number of families now struggling to get mental health coverage. The cases are so numerous, he said, he hopes collectively they’ll eventually force a change.

About This Project

“Diagnosis: Debt” is a reporting partnership between KHN and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country.Ìý

Additional research was , which analyzed credit bureau and other demographic data on poverty, race, and health status for KHN to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute  from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with KHN on a survey of its clients to explore links between medical debt and housing instability.Ìý

KHN journalists worked with KFF public opinion researchers to design and analyze the “.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from KHN and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

“Every day was tough. Every day, I’m thinking about what I owe, how am I going to get out of this? Tough.”

Terri Logan, 42, Spartanburg, South Carolina

Approximate Medical Debt: $1,400, now $0

Medical Issue: Premature childbirth

What Happened: Two months ahead of her due date with her second daughter, Terri Logan felt weighed down by stress. She was a high school math teacher in Union City, Georgia, and was ending her relationship with the baby’s father.

One day the baby stopped moving. Logan went to the hospital, where her blood pressure spiked, her head throbbed, and she blacked out. Hours later, her daughter was born by cesarean section, weighing only 3 pounds. Logan had health insurance through work, but she was responsible for out-of-pocket charges. She and her baby were in a health crisis, so the issue of money didn’t come up: “That conversation just wasn’t had in that moment.”

About two weeks after her daughter was discharged, Logan was hit with a bill. She couldn’t bring herself to take a close look at the total. “It was one of those moments when you see … commas,” she said. She never opened the bills that arrived after that, knowing she couldn’t pay them or handle the stress. “I just avoided it like the plague.”

Other bills followed. Eventually, they were sent to collections.

The debt piled on to other stressors for the single mom. She developed debilitating anxiety, which brought on more headaches. She had to give up her full-time teaching job. “The weight of all of that medical debt — oh, man, it was tough,” she said. “Every day was tough. Every day, I’m thinking about what I owe, how am I going to get out of this.”

What’s Broken: Logan is among a growing number of working people who are considered under-insured; that is, they have an employer-sponsored plan but it pushes a lot of costs — in the form of copays, coinsurance, and deductibles — onto the patient.

This cost sharing, as it’s called, has increased steadily over the past two decades. Last year, the average annual deductible for a single worker with job-based coverage topped $1,669, which is 68% higher than a decade ago, according . Family deductibles can top $10,000.

At the same time, millions of Americans have next to no savings. A nationwide poll conducted by KFF for this project found that half of U.S. adults don’t have the cash to cover an unexpected $500 health care bill.

That makes debt almost inevitable for anyone with a large expense like the birth of a child, even if they have health insurance. Indeed, most Americans who have medical debt had coverage, according to the KFF poll.

With her older daughter, Logan said, she never saw a bill. It was an uncomplicated birth with no out-of-pocket charges. So she assumed her insurance would provide similar coverage for the second birth.

What’s Left: Nearly 13 years after her second daughter’s birth, Logan received yellow envelopes by mail and braced herself to open them. She was finally able to work again, whenever her health permitted. It was time to start tackling the problem that had dogged her.

As she put it: “It was like, ‘OK, even if you can’t pay it, you need to know who you owe. At some point, you gotta start, because you gotta take care of this to get into a better situation.’”

To her surprise, the envelopes did not contain bills, but rather a notice from RIP Medical Debt, a nonprofit, saying it had bought her unpaid medical debts and forgiven them on her behalf. She was shocked: “Wait: What? Who does that?”

Logan reread the letter and cried, absorbing the unexpected gift. “It definitely gives you a sense of, ‘You know what? There’s still good in this world,’” she said.

RIP Medical Debt uses donated funds to buy unpaid medical debt, directly from hospitals or on the secondary market, for about 1% of the original value. It selects unpaid bills held by lower-income patients — those making up to four times the federal poverty level — and instead of trying to collect on those loans, simply forgives them.

Through the pandemic, donations have skyrocketed, enabling the group to accelerate its purchase of hospital debts. To date, it has forgiven $6.7 billion in medical debt, helping 3.6 million people.

The lifting of her own debt burden, Logan said, has freed her to pursue long-dormant interests. A lover of the stage, she planned her first singing performance this month.

About This Project

“Diagnosis: Debt” is a reporting partnership between KHN and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country.Ìý

Additional research was , which analyzed credit bureau and other demographic data on poverty, race, and health status for KHN to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute  from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with KHN on a survey of its clients to explore links between medical debt and housing instability.Ìý

KHN journalists worked with KFF public opinion researchers to design and analyze the “.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from KHN and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Logan, who was a high school math teacher in Georgia, shoved it aside and ignored subsequent bills. She was a single mom who knew she had no way to pay. “I avoided it like the plague,” she said, but avoidance didn’t keep the bills out of mind.

“The weight of all of that medical debt — oh man, it was tough,” Logan said. “Every day, I’m thinking about what I owe, how I’m going to get out of this … especially with the money coming in just not being enough.”

Then a few months ago — nearly 13 years after her daughter’s birth and many anxiety attacks later — Logan received some bright yellow envelopes in the mail. They were from a nonprofit group telling her it had bought and then forgiven all those past medical bills.

This time, it was a very different kind of surprise: “Wait, what? Who does that?”

does. The nonprofit has boomed during the covid-19 pandemic, freeing patients of medical debt, thousands of people at a time. Its novel approach involves buying bundles of delinquent hospital bills — debts incurred by low-income patients like Logan — and then simply erasing the obligation to repay them.

It’s a model developed by two former debt collectors, Craig Antico and Jerry Ashton, who built their careers chasing down patients who couldn’t afford their bills.

“They would have conversations with people on the phone, and they would understand and have better insights into the struggles people were challenged with,” said Allison Sesso, RIP’s CEO. Eventually, they realized they were in a unique position to help people and switched gears from debt collection to philanthropy.

What triggered the change of heart for Ashton was meeting activists from the Occupy Wall Street movement in 2011 who talked to him about how to help relieve Americans’ debt burden. “As a bill collector collecting millions of dollars in medical-associated bills in my career, now all of a sudden I’m reformed: I’m a predatory giver,” Ashton said in a , a new media journalism site.

After helping Occupy Wall Street activists buy debt for a few years, Antico and Ashton . They started raising money from donors to buy up debt on secondary markets — where hospitals sell debt for pennies on the dollar to companies that profit when they collect on that debt.

RIP buys the debts just like any other collection company would — except instead of trying to profit, it sends out notices to consumers saying their debt has been cleared. To date, RIP has purchased $6.7 billion in unpaid debt and relieved 3.6 million people of debt. The group says retiring $100 in debt costs an average of $1.

RIP bestows its blessings randomly. Sesso said it just depends on which hospitals’ debts are available for purchase. “So nobody can come to us, raise their hand, and say, ‘I’d like you to relieve my debt,’” she said.

Yet RIP is expanding the pool of those eligible for relief. Sesso said that with inflation and job losses stressing more families, the group now buys delinquent debt for those who make as much as four times the federal poverty level, up from twice the poverty level.

A surge in recent donations — from college students to philanthropist — is fueling RIP’s expansion. That money enabled RIP to hire staff and develop software to comb through databases and identify targeted debt faster.

New regulations allow RIP to buy loans directly from hospitals, instead of just on the secondary market, expanding its access to the debt.

Sesso said the group is constantly looking for new debt to buy from hospitals: “Call us! We want to talk to every hospital that’s interested in retiring debt.”

Sesso emphasized that RIP’s growing business is nothing to celebrate. It means that millions of people have fallen victim to a U.S. insurance and health care system that’s simply too expensive and too complex for most people to navigate. As KHN and NPR have reported, more than half of U.S. adults say they’ve gone into debt in the past five years because of medical or dental bills, according to a . A quarter of adults with health care debt owe more than $5,000. And about 1 in 5 with any amount of debt say they don’t expect to ever pay it off.

RIP is one of the only ways patients can get immediate relief from such debt, said Jim Branscome, a major donor. Policy change is slow. Numerous factors contribute to medical debt, he said, and many are difficult to address: rising hospital and drug prices, high out-of-pocket costs, less generous insurance coverage, and widening racial inequalities in medical debt. The pandemic, Branscome added, exacerbated all of that.

The “pandemic has made it simply much more difficult for people running up incredible medical bills that aren’t covered,” Branscome said. He is a longtime advocate for the poor in Appalachia, where he grew up and where he says chronic disease makes medical debt much worse. It undermines the point of care in the first place, he said: “There’s pressure and despair.”

For Terri Logan, the former math teacher, her outstanding medical bills added to a host of other pressures in her life, which then turned into debilitating anxiety and depression. Now a single mother of two, she described the strain of living with debt hanging over her head. She had panic attacks, including “pain that shoots up the left side of your body and makes you feel like you’re about to have an aneurysm and you’re going to pass out,” she recalled.Ìý

Some hospitals say they want to alleviate that destructive cycle for their patients. Heywood Healthcare system in Massachusetts , essentially turning over control of that debt, in part because patients with outstanding bills were avoiding treatment.

“We wanted to eliminate at least one stressor of avoidance to get people in the doors to get the care that they need,” said Dawn Casavant, chief of philanthropy at Heywood. Plus, she said, “it’s likely that that debt would not have been collected anyway.”

One criticism of RIP’s approach has been that it isn’t preventive: The group swoops in after what can be years of financial stress and wrecked credit scores that have damaged patients’ chances of renting apartments or securing car loans. (The three major credit rating agencies recently to the way they will report medical debt, reducing its harm to credit scores to some extent. However, consumers often take out second mortgages or credit cards to pay for medical services.)

“A lot of damage will have been done by the time they come in to relieve that debt,” said Mark Rukavina, a program director for Community Catalyst, a consumer advocacy group.

Rukavina said state laws should force hospitals to make better use of their financial assistance programs to help patients. “Hospitals shouldn’t have to be paid,” he said. “Basically: Don’t reward bad behavior.”

Most hospitals in the country are nonprofit and in exchange for that tax status are required to offer community benefit programs, including what’s often called “charity care.” Depending on the hospital, these programs cut costs for patients who earn as much as two to three times the federal poverty level. But many eligible patients never find out about charity care — or aren’t told. They are billed full freight and then hounded by collection agencies when they don’t pay.

Recently, RIP started trying to change that, too.

RIP CEO Sesso said the group is advising hospitals on how to improve their internal financial systems so they better screen patients eligible for charity care — in essence, preventing people from incurring debt in the first place. Ultimately, that’s a far better outcome, she said.

“We prefer the hospitals reduce the need for our work at the back end,” she said. “I would say hospitals are open to feedback, but they also are a little bit blind to just how poorly some of their financial assistance approaches are working out.”

Terri Logan said no one mentioned charity care or financial assistance programs to her when she gave birth. Nor did Logan realize help existed for people like her, people with jobs and health insurance but who earn just enough money not to qualify for support like food stamps.

The debt shadowed her, darkening her spirits. “I don’t know; I just lost my mojo,” she said. “But I’m kinda finding it,” she added. Logan’s newfound freedom from medical debt is reviving a long-dormant dream to sing on stage.

Her first performance is scheduled for this summer.

About This Project

“Diagnosis: Debt” is a reporting partnership between KHN and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country.Ìý

Additional research was , which analyzed credit bureau and other demographic data on poverty, race, and health status for KHN to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute  from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with KHN on a survey of its clients to explore links between medical debt and housing instability.Ìý

KHN journalists worked with KFF public opinion researchers to design and analyze the “.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from KHN and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Incluso con seguro, Mangum pagó $36,000 de su bolsillo, cargos que surgieron del hospital, el cirujano, el anestesiólogo, la farmacia y la atención de seguimiento. Y todavía tiene que pagar alrededor de $7,000 más.

Mientras intentaba manejar su tratamiento y los costos médicos, Mangum recuerda haber pensado: “Debería poder resolver esto. Debería ser capaz de hacer esto por mí mismo”.

Pero los sistemas de facturación médica y seguro de salud en del país son complejos y muchos pacientes tienen dificultades para lidiar con ellos.

“Es increíblemente humillante, sentir que no tienes idea de qué hacer”, dijo Mangum.

Si te preocupa terminar endeudado durante una crisis de salud o tienes dificultades para hacer frente a las facturas que ya recibiste, no estás solo. Unas 100 millones de personas, incluido el 41 % de los adultos estadounidenses, tienen deudas de atención médica, según de KFF.

Pero puedes informarte y protegerte. KHN y NPR hablaron con pacientes, defensores de los consumidores e investigadores para saber cómo evitar o administrar las deudas médicas.

“No debería ser responsabilidad de los pacientes que están experimentando problemas médicos navegar por este complicado sistema”, dijo , abogado de atención médica del New Mexico Center on Law and Poverty. Pero los consumidores que se informan tienen más posibilidades de evitar las trampas de la deuda.

Eso significa conocer en profundidad varias políticas, la cobertura de su seguro, el programa de asistencia financiera de un hospital o las leyes de protección al consumidor del estado. Haz muchas preguntas y persiste. “No aceptes un ‘no’ por respuesta”, dijo Cordova, “porque a veces puedes obtener un ‘sí’”.

Incluso las personas con seguro de salud pueden endeudarse; de hecho, uno de los mayores problemas, dijeron los defensores de los consumidores, es que muchas personas no tienen seguro suficiente, lo que significa que pueden verse afectados por enormes costos de desembolso por los coseguros y deducibles altos.

Aquí hay algunos consejos prácticos sobre cómo enfrentar la deuda médica, en cada etapa de la atención y después.

Antes de recibir atención

Familiarísate con la cobertura de tu seguro y los gastos de bolsillo. Obtén la mejor cobertura que puedas pagar, incluso si estás sano. Asegúrate de saber cuáles serán los copagos, coseguros y deducibles. No dudes en llamar a la aseguradora y pedirle a alguien que te guíe a través de todos los posibles gastos de bolsillo. Tén en cuenta que no puedes realizar cambios en tu póliza, salvo durante ciertos períodos, como la inscripción abierta (generalmente en el otoño o principios del invierno), o después .

Si calificas, inscríbete en un seguro público. Si no tienes seguro pero necesitas atención médica, puedes calificar para cobertura pública como Medicaid o Medicare. Pregúntale al proveedor o al hospital si pueden ayudarte a verificar tu elegibilidad antes de comprometerte con un plan de atención, y luego utiliza a los proveedores que participan en esos programas.

Comprueba los detalles específicos de la atención que necesitas están cubiertos. Verifica si todos los proveedores que necesitas ver están dentro de la red de tu plan, y si alguna parte del tratamiento necesita autorización previa. Haz muchas preguntas a tu aseguradora, consultorio médico u hospital, especialmente para procedimientos planificados, dijo , abogada de Central California Legal Services, una firma de abogados de interés público. “¿Están mis autorizaciones vigentes? ¿Cuáles serán mis copagos? Averigua todo de antemano”, dijo.

, director de programas del grupo de defensa de equidad en salud Community Catalyst, dijo que si el medicamento que quieres no está cubierto por tu seguro, pregunta si el fabricante tiene un programa de asistencia al paciente; muchos tienen, aunque los requisitos de elegibilidad varían.

Obtén una estimación de costos. Si no tienes seguro, solicita una estimación de costos por adelantado. Rukavina señaló que el No Surprises Act, que entró en vigencia en enero, requiere que los proveedores proporcionen a los pacientes sin seguro de lo que costará la atención planificada.

Averigua si eres elegible para recibir asistencia financiera y prepárate para presentar tu caso. Casi todos los hospitales ofrecen algún tipo de asistencia financiera o “atención de caridad”. Cada hospital establece sus propios requisitos de elegibilidad pero, por lo general, eximirá o descontará las facturas de los pacientes que ganen menos de dos o tres veces el . (Tres veces el nivel federal de pobreza para un hogar de cuatro personas en 2022 sería $83,250).

Generalmente, las personas con trabajo aún califican para un descuento, si no para atención gratuita, dijo Jared Walker, fundador de , un grupo sin fines de lucro que ayuda a los pacientes a obtener atención de caridad. Su grupo desarrolló una base de datos de políticas de atención caritativa de hospitales y tiene una herramienta en línea que permite a los pacientes .

Incluso si no estás seguro si calificas, vale la pena intentarlo. Reúne documentos como colillas de pago o declaraciones de impuestos. No esperes que este sea un proceso fácil. Por ejemplo, dijo Walker, los proveedores de atención médica a menudo requieren que se envíe la documentación por fax.

Si ya calificaste para beneficios del gobierno, como el Programa de Asistencia Nutricional Suplementaria (SNAP) eso puede simplificar la solicitud de ayuda financiera de un hospital.

Si no eres ciudadano estadounidense o residente legal, verifica si tu estado prohíbe que el hospital considere el estatus migratorio, como es el caso de Nuevo México y Maryland.

Consulta por otras formas de asistencia financiera. Los servicios de ambulancia, que pueden generar facturas elevadas, pueden ofrecer programas de atención de caridad, así que pregunta si calificas. También consulta con tus proveedores médicos si saben de otros programas caritativos que cubrirían los costos de cosas como transporte a citas médicas.

Durante el tratamiento o poco después

Pide el detalle de los costos de cada servicio, receta o tratamiento que recibas. Presta atención a los costos a medida que aumentan, dijo Lori Mangum, paciente de cáncer de Louisville, quien ahora es directora de operaciones de Gilda’s Club Kentuckiana, un grupo de apoyo que la ayudó a ella como paciente. Pídele a un familiar o a tu grupo que te ayude a llevar un registro, agregó. Y nunca asumas que solo porque el seguro cubre una parte de tu tratamiento, lo mismo aplica a todo lo demás.

Examinar todo con lupa puede ayudarte a evitar costos. Mangum dijo que se dio cuenta demasiado tarde de que podría haber tomado su propio Tylenol, en lugar de pagar sobreprecios “exorbitantes” por el mismo medicamento en el hospital. Dijo que la autodefensa comienza con presionar para obtener respuestas sobre cuánto costará cada servicio, tratamiento y medicamento. Y por adelantado, si es posible.

Verifica si todos los proveedores están dentro de la red. Las protecciones al consumidor en el No Surprise Act deberían ayudar a limitar los cargos fuera de la red. Esa ley prohíbe la facturación “sorpresa” para la mayoría de los cuidados de emergencia, así como para cierta atención de rutina con proveedores fuera de la red. También limita lo que los proveedores pueden facturar a los médicos fuera de la red, explicó Rukavina, y brinda a los pacientes una mayor capacidad para disputar los cargos.

Asegúrate de que todos tus proveedores, incluido un anestesiólogo, por ejemplo, estén dentro de la red de tu plan. Si no se te informó con anticipación, puede valer la pena apelar ese cargo.

Rukavina señaló que si no tienes seguro y solicitas un presupuesto por adelantado, puedes apelar las facturas que excedan los $400. Rukavina recomendó llamar a del gobierno al 1-800-985-3059. Para los pacientes con quejas, recomendó presentar una ante la Oficina de Protección Financiera del Consumidor.

Consulta por doble facturación. Revisa cada item en tu factura. Mangum dijo que “no es raro que algo se facture dos veces”. Incluso si ya has sido dado de alta y te atrasaste en los pagos, vale la pena verificar para asegurarte de que no te hayan cobrado de más.

Negocia directamente con el hospital. Defensores de los consumidores dijeron que la gente piensa erróneamente que los costos médicos son fijos y no negociables. Ese fue el caso de John DeAnda, quien se desmayó mientras trabajaba como limpiador en un hospital de Nuevo México. Los médicos no pudieron determinar qué le pasaba después de cuatro días de pruebas, pero el hospital le facturó $8,000, que todavía está tratando de pagar, con intereses, nueve años después.

“En realidad, no me di cuenta de que podía negociar”, dijo DeAnda. “Lo que hubiera hecho diferente es que primero hubiera hablado con el hospital, para ver si podían llegar a un acuerdo conmigo” antes de enviaran las facturas a agencias de cobros. Un proceso que es costoso para los hospitales y que quieren evitar, dijo , profesora de contabilidad y políticas de salud de la Universidad Johns Hopkins.

Pregunta una y otra vez sobre cualquier otra forma de asistencia financiera que el hospital pueda ofrecer. Negocia los términos de pago a un nivel mensual que sea asequible para tí.

Prioriza los alimentos y vivienda sobre las facturas médicas. Las instituciones financieras y los prestamistas tratan la deuda médica de manera diferente a las facturas de consumo impagas. Las personas optan por pedir un préstamo para comprar un auto; no eligen enfermarse o lesionarse. Entonces, el hecho de que las personas tengan deudas médicas no significa que no sean confiables o que tengan menos probabilidades de pagar sus facturas en general. Las tres principales agencias de calificación crediticia que las facturas médicas impagas no afectarán los puntajes de crédito de las personas durante un año. Una vez que se paga una factura, debe salir de su informe de crédito inmediatamente. A partir de 2023, las deudas médicas impagas de menos de $500 tampoco deberían aparecer en los informes.

Eso significa que debe concentrarse primero en pagar las necesidades de la vida: alquiler o hipoteca, gasolina para ir al trabajo y alimentos, dijo Marceline White, directora ejecutiva de la Coalición de Derechos del Consumidor de Maryland.

No aceptes tarjetas de crédito que ofrezcan pagar tus facturas médicas. Los expertos advierten contra el uso de tarjetas de crédito ofrecidas por dentistas, hospitales y consultorios médicos para pagar los gastos médicos. Una vez que tengas la tarjeta, la deuda se agrupará con cualquier otra forma de deuda de consumo, al igual que si gastaras de más en ropa o en un SUV de lujo. Esa es una de las razones por las que la deuda médica a menudo no se informa; gran parte se “camufla” como otras formas de deuda. Una vez que una factura médica entra en una tarjeta de crédito o un préstamo personal, es más probable que perjudique tu puntaje de crédito y, por lo tanto, tu capacidad para pedir préstamos en el futuro.

Si ya tiene deudas, y si están en agencias de cobro

Trata de calificar, incluso después del hecho, para atención de caridad. Los hospitales a veces pasan por alto o no evalúan a los pacientes elegibles para sus programas de asistencia financiera. Los hospitales sin fines de lucro están obligados por ley a ofrecer atención caritativa y otros beneficios comunitarios. Aquí es donde la autodefensa puede hacer la mayor diferencia. A veces, los hospitales califican retroactivamente a los pacientes y cancelan sus deudas. Los voluntarios de Dollar For ayudarán a los pacientes a lograrlo.

Disputa tu factura si es inexacta. Rukavina dijo que, según el Fair Debt Collection Practices Act, los cobradores de deudas deben proporcionar un aviso por escrito, dentro de los cinco días posteriores a contactar a un paciente, detallando el monto adeudado, el nombre del acreedor y cómo disputar la factura. Los pacientes pueden disputar facturas inexactas si responden dentro de los 30 días.

Contacta a servicios de asistencia jurídica gratuitos. Abogados de todo el país de forma gratuita para resolver casos legales, incluidos los casos de deudas médicas. A menudo tienen experiencia en el trato con hospitales y empresas de cobro, y podrían defender tu caso en tu nombre, especialmente si uno o ambos han violado las leyes de protección al consumidor de tu estado.

No ignores el problema. El impulso es comprensible, pero no ayudará y probablemente hará que la deuda sea aún más complicada de abordar, dijo Rukavina. Por desalentador que pueda ser, trata de seguir abogando por tí y por tu familia, y busca ayuda.

ACERCA DE ESTE PROYECTO

“Diagnóstico: Deuda” (Diagnosis: Debt) es una colaboración periodística entre KHN y NPR que explora la magnitud, el impacto y las causas de la deuda médica en Estados Unidos.

La serie se basa en un sondeo nacional llevado a cabo por KFF para la investigación que encuestó a una muestra representativa de 2,375 adultos estadounidenses, entre los que se encontraban 1,674 con deudas actuales o pasadas por facturas médicas o dentales.

 hizo una investigación adicional, en la que se analizaron datos de la oficina de crédito y otros datos demográficos sobre la pobreza, la raza y el estado de salud para explorar dónde se concentra la deuda médica en Estados Unidos y qué factores se asocian con los altos niveles de deuda.

El Instituto JPMorgan Chase  de una muestra de titulares de tarjetas de crédito de Chase para ver cómo los saldos de los clientes pueden verse afectados por gastos médicos importantes.

Los reporteros de KHN y NPR también realizaron cientos de entrevistas con pacientes de todo el país; hablaron con médicos, líderes de la industria de la salud, defensores del consumidor, abogados especializados en deudas e investigadores; y revisaron decenas de estudios y encuestas sobre la deuda médica.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Even with insurance, Mangum paid $36,000 out-of-pocket, charges that stemmed from the hospital, the surgeon, the anesthesiologist, the pharmacy, and follow-up care. And she still has about $7,000 more to pay.

While she was trying to manage her treatment and medical costs, Mangum remembers thinking, “I should be able to figure this out. I should be able to do this for myself.”

But medical billing and health insurance systems in the U.S. are complex, and many patients have difficulty navigating them.

“It’s incredibly humbling — and sometimes even to the point of humiliating — to feel like you have no idea what to do,” Mangum said.

If you’re worried about incurring debt during a health crisis or are struggling to deal with bills you already have, you’re not alone. Some 100 million people — including 41% of U.S. adults — have health care debt, according to a by KFF.

But you can inform and protect yourself. KHN and NPR spoke with patients, consumer advocates, and researchers to glean their hard-won insights on how to avoid or manage medical debt.

“It shouldn’t be on the patients who are experiencing the medical issues to navigate this complicated system,” said , a health care lawyer with the New Mexico Center on Law and Poverty. But consumers who inform themselves have a better chance of avoiding debt traps.

That means knowing the ins and outs of various policies — whether it’s your insurance coverage, or a hospital’s financial assistance program, or a state’s consumer protection laws. Ask a lot of questions and persist. “Don’t take ‘no’ for an answer,” said Cordova, “because sometimes you might get a ‘yes.’”

Even people with health insurance can land in debt; indeed, one of the biggest problems, consumer advocates said, is that so many people are underinsured, which means they can get hit with huge out-of-pocket costs from coinsurance and high deductibles.

Here is some practical advice about facing down medical debt, at every stage of care and after.

Before You Get Care

Get familiar with your insurance coverage and out-of-pocket costs. Get the best insurance coverage you can afford — even when you’re healthy. Make sure you know what the copays, coinsurance, and deductibles will be. Don’t hesitate to call the insurer and ask someone to walk you through all the potential out-of-pocket costs. Keep in mind that you cannot make changes to your policy except during certain windows of time, such as open enrollment (typically in the fall or early winter) or after a .

Sign up for public insurance if you qualify. If you’re uninsured but need health care, you might qualify for public insurance like Medicaid or Medicare. Ask the provider or hospital if they can help you check your eligibility before you commit to a care plan — and then stay with providers who participate in those programs.

Check whether the specifics of your care are covered. After your doctors map out your treatment plan, check whether all the providers you need to see are in-network and whether any part of the treatment needs to be preauthorized. Ask lots of questions of your insurance provider, doctor’s office, or hospital, especially for planned procedures, said , a lawyer at Central California Legal Services, a public interest law firm. “‘Are my authorizations in place? What are my copays going to be?’ Find all that out beforehand, if you can,” she said.

Additionally, said , a program director at health equity advocacy group Community Catalyst, if the drug you want isn’t covered by your insurance, ask whether the drugmaker has a patient assistance program; many do, though eligibility requirements vary.

Get a cost estimate. If you’re uninsured, ask for a cost estimate in advance. Rukavina noted that the federal No Surprises Act, which took effect in January, requires providers to give uninsured patients of what planned care will cost.

Find out whether you’re eligible for financial assistance — and come prepared to make your case. Almost every hospital offers some form of financial assistance, or “charity care.” Each hospital sets its own eligibility requirements but typically will waive or discount bills for patients earning less than two to three times the . (Three times the federal poverty level for a household of four in 2022 would be $83,250.)

People who are employed often still qualify for a discount, if not for free care, said Jared Walker, founder of , a nonprofit group that helps patients secure charity care. His group developed a database of hospital charity care policies and has .

Even if you’re not sure whether you qualify, it’s worth trying. Gather up documents such as pay stubs or income tax returns. Do not expect this to be an easy process. For example, Walker said, health care providers often require documentation to be faxed. “One of the most common refrains I heard from experts: Persistence pays,” Walker said.

If you’ve already qualified for government benefits like the Supplemental Nutrition Assistance Program, or SNAP, that may streamline applying for a hospital’s financial aid.

If you’re not a U.S. citizen or legal resident, check whether your state bars the hospital from considering immigration status, as is the case in New Mexico and Maryland.

Check for other forms of financial assistance. Ambulance services, which can lead to huge bills, might offer charity care programs, so ask whether you qualify. Also ask your medical providers if they know of other charitable programs that would cover costs for things like rides to medical appointments.

During Treatment or Soon After

Ask for line items of the costs for every service, prescription, or treatment you receive. Keep an eye on costs as they come up, said Louisville cancer patient Lori Mangum, who is now chief operating officer of Gilda’s Club Kentuckiana, a cancer support group she relied on. Ask a family member or a support group to help you keep track, she said. And never assume that just because insurance covers one part of your treatment, that goes for everything else.

Scrutinizing your care can help you avoid costs. Mangum said she realized too late that she could’ve taken her own Tylenol, instead of paying “exorbitant” markups on the same medicine at the hospital. She said self-advocacy begins with pressing for answers about how much each service, treatment, and medication will cost — in advance, if possible.

Check whether providers are in-network. Consumer protections in the No Surprises Act should help limit out-of-network charges. That law bans “surprise” billing for most emergency care, as well as for some routine care with out-of-network providers. It also limits what providers can bill for out-of-network doctors, Rukavina said, and gives patients greater ability to dispute charges.

Make sure all your providers — including an anesthesiologist, for example — are in-network for your insurance. If it wasn’t disclosed to you in advance, that charge may be worth appealing.

Rukavina noted that if you are not insured or not using your insurance and asked for an estimate in advance, you can dispute bills that exceed the estimates by $400. For patients seeking more information about the No Surprises Act and what it covers, Rukavina recommended calling the government’s at 1-800-985-3059. For patients with complaints, he recommended filing an with the Consumer Financial Protection Bureau.

Check for double billing. Go through each item on your bill. Mangum said that “it’s not infrequent for something to be double-billed.” Even if you’ve already been discharged and gotten behind on payments, it is worth checking to make sure you weren’t overcharged.

Negotiate with the hospital directly. Consumer advocates said people mistakenly think medical costs are fixed and nonnegotiable. That was the case for John DeAnda, who fainted while working as a cleaner at a New Mexico hospital. Doctors couldn’t figure out what was wrong with him after four days of tests, but the hospital billed him for $8,000, which he’s still trying to pay off, with interest, nine years later.

“I actually didn’t realize you could negotiate,” said DeAnda. “What I would’ve done differently is I would’ve talked to the hospital first, to see if they could work out a deal with me” before the bills were sent to collections.

If you know you cannot pay the bill, negotiate with the hospital administration or billing department. “That’s almost always possible” because hospitals want to avoid the costly administrative burden of sending bills to collections, said , a professor of accounting and health care policy at Johns Hopkins University.

Ask repeatedly about any other forms of financial assistance the hospital might offer. Negotiate the terms of payment to a monthly level that is affordable for you. This also saves the hospital the administrative headaches of unpaid bills, and it might help you avoid having bills sent to collections.

Prioritize paying for food and shelter over medical bills. Financial institutions and lenders treat medical debt differently than unpaid consumer bills. People choose to take a loan to buy a car; they don’t choose to get ill or injured. So just because people have medical debt does not mean they are unreliable or less likely to pay their bills in general. The three major credit-rating agencies that unpaid medical bills will not affect people’s credit scores for a year. Once a bill is paid, it should come off your credit report immediately. Starting in 2023, unpaid medical debt under $500 should not appear on reports either.

That means you should focus first on paying for life necessities — rent or mortgage, gas to get to work, and food, said , executive director of the Maryland Consumer Rights Coalition.

Do not sign up for credit cards that offer to pay medical bills for you. Experts warn against using credit cards offered by dentists, hospitals, and doctors’ offices to pay medical charges. Once you take out credit cards, personal loans, or second mortgages, the debt will get lumped in with any other form of consumer debt — the same as if you overspent on clothes or a luxury SUV. That’s one reason medical debt is often underreported; a lot of it masquerades as other forms of debt. Once you convert a medical bill to a credit card or personal loan, it’s more likely to hurt your credit score and therefore your ability to borrow in the future.

If You Are Already in Debt or in Collections

Try to qualify, even after the fact, for charity care. Hospitals sometimes overlook or fail to screen patients eligible for their financial assistance programs. Nonprofit hospitals are required by law to offer charity care and other community benefits. This is where self-advocacy can make the biggest difference. Sometimes hospitals will retroactively qualify patients and write off their debts. Volunteers at will help patients push for that.

Dispute your bill if it is inaccurate. Rukavina said that under the Fair Debt Collection Practices Act, debt collectors are required to provide a written notice, within five days of contacting a patient, detailing the amount owed, the name of the creditor, and how to dispute the bill. Patients can dispute inaccurate bills if they respond within 30 days. Rukavina said even patients whose bills are in collections can tell bill collectors they wish to apply for financial assistance if they haven’t already. If the patient qualifies, the collector cannot charge more than what the patient would’ve had to pay.

Contact free legal aid services. free of charge to resolve legal cases, including medical debt cases. They often have experience dealing with hospitals and third-party collections companies and might be able to argue your case on your behalf, especially if one or both have violated your state’s consumer protection laws.

Do not ignore the issue. The impulse is understandable, but it will not help and will likely make the debt even more complicated to address, said Rukavina. As daunting as it might be, try to keep advocating for yourself and your family and get help.

About This Project

“Diagnosis: Debt” is a reporting partnership between KHN and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country.Ìý

Additional research was , which analyzed credit bureau and other demographic data on poverty, race, and health status for KHN to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute  from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with KHN on a survey of its clients to explore links between medical debt and housing instability.Ìý

KHN journalists worked with KFF public opinion researchers to design and analyze the “.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from KHN and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Some lost their homes. Some emptied their retirement accounts. Some struggled to feed and clothe their families. Medical debt now touches more than 100 million people in America, as the U.S. health care system pushes patients into debt on a mass scale. Debtors are from all walks of life and all corners of the country. Here are their stories ― how they got into debt, what they’ve given up for it, and how they’re living with the burden.

An Air Force career held up because of debt owed for medical bills

By Aneri Pattani, KHN

Samaria Bradford, 27, Goldsboro, North Carolina

Approximate Medical Debt: $5,000

Medical Issue: Emergency room care

What Happened: In late August 2022, Samaria Bradford was prepared to leave for basic training any day. She’d been in contact with an Air Force recruiter. Her qualifying test score from two years earlier was still valid, and she’d lost weight to meet the physical requirements. She felt so good about it that she gave two weeks’ notice at her nursing home job.

Then the recruiter sent a text: “We got your credit check back you have multiple accounts in collects.”

Bradford had unpaid bills — mostly from hospitals and ambulance companies — that had gone to collections. The recruiter said she needed to set up payment plans to address the debts before she could enlist.

“I was very upset and surprised,” Bradford said. “I didn’t know your medical debt could stop you from joining.”

Bradford had dreamed of enlisting in the Air Force for years. She took the qualifying exam in 2020 but delayed her enlistment so she could stay close to home and support her younger sister, who was in high school at the time.

She worked a variety of jobs to stay afloat — as a cashier, then as a cook and a staff member at a bowling alley for a bit. Later, she took overnight shifts at a hospital. The pay covered rent, utilities, and food, but she had little left over.

Most of the jobs didn’t offer benefits, and since North Carolina had not expanded Medicaid, Bradford did not qualify for the public insurance.

Over the years, when she landed in the emergency room without insurance, bills racked up quickly. One time, she had a rash along her back that she feared was an allergic reaction. Another time, she was dehydrated and had to be brought to the hospital by ambulance. A car wreck led to another visit.

By 2022, when the Air Force recruiter looked into her finances, Bradford owed roughly $5,000 spread across a half-dozen bills. In response to his text about the debts, she wrote, “I’m guessing is doctor bills?”

What’s Broken: Several branches of the military check financial histories when evaluating recruits. “Credit checks aid in determining recruit financial responsibility while aiming to safeguard national security,” said Christine Cuttita, an Air Force Recruiting Service spokesperson. Depending on the particulars of the case, she confirmed, an individual can be disqualified from enlisting because of debt.

Red flags on a credit report include late payments, long-term debts, or total debt — including student loans, mortgages, and medical debt — that exceeds 40% of the person’s income. There’s no strict disqualifier; rather, a squadron commander evaluates each case and assesses it in the “best interest of the Air Force,” Cuttita said.

Employers in other sectors also commonly use credit checks to evaluate candidates.

However, medical debts should be treated differently than other debts.

The CFPB found that unlike credit card debt, medical bills that have gone to collections aren’t an accurate predictor of someone’s likelihood to pay bills. In fact, the agency determined that people with “paid medical collections were less likely to be delinquent than other consumers with the same credit score.”

The Biden administration this year advised federal lenders to when evaluating loan applications. VantageScore, one of the companies that calculate consumers’ credit scores, has said it will in its formula.

But running credit checks on job candidates remains common. For those with medical debt, that can mean being turned away from jobs because of the bills they are trying to pay off.

What’s Left: After receiving the recruiter’s text, Bradford set out to make payments on as many medical bills as she could. Using savings from the nursing home job she had recently left, she closed out two accounts on which she owed a few hundred dollars and made smaller payments toward bills of $1,000 or more.

But, it turned out, those were not the debts showing up on the Air Force credit check.

“Of the five payments I made, only one of them was connected to what my recruiter saw on his end,” Bradford said.

Medical debts can be difficult to track, especially once hospitals and doctors’ offices sell them to collection agencies. A given bill may be reported to one credit agency but not another, meaning any single report cannot give a full picture of someone’s debt.

Adding to the confusion, the credit check that Bradford’s recruiter shared with her showed the amount of each debt but not to whom it was owed.

Bradford is now getting help to track down each debt from a friend who used to work in hospital billing. She has also taken a new job to ensure she can pay down those bills.

With the time that has passed, her previous score for the Air Force’s qualifying test is no longer valid. She’s planning to retake the exam and try to enlist next year.

“I’m trying to solve the problem now to go ahead,” Bradford said. But she still questions why the Air Force would delay anyone’s enlistment for this kind of debt.

“If you need people to be there for the country and to fight for the country,” she said, “why would you hold them up for a medical bill?”

Her credit was ruined by medical debt. She’s been turned away from doctors, jobs, and loans

By Aneri Pattani, KHN

Penelope Wingard, 58, Charlotte, North Carolina

Approximate Medical Debt: More than $50,000

Medical Issue: Breast cancer

What Happened: After a year of chemo and radiation, in 2014, Penelope Wingard finally heard the news she’d been praying for: Her breast cancer was in remission. But with relief immediately came worry about her finances.

Wingard had received Medicaid coverage through a temporary program for breast cancer patients. When her treatment ended, she became uninsured.

Bills for follow-up appointments, blood tests, and scans quickly piled up. Soon, her oncologist said he wouldn’t see her until she paid down the debt.

“My hair hadn’t even grown back from chemo,” Wingard said, “and I couldn’t see my oncologist.”

It took about six months to find a doctor who would see her while unpaid bills accrued.

Wingard was later diagnosed with an aneurysm that required brain surgery and, separately, vision problems that prompted corneal transplants in both eyes. Within a few years, she was buried under tens of thousands of dollars in medical debt.

She learned to recognize the phone numbers of bill collectors and ignore the past-due notices arriving in the mail. She wanted to pay them but had to prioritize rent, utilities, and food. After taking care of those expenses, she had little money left from her jobs as a covid-19 contact tracer and a driver for ride-hailing services.

The unpaid medical bills began hitting her credit. Soon, she struggled to qualify for loans. Applying for apartments and jobs became a nightmare.

“It’s like you’re being punished for being sick,” Wingard said.

What’s Broken: Unpaid medical bills can be reported to credit agencies and show up as black marks on a person’s financial record, making it harder to qualify for a car loan, rent an apartment, or get a job.

Earlier this year, three national credit agencies that would remove from credit reports paid medical debts and those that are less than $500 even if they are unpaid.

The changes, slated to go into full effect in 2023, are expected to benefit an estimated 16 million Americans.

But millions of Americans who owe far more than $500 may not benefit — 1 in 4 U.S. adults with health care debt owe more than $5,000, according to conducted for this project; 1 in 8 owe more than $10,000.

A by the Consumer Financial Protection Bureau also suggests that the changes to credit reports may disproportionately benefit wealthier Americans living in predominantly white neighborhoods. They’re more likely to have health insurance, experts say, and collections under $500 often come from an unpaid copay or coinsurance.

In contrast, people with the highest levels of medical debt tend to be Black or Hispanic, have low incomes, and live in the South. According to the KFF poll, 56% of Black adults and 50% of Hispanic adults said they have debt because of medical or dental bills, compared with 37% of white adults. And a found that medical debt was highest within low-income communities and in Southern states that had not expanded Medicaid.

As an uninsured Black woman living in North Carolina, Wingard sits squarely among the communities hit hardest by medical debt. Yet she will not benefit from the credit agencies’ new policies.

What’s Left: Wingard has resigned herself to living with medical debt. That means worrying that another doctor will turn her away because of unpaid bills and having employers reject her from jobs because poor credit shows up as a red flag on background checks.

Her fridge and stove have both been broken for over a year. She can’t qualify for a loan to replace them, so instead of making baked chicken from her favorite family recipe, she often settles for a can of soup or fast-food chicken wings.

But there are signs that help is on the way. The Biden administration the Consumer Financial Protection Bureau to investigate whether medical debt should ever appear on credit reports, and some states — including North Carolina — are considering strengthening protections against medical debt.

Wingard is hopeful she’ll get relief soon. “I’m hoping someone will listen and say we need to focus more on health care for all Americans,” she said. “I don’t know if they will, but it’s just a blind hope.”

A retiree returns to work after a calamitous year of health emergencies

By Noam N. Levey, KHN

David Zipprich, 65, Fort Worth, Texas

Approximate Medical Debt: More than $200,000

Medical Issue: Diabetes and covid-19

What Happened: David Zipprich, a Fort Worth businessman and grandfather, was forced out of retirement after a series of hospitalizations left him owing more than $200,000.

Zipprich had spent a career in financial consulting. He owned a small bungalow in a historical neighborhood near the Fort Worth rail yards. His daughters, both teachers, and his four grandchildren lived nearby. He had health insurance and some savings, and he’d paid off his mortgage.

In early 2020, though, Zipprich landed in the hospital. While he was driving, his blood sugar dropped precipitously, and he blacked out and crashed his car.

Three months later, after he was diagnosed with diabetes, another complication sent him back to the hospital. In December 2020, covid-19 put him there again. “I look back at that year and feel lucky I even survived,” Zipprich said.

What’s Broken: Of the nation’s 20 most populous counties, none has a higher prevalence of medical debt than Tarrant County, where Fort Worth is located. Second is adjacent Dallas County, credit bureau data shows.

Nevertheless, Dallas-Fort Worth medical systems have been thriving. Though many are exempt from taxes as nonprofit institutions, several notched double-digit profit margins in recent years, outperforming many of the area’s Fortune 500 companies.

A KHN review of hospital finances in the country’s 306 hospital markets found that several of the most profitable markets also have some of the highest levels of patient debt.

Overall, about a third of the 100 million adults in the U.S. with health care debt owe money for a hospitalization, according to . About a quarter of those owe $10,000 or more.

“The fact is, if you walk into a hospital today, chances are you are going to walk out with debt, even if you have insurance,” said Allison Sesso, chief executive of RIP Medical Debt, a nonprofit that buys debt from hospitals and debt collectors so patients won’t have to pay it.

Overall in Tarrant County, 27% of residents with credit reports have medical debt on their records, credit bureau data analyzed by KHN and the nonprofit Urban Institute shows. In Dallas County, it’s 22.5%

What’s Left: Even with insurance, Zipprich was inundated with medical bills, debt notices, and calls from collectors.

As he struggled to pay, his credit score plummeted below 600, and he had to refinance his home. “My stress was off the charts,” he said, sitting in his tidy living room with his Shih Tzu, Murphy.

Last year, Zipprich returned to work, taking a job in New Jersey that required him to commute back and forth to Texas. He recently quit, citing the strain of so much travel. He’s job-hunting again. “I never thought this would happen to me,” he said.

From her view in Knoxville, the health system is ‘not designed for poor people’

By Noam N. Levey, KHN

Monica Reed, 60, Knoxville, Tenn.

Approximate Medical Debt: $10,000

Medical Issue: Cancer

What Happened: Monica Reed considers herself luckier than most. Born in Knoxville and raised by a single mother, Reed became the first in her family to own a home, a small house built after the city demolished The Bottom, a once thriving Black neighborhood that was systematically wiped out in a midcentury urban renewal campaign. For the past 15 years, Reed has worked for a faith-based nonprofit that assists low-income residents of Knoxville.

“It hasn’t always been easy,” Reed said. She raised her son by herself. And though she’s always worked, her modest salary made saving difficult. “I just tried to live a frugal kind of life,” she said. “And by the grace of God, I didn’t become homeless.”

She couldn’t escape medical debt, though. Diagnosed with cancer five years ago, Reed underwent surgery and chemotherapy. Although she had health insurance through work, she was left with close to $10,000 in medical bills she couldn’t pay.

What’s Broken: In and around Knoxville, residents of predominantly Black neighborhoods are more than twice as likely as those in largely white neighborhoods to owe money for medical bills, Urban Institute shows. That is one of the widest racial disparities in the country.

Health care debt in the U.S. now affects more than 100 million people, according to conducted for this project. The toll has been especially high on Black communities: Fifty-six percent of Black adults owe money for a medical or dental bill, compared with 37% of white adults.

The explanation for that startling disparity is deeply rooted. Decades of discrimination in housing, employment, and health care blocked generations of Black families from building wealth — savings and assets that are increasingly critical to accessing America’s high-priced medical system.

Against that backdrop, patients suffer. People with debt avoid seeking care and become sicker with treatable chronic conditions like diabetes or multiple sclerosis. Worse still, hospitals and doctors sometimes won’t see patients with medical debt — even those in the middle of treatment.

Nationwide, Black adults who have had health care debt are twice as likely as white adults with such debt to say they’ve been denied care because they owe money, the KFF poll found. Many Black Americans also ration their care out of fear of cost.

If Black patients go into debt, they face yet another challenge: a medical debt collection industry that more aggressively than their white counterparts, particularly for smaller debts.

What’s Left: Reed has been pursued by debt collectors and even taken to court. That has forced Reed to make difficult choices. “There’s always a sacrifice,” she said. “You just do without some things to pay for other things.”

Reed said she cut back on trips to the grocery store: “I don’t buy a lot of food. Just plain and simple.”

She has adjusted, she said. “You just do what you have to do.” What angers Reed, though, is how she’s been treated by the cancer center where she goes for periodic checkups to make sure the cancer remains in remission. When she recently tried to make an appointment, a financial counselor told her she couldn’t schedule it until she made a plan to pay her bills.

“I was so upset, I didn’t even find out how much I owed,” Reed said. “I mean, I wasn’t calling about a little toothache. This is something that affects someone’s life.”

Reed said she tries to stay upbeat. “I don’t sweat the small stuff,” she said. “What am I going to do against this hospital?”

But, she said, she has realized one thing about the nation’s health care system: “It’s not designed for poor people.”

A medical cost-sharing plan left pastor with most of the cost

By Bram Sable-Smith, KHN

Jeff King, 63, Lawrence, Kansas

Approximate Medical Debt: $160,000

Medical Issue: Heart ablation

What Happened: Kareen King calls it “the ultimate paradox”: The hospital that saved her husband’s heart also broke it.

Jeff King needed his heart rhythm restored to normal with a procedure called an ablation — sooner rather than later, his doctor said. Jeff asked the hospital for a cost estimate but said he didn’t hear back before his scheduled surgery in January 2021 at Stormont Vail Health in Topeka, Kansas.

The real pain came when the $160,000 bill arrived in the mail a few weeks later. The Kings, who were uninsured at the time, were on the hook for nearly all of it.

For health coverage, they’d joined a medical cost-sharing plan with a company called Sedera, which describes its service as a “refreshing non-insurance approach to managing large and unexpected healthcare costs.” With this alternative to health insurance, members agree to share one another’s expenses. The plans are often faith-based and have surged in popularity because they can be cheaper than traditional insurance — the Kings said their plan cost $534 a month, plus an additional $118 a month to join a direct primary care medical practice.

But the sharing plans offer fewer protections than insurance and come with provisos. The Kings said their plan did not fully cover preexisting conditions like Jeff’s heart condition for the first two years of coverage — and he needed the surgery after 16 months.

In a statement, a Sedera spokesperson said it’s important that members understand the cost-sharing model and membership guidelines. “Sedera members read and agree to these prior to joining,” the statement read.

The Kings have dabbled in all sorts of health coverage in their 42 years of marriage. Jeff’s work as an evangelical pastor in his hometown of Osage City, Kansas, almost never provided insurance for the couple or their five children, all of whom are now grown. The exception came during Jeff’s most recent stint leading a congregation, starting in 2015. Kareen remembered feeling “unworthy” of the $1,800 a month the congregation paid for their insurance.

“We certainly had never come up with those kinds of premiums ourselves,” she recalled.

But Jeff decided he had to leave that job in 2018. He said he felt forced out over differences with some of his congregants on eternal damnation (“As a loving parent, I could never punish my child forever”) and gay marriage (“Maybe God is a whole lot more inclusive than we are”).

After Jeff resigned, the Kings briefly bought insurance through the Affordable Care Act marketplace but later dropped it because they weren’t eligible for subsidies and felt they couldn’t afford it.

That’s when they joined the Sedera plan. They knew the preexisting condition clause was a gamble, but medication had managed Jeff’s heart condition for years, and they didn’t expect he’d need medical procedures to address it.

What’s Broken: Without employer-sponsored insurance or federal subsidies to help fund their coverage, the Kings felt priced out of traditional insurance. But being uninsured left them exposed to hospital charges that ordinary patients typically never see.

Hospital charges are generally understood by health economists to  to the actual . Instead, they are more of an opening salvo in the high-stakes negotiations between hospitals trying to get as much money as they can for providing care and insurance companies trying to pay as little as possible.

But patients lack the bargaining power of large insurers, which may cover hundreds of thousands of patients in any given hospital’s catchment area. For patients like Jeff, the main recourse is to go through a hospital’s financial assistance program, although even with that help many patients can’t afford the bills hospitals send them.

Stormont Vail’s assistance program eventually knocked about $107,000 off Jeff’s original bill. Sedera provided a negotiator to help him haggle over costs.

Stormont Vail provided $19.5 million in financial assistance in tax year 2020 and wrote off about $13 million in bad debt, according to tax filings. Its net revenue from patient services was $838.7 million.

Bill Lane, a Stormont Vail administrator, said that in addition to providing financial assistance, the hospital works with patients facing high bills and offers payment plans with zero interest. Payments are often in the range of 10% of a person’s monthly income, Lane said. For some patients the hospital has a “catastrophic discount” program that caps their balance at 30% of their gross household income. The hospital also works with a local bank to provide loans to patients to pay their bills. And the hospital sometimes sends patients’ balances to debt collection agencies.

Lane said he generally recommends for patients to carry traditional insurance. He also said the hospital now offers a “patient estimates module” and suggests patients wait to schedule surgery, if possible, if they want an estimate “to make an informed decision.”

What’s Left: Despite Sedera’s two-year waiting period to cover preexisting conditions, the plan did give Jeff $15,000 to help with his bills. After Jeff paid that to the hospital and then negotiated for several months, his final balance was reduced to $37,859.34 in November 2021.

For his payment plan, Jeff said he was told the hospital would accept no less than $500 per month — the equivalent of an additional mortgage payment for the Kings. Jeff estimates it will take the family more than six years to pay it off.

“I never expected this to not cost me anything,” Jeff said, “but I wasn’t expecting what it turned out to be either.”

The Kings are piecing together the funds to pay what they owe the hospital. A few months after Jeff’s ablation, they sold their home in Osage City — where they raised five children and where Jeff grew up — and bought a smaller house in Lawrence. They had hoped to use that money to build their retirement account, since Jeff’s decades of pastoral work didn’t include a pension or 401(k).

Instead, the home sale is helping pay Jeff’s medical debt. Kareen has part-time jobs, and the couple leveraged their life insurance policy, as well.

Jeff began work as a hospice chaplain — for the extra income, but especially to qualify the couple for health insurance. That meant less time for his passion project, running a  through which he provides spiritual guidance.

In February, Kareen checked again on whether the couple could afford Affordable Care Act insurance so Jeff could get back to Transmuto full time. Her Google searches for the federal government’s health insurance marketplace (healthcare.gov) instead unwittingly landed her on websites that sell consumer information to insurance brokers. Speaking to one of those brokers on the phone, she bought what she said she was told was an Aetna plan. But it turned out to be a membership in a cost-sharing plan with a company called Jericho Share, which has received  on the Better Business Bureau website in the past year.

Jericho Share spokesperson Mark Hubbard said in a statement that the organization is “issuing full refunds when there is consumer confusion” and is continuing to “evaluate and update our marketing efforts to increase transparency and awareness.”

Hubbard also said Jericho Share is cooperating with regulators in California and  that have questioned whether the organization meets state requirements of a health care sharing ministry. California is also questioning whether Jericho Share has indeed received 501(c)(3) nonprofit status from the IRS.

After canceling that plan and getting their money back, the Kings eventually did sign up for an Affordable Care Act marketplace plan. Jeff has reduced his hours as a chaplain, freeing up more time for Transmuto. All in all, the couple feels pretty fortunate.

“It’s just so tragic the way our system is,” Jeff said. “It puts so many people into impossible financial straits.”

Double shifts, credit card debt, and family loans when twins were born early

By Noam N. Levey, KHN

Allyson Ward, 43, Chicago

Approximate Medical Debt: $80,000

Medical Issue: Childbirth

What Happened: There were times after her sons were born 10 years ago when Allyson Ward wondered whether she and her family would lose their home.

On some days, she would tick through a list of friends and family, considering who could take them in. “We had a plan that we were not going to be homeless,” Ward recalled.

Ward is a nurse practitioner who works at a neonatal intensive care unit in Chicago. Her husband, Marcus, runs a small nonprofit.

But when the couple’s boys, Milo and Theo, were born 10 weeks prematurely, their lives were upended financially.

The twins were diagnosed with cerebral palsy. One required multiple surgeries to fix a breathing disorder. The babies spent more than three months in a NICU.

Ward and her husband scrambled to get the boys the care they needed, including years of physical and occupational therapy. The bills, which topped out at about $80,000, overwhelmed them.

Much of it at first was from hospital care. Then their health plan denied thousands of dollars in claims for the boys’ therapies, deeming some unnecessary.

Desperate, Ward and her husband loaded up credit cards, borrowed from relatives, and delayed repaying student loans. They moved back to the Midwest from Dallas to be closer to family who could help them.

In Chicago, Ward took on extra nursing shifts, working day and night several times a week. Her husband, who was finishing a master’s degree, watched the babies.

“I wanted to be a mom,” she said. “But we had to have the money.”

What’s Broken: Ward and her husband had health insurance through her employer in Texas.

But that’s often not enough to protect patients from a major medical event. Most Americans who have medical debt had coverage, according to a .

Even with health insurance, childbirth can be very expensive. One in 8 Americans who have health care debt say it was at least partially caused by pregnancy and childbirth.

Ward and her husband are also among tens of millions of Americans who end up with medical debt because their health plan didn’t pay for something they believed would be covered. Such insurance issues are the most common form of billing problem cited by Americans with debt.

What’s Left: Since moving back to the Midwest, Ward and her husband have been slowly paying down the debt.

They bought a small house in Chicago in 2016. And Milo and Theo have been able to stay on grade level at school.

Although cerebral palsy can be severely disabling, the boys can run, ride bikes, and go rock climbing, which Ward credits to the many therapists who have worked with them.

Ten years later, though, the family is still paying off nearly $10,000 in medical debt on their credit cards.

Ward said sometimes at work she looks sadly at new parents in the NICU, thinking about their financial strains ahead. “They have no idea,” she said.

A surgery shatters retirement plans and leads to bankruptcy

By Noam N. Levey, KHN

Sherrie Foy, 63, Moneta, Virginia

Approximate Medical Debt: $850,000

Medical Issue: Colon surgery

What Happened: Sherrie and Michael Foy thought they’d made all the right preparations when they moved to rural southwestern Virginia after Michael retired from Consolidated Edison, New York’s largest utility.Ìý 

Sherrie Foy loved horses and had started to rescue unwanted animals. The couple had diligently saved. And they had retiree health insurance through Con Edison.

“We were never rich,” Sherrie said. “But we had what we wanted.”

Then in 2016, Sherrie, who had lived for years with persistent bowel irritation, had her colon removed. After the surgery, she contracted a dangerous infection and barely survived.

The complications produced nearly $800,000 in bills from the University of Virginia Health System for services that weren’t covered by the Foys’ health insurance.Ìý 

When the couple couldn’t pay, the state sued Sherrie. The only way past it, the Foys concluded, was to declare bankruptcy.

The nest egg they’d carefully built so her husband could retire early was wiped out. They cashed in a life insurance policy to pay a lawyer and liquidated savings accounts they’d set up for their grandchildren.

“They took everything we had,” Foy said. “Now we have nothing.”

What’s Broken: Foy fell victim to a gap in her husband’s retiree health insurance plan that capped lifetime coverage at $1 million.

Such caps were more common before the 2010 Affordable Care Act, though some plans with these caps were grandfathered in.

Relatively few patients with medical debt are sued, and some medical centers have been forced to scale back the practice in recent years after news reports about the lawsuits. (The University of Virginia Health System changed its policies following a 2019 KHN investigation.)

But hospitals and other medical providers still rely on the courts to collect from patients.

More broadly, bankruptcy caused directly or partially by medical debt remains a significant problem.

A conducted for this project found about 1 in 8 adults with health care debt have been forced to declare bankruptcy.

What’s Left: Sherrie said her health has improved.

After the complications from her surgery in Virginia, she returned to New York to seek care at a hospital she said saved her life. That hospital never billed her, she said. She doesn’t know why, but she believes she may have qualified for charity care.

The bankruptcy has been devastating. The Foys get by on Michael’s pension and their Social Security checks.

The same year they declared bankruptcy, Michael also had a heart attack, and their daughter was diagnosed with breast cancer.

“It was a disaster of a year,” Sherrie said. “No one should have to go through this.”

Sherrie has no health insurance. She hopes there won’t be more major medical bills before she turns 65 and qualifies for Medicare.

A sexual assault and years of calls from debt collectors

By Noam N. Levey, KHN

Edy Adams, 31, Austin, Texas

Approximate Medical Debt: $131

Medical Issue: Sexual assault

What Happened: Edy Adams had just graduated from college when she was sexually assaulted in 2013.

She was living in Chicago, and believes she was drugged while at a bar.

Adams doesn’t remember what happened. When she woke up the next morning bruised and confused, she contacted the police and was directed to get an exam at a local hospital emergency room, which confirmed the assault.

Police never found the perpetrator. Then two years later, Adams started getting calls from debt collectors saying she owed $130.68.

At first, Adams was confused. The hospital had told her that Illinois law prohibited medical providers from charging rape victims for a medical exam.

“I thought someone didn’t put in the proper billing code or something,” said Adams, who is now a medical student in Texas.

She explained the situation to the debt collector, who said the company would put a note in her file.

Nevertheless, about six months later, another call came from another debt collector seeking the same $130.68.

Adams again explained the situation. A few months later, there was yet another call.

It kept on for years, as her small debt was passed from one collector to another.

Adams tried to contact the hospital, but the bill was not theirs. It had originated with a physicians’ practice that had closed.

Sometimes when the debt collectors called, Adams would break down in tears on the phone. “I was frantic,” she recalled.

With each call, Adams said, she was forced to relive the worst day of her life and explain her trauma to a disembodied voice in a call center somewhere in America.

“I was being haunted by this zombie bill,” she said. “I couldn’t make it stop.”

What’s Broken: Federal regulators and consumer advocates for years have documented widespread problems across the debt collection industry, calling out collectors for not doing enough to verify and document bills before pursuing consumers.

The problems are particularly acute in medical debt collection. From 2018 to 2021, people contacted about a medical debt complained most frequently to the Consumer Financial Protection Bureau about being hounded for a debt they did not owe, .

And in a , a third of Americans who had been contacted by a collection agency because of a medical or dental bill said the debt was not theirs.

What’s Left: Adams found relief only after the last debt collector reported the bill to a credit reporting agency, which lowered her credit score.

Adams petitioned the agency to have the debt removed, which it quickly did.

Adams said she didn’t begrudge most of the people who called her over the years. “It seemed like they were only cogs in this giant debt machine,” she said.

Hospital lawsuits and garnished wages on top of diabetes

By Noam N. Levey, KHN

Nick Woodruff, 37, Binghamton, New York

Approximate Medical Debt: $20,000

Medical Issue: Diabetes

What Happened: Nick Woodruff’s wages were garnished for the first time in 2016.

Woodruff, who was diagnosed with diabetes in his 20s, had a good job. He worked for a truck dealership in this small city 175 miles northwest of New York while his wife, Elizabeth, completed her degree in social work. His job had health benefits. The couple had recently bought a home.

But a small infection on Nick’s foot related to the diabetes set off a cascade of medical emergencies and financial struggles that the Woodruffs are still laboring to put behind them.

First Nick’s infection spread to the bone and threatened to overwhelm his immune system. He was hospitalized and suffered damage to his heart and kidneys.

More complications followed. Nick slipped going down the stairs, shattering his foot. Doctors later had to amputate it.

Then came thousands of dollars of medical bills, followed by debt collectors.

“We were drowning in medical debt, and he was not doing well,” Elizabeth recalled.Ìý

The bills were overwhelming and often incomprehensible. “There’s a lot that we owe that we don’t even know,” Elizabeth said.

The Woodruffs withdrew money from their retirement accounts. Their siblings kicked in to pay off some bills.

Elizabeth got a job as a social worker at the hospital, Our Lady of Lourdes Memorial Hospital, a Catholic institution that is now part of the Ascension chain. But that did little to forestall the debt collectors.

The hospital sued Nick, and he was ordered to pay an additional $9,391 before Elizabeth persuaded the hospital to lower the bill by several thousand dollars.

What’s Broken: The Woodruffs’ struggles with debt are a common experience for Americans who have chronic illnesses such as diabetes, heart disease, and cancer.

These people are more likely to end up with medical debt than those who are healthy, a found.

In fact, illness is the strongest predictor of medical debt, according to an analysis by the Urban Institute, which looked at county-level debt and disease data across the country.

In the 100 U.S. counties with the highest levels of chronic disease, nearly a quarter of adults have medical debt on their credit records. By contrast, in the healthiest counties fewer than 1 in 10 have debt.

What’s Left: The Woodruffs have managed to pay down some of their debt, and Nick is on disability benefits because he’s no longer able to work.

Elizabeth has a new job, so she doesn’t have to work for the hospital that sued them.

They said they feel lucky to have been able to pay many of their bills. “I feel sorry for the people who don’t have the resources that we did,” Nick said.

But the couple remains shocked by the aggressive debt collections.

“This hospital boasts Catholic values and states they take pride in their charity work,” Elizabeth said, “but I am taken aback by how callous they have been.”

Denied care for a dangerous infection because of past-due bills

By Noam N. Levey, KHN

Ariane Buck, 30, Peoria, Arizona

Approximate Medical Debt: $50,000

Medical Issue: Infection

What Happened: Ariane Buck knew it was important to stay on top of his health care.

The young father, who lives with his wife and three children outside Phoenix, had survived cancer when he was a child.

But making ends meet hasn’t always been easy for Ariane, who sells health insurance, and his wife, Samantha, a therapist who cares for people with autism.

At times the family has fallen behind on medical bills. Still, they never expected to be denied care.

Just before Father’s Day in 2016, Ariane grew very sick. He couldn’t hold down food without vomiting. There was blood in his stool.

Samantha called the family’s primary care doctor seeking an appointment. But the office turned the Bucks away.

“They said they wouldn’t see him because of past due bills,” Samantha said, estimating they owed a few hundred dollars.

Ariane’s only choice was to go to a hospital emergency room. There he was diagnosed with a serious intestinal infection that required intravenous fluids and antibiotics.

The Bucks were also hit with thousands of dollars of additional bills they couldn’t pay.

What’s Broken: Hospitals for decades have been required by federal law to provide emergency medical care to any patients who need it, regardless of their ability to pay.

But many medical providers, including physicians, have policies that allow them to turn away patients with past-due bills for nonurgent care.

The practice is surprisingly common. Nationwide, 1 in 7 Americans with health care debt say they have been denied care because of money they owe, a found.

On top of that, tens of millions of Americans ration their care. About two-thirds of U.S. adults with debt from medical or dental bills say they or a member of their household have put off getting care they needed because of costs.

What’s Left: Buck recovered from the infection and is now in good health. But the family’s medical debt has swelled to more than $50,000, from Ariane’s bills and Samantha’s.

Samantha went to the emergency room twice in the past several years with painful cases of endometriosis.

The Bucks have taken out loans, loaded up their credit cards, and sought help from charities.

“We’ve all had to cut back on everything,” Buck said. The kids wear hand-me-downs. They scrimp on school supplies and rely on family for Christmas gifts. A dinner out for chili is an extravagance.Ìý

“It pains me when my kids ask to go somewhere, and I can’t,” Buck said. “I feel as if I’ve failed as a parent.”

The couple is preparing to file for bankruptcy.

Nineteen surgeries over five years. Then they lost their house.

By Noam N. Levey, KHN

Cindy Powers, 52, Greeley, Colorado

Approximate Medical Debt: $250,000

Medical Issue: Twisted intestine

What Happened: Cindy Powers was 34 when doctors discovered she had a twisted intestine, a potentially life-threatening condition that doctors told her required immediate surgery.

She and her husband, Jim, were living outside Dallas at the time, where Jim had a job with a school district.

They had health insurance. But it couldn’t protect them from the flood of medical bills that swamped them after Cindy’s diagnosis.

Cindy’s first surgery, which lasted nine hours, would be followed by 18 more operations at hospitals across the Dallas-Fort Worth area. “Nobody was able to come up with a solution,” Jim said.

Cindy had recurring infections and hernias. Persistent pain left her addicted to the opioids she’d been prescribed.

“It was five years of hell,” Jim said of his wife’s medical ordeal.

By the time a surgeon finally repaired Cindy’s intestines in 2009, the couple had some $250,000 in medical debt. They declared bankruptcy.

The Powers also ended up losing their home when their mortgage was sold and the new lender rejected the payment plan set up through the bankruptcy.Ìý

A few years later, their adult daughter died. And in 2017, Cindy and Jim moved back to Colorado, where Cindy was from.

What’s Broken: How much medical debt contributes to housing insecurity is difficult to measure, as many people forced out of their homes face a mix of financial challenges.

But a recent suggests that the debt from health care is forcing millions of people from their homes.

About 1 in 12 Americans with health care debt say they have lost their home to eviction or foreclosure at least in part because of what they owed, the survey found.

And about 1 in 5 say they or someone in their household have moved in with family or friends or made some other change in their living arrangement because of health care debt.

What’s Left: After the bankruptcy and the move, the couple slowly got back on their feet financially.

Jim began work at an animal welfare group. Cindy, whose health has improved, got a job as well. The couple adopted their daughter’s girl, who’s now in sixth grade.

Then Jim needed prostate surgery. As he worked to scrape together the $1,100 he owed, he was sued by a debt collector.

“Things have got to change,” Jim said.

Damaged credit delays the dream of buying a home

By Aneri Pattani, KHN

Joe Pitzo, 42, Brookfield, Wisconsin

Approximate Medical Debt: $350,000

Medical Issue: Cancer

What Happened: Joe Pitzo and his wife, Amanda, had been married only five months when Joe was diagnosed with brain cancer in 2018. He would need brain surgery and extensive rehab.

They’d been planning to buy a house for their blended family of five children. Instead, they shifted their attention to doctor’s visits, insurance paperwork, and hospital bills. And their finances fell apart.

“This just took a major toll on my credit,” Joe said. “It went down to next to nothing.”

Joe had insurance through his employer. Prior to his brain surgery, the couple confirmed that the surgeon and hospital were in their insurer’s network. But around 4 p.m. the day before the procedure, their insurer said a device the surgeons planned to use was medically unnecessary. It was not covered.

Joe and Amanda proceeded with the surgery, figuring they could deal with the bills later.

The bills, it turned out, topped $350,000.

Joe said the debt dragged down his credit score by several hundred points.Ìý

Their best hope for a home loan became Amanda, who didn’t have much credit, she said. She’d never taken out a mortgage or a car loan.

What’s Broken: Difficulties with health insurance are a common feature of medical debt in the U.S.

Two-thirds of Americans with health care debt say they haven’t fully paid a bill because they were expecting their health plan to cover it, according to a .Ìý

But health insurance rules and restrictions are often so complex that even diligent patients struggle to make sense of them.Ìý

It’s also not uncommon for medical debts to hurt patients’ credit scores. There’s growing pressure to change that.Ìý 

This spring, the three leading credit agencies announced they would small past-due medical bills in credit score calculations. And the federal Consumer Financial Protection Bureau whether any health care bills should be counted.Ìý 

What’s Left: The Pitzos managed to get the hospital to reduce their charges to about $30,000.

They worked to build Amanda’s credit so she could apply for the loan and were finally able to buy a house in spring 2022.

They’re still making payments on about $19,000 in medical bills.

“It makes me sick about medical costs and how this whole thing is done,” Amanda said.

Haunted for 13 years by debt from childbirth, then rescued by a nonprofit

By Yuki Noguchi, NPR

Terri Logan, 42, Spartanburg, South Carolina

Approximate Medical Debt: $1,400, now $0

Medical Issue: Premature childbirth

What Happened: Two months ahead of her due date with her second daughter, Terri Logan felt weighed down by stress. She was a high school math teacher in Union City, Georgia, and was ending her relationship with the baby’s father.

One day the baby stopped moving. Logan went to the hospital, where her blood pressure spiked, her head throbbed, and she blacked out. Hours later, her daughter was born by cesarean section, weighing only 3 pounds. Logan had health insurance through work, but she was responsible for out-of-pocket charges. She and her baby were in a health crisis, so the issue of money didn’t come up: “That conversation just wasn’t had in that moment.”

About two weeks after her daughter was discharged, Logan was hit with a bill. She couldn’t bring herself to take a close look at the total. “It was one of those moments when you see … commas,” she said. She never opened the bills that arrived after that, knowing she couldn’t pay them or handle the stress. “I just avoided it like the plague.”

Other bills followed. Eventually, they were sent to collections.

The debt piled on to other stressors for the single mom. She developed debilitating anxiety, which brought on more headaches. She had to give up her full-time teaching job. “The weight of all of that medical debt — oh, man, it was tough,” she said. “Every day was tough. Every day, I’m thinking about what I owe, how am I going to get out of this.”

What’s Broken: Logan is among a growing number of working people who are considered under-insured; that is, they have an employer-sponsored plan but it pushes a lot of costs — in the form of copays, coinsurance, and deductibles — onto the patient.

This cost sharing, as it’s called, has increased steadily over the past two decades. Last year, the average annual deductible for a single worker with job-based coverage topped $1,669, which is 68% higher than a decade ago, according . Family deductibles can top $10,000.

At the same time, millions of Americans have next to no savings. A nationwide poll conducted by KFF for this project found that half of U.S. adults don’t have the cash to cover an unexpected $500 health care bill.

That makes debt almost inevitable for anyone with a large expense like the birth of a child, even if they have health insurance. Indeed, most Americans who have medical debt had coverage, according to the KFF poll.

With her older daughter, Logan said, she never saw a bill. It was an uncomplicated birth with no out-of-pocket charges. So she assumed her insurance would provide similar coverage for the second birth.

What’s Left: Nearly 13 years after her second daughter’s birth, Logan received yellow envelopes by mail and braced herself to open them. She was finally able to work again, whenever her health permitted. It was time to start tackling the problem that had dogged her.

As she put it: “It was like, ‘OK, even if you can’t pay it, you need to know who you owe. At some point, you gotta start, because you gotta take care of this to get into a better situation.’”

To her surprise, the envelopes did not contain bills, but rather a notice from RIP Medical Debt, a nonprofit, saying it had bought her unpaid medical debts and forgiven them on her behalf. She was shocked: “Wait: What? Who does that?”

Logan reread the letter and cried, absorbing the unexpected gift. “It definitely gives you a sense of, ‘You know what? There’s still good in this world,’” she said.

RIP Medical Debt uses donated funds to buy unpaid medical debt, directly from hospitals or on the secondary market, for about 1% of the original value. It selects unpaid bills held by lower-income patients — those making up to four times the federal poverty level — and instead of trying to collect on those loans, simply forgives them.

Through the pandemic, donations have skyrocketed, enabling the group to accelerate its purchase of hospital debts. To date, it has forgiven $6.7 billion in medical debt, helping 3.6 million people.

The lifting of her own debt burden, Logan said, has freed her to pursue long-dormant interests. A lover of the stage, she planned her first singing performance this month.

Sleepless nights over her children’s future as debts pile up

By Noam N. Levey, KHN

Jeni Rae Peters, 44, Rapid City, South Dakota

Approximate Medical Debt: More than $30,000

Medical Issue: Breast cancer

What Happened: Jeni Rae Peters’ budget has always been tight. But Peters, a single mom and mental health counselor, has worked to provide opportunities for her children, including two girls she adopted and a succession of foster children. One of her daughters had been homeless.

Then two years ago, Peters was diagnosed with stage 2 breast cancer.

Multiple surgeries, radiation, and chemotherapy controlled the disease. But, despite having insurance, Peters was left with more than $30,000 of debt and mounting threats from bill collectors.

One collection call came as Peters was lying in the recovery room after her double mastectomy. “I was kind of delirious, and I thought it was my kids,” she said. “It was someone asking me to pay a medical bill.”

Through the surgeries and treatments, Peters kept working so she would not lose her insurance. She took on extra work to pay some of the bills. Five days a week, she works back-to-back shifts at both a mental health crisis center and a clinic where she counsels teenagers, some of whom are suicidal. Last year, three friends on the East Coast paid off some of the debt.

But Peters’ credit score has tumbled below 600. And she worries constantly about how she will provide for her children.

Peters said she could drop car insurance for her teenage daughter, who just got her license. Canceling ice skating for another daughter would yield an extra $60 a month. But Peters is reluctant. “Do you know what it feels like to be a foster kid and get a gold medal in ice skating? Do you know what kind of citizen they could become if they know they’re special?” she said.

Peters added: “My doctor saved my life, but my medical bills are stealing from my children’s lives.”

What’s Broken: Despite many advances in cancer treatments, millions of Americans end up in debt after being diagnosed with the disease.

That’s in part because medications and treatments are now so expensive. It’s also because health plans typically require patients to pay thousands of dollars out-of-pocket in deductibles and other cost sharing.

One study found that cancer patients were 71% more likely than Americans without the disease to have bills in collections or to have a credit account closed for nonpayment.

The debt forces many to make difficult sacrifices. Two-thirds of U.S. adults who’ve incurred health care debt who’ve had cancer themselves or in their family have cut spending on food, clothing, or other household basics, according to a poll conducted by KFF for this project. One in 4 have declared bankruptcy or lost their home.

The financial stress from debt can hinder cancer patients’ recovery and even hasten death, researchers have found.

What’s Left: Peters’ cancer is in remission, and her health has improved. She said she’s excited about adopting two more of her foster children.

But the threats from debt collectors keep coming. She recently received a new collection notice for $13,000, warning her that she would soon face legal action.

Peters said she has no way of paying off all her debts. She recently told one bill collector that she was prepared to go to court and ask the judge to decide which of her children should miss out on after-school activities to pay off debt.

She asked another debt collector whether he had kids. “He told me that it had been my choice to get the surgery,” Peters recalled. “And I said, ‘Yeah, I guess I chose not to be dead.’”

Her brother landed in a nursing home. She was sued over his bill.

By Noam N. Levey, KHN

Lucille Brooks, 74, Pittsford, New York

Approximate Medical Debt: $8,000

Medical Issue: None. She was billed for her brother’s care.

What Happened: Lucille Brooks was stunned to discover a nursing home in Monroe County, New York, was suing her. She had never been a patient there. Nor had her husband. “I thought this was crazy,” she said, figuring it had to be a mistake.

The bill was for care her brother, James Lawson, received in summer 2019. He’d been hospitalized for complications from a diabetes medication. The hospital released him to the county-run nursing home, where Brooks had visited him a few times. No one ever talked to her about billing, she said. And she was never asked to sign anything.

Brooks and Lawson were part of a big family that moved north from Mississippi to escape segregation in the 1960s. Lawson had a career at the Rochester Parks and Recreation Department. Brooks worked in insurance. They lived on opposite sides of the city. “My brother always took care of his own business,” she said.

Lawson spent two months in the nursing home. A year later, .

The county alleged that Brooks should have used her brother’s assets to pay his bills and that she was therefore personally responsible for his debt. Attached to the suit was an admissions agreement with what looked like Brooks’ signature.

What’s Broken: Admissions agreements often designate whoever signs as a “responsible party” who will help the nursing home collect payments or enroll the resident in Medicaid, the government safety-net program.

Consumer advocates say nursing homes slip the agreements into papers that family members sign when an older parent or sick friend is admitted. Sometimes people are told they must sign, a violation of federal law. “They are given a stack of forms and told, ‘Sign here, sign there. Click here, click there,” said Miriam Sheline, managing attorney at Pro Seniors, a nonprofit law firm in Cincinnati.

Litigation is a frequent byproduct of America’s medical debt crisis, which a KHN-NPR investigation found has touched more than half of all U.S. adults in the past five years.

About 1 in 7 adults who have had health care debt say they’ve been threatened with a lawsuit or arrest, according to a . Five percent say they’ve been sued.

The nursing home industry has quietly developed what consumer attorneys and patient advocates say is a pernicious strategy of pursuing family and friends of patients despite federal law that was enacted to protect them from debt collection.

In Monroe County, 24 federally licensed nursing homes filed 238 debt collections cases from 2018 to 2021 seeking almost $7.6 million, KHN found. Nearly two-thirds of the cases targeted a friend or relative.

Many were accused — often without documentation — of hiding residents’ assets. The practice can intimidate people with means into paying debts they do not owe, said Anna Anderson, an attorney at the nonprofit Legal Assistance of Western New York. “People see that on a lawsuit and they think they’re being accused of stealing,” she said. “It’s chilling.”

What’s Left: When the bill came, Brooks was so worried that she didn’t tell her husband. “People like us live on a fixed income,” she said. “We don’t have money to throw around, especially when you don’t see it coming.”

Brooks turned to Legal Assistance of Western New York, a nonprofit, which has represented defendants in such cases. In time, Monroe County dropped its case against her. Brooks said she thinks the signature on the admissions agreement was forged from the nursing home’s visitor log, the only thing she signed.

Now she tells anyone with a friend or relative in a nursing home not to sign anything. “It’s ridiculous,” she said. “But why would you ever think they would be coming after you?”

About This Project

“Diagnosis: Debt” is a reporting partnership between KHN and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country.Ìý

Additional research was , which analyzed credit bureau and other demographic data on poverty, race, and health status for KHN to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute  from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with KHN on a survey of its clients to explore links between medical debt and housing instability.Ìý

KHN journalists worked with KFF public opinion researchers to design and analyze the “.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from KHN and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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The Obama administration’s hopes ran high that millions would flock to enroll for health insurance on state and federal exchanges established under the Affordable Care Act.

Those exchanges went online Oct 1. The administration that half a million individuals or families would enroll within 30 days, according to the Associated Press.

But three weeks in, the data suggest the actual number of enrollments is lagging far behind that number.

The promise of signing up for health insurance with point-and-click ease at and state exchange sites has not come to pass — at least not yet.

“This is a fiasco,” says health policy analyst . He says the sites are plagued by glitches and problems with data transfer.

“Literally a handful of enrollments [are] coming through to the largest insurance companies every day,” Laszewski says. “Just a handful, like maybe 10 or 20 or 30. So anecdotally, the enrollments are very, very, very low.”

Laszewski says the inability to get through to a website is not the only issue. Insurance companies are getting bad information, too.

“It’s not uncommon for, say, John Doe’s enrollment to come through at 10 in the morning. And then at 10:30 something comes through that says John Doe’s unenrolled … and then enrolled and unenrolled again,” he says.

The federal government, which is for 36 states through healthcare.gov, has been plagued by technical problems. Health and Human Services hasn’t disclosed enrollment figures. But the digital marketing company Millward Brown estimates that 83,000 people enrolled through the federal site in the

The 14 states that opted to  appear to be faring better, though not by much. Among those states, the estimate of total enrollees so far is about 46, 000. Those numbers are complicated by the fact that there is no common definition of what “enrolled” means. In some states, you’re not considered “enrolled” until you’ve paid.

Laszewski says these small numbers could threaten the economics for insurers.

“They’re very worried about only sick people showing up for coverage, because only sick people are willing to go through the gauntlet,” he says.

There are two ways of looking at this: One is that the new law is failing to meet expectations. But proponents of the law argue it’s still early and that many of these problems can be overcome.

Things will improve, says , a law professor at Washington and Lee University. He points to the prescription drug benefit known as Medicare Part D. The federal program launched in 2005 during the Bush administration, and had its own technical difficulties.

“Once people were finally signed up, there were problems that they would go to the pharmacy and there was no record of them,” Jost says. He expects similar problems here.

“So it will take a while to get the kinks ironed out,” he says. “But the important thing right now is to allow people to get signed up, and I think there’s an awful lot of people who want to do that.”

In fact, there are two states that are declaring their sign-up efforts a success. Carrie Banahan, executive director of Kentucky’s , says more than 15,000 individuals have enrolled.

“We’re thrilled with these numbers. We had no idea that there would be such a demand and an overwhelming response,” says Banahan.

Kentucky’s site was so overwhelmed that administrators had to add servers to its system.

Washington state reports about 30,000 enrollees. , CEO of Washington’s health exchange, says his state was prepared.

“We started early. We’ve been working on this for nearly 2 1/2 years,” says Onizuka.

Still, even Washington’s system crashed. It went down for 4 1/2 hours on the first day.

“It was nerve wracking. We did a lot of analysis and diagnosis,” he says. “We were hoping it would get better the second day. It got a little bit better …. We took it down the second night and it got better the third day.”

Onizuka says with time, anxiety has gone down.

“I’m breathing a little easier,” he says.

The federal government plans to release its first enrollment figures in mid-November.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).