Absolutely. I first started hearing about aggressive medical debt collection, things like lawsuits against patients and wage garnishment and home foreclosures, probably about five or six years ago. I was picking them up in the newspaper, in part because there was a campaign going on in Baltimore, Maryland, where a lot of community members, unions, activists, and nurses were protesting the lawsuits filed by Johns Hopkins Hospital against low-income patients.

I was pretty horrified at what I was reading, and gratified by the fact that so many people were standing up against it. But I was curious to know: Was this sort of thing happening at my hospital? I didn’t think it was. I’d never heard of it happening anywhere in my, you know, nearby area. So, I just assumed it wasn’t. But I just wanted to know. I wanted to make sure. So, I went to the local county courthouse — a place I’d never been before and hope rarely to be again. But I started looking up court cases, and there they allowed me to type in the names of the hospitals into the search function on the county database, and you would see a lot of cases involving the hospital. Now, some of them were malpractice cases in which the hospital or physicians at the hospital were defendants. Some of the cases involved lawsuits against contractors and things like that.

But then I saw a bunch of cases where my hospital, the hospitals where I was training, were suing patients. They were suing them oftentimes for $1,000, $1,500, $2,000 for single visits, sometimes emergency-room visits, hospitalizations. And the really amazing thing is that you can see the letters that patients wrote back in response to receiving notice that they were being sued. They would write really plaintive letters about what was going on.

They would say, “Listen, I’m a single mom, very limited income. I can’t afford to pay back $2,000 right now.” Some folks were on Social Security disability income, some folks were recent immigrants, and their pleas really were answered with the slightest degree of lenience, really in the form of onerous payment plans. So instead of being charged $2,000 at once, they would be charged $25 a month for the next seven years for a single visit. If they didn’t repay on that schedule, then they would be charged interest at a rate of 10 or 11 percent. They already had late charges in court, fees to deal with, and the fact that patients could be placed into such a hole, which we know from years and years of rigorous study, leads people to forgo care, to miss needed medicines and to die sooner, is shocking. The fact that that was happening at my hospital was just really too much to bear.

I started talking to other doctors and other nurses and other folks at the hospital about it. They were equally horrified at what was going on, and I thought I had to do something. I didn’t know quite what. I didn’t think that a series of meetings with C-suite executives where we discussed the merits of doing this or that was going to pan out to that much. So, I wrote an op-ed, and I sent it around to some newspapers: the New York Times, the Boston Globe, no interest; the Providence Journal, no interest. And then I sent it to Steve Ahlquist, who is a muckraking journalist who chronicles the issues that matter for people’s lives in the Rhode Island area, who runs a blog called Uprise Rhode Island.

He was interested, which I was grateful for. He ran it on his blog. I was concerned when I wrote it that I would be the only one to read it. I didn’t know what Steve’s readership was. I thought it was just folks like me. But then I got a call from my boss at the hospital the very day that the article ran saying that I needed to have some meetings because they had seen it very quickly. And at first when they met with me, they told me that I was wrong, that the hospital didn’t sue patients, that I was mistaken.

I was kind of flummoxed by this. I knew that a lot of people, even administrators, didn’t know what hospitals were doing, but I didn’t realize just how far that went. I ended up sending them the court records that I had. I said, “You sued two hundred people this year. You sued someone two weeks ago,” and they, to their credit, looked into it, and in a matter of weeks they’d cut off their relationship with the debt collector they had been using, and they dismissed the remainder of the cases.

To my knowledge, the folks who were still on those payment plans from the past remained on those payment plans. We couldn’t get them to reverse that decision. But so, something had changed. But that was the beginning of my journey into trying to understand what was it that we were doing to patients, and how could it have come to pass that bills for hospitalizations became these tradable assets, that became these, you know, bludgeons with which we would take people to court and take their homes and take their bank accounts and put them in jail. I really needed to know how this had happened. And so, I put on my historian hat and started to look into it that way, too.

Yes, absolutely. Patients bring this up. And I guess I wasn’t initially as understanding or as attuned to their concerns as I should have been. You know, I’d have patients who I’d ask to stay overnight. One particular patient comes to mind, a woman who was having some chest pain. It was slightly concerning. Her labs were a little concerning for a small heart attack, and I asked her to stay overnight. She turned to her husband. She turned to me. She said, “How much is this going to cost?” I said, “I don’t know.” I went and asked around anyone who I could find at the hospital, including a lot of folks who’d worked there for decades, and they said, “We have no idea. You know this, it all depends on her insurance and what they’ll cover and how long she stays.”

There’s really no way for us to tell her that with any degree of accuracy. And we really have nothing to do with that process. We can have her talk to the social worker or have her talk to, you know, registration and billing. But we don’t know. Physicians don’t know. She was willing to stay, but her concern kind of worried me — how long she waited to say yes to this, what I thought was a pretty routine admission. Sometimes it got even worse. I mean, one story that comes to mind is a woman who came in with a widely metastatic cancer, a tremendously painful, fungating mass that she had seen six months earlier and had not sought care for.

She’d worked in health care her whole life, and she told me that she worried about the unbearable cost that she would leave to her family if she did seek care. And so, by the time she came in, she knew what her fate was. She just needed some pain relief at that point. And so I started to understand from them, from these patients, that this was something that weighed on them heavily, and that I just couldn’t ignore it any longer, that blindness was no longer an excuse.

I think a lot of us in medicine have hidden behind the reality that we really don’t have much to do with the billing process for our patients. We used to be physicians, used to be the people delivering the bills to patients and asking them to pay and negotiating with them when they couldn’t. That was no halcyon day. That was not a perfect era. People still struggled to pay their bills then, but the fact that we have outsourced that first to hospital administration and then to third-party collectors and to debt buyers certainly hasn’t made it any better for patients.

Absolutely. And this is something that we’ve only started to understand in greater detail in recent years. Unfortunately, the medical debt crisis, though it has been well understood by people going through it, wasn’t really a subject of the medical and public health literature in the way it should be, I’d say until a few years ago. But what we’ve started to learn is that approximately one hundred million Americans owe debt to a medical or dental provider in some form. The amount of debt owed varies depending on the measure you use to try to estimate it, but some of the more recent estimates put it at least $140 billion. And it is a huge crisis. It extends over the entire country, but it is not evenly felt, as you might imagine, among every social and racial demographic group. It’s more common in women than men. It’s more common in black and Hispanic Americans than in white Americans, and it’s more common in low-income Americans than in middle- and upper-class Americans, although it is a widespread phenomenon.

I live in Rhode Island. I grew up in Massachusetts and New York. And as chance would have it, these are the places where medical debt is the least common. I mean, it’s a relative term, but the geographic distribution of medical debt is very wide. The percentage of people with medical debt on their credit reports varies from about 3 percent in Manhattan, New York County, as it’s known, to 27 percent in Dallas–Fort Worth.

So, the number of people experiencing this on a day-to-day basis really does vary. And some of those differences can be explained by, you know, deep, deep history of lack of access to care and threadbare social benefits in the states of the former Confederacy, which extended into the decision about whether or not to expand Medicaid after the National Federation of Independent Business v. Sebelius decision in 2012, where Chief Justice John Roberts said that not every state could be forced to expand Medicaid.

Doing so, he argued, was against states’ rights, and every state had to be allowed to make its own decision. As a result, half the states initially declined to expand Medicaid, even though 90 percent of the cost would be borne by the federal government. In those states that did expand Medicaid, allowing a larger number of people to access public insurance, medical debt declined precipitously, falling by almost one-half, but stayed relatively constant in the states that didn’t.

Yeah, that’s a great point. Every estimate we have is inevitably probably an underestimate, because you can measure the number of people who have medical debt by their credit reports. But that’s an underestimate, because not all medical debt is always reported to credit bureaus. But as you said, some medical debt is paid at the point of care by patients and placed onto credit cards or borrowed from family members. And so, it’s extremely difficult to get an accurate count of how many people actually owe medical debt. And the numbers we have, as large as they are, are likely underestimates.

This has been known for a long time. I mean, Elizabeth Warren, before she was senator, was a legal scholar who studied bankruptcy and in particular medical debt. And her work from the ’80s to the ’90s to the 2000s did show that these bills were often placed on credit cards and would be really hard to tally. And the debates about how many medical bankruptcies there were, how many people were actually placed into bankruptcy as a result of medical debt, stem in large part from the fact that it’s still really hard to know how many people are placed in arrears because of seeking care.

Let’s go from, from “gentlest,” if you want to ever use that term, to the most aggressive collection measures. And let’s put it in the context of a specific patient. A patient goes into the hospital, gets their care, and leaves. A few months later, they get their bill, and they don’t pay it or don’t pay it in full or don’t pay it on time. Their bill is referred to a collections agency, and that collections agency might start with phone calls. They can call multiple times a day. They can call their workplace. They can put the screws to them. That way they can send a number of letters of increasing severity and threatening language. And so those are the first steps that most patients experience.

After that, if after a time the debt still isn’t paid and satisfied in full, then the hospital and the debt collector and the debt buyer can resort to what are called “extraordinary collection actions.” That is a legal term used to refer to any number of tactics that can be used against patients in medical debt, which can be used for people with other forms of debt. These tactics include reporting debt to a credit bureau. That’s a negative action on a credit bureau that can affect the patient’s ability to get a mortgage, even get a job. Their credit can be shot for years thereafter.

The hospital or debt collector can also file a lawsuit against a patient. In those lawsuits, they almost always win. Patients rarely show up. Even if they do, they usually have little recourse; if they lose that lawsuit, as they almost always do, then they can have their wages garnished. So up to 25 percent of their wages can be taken out of their paycheck and sent directly to the creditor. They can have a lien placed on their home — that’s basically a right over that asset that the hospital now has that prevents the patient from doing with their property as they wish.

If the debt still isn’t satisfied and the hospital wishes to do so, it can foreclose on that property. So, take the patient’s home away from them. It can seize a patient’s bank account and drain it of its funds, and direct that right into the hospital account. And if all those measures fail, or if the hospital seeks more rapid resolution, then it can actually put the patient in jail. Specifically, if a patient fails to show up for a postjudgment hearing where their assets are discovered for the hospital to claim, then the hospital or a judge can seek what’s called a “body attachment,” where a warrant is issued for the patient’s arrest and the patient can be placed in jail. So, patients can and do face any and all of these measures, these extraordinary collection actions, if they do not pay in time.

Yeah, this was the thing that was most astonishing to me, because I didn’t consider that exertion of state power, as you rightly point out, could be the consequence of a patient seeking care in my hospital. Someone comes into the emergency department in a moment of profound vulnerability. They’re having a heart attack, they’re having a stroke, they’re in pain, they’re, you know, sometimes unconscious. And the fact that they also have to worry that going to the hospital may lead to them having to go to the courtroom months later, would lead them into a jail cell months later — that was a revelation for me that I should have known before, but was shocked to learn, nonetheless.

Yeah, it’s a fair question, because at the end of the day, I think a lot of the thought about what the solution is — single-payer health care — is right on. I mean, that would eliminate payments at the point of care, if designed correctly, and largely eliminate the problem of medical debt. It’s a problem that has, to a greater or lesser extent, been solved by every other country in the Organisation for Economic Co-operation and Development (OECD) and many low- and middle-income countries as well.

So, it’s not necessarily a mystery where we should be driving. But I do think there are a few reasons why socialists would want to understand this better and to focus their energies on it. There is a large tapestry of injustice in the United States and in medicine in general. But this is a particularly egregious kind of predation on a particularly vulnerable population that arouses the ire of most everyone studying this. I was heartened to learn how easily this crosses ideological boundaries. I mean, people have varied solutions for this, some of which would, you know, only tinker at the edges and some of which would, I think, solve the problem in a much more meaningful way. But when confronted with the reality of what is going on, folks on the center right, folks in the center, people of faith, people of no faith, socialists, anarchists, and even some pretty conservative voices are horrified.

They are horrified that a nonprofit, voluntary, what used to be known as a charity hospital is taking patients to court, seizing their assets, and placing them in jail. That is not something that tends to divide audiences. It is an entry point for folks to understand how far we have gone into the era of financialization and privatization, how it has corrupted even our most charitable institutions, our institutions that we would think were most communal in nature, most devoted to fellow feeling, most overtly outside the capitalist system. These are nonprofit hospitals that have forsworn profits, that have no shareholders, that are descendants of the medieval almshouse tradition — those are now places where people can be expected to be hounded to the ends of the earth for their debts. I think that does help bring people into the fold. The history of transformation is one that often draws on this sense of ire, this sense of anger, this sense that things can be better.

I mean, Tommy Douglas, when he became the head of a socialist government in Saskatchewan and proposed the Canadian single-payer health care system, doctors went on strike. Doctors said, “We will not stand for this.” They went on strike only for a time, only for a few weeks before that effort was defeated. Within ten years Douglas had helped spread Medicare to the entirety of Canada. I mean, Margaret Atwood, in her Massey Lectures, talks about her own family’s experience with this. When her brother was born, her parents had difficulty leaving the hospital because the hospital was essentially detaining them because they couldn’t pay.

They had to wait until her father got his paycheck and was able to scrape by and pay that bill in order to even leave the hospital. That problem of medical detention continues to exist today in countries around the world, but it does not exist in Canada because of the efforts of folks like Douglas and the folks who organized with him to change the system. So, I do think this is a rallying cry. This is something we can organize around, and it’s something that can be a bulwark for change.

Yeah. I mean, I didn’t start out thinking that I was going to spend most of my time studying medical care in the United States. I always knew it was a pretty dismal subject, and a lot of the folks who inspired me to go into medicine were people like Paul Farmer, who work in, you know, former colonized countries or places like Haiti, which has its own revolutionary tradition, where my own father was born. And so those were the places that I was most interested in working in.

When I finished college, I worked in Rwanda and then in Malawi during graduate school, and I wrote my first book about the British colonial system and postcolonial medicine in Malawi. And those were the places I was most interested in practicing, because I thought that honestly, when you care for patients in a place where they’re not made to pay at the point of care — actually, Malawi is one of those places that you are a member of a public system and can be a part of helping patients without burdening them with that concern — it makes you feel like you can go to work and wake up in the morning a little easier. So those were the places I was interested in working, interested in studying. But as a result of going to medical school in the United States and seeking my specialty training here, you know, I was ensconced in this total institution of the American hospital for about a decade and could not ignore what I was seeing as a result.

These are three problems particular to patients and the patient experience, which is a particular concern of mine because I am a doctor and I treat patients in the emergency department. One is that medical debt ruins patients’ financial lives. We know that folks who have their debt reported to credit bureaus face tremendous burdens in seeking employment, in getting homes. We know that one hundred million Americans, as we went over, have medical debt, and it is the largest single source of debt on patient’s credit reports. It’s a tremendous burden on patients. Secondly, it’s one that we know affects patients’ health, that patients in debt are less likely to seek care.

There have been a number of studies on this that patients who have medical debt are six times more likely to skip a doctor’s visit or a prescription and are more likely to die. Patients with cancer who experience financial toxicity, as it’s known, who have problems with medical bills, die sooner, and we have ample evidence to support this. It’s filled the medical literature. We really don’t need to understand it too much more than we do already before we solve it. And the third is that it destroys trust. Sometimes it doesn’t sound materialist enough to talk about things like trust in the relationships in medicine, but I do think it’s important.

So much of what we do in medicine asks people to submit themselves — it’s a weird way of saying it — to really terrible procedures and medicines that have side effects and long hospital stays. These are not easy things to ask of people. If they do not trust that you have their best interests at heart, they will not submit themselves to these things, and they shouldn’t. I think that we have to work a lot harder, as physicians and nurses (nurses have done a lot better job of this than physicians have), to make sure that patients do know and do have reason to know that we have their best interests at heart. A recent survey found that still, even today, 70, 77, 78 percent of Americans trust that their physician has their best interests at heart, at least most of the time. Not everyone, but still a vast majority of the population. We don’t have the same numbers as nurses, but we’re not terrible. For hospital administrators, that figure is 22 percent, and there’s reason for that as we go into greater detail in the history. But I think physicians and even nurses risk getting dragged down to those levels if we don’t ally ourselves with patients relatively quickly.

Perhaps I’ll get at the first part of your question by getting at the second. The majority of the around six thousand hospitals in the United States, about 57 percent of them, are private, nonprofit hospitals. These are the hospitals that draw their histories from almshouses, from ethnic associations, from religious orders. They also are known as voluntary or charity hospitals. They’re not the only hospitals in the United States. The federal government runs hospitals. The Department of Defense runs hospitals; the Indian Health Service runs hospitals.

And there are for-profit hospitals that often bought up closing charity hospitals and public hospitals in the ’70s and ’80s and built these mammoth conglomerates of for-profit facilities that compose a large portion of hospitals in the United States today. But still, most hospitals in the United States are private, nonprofit hospitals. And the distinctions are sometimes lost on people.

People have reason to not know the distinctions, because hospitals have worked pretty hard to narrow them. For the longest time, private nonprofit hospitals justified their existence and their tax exemptions because they claimed to care for poor patients, often without seeking recompense. Even in the 1950s, the Internal Revenue Service (IRS) had a standard that said that a private nonprofit hospital would only receive a tax exemption from the agency if it agreed to provide care to indigent patients, as they call them, to the extent of its financial ability.

And for the next fifteen years, hospitals worked mightily to change that standard, and they did, so that what was known as the “charity care standard” became the “community benefit standard,” a far laxer standard that the IRS took up at the behest of a single a single IRS attorney, Robert Bromberg, who said that the charity care hospital was an anachronism, that with the passage of Medicare and Medicaid and the rise of private insurance in the mid-twentieth century, no one would really even need it anymore. Who would even need care that was free at the point of service? He changed the standard so that a hospital could receive a tax exemption and retain its nonprofit, tax-exempt status; as long as it agrees to accept all paying patients, it could turn away nonemergent care, and even at that time, emergent care for patients who were not paying. And so those distinctions between private, for-profit hospitals and nonprofit hospitals, at the end of the day, for a lot of patients, don’t matter as much as you’d think it would any longer.

Yeah, absolutely. I mean, it is still a part of the law that hospitals are supposed to provide community benefits. And those can come in multiple forms, including care for low-income patients without charging them — so, either free or discounted care often on a sliding scale. But the wild thing is that there’s very little regulation of how much or at what level that care should be provided. Some of the organizing that’s already been done has helped to change this in different states. Maryland, due to the great organizing efforts of community organizations and unions and nurses, passed a series of laws about medical debt in 2020 and 2021.

There is a floor below which every patient is supposed to have free care. And then hospitals are supposed to take a number of measures to make sure they’re never sending bills to folks who fall below that floor. But in most places in the country, hospitals have completely free rein. They can say at what level of income someone should qualify for free care. So, in some places in the country, in some hospitals, that’s 75 percent of the federal poverty level. That’s $22,000 for a family of four in 2023. At other hospitals, it’s 600 percent of the federal poverty level. That’s $180,000 for a family of four. So, these wide, wide disparities really do impact patients’ financial outcomes, patients’ ability to access care in the future. There’s a historical logic to it. There’s a racial logic to it, but there’s not a reasonable logic to these differences.

You’re totally right that this is a leverage point. This is a point at which we should be holding hospitals accountable to their legal obligations. And I would say also to the obligations that we still collectively hold of them, even these extralegal obligations that hospitals are still subject to some measure of shame, some measure of public accountability beyond their legal obligations.

Yeah, it’s difficult sometimes to imagine what that world was like. But today, three-quarters of physicians work for large corporate entities like large hospital systems, private equity companies, health insurers. But in the early nineteenth century, most physicians were private solo practitioners, and the medical marketplace was replete with different kinds of practitioners. And allopathic providers didn’t have a monopoly on people’s thoughts about who they should seek care from when they were sick. And even among those providers, there was a lot of competition. And so, it was hard for patients. It was hard for physicians to charge whatever price they wanted or to always get the payments that they thought they deserved after providing care.

So physicians would often either have contracts for annual attendance (you pay annually for your family to get care) or on a fee-for-service basis (you would pay for every visit). Those bills would often be presented on a quarterly, semiannual, or annual basis. The physician would be the one presenting them to the patient and saying, “What can you pay of this bill?” And they would complain frequently to whoever who would listen — medical journals and elsewhere — about their difficulty in collecting these payments. They worried that patients would often tell them their crops didn’t come in, or another family member was sick, and that they just didn’t have the money at the moment.

And physicians themselves talked about their own debts, and the prospect of dying in debt because they weren’t able to collect adequately from their own patients. They would write these plaintive verses in medical journals: “Book, o doctor, book your fee. Charge, I’ll pay it futurely.” They really worried about this. And it drove some of the first medical societies to organize largely around trying to have standardized fee schedules and standardized policies about patients who did not pay. Some physicians wanted to come down hard on those patients and cut them off from care or even seek legal action against them. Most of the medical societies continued to include some statements about the need to treat patients for free, or for discount, if they could not afford to pay, that it was the doctor’s duty to do so. This remained in the language. It wasn’t always honored; it wasn’t always practiced. But this was part of the moral imaginary of being a physician in the United States for much of the nineteenth century.

All this began to change by the twentieth century, as hospitals became more common places to seek care for nonpoor patients. Before that, hospitals were really places you would only go if you didn’t have anyone else to care for you. They were derived from almshouses. They weren’t centers of high-tech scientific inquiry, and they weren’t often frequented by people who had any means. That started to change in the twentieth century. New surgical techniques, X-rays, new forms of organization of physicians and nurses made hospitals much more appealing to middle- and upper-income patients, and hospitals strove to make themselves appealing to them.

Private rooms, new linens: hospitals would advertise their amenities to upper-income patients. And hospitals became kind of a locus of where physicians worked, where nurses sought employment. And they, too, started to change their practices instead of seeking to care only for what they called “charity cases” or the “worthy poor”; they were never providing care for everyone. There were many people whom they wouldn’t allow in their doors, but they sought to move from caring for the worthy poor in these large open wards to caring for the paying patient in private rooms. And so, they became changed institutions as well. But that was the backstory — that the nineteenth century was a different country. It was a different world in which physicians themselves had to negotiate with patients in these fraught interactions about how much would be paid and what would happen if the payment wasn’t made.

There was affirmatively a right to refuse care, in fact. I mean, this came from the case of Geraldine Cruz in 1934, in Birmingham, Alabama. This went to one of the state courts. It’s a really tragic case of a two-year-old whose father brought her to the hospital, where he noted she was extremely sick. She was having difficulty breathing. She was suffering from diphtheria disease, which we don’t see very often thanks to vaccines in the United States. But this is a terrible disease. It’s basically a bacterial illness that causes this sickly gray film to coat your throat until you cannot breathe, and you suffocate. A terrible illness, but one for which, even at the time, in 1934, there was an antitoxin and other forms of treatment available. But instead of admitting her for treatment, the hospital told his daughter to go home.

The hospital refused care. Its justification for doing so was that this was a contagious disease, and it worried about infecting other patients. But when he brought his daughter home and she died shortly thereafter, he sued the hospital. And the decision that the court made wasn’t this narrow ruling that it was a contagious case, and the hospital has a right to try to prevent contagion. They spoke: the hospital has the right to refuse care to whomever it wishes, on whatever grounds it wants. And that was the reigning ideology of the day, and one that continued for a long time, basically, until we got to the 1980s. Hospitals could refuse on whatever grounds they wished. And as you mentioned, I mean, hospitals were, until the 1960s, until the passage of Medicare, largely segregated in the United States. And so black patients had to seek care either at black hospitals or in segregated wards. The voluntary charity hospital at which every patient could seek care was not a reality for everyone, even then.

Yeah, absolutely. I mean, the ’60s were watershed moment in this story. By the 1950s–60s, you have the rise of private insurance. Gabriel Winant talks about this in his book. These were islands of social citizenship, in which some, but not all, Americans could achieve some measure of social protection. The passage of Medicare and Medicaid in 1965 did afford a measure of protection to some low-income Americans and Americans over sixty-five. You saw a rapid decrease in the number of Americans who were uninsured. The pace of that decrease would not be matched again until the Medicaid expansion of the 2010s.

I mean, President Lyndon B. Johnson basically said it was like the end of medical debt for elderly patients. That’s not true. Medicare does not cover everything all the time. It leaves patients with significant debts. But it was a huge breakthrough. The funding from that law was used as kind of a battering ram to desegregate hospitals throughout the country. A small team of folks in the federal government basically ensured that hospitals would not receive the funding they desperately needed until they desegregated. And so, it did speed the desegregation of American hospitals. But hospitals could still refuse care for nonpaying patients.

And they did. One of the major tipping points in this history is the early 1980s, when Medicare and Medicaid payments were pretty drastically cut — a deceleration in reimbursements for care, even as care became more expensive. And so, hospitals started to suffer from shortfalls in the 1980s at the start of Reagan-era deregulation and privatization, because they couldn’t afford to care for these publicly insured patients. As a result, they turned away patients at the door, or private hospitals would start dumping patients — that is, transferring them directly to the public hospital on nonmedical grounds. This would happen often while they were quite unstable: so, patients in active labor who are about to deliver, folks who had been shot or were in trauma and were bleeding to death. This was an outrage for the physicians working at these public hospitals, who saw this tie to patients coming in from private facilities at which they could have been treated and could have been saved, basically dying en route. Some of the folks who wrote about this at the time, young physicians like David Himmelstein, would go on to start Physicians for a National Health Program and push for single-payer health care for the rest of their careers.

But as a result of some of their documentation of what was going on and publicizing what was happening, this patient-dumping phenomenon, EMTALA was written by Pete Stark, a Democrat from Oakland, in part because thirty-two-year-old Eugene Barnes, an Oakland resident, had been stabbed and then refused care at a hospital nearby and died as a result. EMTALA required hospitals and emergency departments, in particular, to provide screening exams to whoever walked in their door and to stabilize any emergent conditions.

They didn’t have to treat these patients thereafter, but they did have to treat emergent conditions. And this is a law with which we still live today. Hospitals complained with some reason that they had another unfunded mandate. They weren’t given additional money to live by this edict. And patients were not relieved of debts as a result of the care they sought that was protected by EMTALA. They could seek care, but they could still be hounded to the ends of the earth for it. But those two moments, you know, Medicare and Medicaid passage and EMTALA, were steps forward, but vastly incomplete.

Yeah, it’s almost unthinkable. You can see why the physicians, the young physicians, writing about this at the time were so outraged. So much of our medical training involves an appreciation and a respect and a fear of time. Time is in some ways our greatest enemy. When someone comes in with a heart attack, we know that every hour, every minute we delay more of their heart muscle dies and will not be recovered. The same is true of stroke. The fact that you could take a patient coming in with one of these sicknesses and put them in an ambulance to make their way to some public institution somewhere else instead of caring for them is just almost unthinkable now. But it wasn’t unthinkable then. And I’m hoping that there’s so much that’s thinkable now that will be unthinkable soon.

Yeah. Although the American Hospital Association (AHA) really appreciated his work and hired them as a special tax counsel after he left the IRS. So, he became an expert on health care provision, thereafter, working for the AHA. But at the time, he was just, you know, a thirty-two-year-old IRS attorney who rewrote these regulations without public comment.

The 1980s are really a seminal moment in this story. I mean, before the 1980s, medical debts were held, usually by hospitals, on their books for years and even decades. And so even if a patient wasn’t immediately given free or discounted care, that debt would sit on their books, and it wouldn’t be pursued too aggressively.

Most often by the 1980s, things had changed. We mentioned the change in reimbursement for Medicare and Medicaid: Medicare went from reimbursing what were called “all reasonable costs.” Basically, the hospital just sent its bill to Medicare and said, “This is what we need for this procedure, this hospitalization.” And Medicare didn’t ask too many questions to a prospective payment system where hospitals could only get a certain amount and couldn’t really dictate the terms of how much they were given. Similar things happened to Medicaid, and states began to be much stricter in who would qualify for Medicaid.

So as a result you had, at a time of increasing poverty, a decrease in the number of people enrolled in Medicaid across the country and hospitals facing losses. Essentially every time they cared for a Medicare or Medicaid patient, the cost-to-charge ratio, or the amount of cost they had to the reimbursement they got, fell to the point where they were losing about ten to twelve cents on the dollar every time they took care of a Medicare or Medicaid patient.

And so this was this was harmful to a number of hospitals, especially ones that took care of a lot of publicly insured patients. Hospitals, even today, seek to optimize what they call their “payer mix.” They want those privately insured patients. The privately insured patients will give them the most reimbursement for any given episode of care. Different kinds of private insurance, or more or less remunerative. But in general, private insurance is better for hospital bottom lines. But hospitals that took care of publicly insured patients were in deep trouble; 9.7 percent of them closed their doors.

During the 1980s, a number of public hospitals that closed sold themselves to for-profit hospitals that began to spring up in the ’70s and ’80s. So that was a hugely influential moment. And what it did for folks in debt was it abandoned that era of lenience. Hospitals said, “We’re not going to wait for that money anymore.” I mean, it’s amazing when you read the trade journals; hospital administrators and folks involved in the debt-collection process are much more honest and candid about what their concerns are, what their motivations are.

And in those trade journals, every time they interviewed a billing executive in a hospital, they said, “We’re not going to wait for that money anymore. We’re going for it.” And so, they would, in increasing numbers, assign their debts to third-party collection agencies on a contingency basis. So, hospitals would assign the debt to a third-party collection agency. The collection agency would seek to collect for a given amount of time, maybe a year, maybe two, and then anything that the collection agency was able to collect, they’d keep a portion of that. Often at that moment it was between 30 and 40 percent. It was a pretty high number.

Alternatively, the hospitals would sell the debt outright: for pennies on the dollar they would sell the debt outright and hand the paper over to the third party. And that third party would then keep anything that it was able to collect thereafter. Those arrangements became much more common after the ’80s and ’90s, after some of those structural changes we talked about. The changes accelerated further after one more law, which I think is worth mentioning, which is the Medicare Modernization Act in the early 2000s, which promoted the use of high-deductible health plans. This was the George W. Bush administration.

The reigning ideology there was that patients needed skin in the game in order to be discerning consumers of health care. And that was the line they, you know, gave to the American public, even as subsequent studies would find that a lot of the folks who were pushing this stood to benefit a lot from the sale of high-deductible health plans.

Those became the most common health plans that Americans had. The deductibles that patients have to pay before any insurance kicks in started to rise rapidly. They’ve tripled over the last decade. So, they continue to rise. And patients, insured patients, faced increasing out-of-pocket costs. And hospitals, which were really built to collect from insurance companies, not from individual patients, started to have this wave of bad debt. They called it a tide of bad debt that they couldn’t collect from insurance companies. They were supposed to collect it from individual patients, and they weren’t built to do that. Their billing departments weren’t built to do that. And so, they increasingly turned toward debt collectors to help them do that as well. That was the sales pitch from the debt-collection companies: “We will do this for you.” The debt-collection agencies benefited from both of those changes, the changes in the ’80s and the changes in the 2000s.

The patient becomes a figure on a spreadsheet. I go into detail about some of the individual debt-collection companies in the book. I devote a whole chapter to chronicling the careers of a few of them, not because I think they’re individually heinous actors. I think we do a disservice to ourselves when we privilege individual agency over structure. But the careers of these debt collectors do highlight some of these structural changes.

For a lot of these prominent debt collectors, they’re buying and selling paper. They’re making relationships with hospital executives to sell them or assign patients’ debts. They really have nothing to do with health care. They’ve never been doctors. They’ve never been nurses. They’ve never been techs. They’ve never been involved in the health care process, but they hold sway over the fates of so many of our patients. It is increasingly a story of financialization, of alienation, of increasing distance between patient and physician and the bill. Those things become increasingly divorced. Physicians, for our part, have completely divorced ourselves from this process and basically left patients to the devices of these third parties.

So why do hospitals do this? It’s not because it’s remunerative. Hospitals that garnish the wages of low-income patients, sometimes their own employees.

Yeah, some of the investigative journalists who show up to courtrooms have been surprised to see that they’re filled with people in scrubs who are coming from work to their court cases about debts they owed to their own hospital for care sought there. So why are hospitals doing this? Why are they garnishing wages, including those of their own employees?

Well, it’s not because it makes them a ton of money. The good study that was done a couple of years ago of every one of these cases in Virginia found that the average hospital that sought to do this made about 0.1 percent of its revenue on the tactic by garnishing wages. The hospital that did this the most in the state, Mary Washington Hospital in Fredericksburg, made 0.2 percent of its revenue by this practice. One of the large cases of a hospital that continued to sue patients was the Mayo Clinic, which continued to sue patients even after the onset of the COVID pandemic. It made 0.01 percent of its revenue through lawsuits.

So why would hospitals resort to this level of aggression and use of state power when it really doesn’t help them stay afloat? You might assume that the hospitals that are doing this might be the ones that are about to go under. Well, they’re not; Mayo Clinic isn’t going under. These are well-heeled institutions, often with very comfortable operating margins. Even if you were about to go under — and hospitals do close — this isn’t going to save you. As I say in the book, it’s like trying to bail out the Titanic with a pail of water, and then throwing it into a crowded lifeboat. You might capsize the lifeboat, but you’re not going to save the Titanic. It’s really not worthwhile.

There have been a few reasons proposed by interlocutors, people I interviewed, that came up in the archival research about why this even exists. One reason this system is still in place has to do with the distance between anyone who has a clinical and social bond, and the decision-making about how aggressively to pursue the patient. If only a couple administrators and a C-suite executive are contracting with a third-party debt collector, which has a series of increasingly aggressive debt-collection tactics, then most of the folks working at the hospital really have no idea. And unless that individual in the C-suite or the billing office is attuned to it or paying attention or cares, then then those aggressive debt-collection measures can go forth with very little input from any of the staff at the hospital.

I think that’s a powerful motive, and I think part of the proof of that is that as soon as people realize what’s going on at most facilities, they can put an end to the most egregious practices pretty quickly. Not the existence of debt or the pursuit of debt, but those extraordinary collection actions tend to fall off pretty precipitously. I mean, in Maryland, we’ve seen that almost none of these cases are being filed anymore, in part because of the laws that have been passed, but also in part because of the public attention on them.

Another thing — and this was proposed by a trial attorney named Dickie Scruggs, a Mississippi trial attorney who made a fortune filing class-action lawsuits against shipyard companies (for asbestos) and Big Tobacco in the 1980s and 1990s. He started suing hospitals in the 2000s, saying that they weren’t meeting their obligations as charitable institutions by pursuing patients so aggressively. He lost those cases because there was at the time no right to financial assistance in a way that actually changed with the passage of the Affordable Care Act (ACA). So now there is that point of leverage that I think could be used more successfully.

But Scruggs said he thought that hospitals were doing this not necessarily to collect money from individual patients, but to prevent low-income patients from showing up in the first place. It was basically a slim measure to improve their payer mix. And we know that patients know where they’re welcome and where they’re not. Patients know where they’ll be hounded and where they won’t. There’s a reason why low-income patients show up more often to public hospitals or to private nonprofits that don’t employ these measures. And so, I think there is some truth in that. There have been explicit statements to that effect in some depositions that I’ve seen out of private hospitals in Washington State. To what extent is this an overtly articulated tactic is still not clear, but I do think it definitely has the effect of deterring people from seeking care.

He hit the nail on the head right there! It is definitely important to bring in other actors here. As even folks like Melissa Jacoby and Elizabeth Warren have written like twenty years ago, focusing on hospital misbehavior or individual actors is always going to be incomplete. There are a lot of middlemen in health care. There’s an increasing number of middlemen in health care: pharmacy benefit managers, private equity companies, brand-name drug companies, and insurance companies. Some insurance companies play a large role in this story, because when a patient can’t afford to pay their bill, the question becomes, who foots it?

We’ve had varied answers to those questions over time. In the nineteenth century, it was the physicians who footed the bill and had to make up the difference themselves or go into debt. In the early twentieth century, hospitals took on that measure themselves as a part of their mission. With the rise of public insurance for a time in the 1960s and 1970s, it was Medicare and Medicaid who paid any reasonable cost the hospital saw fit to charge them. In the 1980s, though, when hospitals could no longer turn to public insurers to pay the cost that they thought they needed to cover, it was private insurers. For a time, hospitals would increase their list prices and seek to have private insurers cover those costs and kind of make up the difference for publicly insured patients who weren’t covering their costs.

But by the 1990s, that’s part of what drove the rise of health maintenance organizations (HMOs): private insurance companies that sought to cut costs quite vigorously. And then in the 2000s, after the backlash against HMOs, it drove the rise of high-deductible health plans — an error that we are still living in today. And so, health insurers for a time were the folks footing the bill. But that was the very era when Cohodes was writing that piece that you quoted from where he was extremely worried about hospitals not doing enough to collect aggressively.

So basically, whoever is footing that bill — if it’s not the patient — is the one advocating most vigorously to make sure that it is the patient, unless the patients themselves and folks who are their allies are organizing to make sure it isn’t the patient. It’s a big game of football to try to see who is holding the bill at the end. And insurers have been pretty successful in making sure that it’s not them, at least not for long.

That’s definitely a fair conclusion. Really the only conclusion that one can draw from this history is that these attempts are inadequate. There have been laws regulating debt collection, not only medical debt collection, but other forms of consumer debt collection for decades. The 1970s saw some of the most prominent ones, the ones we still live with today — the Fair Debt Collection Practices Act in the late 1970s. More were passed in the 2000s; more were passed along with Dodd-Frank in 2010. As you say, these federal laws largely seem to exist to maintain a certain sense of decorum over the phone when patients are contacted by their creditors: that they cannot be contacted after a certain time, that they could only be contacted a certain number of times, that abusive language shouldn’t be used. These laws weren’t always honored. We have countless examples in the book of patients facing abusive language and harassing calls from debt collectors, from medical debt collectors, and some slaps on the wrist by the Federal Trade Commission or the Consumer Financial Protection Bureau as a result in the form of fines. But that’s really the extent of those federal regulations thus far. State laws have tried to go further largely as a result of organizing efforts.

I’ll give the example of Connecticut, after organizing around Yale New Haven Hospital, which was suing and placing liens on the homes of vast numbers of low-income patients in New Haven. The Service Employees International Union and other unions and organizers sought to prevent these practices. They were able to change Connecticut state law in a way that limited the amount of debt that could be collected. They did limit the amount that could be collected through payment plans in a given month as a percentage of patients’ incomes. And so, these were smaller measures, I would say, and they were more meaningful than the federal measures that were done.

But they didn’t halt the lawsuits against patients forever. The public attention did slow it for a time. But in the 2010s, we saw that in Connecticut, tens of thousands of people were being sued for medical debts still. So, it hasn’t proven an enduring solution. These measures, these piecemeal reforms, did make a difference for some patients, but they really aren’t achieving the kind of structural transformation we seek.

Yeah. I focused a lot on this particular episode because it was a big turning point in public attention. It was one of the first times that it became clear to the public that this was what was going on, because it became the subject of a series of Wall Street Journal exposés. And this was only possible because of the work of local journalists writing in alt weeklies in the city of New Haven. And it did result in some changes.

There was a seventy-seven-year-old man who had been sued by Yale New Haven and had had his debt collected for the last twenty years for a single visit. His now deceased wife had gone there in 1982. So, you know, these were really onerous practices that the exposure and the changes in state law did help relieve some patients of that debt. But the fact that we’re still seeing patients being sued in the state of Connecticut all these many years later does tell us that we have to do something more.

The ACA is an important law for a couple of reasons. One is that the expansion of Medicaid, imperfect and piecemeal as it was, did decrease the flow of medical debt in states that expanded Medicaid. The second is that it does include a provision that requires nonprofit hospitals as a standard, as a condition of their tax exemption, to publicize and author financial assistance policies (FAP). These policies should lay out at what level of income patients should qualify for free and discounted care. And that was actually partially a result of the work of Dickie Scruggs and those failed class-action lawsuits.

He ended up going to federal prison for bribing a judge. But he was really well connected. He was related by marriage to Trent Lott, who was the Senate majority leader and knew Chuck Grassley, who ended up taking this up as an issue when the ACA was written. And even though Grassley voted against the ACA, his preference that this FAP provision be included in the law was honored. And so right now, hospitals are supposed to have these policies written. Usually, they’re hard to find. You have to go online and hunt pretty, pretty long and hard to find some of them.

They’re supposed to be readily available, but they’re not always. And through the work of some really dogged researchers, I want to point out Dollar For, an organization started by Jared Walker, a former bartender whose own family had dealt with medical debt, who organized a group of volunteers to build this tool online. So, if you go to Dollar For’s website, you can find out, by typing in what hospital you’re looking at and what your income is, whether you qualify for this free or discounted care. That’s their work — looking through PDFs of six thousand hospitals and figuring out what those thresholds are. Otherwise, we’d all be up a creek trying to find those documents ourselves.

And we were able to work with them. We’re working on a paper right now to analyze this and see: What are these cutoffs? Is there any logic to them? Is there any reason to them? And as I mentioned, it’s a huge variety. It extends from 75 percent to 600 percent of the federal poverty level, from $22,000 for a family of four to $180,000 for a family of four. And there’s regional variations in that as well. The South and the Mountain West have these really low cutoffs for free and discounted care. So, folks who seek care in those areas have less access to financial assistance. People who live in areas with high levels of poverty have lower cutoffs, probably as a result of higher demand. If you live in an area with concentrated poverty, you’ll have less access to the free and discounted care.

So, there are systemic problems with the financial assistance policy as it’s written. But thanks to the work of Jared and others, we’ve come to realize that. I think that is another point of leverage — that some degree of systematization of these cutoffs could be done. This isn’t a long-term solution. This isn’t where we’re driving at. But at least we could make some of these disparities disappear on our way to single-payer health care.

Thank you for bringing that up. That’s an amazing part of the story too, because it’s another part of the legal history that I think is worth going into in a little bit of detail. When the ACA was passed, it stated that hospitals are supposed to take “reasonable efforts” to ensure that patients do not qualify for this assistance before they resort to extraordinary collection actions, before reporting them to a credit bureau or taking them to court, or any of that stuff. Now, hospitals worked really hard alongside debt collectors to help define what a “reasonable effort” was.

I’m working on a paper with some really amazing undergrads, looking into the public comments that the IRS fielded from hospitals, from debt collectors, from community organizations, when it was deliberating exactly what reasonable efforts would entail. And we found that hospitals were almost always allied with debt collectors. They were a block in these comments about what exactly reasonable efforts should entail, what an extraordinary collection action should be, and how much work they should be forced to do to determine whether a patient qualified before they went ahead with lawsuits and with negative actions on credit reports.

They didn’t win everything they wanted, but they did win the definition of reasonable efforts. Basically, all they have to do is make sure that patients are informed at some point about the existence of a financial assistance policy, and that if the patients submit an application that it’s processed. Now, those applications can be as onerous as you want them to be. I mean, Jared knows this better than anyone because his organization not only has that tool, but it will help anyone who wants to apply for financial assistance from their hospital, and it’ll do it for free, right? It’ll do it out of solidarity.

Jared’s found, in the course of doing this work for thousands of people, that these applications can be onerous. They ask for all sorts of documents. They ask for them in a specific amount of time, and they require you to submit them, sometimes by snail mail or fax. Who has a fax machine? Or, tell them if you’ve started a GoFundMe campaign. So, have you raised enough money so we can take that too? These are really onerous processes that hospitals can use, and they’re not required to do any proactive work to determine whether someone qualifies.

And there’s the easy ways for hospitals to do this. Hospitals can get a hold of your tax return if they want to. They just basically call up the IRS and get it. They could do that. Hospitals can see whether you are a part of a public program like Women, Infants, and Children (WIC) benefits or Supplemental Nutrition Assistance Program (SNAP) benefits, food stamps or other public benefit programs that have income cutoffs that are similar to or below most hospitals’ income cutoffs. So, if you qualify for WIC or food stamps, you’re probably going to qualify for your hospital’s free care. And some states have started to require hospitals to do this, but the federal government doesn’t. There’s so much we can do to make hospitals do their due diligence and make sure that folks aren’t charged when they shouldn’t be charged.

Yeah, absolutely. I think I’d never realized some of the structural connections between some of the problems I was writing about in postcolonial and colonial-era African medicine and some of the things I’m dealing with on a day-to-day basis in the United States. When I wrote about Malawi, when I was writing about the British colonial era, I wrote about how the colonial officials would often really use their rhetoric to justify scarcity, to justify continued scarcity, to say that nothing more could be done, even as they were extracting massive debt repayments out of impoverished, colonized peoples for infrastructure like railroads that were built basically to benefit financiers in the home country.

I thought about that scarcity a lot. I was grateful to a certain extent that I didn’t have to deal with it as much in the United States until COVID hit, when scarcity became basically a way of life. We didn’t have enough personal protective equipment at first, and that was a constructed scarcity. We didn’t have enough medicines, as supply-chain bottlenecks became a reality in our everyday work. Every day we’d come into the hospital and find out we’re out of this antibiotic, we’re out of this anesthetic, we’re out of that supply.

The most meaningful scarcity became our own workers, specifically nurses. There were never enough nurses. Some nurses left the profession. Some nurses went to become travel nurses as they became a scarce commodity and different hospital systems basically bid for their services. But their work was so taxing and so difficult and so dangerous in the context, especially in the context of COVID, that they became truly scarce. And we’re still living with that today.

In most of our hospitals, the emergency departments are constantly full. You’re waiting longer than ever. At one of the hospitals I worked in (not the hospital I work in now), I saw a patient come in twelve hours after waiting in the waiting room saying he was no longer in pain, and I said, “Why?” He said, “I think I passed my stone. I was in your bathroom vomiting for twelve hours, but I think I finally passed it.” The fact that he was so close to relief being in our waiting room, but never got in until basically the natural course of his illness continued — that was just awful. That was something we deal with every day in our hospitals.

To a certain extent, I think there have been some sanguine developments in this world, largely because organizing has become mainstream. Previously, hospitals weren’t really a place in which physicians were known to organize. Nurses and other staff and sanitary workers were organized, food service workers were organized. But as physicians, we saw ourselves as kind of a world apart: that wasn’t appropriate for us; we were independent professionals. But I think more and more we’ve come to realize that we’re not special. We’re workers too.

Yeah, the history of the politics of my profession provides pretty dispiriting reading. The American Medical Association was for most of its history, and still today, a force against single-payer health care. It organized its members to the extent of its ability to make sure that that did not pass, decisively in some cases, like in the mid-1940s, right after World War II, when most countries, including the UK, were passing their national health systems. Organized efforts were made to do the same thing in the United States. Some of that has started to change.