The Growing Burden of Medical Debt for Insured Americans
Health insurance, designed as a financial safeguard against illness and chronic conditions, presents a paradox in America: many insured individuals are burdened by substantial medical debt. This contradiction highlights systemic flaws in our healthcare system, where high out-of-pocket costs, aggressive debt collection by hospitals, and policy gaps create a crisis impacting financial stability, equitable healthcare access, economic mobility, and both financial and health disparities.
The Rising Tide of Medical Debt Among the Insured
Penelope Wingard's experience, a 58-year-old black woman from Charlotte, North Carolina, starkly illustrates the human cost of medical debt for the insured. After her breast cancer treatment in 2014, she faced a new challenge: escalating medical bills. Despite Medicaid coverage during treatment, she found herself uninsured and overwhelmed by costs for follow-up care. "My hair hadn’t even grown back from chemo, and I couldn’t see my oncologist," she recalls, underscoring the immediate financial burden of her illness.
Her financial woes deepened with subsequent medical issues, including an aneurysm and vision problems, leading to tens of thousands of dollars in debt. "It’s like you’re being punished for being sick," Wingard's experience reflects a broader trend affecting many insured Americans - not just the uninsured.
This trend is echoed in recent reporting by The Guardian, showing most hospital debt in the U.S. now involves insured patients, rather than uninsured patients, often due to high deductibles and unexpected out-of-pocket costs. The Kaiser Family Foundation’s 2023 Employer Health Benefits Survey further highlights it, noting a rise in high-deductible health plans, which, despite lower premiums, can lead to significant financial strain during medical emergencies. This change also represents employers selecting benefit designs that shift costs to employees or, more directly, a lower overall value of compensation packages.
Wingard's ordeal and these findings paint a concerning picture of U.S. healthcare, where insurance all too frequently fails to provide adequate financial protection, underscoring the need for a critical reevaluation of insurance structures and policies.
The Role of Hospitals and Aggressive Collection Practices
The medical debt crisis in the U.S. is worsened by many hospital systems, particularly so-called nonprofit hospitals, adopting aggressive debt collection tactics. A Nonprofit Quarterly article highlights that these hospitals, despite tax exemptions, often pursue lawsuits, wage garnishments, and home liens, exacerbating patients' financial woes.
The Human Rights Watch report, "In Sheep’s Clothing," reveals that about 60% of U.S. community hospitals are tax-exempt nonprofits, yet they spend significantly less on charity care than they receive in tax benefits, raising questions about their commitment to community service.
Additionally, the decline in charity care, vital for both uninsured and insured patients facing high out-of-pocket costs, is alarming. Hospitals' aggressive pursuit of unpaid bills, including legal actions and debt sales, seemingly contradicts their community-serving role and intensifies the medical debt crisis.
In response, legislative measures like New York State's Fair Medical Debt Reporting Act are emerging. This law, preventing hospitals from reporting unpaid medical debts to credit agencies, marks progress towards protecting patients and signals a shift towards more ethical debt management practices in healthcare.
Policy Gaps and the Need for Reform
The Affordable Care Act (ACA) and Medicaid Expansion stand as monumental efforts to increase coverage. Yet, the persistence of medical debt among the insured underscores a critical disconnect between policy intentions and real-world outcomes.
The ACA and Medicaid Expansion: Coverage vs. Cost
While the ACA and Medicaid Expansion have expanded healthcare access, they often fail to protect individuals from medical debt due to rising out-of-pocket costs. The Peterson-KFF Health System Tracker Brief indicates that the ACA’s maximum out-of-pocket limit is increasing faster than wages, burdening insured individuals with escalating healthcare expenses.
High-deductible health plans (HDHPs) exacerbate this affordability crisis. These plans, with lower premiums but higher initial costs, are increasingly common. The Kaiser Family Foundation’s 2023 Employer Health Benefits Survey shows a rise in HDHP enrollment, leading to significant debt for families as they pay more out-of-pocket before insurance coverage starts.
Coverage limitations under the ACA also contribute to this issue. Essential health benefits vary by state and plan, often leaving gaps in coverage for critical services like mental health or certain prescriptions. This variability, coupled with high deductibles, results in insured individuals facing substantial medical debt, contradicting the purpose of insurance.
Addressing this requires reevaluating health insurance structures and regulatory frameworks to balance affordable premiums with comprehensive, consistent coverage, reducing the risk of overwhelming medical debt for insured individuals.
Commonwealth Fund's 2023 Health Care Affordability Survey: Key Insights
The Commonwealth Fund's 2023 Health Care Affordability Survey reveals more than statistics; it highlights the real struggles of Americans with healthcare costs. The survey underscores the healthcare affordability crisis, showing that insurance doesn't always shield from financial burdens.
A major finding is the impact of high deductibles and copayments, which consume a significant part of many people's incomes, forcing tough choices like delaying medical care or incurring debt. Particularly affected are lower-income families, those with chronic conditions, and older adults, who often face a cycle of debt and deferred care, worsening health disparities.
The survey also points to a trend of underinsurance, especially in employer-sponsored plans with high deductibles, leaving many at financial risk. These insights call for urgent policy reforms to make healthcare truly affordable, focusing on reducing out-of-pocket costs, restructuring insurance plans, and enhancing subsidies for those in need.
State-Level Initiatives: Pioneering Change
States are at the forefront of combating medical debt with innovative solutions. The Commonwealth Fund State Protections report highlights diverse strategies to mitigate medical debt's impact.
Key initiatives include laws to limit aggressive hospital debt collection practices, crucial for protecting vulnerable groups like low-income families and those with chronic conditions. Some states have set legal boundaries on pursuing unpaid medical bills and capped interest rates on medical debt.
Expanding eligibility for charity care and financial assistance is another significant move. This broadening ensures more people, particularly those with limited resources, can access medical care without the fear of crippling debt, thereby improving community health outcomes.
States are also focusing on enhancing transparency in medical billing and insurance coverage, ensuring patients have clear information about service costs and their financial obligations. This clarity is essential for informed healthcare decisions and avoiding unexpected bills.
Furthermore, states are strengthening consumer protection laws to defend against unfair medical billing practices, holding providers and insurers accountable for billing errors and offering patients better dispute resolution options.
These state-level actions, varying in scope but united in purpose, demonstrate encouraging progress toward a more equitable healthcare system. They address not only the symptoms of medical debt but also several of the root causes, paving the way for broader healthcare reforms. These initiatives, alongside federal efforts, are shaping a future where healthcare affordability is accessible to all, not a privilege for a few. State governments' role in this fight is pivotal, with their policies and programs serving as models for national reform and effective strategies to alleviate medical debt.
Federal Actions: A Unified Approach with Enhanced Consumer Protection
Federally, initiatives like the White House Convening on Medical Debt and the Consumer Financial Protection Bureau's (CFPB) plan are key in combating medical debt. These efforts merge federal oversight with state innovation, addressing medical debt's complexities.
The White House Convening united federal and state policymakers, healthcare experts, and advocates to strategize on reducing medical debt and improving healthcare policies. This meeting was pivotal for sharing insights and identifying best practices for nationwide implementation, recognizing medical debt as a multifaceted issue.
Additionally, the CFPB's plan, noted in a National Consumer Law Center (NCLC) announcement, marks a significant move towards consumer protection. It proposes prohibiting medical debts from being reported on credit reports, a major relief for those burdened by medical debt. This initiative is widely supported by consumer groups and reflects an understanding of the disproportionate impact of medical debt on financial stability.
The collaboration of federal agencies like the Department of Health and Human Services, the CFPB, and the Centers for Medicare & Medicaid Services is crucial in formulating effective healthcare policies. Their joint efforts are expected to lead to comprehensive strategies that significantly alleviate the burden of medical debt.
This federal approach, emphasizing interagency cooperation and stakeholder engagement, is helping to create policies and practices that effectively reduce medical debt, integrating federal oversight with state-level innovation and consumer protection measures like the CFPB's plan. This integrated strategy is essential for relieving American families of medical debt and advancing towards a more equitable healthcare system.
The Blind Spot: Medical Credit Cards
Despite the good intentions of these proposals, a “blind spot” persists and more and more hospital systems are taking advantage of it by pressuring patients to agree to take on “medical credit” debt, prior to providing services - even in emergency departments. The most popular of these programs is known as “Care Credit” and the American public assumed some $23 billion in medical credit card debt across- more than 11 million users from 2018 through 2020. Unlike traditional medical debt, these medical credit programs accrue interest and do not qualify for financial assistance or charity care. They result in as much if not more damage to patient-consumer credit reports as traditional medical debt.
Once primarily limited to dental costs, which are not a required covered benefit for adults, the company that owns Care Credit says it believes patients typically generate this debt through “elective procedures”. However, patients urged to accept credit based medical debt in an emergency room or when facing cancer care or even in seeking dental care for an infected tooth may not feel these procedures are “elective” and the financial institution is not necessarily going to operate with the same definitions the general public would. Indeed, it does not serve Synchony’s interests to do so. In fact, Synchrony partners with multiple provider associations and as of 2023 with at least 17 hospital systems or about 300 hospitals but, when interviewed, refused to provide details because those agreements likely include “sponsorships” or what would otherwise be called a kick back scheme. That scheme structure is very likely prohibited by federal law protecting patients of public health programs like Medicare from providers and their affiliates that would take advantage of needy or elderly patients.
Once assumed as a means of paying for medical care, medical credit card debt reports just like traditional credit card debt and patient-consumers are no longer protected from those specific protections policymakers are considering now.
Conclusion and Call to Action
It's evident that this crisis is not just financial but a moral and systemic failure. The experiences of individuals like Penelope Wingard and findings from the Commonwealth Fund's 2023 Health Care Affordability Survey underscore the need for compassionate healthcare reform.
Policymakers, healthcare providers, patient advocates, and citizens must unite to address this crisis's root causes and reshape our healthcare system.
For Policymakers:
Implement policies that go beyond expanding coverage to ensure affordability and accessibility.
Reassess high-deductible health plans and their impact on families.
Mandate comprehensive coverage in health plans, including closing the essential benefits loophole and ensuring network parity for services like mental health and chronic disease management.
Enforce regulations ensuring hospitals commit to community-serving mandates, particularly in providing sufficient levels of charity care to justify nonprofit status. This can be implemented on both the state and federal levels.
For Healthcare Providers and Institutions:
Prioritize ethical patient care over financial gains.
Establish transparent billing practices and expand charity care programs.
Collaborate with community organizations to identify and support vulnerable patients.
Train staff in empathy and patient advocacy, focusing on the human aspect of healthcare.
For Patient Advocates and Community Members:
Support legislation that protects patients from aggressive debt collection and unfair billing.
Educate communities about their rights and resources regarding medical debt.
Partner with local health systems to develop patient-centered care models.
For All Stakeholders:
Collaborate to create a healthcare system that balances efficiency with empathy, justice, and accessibility.
Strive to make medical debt a rarity, ensuring healthcare access for all, regardless of insurance status.
Remember the human element in healthcare.
We possess the knowledge and resources to drive change. Let's collectively push for policies that safeguard the vulnerable and work towards a healthcare system where access is a right, not a privilege. The time to act is now and it is past time that our state and federal policymakers evaluate their allegiance to hospitals systems abusing government programs, the dollars that support those programs, and the patients those dollars are meant to benefit.
Patient Care Suffers at the Intersection of Nursing Shortages and Hospital Consolidation
Last week, New York City nurses at Mount Sinai and Montefiore hospitals went on strike for about three days before the hospitals reached a tentative agreement, bringing nursing staff back to work immediately. The New York State Nurses Association, which organized the strike, lead an incredible media campaign around the strike effort, warning communities (and hospitals) well ahead of the strike about the need for good faith negotiation and changes weren’t just about ensuring nursing staff compensation kept up with inflation, but primarily based on working environments and patient safety, with key demands around improving staff to patient ratios. The campaign was so successful, four other hospitals which would have been subject to the strike reached agreements ahead of the Monday deadline. While the American Nurses Association did not have a direct hand in the strike, they supported the move by the New York State Nurses Association, stating the need indicates a “systemic breakdown” regarding safe staffing levels, protecting nurses from workplace violence, and supporting nurses’ mental health and well-being, among other challenges.
That idea offered by the American Nurses Association isn’t wrong – this issue is systemic. Lats month, the New York Times outlined how Ascension, one of the nation’s largest hospital systems, had neglected staffing needs for years, leading to hospital locations across the country being ill-prepared for the demands and challenges COVID-19 brought. The piece, entitled How a Sprawling Hospital Chain Ignited Its Own Staffing Crisis, details how Ascension bragged about reducing its labor costs and reducing its number of employees per occupied bed. But this, in combination with other factors like health care workers becoming sick, left Ascension hospitals in a near unimaginably bad position to handle waves of COVID-19 patients. Indeed, the New York Time also ran a piece in August of 2021, highlighting the plight of nurses struggling to keep up with demand of the “Delta variant wave”. The beds were there, the staff to ensure those beds could be safely occupied were not. On top of already having poor staffing to patient ratios and many staff falling ill with COVID-19, thousands of health care workers died in these “crisis” waves. Several times throughout various COVID-19 “waves”, hospitals advertised their need for nursing talent and offered to pay exceptionally well for those traveling nurses who could help meet the immediate demands of the moment. Already retained nurses were not necessarily offered similar compensation as their traveling counterparts, even if some hospitals did end up offering supplemental pay. Largely, those supplemental payments have dropped off as CARES Act dollars have dried up.
Put yourself in the nurse’s position, for a moment. If you could get paid say… three months’ worth of salary working two weeks away from home by traveling, would you do it? Consider now, there is no end in sight for the demand in traveling nurses. You can find work whenever you want and it’s well-paid enough that you don’t have to worry things like negotiating to compensate for inflation. And if the area you’re working is experiencing workplace safety issues or violence from patients who have bought into conspiracy theories that you and your colleagues are somehow making up a respiratory pandemic, you can just leave. More and more nurses weighed this position and more and more nurses opted to travel. This has had likely one of the most significant drivers of hospital labor costs increasing by at least 37% since 2019. And hospitals, for their part, aren’t necessarily cutting out activities like buying up other entities or executive compensation in order to reinvest in their staff, rather, they’re billing insurance companies more. That increase in cost of care also translates to an increase in insurance premiums for consumers and other plan changes that might adversely affect patients and patients’ ability to afford care. For example, Health System Tracker, a project of Peterson Center on Healthcare and Kaiser Family Foundation, detail how the Affordable Care Act’s maximum out of pocket limit is growing faster than wages and how emergency department visits are now exceeding affordability thresholds for many consumers with private insurance.
These systemic changes need to be addressed immediately by state and federal policymakers. Unions alone cannot stop hospital consolidation and can only leverage so much to ensure appropriate staffing levels without risking the quality of care patients receive in any given community.
Because of the greed that drives hospital consolidation, the “rural hospital crisis” is coming to an urban area near you. An example of the emergency nature of this situation can be found in Atlanta Medical Center’s sudden closure, an issue Louisiana Children’s Medical Center’s purchase of Tulane hospitals from HCA Health could replicate in another majority Black city.
Given the billions of dollars hospitals have received in CARES Act dollars and continue to receive in 340B dollars, regulators need to slam on the breaks of approving hospital consolidation purchases. Communities and their elected officials should also critically ask hospital executives (and investigate a factual answer, not a public affairs answer), “Are you really operating as a health care provider or are you operating as a real estate entity and buying out all of your competition at the expense of our communities?” Indeed, the real question that’s going to drive some much, much needed oversight on hospitals would be, “Are you using these dollars meant for public benefit to buy out your competition?”
It's high time hospitals be held accountable.