- michael barbaro
From The New York Times, I’m Michael Barbaro. This is “The Daily.”
Today: for decades hospitals could assume that patients with jobs and health insurance would pay their medical bills. Sarah Kliff on why that’s no longer the case and the aggressive new way that hospitals are forcing those patients to pay up.
It’s Monday, December 2.
- sarah kliff
Hi, Amanda.
- amanda sturgill
Hi!
- sarah kliff
It’s been a while.
- amanda sturgill
It has been. Hi.
- michael barbaro
Sarah, tell me about Amanda Sturgill.
- amanda sturgill
Oh, yeah.
- sarah kliff
So Amanda is 41 years old. She lives in this tiny little town in rural Virginia called Norton.
- amanda sturgill
It’s very small. I don’t even know why it’s called a city, because it’s not very big.
- sarah kliff
She has four children. She’s a single mom.
- michael barbaro
Sarah Kliff writes about health care for The Times.
- sarah kliff
She works full time at an audio equipment company, where she processes orders.
- amanda sturgill
So it’s just like a little freak thing that happened.
- sarah kliff
And a few years ago —
- amanda sturgill
I was working —
- sarah kliff
— Her daughter Michaela was giving one of the other kids a bath.
- michael barbaro
Mm-hm.
- amanda sturgill
And she bent down to pick her up, to get her out the bathtub.
- sarah kliff
She bent down to pick up her sibling and just got this terrible pain in her back.
- amanda sturgill
Kind of go down her legs. And she was just in this horrible, excruciating pain. Took her to the emergency room —
- sarah kliff
Amanda, obviously, is worried. She doesn’t understand what’s going on, so she takes her daughter to the emergency room at the local hospital system, a company named Ballad. They give her a pain shot, go back home, but this pain doesn’t go away.
- amanda sturgill
I went back to the pediatrician. It was probably weekly with Michaela to tell them this is not getting any better.
- sarah kliff
They start seeing specialists and doctors. There are M.R.I.s. There are more pain shots. And no one can really figure out what’s going on with Michaela, and the pain is getting worse.
- amanda sturgill
She’s just like, something’s not right. I’m in really bad pain. And —
- sarah kliff
She can’t walk without pain. She’s having trouble sleeping, and Amanda’s like, oh my gosh, is my teenage daughter going to have to live with this terrible pain for the rest of her life?
- michael barbaro
Hm. So what happens?
- amanda sturgill
So it came back on the M.R.I. there was a slight bulge down there.
- sarah kliff
They figure out that Michaela has a degenerative disk disease.
- amanda sturgill
He’s like, your daughter’s back is the back of a 70-year-old woman.
- michael barbaro
Hm.
- sarah kliff
So it’s serious, and a doctor recommends that the best course of action is surgery.
- sarah kliff
When you found out Michaela needed surgery, what was going through your mind?
- amanda sturgill
I was terrified, terrified of thinking your young child is going to have to go through this excruciating surgery.
- sarah kliff
And were you worried about money at all, when you found out about the surgery?
- amanda sturgill
No, I honestly didn’t care. I was like, I don’t care. Run whatever tests you run. I will deal with the bills when they come. I was like, just help her, get her better.
- sarah kliff
So the surgery happens. It goes decently well. It doesn’t fully relieve Michaela’s pain, so that issue still lingers. But they go home, and then the bills start showing up.
- amanda sturgill
It was just one of those days, where just go check the mail, go walk out to the end of the road. And we get a couple bills that were about 200 here and there.
- sarah kliff
They trickle in, because remember, there have been all these doctor appointments, all these specialists, and M.R.I.s, and shots. So there’s a few that are like —
- amanda sturgill
50 something.
- sarah kliff
100 there.
- amanda sturgill
200 here.
- sarah kliff
But then the bills get bigger.
- amanda sturgill
I ended up owing like that 500 and something dollars per M.R.I.. And then the surgeon —
- sarah kliff
The surgery bill comes, and that’s over $2,000.
- michael barbaro
Wow.
- amanda sturgill
And I was like, oh, wow, hello. I wasn’t expecting that.
- sarah kliff
For Amanda, she earns $12.70 per hour at her job. This is a really significant bill, and she just does not have the money to pay it.
- michael barbaro
And does Amanda have insurance?
- sarah kliff
She does. Yeah, she has insurance at work. She felt like it was good insurance, but then she’s finding that her insurance actually expects her to pay a lot of co-pays, a certain share of the surgery. And it’s starting to get pretty stressful.
- amanda sturgill
It’s like, well, let’s just start from what we can and what we can’t do. So I just started filling some out and sending them. But there’s so many.
- sarah kliff
She really wants to pay the bills.
- amanda sturgill
I pretty much clinch every penny I possibly can.
- sarah kliff
And what is going through your mind about these bills as they’re piling up?
- amanda sturgill
I will go to flea markets, have yard sales, that sort of thing.
- sarah kliff
She’s trying to scrape together the money.
- amanda sturgill
I will sometimes not eat but like once a day, to try to save money, so I don’t have to buy food, and just save it all for them. We’ll have dinner together. And they see me do that, but they have no idea that I do that during the day.
- sarah kliff
But then, during the entire day, you don’t eat to save money.
- amanda sturgill
Right, right. [CHUCKLING] Right.
- sarah kliff
How do you feel by the end of the day? I know you work a full time job.
- amanda sturgill
Um, I get pretty emotional sometimes. I’ll go and cry and hide in the bathroom, then just come out and be the happy mom that I need to be to make sure that their life is as normal as possible. I don’t let them know any of this.
- sarah kliff
So for a while, this works and she’s able to keep up with the bills. She’s sending in payments to the hospital. But a few months ago, she falls behind. She just isn’t able to come up with the payments that she’s supposed to be making on these bills. And then one day, there’s a knock at the door.
- amanda sturgill
It was about midday. The kids were home.
- sarah kliff
And the dogs start barking.
- amanda sturgill
And the kids were like, mom, there’s a cop on our porch. And I was like, oh, O.K., someone out there. He was in his brown sheriff’s uniform. He had his sheriff car that had the lights and the sheriff stickers all over it.
- sarah kliff
And he has a document that he needs to give Amanda.
- amanda sturgill
We’ve got you this summons to court. And I was like, wow, O.K.
- sarah kliff
So Amanda takes the documents.
- amanda sturgill
I just, I said, thanks for bringing it to me. So I ended up having to —
- sarah kliff
She tells the kids, don’t worry, it’s just some important papers that they couldn’t deliver in the mail.
- amanda sturgill
Just so they wouldn’t freak out.
- sarah kliff
And then she actually opens it up, and it turns out that the hospital is suing her for the medical debt that she owes them. And this is a court warrant with a court date that they’re asking her to attend.
- amanda sturgill
I was very shocked, and scared, because then I’m just like, oh my gosh, I don’t know what to do.
- michael barbaro
So she has fallen behind on this bill, and the hospital is now taking her to court over this unpaid bill.
- sarah kliff
Exactly, and things have moved from the billing department into the courtroom. Amanda has a court date.
- amanda sturgill
June 27.
- sarah kliff
But it turns out her court date is actually a day she has an appointment.
- amanda sturgill
I had to go to get checked, because I had a lump in my breast. So we had to go and get that checked out, and I wasn’t missing that for nothing, because —
- sarah kliff
She had recently found a lump in her breast, and it had taken her weeks to schedule a mammogram.
- michael barbaro
Hm.
- sarah kliff
And where did you have that doctor’s appointment?
- amanda sturgill
It was in Ballad. It’s one of their physicians.
- sarah kliff
And how did that turn out? Is everything O.K. with the lump that they found?
- amanda sturgill
Yes.
- sarah kliff
O.K., good.
- amanda sturgill
Yes, yes, yes.
- sarah kliff
Glad to hear that.
- amanda sturgill
It was just a benign little tumor thing, so yeah, it’s good.
- sarah kliff
So you were going to get health care from the same provider that was suing you over your medical bills on the same day?
- amanda sturgill
Yeah, because we have nothing else. We have no other options.
It really makes you feel uncomfortable, because it’s like when you go, it’s like, do they know that Ballad is suing me over this? Are they going to say something to me? Are they going to deny me health care, because I owe them money? It was pretty terrifying.
- michael barbaro
Sarah, nothing about this sounds normal. A mother with a solid job and health insurance suddenly has a sheriff at her door, and she faces legal action over falling behind on a medical bill.
- sarah kliff
It is actually becoming surprisingly common in our health care system. There are thousands of Americans many with private insurance currently being sued by their hospitals. They’re in big cities. They’re in small towns. And the reason I know this is actually the story of how I found Amanda.
- michael barbaro
We’ll be right back.
O.K., Sarah, you said that finding Amanda helped you understand how widespread this problem was. So how did you find Amanda?
- sarah kliff
I found Amanda a few months ago, when I went to this tiny little courtroom in rural Virginia, about six hours west of Washington, D.C., where I live. And on the day I went to court, there were 160 cases on the docket. 102 of those cases were being brought by the local hospital system, Ballad. In each of those cases, the hospital was suing one of its patients for outstanding medical debt.
- michael barbaro
Hmph.
- sarah kliff
And Amanda was one of the 102 cases that would be heard that day.
- michael barbaro
So what’s happening here? Why is a local hospital suing over one hundreds of its patients?
- sarah kliff
Yeah, so that’s something I started to figure out, talking to the people who were in the courtroom, and calling people who weren’t in the courtroom. It turns out most patients actually didn’t show up to their court date. And what I found out is, a lot of these people had health insurance. There was a school teacher, a correctional officer, even a woman who worked at the hospital, who had private insurance, but were responsible for shares of their bills that they just felt like they couldn’t pay. And now Ballad was turning to the courts to recoup the money that they were owed.
- michael barbaro
Why is that the case? Why are people with jobs and insurance falling behind on their payments and now being sued?
- sarah kliff
So in order to understand that, I think you need to zoom out from the courtroom and look at a big change that has been happening in our health care system over the past decade or so. What I see in my reporting is patients consistently being asked to spend more and more of their own money on health care, even when they have insurance. A really perfect example of this is deductibles. That’s the amount that a patient has to pay before their insurance will start kicking in and covering their doctor visits and their hospital trips. If you look back to, like, 2006 or so, only about half of people who had insurance even had a deductible. They weren’t that common. You flash forward to this year, and 82% of people who get insurance at work now have a deductible. The size of the average deductible has about tripled between 2006 and 2018. It used to be about $600. Now it’s about $1,700.
- michael barbaro
Hm.
- sarah kliff
So you have this moment when health care prices are going up, and up, and up, and patients are being asked to pay for it and pay more through deductibles, through co-payments.
- michael barbaro
And why is that? Why are so many of these plans now asking people to pay such a high deductible?
- sarah kliff
It mostly comes down to the fact that health care prices are growing really quickly. And if you’re an employer, if you’re an HR department, you have a few ways to deal with this. You could increase your employees’ premiums. That’s the amount they pay each month. Or you could keep premiums constant, and just ask people to pay more when they go to the doctor. A lot of companies have found that the latter option is the way they want to go.
- michael barbaro
Hm.
- sarah kliff
So that’s how employers deal with this problem of rising costs, but then you have someone like Amanda, who does have to go to the doctor a lot, for her daughter, and ends up with this bill she can’t afford. And you have the hospital on the other end of this, who is watching hundreds of Amandas in their system, all of a sudden not being able to pay the bills that the insurance company typically was taking care of.
- michael barbaro
Got it. And when a person can’t pay that bill, now the hospital is suddenly on the hook. So it’s cascading through the system.
- sarah kliff
Exactly. And hospital executives, when they see someone who comes in with insurance, they’re thinking, O.K., this is someone who can pay their bills. They have the backing of an insurance company. But that’s not really the case. You have this whole new bucket of patients that hospital executives aren’t really sure how to deal with. Some are dealing with it by coming up with financial assistance for those people. Others are dealing with it by going to court to try and collect the debt that insurance companies used to pay them.
- michael barbaro
So what do hospitals like Ballad say about why they’re making this decision to sue their patients?
- sarah kliff
They say that, look, we’re a business. We have to stay open. We have to stay afloat. Ballad exists in a pretty rural area, a part of Virginia and Tennessee, and we’ve seen a lot of rural hospitals closing.
- michael barbaro
Hm.
- sarah kliff
They would argue that the financially responsible thing to do is collect the debts that are owed to them. They say that they only pursue patients in court who can afford to pay but have chosen not to pay their medical bills.
- michael barbaro
Hm. So people who, in their minds, if they prioritized paying back these bills and organized their finances around that, they could pay those bills.
- sarah kliff
Exactly. These are people with jobs, people with insurance. From their perspective, these are people who could pay that debt, and Ballad is serious about collecting that debt.
- amanda sturgill
I just feel sometimes like I’m failing my kids, even though I know I’m doing the best that I can for them.
- michael barbaro
And what does someone like Amanda say to that?
- sarah kliff
I know you’re making about $13 an hour. You’re supporting four kids. How do you think you got tagged as someone who should be able to make their payments?
- amanda sturgill
I honestly have no idea.
- sarah kliff
She does not think she fits that description.
- amanda sturgill
How in the world do you all think that I can pay this off? It’s like my paycheck every couple weeks is, I think I clear $806.
- sarah kliff
Amanda feels like she’s skipping meals, and she’s selling her things to pay.
- amanda sturgill
My mortgage and stuff like that.
- sarah kliff
Then there’s kids to take care of.
- amanda sturgill
It’s like I’ve not paid my water bill yet. I just keep thinking, please don’t come turn it off right now. [CHUCKLING] That sort of thing. And then I’ve got a payment arrangement with the electric, because I got a disconnect notice.
- sarah kliff
So you’ve been putting off your electric and —
- amanda sturgill
Yeah.
- sarah kliff
— water to pay the health bills?
- amanda sturgill
Yeah, yeah. Because I don’t want to be taken to jail, if that’s what they would do or whatever. [SIGHS]
- michael barbaro
You’ve said that this is becoming more common, but just how common is this kind of a lawsuit now?
- sarah kliff
So what’s happening at Ballad is pretty representative of a trend we’re seeing across the country. If you look at Ballad’s lawsuit volume, they’ve been suing patients for a while, but back in 2010, it was about 3,600 lawsuits a year in the court records I examined. Flash forward 2018, there’s over 6,700 lawsuits.
- michael barbaro
So double.
- sarah kliff
Doubled in less than a decade. You look at other hospitals, Children’s in Wisconsin is a good example. This is a nonprofit pediatric hospital. They’ve sued more than a thousand patients since the start of 2018. And that’s more lawsuits in two years than the entire decade prior. Johns Hopkins University in Baltimore and New York Presbyterian in Manhattan, they still have pretty low lawsuit volume, but it’s going up.
- michael barbaro
And is it ever the case that a company like Ballad sues a patient, the patient pays and it all resolves itself?
- sarah kliff
Definitely. So hospitals are finding that the courts are a pretty good way to collect money for a few reasons. The first is that patients typically don’t show up to their court date. That means, as long as the hospital sends a lawyer, they’re going to win the case because the other party didn’t show up. Once the hospital wins the case, they have the rights to start garnishing their patients’ wages. You can get a lien on their property. You can even arrest them. It gives the hospital a lot of power working through the court system.
- michael barbaro
So how does Amanda’s case end up playing out in court?
- sarah kliff
So she doesn’t go to the first court date.
- amanda sturgill
I had previously contacted them to let them know that I wasn’t going to be there.
- sarah kliff
There’s a second court date that she said she never heard about, where the hospital does get a judgment against her, but her wages have not been garnished. She ended up setting up a $150 a month payment plan.
- sarah kliff
And have you been able to make the payment each month?
- amanda sturgill
Um, I have, up until this past month. I was really trying to. It’s just hard. Every time my phone would ring, I’d be like, please don’t be Ballad calling me. Please don’t be Ballad.
- michael barbaro
So what happens once she starts falling behind in these payments?
- sarah kliff
So she’s nervous. She’s worried. There’s this court warrant out for me. Could they throw me in jail? And she sees that the hospital is calling her.
- amanda sturgill
I was terrified to answer it, because I hadn’t made the payment. I was scared to death. So I let it go to voicemail, but then I called her back and I was like, hey, it’s Amanda. What do you need?
- sarah kliff
And the person on the other end of the phone says, we’re just calling to tell you —
- amanda sturgill
We had an anonymous donor that paid off your warrant, which was — I think it was 2,200, is what it was final down to.
- sarah kliff
Somebody paid you medical bill. You don’t have to make payments anymore.
- michael barbaro
Hah.
- amanda sturgill
I was shocked. I said, are you sure? You know, can you just recheck? And she goes, no. She said, it is. She said, we are writing it. We’re doing all the stuff to get it taken care of, and it’s paid off. And it was such a relief.
And I was like, you can’t tell me who did it, so I can thank them? And she’s like, no. I was like —
- michael barbaro
So what had happened here?
- sarah kliff
So what happened was, I ended up writing about Amanda’s story in The New York Times. And between that story running and that phone call, an anonymous donor read about the story, called Ballad and offered to pay off Amanda’s bills.
- michael barbaro
So she is now without debt from this back problem that her daughter had? She’s kind of scot-free?
- sarah kliff
Well, sort of.
- sarah kliff
So how much do you still owe to Ballad right now?
- amanda sturgill
Um, shoot. I’ve got a pile of bills that’s about 5,400 and some dollars. Then I know I’m paying on another one, which is like $1,000. My ex has a couple that he’s paying on, that I just — I could not do. So yeah, I mean, it’s a lot. It’s a lot.
- michael barbaro
Sarah, what do you make of what happened to Amanda?
- sarah kliff
I think it shows you something really problematic about the current state of American health insurance. When you think of even the concept of insurance, it’s supposed to mean protection. It’s supposed to mean you have someone else who’s going to pay your medical bills, no matter how high they get.
- michael barbaro
Hm.
- sarah kliff
We spend a lot of time talking about the people who don’t have health insurance, about 30 million or so Americans at this point, but you also have this class of people who you could think of as underinsured, who are paying premiums, who are buying some kind of product that they think of as insurance, but then when they actually have to use a lot of health care, they’re finding that it’s not really protecting them in the way that they expected to be protected.
- amanda sturgill
It’s not like I’m out here trying to live this lavish life and I’m just wanting to forget these doctor bills. You know, I don’t need to pay them. They’re a hospital. It’s not that. I don’t have the means to pay it. What else could I have done? What else could I have done different?
- sarah kliff
Let’s say you were in charge of health insurance in the United States. How do you think it should work for someone like you?
- amanda sturgill
Oh, goodness, I’ve thought about this so many times, and it’s so weird that you asked me this. I just feel like, we’re the United States. We should come together and take care of each other. I would love to see people be healthier and just not have to worry. Everybody can go to the doctor without being afraid to go.
- michael barbaro
O.K., Sarah, right now we’re in the middle of a national debate about those very questions, the future of American health care. And the concept that is most widely debated in the context of the presidential election is Medicare For All, is the United States government taking on health care and eliminating the kind of private insurance that someone like Amanda has. If such a system were created, how would it address the issues that you have discovered in your reporting?
- sarah kliff
The system being proposed now in the presidential primary would get rid of deductibles. There’d be no premiums. There’d be no copayments. When you went to the doctor, you would not pay a single penny. But the money has to come from somewhere, right? You need a lot of those anonymous donors who paid off Amanda’s bill to be financing such a system. So you’d need to have a big shift in who’s paying for health care.
- michael barbaro
Hm.
- sarah kliff
There is going to be a lot of debate around Medicare For All and single payer in the next year. There are a lot of pluses and minuses to that type of system. But what I can certainly say is that if the United States adopted a system like that, I would not have stories like Amanda’s to write anymore.
- michael barbaro
Sarah, thank you very much.
- sarah kliff
Thanks, Michael.
- michael barbaro
We’ll be right back.
Here’s what else you need to know today.
- donald trump
They didn’t want to do a ceasefire, but now they do want to do a ceasefire. I believe it will probably work out that way.
- michael barbaro
During an unannounced trip to Afghanistan, President Trump said that the U.S. would reopen peace talks with the Taliban, aimed at ending the 18-year-old war there. Trump had abruptly ended the talks in September, after the Taliban claimed responsibility for a suicide bombing that killed a U.S. soldier.
- donald trump
The Taliban wants to make a deal. We’ll see if they make a deal. If they do, they do, and if they don’t, they don’t.
- michael barbaro
But the president has now injected confusion into the negotiations by demanding a cease fire from the Taliban, something U.S. diplomats had never before sought, are unlikely to obtain, and have little power to enforce. And in a letter, the House Judiciary Committee has given President Trump a deadline of this Friday to decide whether to present a defense or call a witness as the committee considers articles of impeachment against him. The letter lays out a rapid timetable for impeachment in the House. The Judiciary Committee could vote on articles of impeachment by the week of December 9th, and the full House could vote on impeachment by the week of December 16.
That’s it for “The Daily.” I’m Michael Barbaro. See you tomorrow.