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California May Require Labels on Pot Products to Warn of Mental Health Risks

Liz Kirkaldie’s grandson was near the top of his class in high school and a talented jazz bassist when he started smoking pot. The more serious he got about music, the more serious he got about pot.

And the more serious he got about pot, the more paranoid, even psychotic, he became. He started hearing voices.

“They were going to kill him and there were people coming to eat his brain. Weird, weird stuff,” Kirkaldie said. “I woke up one morning, and no Kory anywhere. Well, it turns out, he’d been running down Villa Lane here totally naked.”

Kory went to live with his grandmother for a couple of years in Napa, California. She thought maybe she could help. Now, she says that was naive.

Kory was diagnosed with schizophrenia. Kirkaldie blames the pot.

“The drug use activated the psychosis, is what I really think,” she said.

Indeed, many scientific studies have linked marijuana use to an increased risk of developing psychiatric disorders, including schizophrenia. The risk is more than four times as great for people who use high-potency marijuana daily than for those who have never used, according to a study published in The Lancet Psychiatry in 2019. One study found eliminating marijuana use in adolescents could reduce global rates of schizophrenia by 10%.

Doctors and lawmakers in California want cannabis producers to warn consumers of this and other health risks on their packaging labels and in advertising, similar to requirements for cigarettes. They also want sellers to distribute health brochures to first-time customers outlining the risks cannabis poses to youths, drivers, and those who are pregnant, especially for pot that has high concentrations of THC, the chemical primarily responsible for marijuana’s mental effects.

“Today’s turbocharged products are turbocharging the harms associated with cannabis,” said Dr. Lynn Silver with the Public Health Institute, a nonprofit sponsoring the proposed labeling legislation, SB 1097, the Cannabis Right to Know Act.

Californians voted to legalize recreational pot in 2016. Three years later, emergency room visits for cannabis-induced psychosis went up 54% across the state, from 682 to 1,053, according to state hospital data. For people who already have a psychotic disorder, cannabis makes things worse — leading to more ER visits, more hospitalizations, and more legal troubles, said Dr. Deepak Cyril D’Souza, a psychiatry professor at Yale University School of Medicine who also serves on the physicians’ advisory board for Connecticut’s medical marijuana program.

But D’Souza faces great difficulty convincing his patients of the dangers, especially as 19 states and the District of Columbia have legalized recreational marijuana.

“My patients with schizophrenia and also adolescents hear very conflicting messages that it’s legal; in fact, there may be medical uses for it,” he said. “If there are medical uses, how can we say there’s anything wrong with it?”

Legalization is not the problem, he said; rather, it’s the commercialization of cannabis — the heavy marketing, which can be geared toward attracting young people to become customers for life, and the increase in THC from 4% on average up to between 20% and 35% in today’s varieties.

Limiting the amount of THC in pot products and putting health warnings on labels could help reduce the health harms associated with cannabis use, D’Souza said, the same way those methods worked for cigarettes.

He credits warning labels, education campaigns, and marketing restrictions for the sharp drop in smoking rates among kids and teens in the past decade.

“We know how to message them,” D’Souza said. “But I don’t think we have the will or the resources, as yet.”

Some states, including Colorado, Oregon, and New York, have dabbled with cannabis warning-label requirements. California’s proposed rules are modeled after comprehensive protocols established in Canada: Rotating health warnings would be set against a bright-yellow background, use black 12-point type, and take up a third of the package front. The bill suggests language for 10 distinct warnings.

Opponents of the proposed labels say the requirements are excessive and expensive, especially since marketing to children is already prohibited in California and people must be 21 to buy.

“This bill is really duplicative and puts unnecessary burdens on the legal cannabis industry, as we already have incredibly restrictive packaging and advertising requirements,” said Lindsay Robinson, executive director of the California Cannabis Industry Association.

The state should focus more on combating the illicit pot market rather than further regulating the legal one, she said. Legal dispensaries are already struggling to keep up with existing rules and taxes — the state’s 1,500 licensed pot retailers generated $1.3 billion in state tax revenue last year. Adding more requirements makes it harder for them to compete with the illicit market, she said, and more likely to go out of business.

“The only real option if they fail out of the legal system is to shutter their businesses altogether or to operate underground. And I don’t think the state of California, with the tax revenue, wants either of those to happen,” Robinson said. “The heart of the issue is that there’s a massive, unregulated market in the state.”

Some people are skeptical that the labels will work. Liz Kirkaldie’s grandson, Kory, is stable now, living with his dad. But she’s not sure a yellow warning would’ve stopped him when he was a teen.

“They’re just not going to pay attention,” she said. “But if it helps even one person? Great.”

Scientists still do not know what causes schizophrenia, but they believe multiple factors are at play, including genetics, family history, trauma, and other influences in a person’s environment, like smoking pot. Some scientists believe having schizophrenia in the first place predisposes people to smoking pot. While it’s difficult to prove a direct causal link between cannabis use and schizophrenia, the associations are strong enough to warrant action, said D’Souza, and, importantly, pot use is one of the few risk factors people can control.

“Not everyone who smoked cigarettes developed lung cancer, and not everyone who has lung cancer smoked cigarettes,” he said. “But I think we would all agree that one of the most preventable causes of lung cancer is cigarette smoking.”

Applying the same health education strategies to cannabis that were used for tobacco, he said, is long overdue.

This story is part of a partnership that includes KQED, NPR, and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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‘American Diagnosis’: Indigenous Advocates Work for Better Reproductive Care

Can’t see the audio player? Click here to listen.

The transcript for this segment is being processed. We’re working to post it four to five days after the episode airs.

Episode 7: Fighting for Reproductive Sovereignty

Rachael Lorenzo works to address reproductive health disparities in Native communities. In 2018, they founded Indigenous Women Rising, a fund that provides financial help for Native people seeking an abortion.

Historically, the federal government has restricted Native people’s reproductive autonomy. Between 1973 and 1976, more than 3,500 Native people were sterilized without their consent.

Today, the chronic underfunding of the Indian Health Service and the remoteness of many reservations create barriers for Native people to access testing for sexually transmitted infections, prenatal care, and contraception.

Lorenzo is determined to fight for their community.

“My people deserve accessible health care, and I will make it happen no matter what, because this is our land,” they said.

Episode 7 explores efforts to protect and expand access to comprehensive reproductive and sexual health care in the face of historical and contemporary efforts of the government to control Native people’s fertility.

Voices from the episode:

Rachael Lorenzo, co-founder of Indigenous Women Rising — @rlorenxo; @IWRising; @IndigenousWomenRising
Sarah Deer, distinguished professor at the University of Kansas — @SarahDeer72
Sunny Clifford, reproductive rights advocate
Elizabeth Rink, professor of community health at Montana State University

Season 4 of “American Diagnosis” is a co-production of KHN and Just Human Productions.

Our Editorial Advisory Board includes Jourdan Bennett-Begaye, Alastair Bitsóí, and Bryan Pollard.

To hear all KHN podcasts, click here.

Listen and follow “American Diagnosis” on Apple Podcasts, Spotify, Google, or Stitcher.

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from Health Industry – Kaiser Health News

His-and-Hers Cataract Surgeries, But His Bill Was 20 Times as Much

Danilo Manimtim’s vision was cloudy and blurred — and it was growing worse.

The 73-year-old retired orthopedic surgeon in Fresno, California, knew it was time for cataract surgery. “It’s like car tires wearing out because you drive on them so much,” he said.

In December 2021, he went to the outpatient department of the local hospital to undergo the common procedure that usually replaces the natural eye lens with an artificial one and is designed to restore vision. The outpatient procedure went smoothly, and Manimtim healed over the next few weeks.

Manimtim, who since retiring took a job evaluating disability claims for the state of California, knows the health care system and keeps tabs on his health benefits. He knew he already had met his health insurance deductible for the year, so he expected a manageable out-of-pocket expense for the surgery. He calculated his coinsurance would be about $750.

Then the bills came.

Patient: Danilo Manimtim, 73, of Fresno, California. He is insured through his employer by Anthem Blue Cross of California for outpatient care and is covered by Medicare for hospitalization.

Total Bill: Overall, the charges were $9,084 for surgery, anesthesia, medical supplies, pharmacy, and clinical laboratory services. Anthem paid $5,027 and initially billed Manimtim $4,057.

Service Providers: Saint Agnes Medical Center. It is part of Trinity Health, a nonprofit hospital system headquartered in Michigan with 88 hospitals and 125 urgent care centers across the country. The hospital system brought in nearly $20.2 billion in revenue for the most recent fiscal year.

Medical Service: Cataract surgery as an outpatient, involving anesthesia.

What Gives: Manimtim’s big bill stems from a simple decision that turned out to be a pitfall in the nation’s complicated health care system: He scheduled his surgery at a nearby hospital — a hospital that happened to charge about $7,000 more for the procedure than his insurer would pay.

Manimtim has proof that it could have been different right under his own roof: Four months later, his wife, Marilou Manimtim, 66, got the exact same procedure at an outpatient eye care surgical center in Fresno called EYE-Q. It is a half-mile from Saint Agnes Medical Center but is not affiliated with the hospital.

Both patients have the same insurance coverage through Anthem Blue Cross of California; they had identical cataract surgeries; and both providers were in Anthem’s coverage network. Marilou owed $204, while Danilo was on the hook for a staggering $4,057.

“This is ridiculous, and it feels very unfair,” Danilo Manimtim said. “How can it be so much more expensive than the surgical center? It’s walking distance away, and if I would have gone there, I would have saved myself a lot of money.”

Manimtim’s insurance plan, via his employer, the California Public Employees’ Retirement System, caps payment for outpatient cataract surgery at $2,000, according to Anthem. CalPERS instituted a “reference pricing” system in recent years, in which it determines a reasonable price for a high-quality procedure of that type in California. It then reimburses only up to that amount, encouraging patients to shop for treatment priced under the bar. For the cataract surgery itself, patients in Manimtim’s plan are on the hook for any charges above $2,000.

Even for hospital-based care, Saint Agnes’ overall charges are high for cataract surgery, said Dr. Ira Weintraub, chief medical officer for WellRithms, which analyzes health care prices for employers. “The hospital charged three to four times the amount of what this surgery typically costs, which is around $3,000.”

“Nobody gets $9,000 for cataract surgery,” he added.

If Manimtim had opted for Medicare Part B, the part of the Medicare program that covers outpatient care, he likely would have been on the hook for only about $565, a Medicare cost comparison tool shows. Medicare pays a set amount for procedures regardless of where they are performed.

But like many older Americans who are still working, Manimtim chose not to sign up for that coverage, instead opting for his employer’s plan because his monthly premium would be significantly cheaper.

Health care prices often have very little to do with the actual costs of providing the care and its quality — and patients often face the “double whammy” of high prices and complex benefits, said Anthony Wright, executive director of Health Access California, a nonprofit advocacy group. Too often, patients are on their own to figure out high prices and complex benefits, he said.

“You wonder what is the rationale for any of the prices in our health care system,” Wright said.

Resolution: After inquiries by KHN, Anthem contacted the hospital, Saint Agnes, seeking help for Manimtim. Although the doctor is responsible for requesting an exemption from CalPERS’ $2,000 limit on payments for cataract surgery under Manimtim’s plan, that didn’t happen before his surgery. Anthem asked the hospital and doctor to consider the request post-surgery, said Anthem spokesperson Michael Bowman.

Saint Agnes spokesperson Kelley Sanchez told KHN that the hospital and provider later requested the exemption that would allow the insurer to pay more than the $2,000 limit and that it was ultimately approved by Anthem. That is expected to leave Manimtim with a much smaller coinsurance bill, around $750 — and get him off the hook for being taken to collections by the hospital. The hospital will receive a higher payment from Anthem, which will cover a large portion of the remaining $4,057 bill.

And that high payment, like all high payments, contributes to rising health insurance payments for all.

Sanchez said the hospital isn’t in the price-gouging business but noted that hospitals generally have higher costs and tend to charge more than outpatient facilities.

“We never want to cause harm or create hardship for our patients, and that extends to our billing practices,” Sanchez said in a prepared statement.

She noted that Saint Agnes has financial assistance programs available and encourages patients to ask questions and understand potential costs before seeking care. “Every patient’s insurance plan is unique so it is their responsibility to understand their plan benefits,” she wrote. “It’s still complicated and we recognize that, and will continue to work toward greater price transparency.”

The Takeaway: The bottom line for patients, experts say, is to be sure to read the fine print of insurance coverage plans to understand all out-of-pocket responsibilities, including premiums, deductibles, copays, and coinsurance. Also, a small number of large employers that self-insure are using reference pricing, putting caps on what they’ll pay for common procedures. Shop around, and ask about prices on the front end if possible.

“People often focus on premiums because they are easy to compare, but premiums don’t tell the full story, and this example illustrates the trade-offs,” said Tricia Neuman, a Medicare expert at KFF.

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Más de 100 millones de estadounidenses viven acosados por las deudas médicas

Elizabeth Woodruff tuvo que usar los ahorros de su jubilación y buscar tres trabajos luego que ella y su esposo fueran demandados por casi $10,000 por un hospital de Nueva York, en donde al hombre le amputaron una pierna infectada.

Ariane Buck, un joven padre de Arizona que vende seguros de salud, no pudo hacer una cita con su médico por una seria infección intestinal porque en la consulta le dijeron que tenía facturas pendientes.

Allyson Ward y su marido cargaron las tarjetas de crédito, pidieron prestado a familiares y retrasaron el pago de los préstamos estudiantiles después de que el nacimiento prematuro de sus gemelos les dejara una deuda de $80,000. Ward, que es enfermera, se vio obligada a hacer turnos extra, trabajando día y noche.

“Quería ser madre”, dijo. “Pero teníamos que disponer de dinero”.

Estas personas se encuentran entre los más de 100 millones de estadounidenses —incluyendo el 41% de los adultos— acosados por un sistema de salud que endeuda sistemáticamente a los pacientes a escala masiva, según muestra una investigación de KHN y NPR.

La investigación revela un problema que, a pesar de la nueva atención prestada por la Casa Blanca y el Congreso, está mucho más extendido de lo que se había informado anteriormente. Esto se debe a que gran parte de la deuda que acumulan los pacientes figura como saldos de tarjetas de crédito, préstamos familiares o planes de pago a hospitales y otros proveedores médicos.

Para calcular el verdadero alcance y la carga de esta deuda, la investigación de KHN-NPR se basó en una encuesta nacional realizada por KFF para este proyecto. La encuesta fue diseñada para captar no solo las facturas que los pacientes no podían pagar, sino también otros préstamos utilizados para pagar la atención médica.

El proyecto también se nutre de los nuevos análisis de la oficina de crédito, la facturación de los hospitales y los datos de las tarjetas de crédito realizados por el Urban Institute y otros colaboradores de la investigación. Además, los reporteros de KHN y NPR realizaron cientos de entrevistas con pacientes, médicos, líderes del sector sanitario, defensores de los consumidores e investigadores.

El panorama es desolador.

En los últimos cinco años, más de la mitad de los adultos estadounidenses afirman haberse endeudado a causa de facturas médicas o dentales, según la encuesta de KFF.

Una cuarta parte de los adultos con deudas de atención de salud debe más de $5,000. Y aproximadamente 1 de cada 5 con una deuda dijo que no esperaba poder pagarla nunca.

"La deuda ya no es solo un error en nuestro sistema. Es uno de los principales productos", dijo el doctor Rishi Manchanda, que ha trabajado con pacientes de bajos ingresos en California durante más de una década y ha formado parte de la junta directiva de la organización sin fines de lucro RIP Medical Debt. "Tenemos un sistema de salud casi perfectamente diseñado para crear deuda".

Esta carga hace que las familias recorten el gasto en alimentos y otros productos esenciales. Millones de personas se ven obligadas a dejar sus hogares o a declararse en quiebra, halló la encuesta.

La deuda médica provoca dificultades adicionales para las personas con cáncer y otras enfermedades crónicas. Los niveles de deuda en los condados de Estados Unidos con las tasas más altas de enfermedad pueden ser tres o cuatro veces superiores a los de los condados más sanos, según un análisis del Urban Institute.

La deuda también agranda las disparidades raciales.

Y está impidiendo que los estadounidenses ahorren para la jubilación, inviertan en la educación de sus hijos o pongan los cimientos tradicionales para un futuro seguro, como pedir un préstamo para la universidad o comprar una casa. Según la encuesta de KFF, las deudas por atención médica son casi el doble de frecuentes entre los adultos menores de 30 años que entre los mayores de 65.

Tal vez lo más perverso sea que la deuda impide a los pacientes recibir atención médica.

Alrededor de 1 de cada 7 personas con deudas dijo que se le había negado el acceso a un hospital, a un médico o a otro proveedor debido a las facturas impagas, según la encuesta. Una proporción aún mayor —alrededor de dos tercios— ha pospuesto la atención que ellos o un miembro de la familia necesitan debido al costo.

"Es una barbaridad", afirmó la doctora Miriam Atkins, oncóloga de Georgia que, como muchos médicos, dijo que ha tenido pacientes que han renunciado al tratamiento por miedo a la deuda.

La deuda de los pacientes se acumula a pesar de la histórica Ley de Cuidado de Salud a Bajo Precio (ACA) de 2010.

ACA amplió la cobertura de seguro a decenas de millones de estadounidenses. Sin embargo, también marcó el comienzo de años de grandes beneficios para la industria médica, que ha aumentado constantemente los precios en la última década.

Los hospitales registraron su año más rentable de la historia en 2019, anotando un margen de beneficio agregado del 7,6%, según el Comité Asesor de Pagos de Medicare federal. Muchos hospitales prosperaron incluso durante la pandemia.

Pero para muchos estadounidenses, la ley no cumplió su promesa de una atención más asequible. En su lugar, han tenido que hacer frente a miles de dólares en facturas, ya que las aseguradoras transfirieron los costos a los pacientes a través de deducibles más altos.

Ahora, una industria muy lucrativa se aprovecha de la incapacidad de los pacientes para pagar.

Los hospitales y otros proveedores de servicios médicos ponen a millones de personas en manos de las tarjetas de crédito y otros préstamos. Y los pacientes sufren altas tasas de interés, al tiempo que generan beneficios para los prestamistas que superan el 29%, según la empresa de investigación IBISWorld.

Las deudas de los pacientes también sostienen un oscuro negocio de cobros alimentado por los hospitales —incluidos los sistemas universitarios públicos y las organizaciones sin fines de lucro a las que se les conceden exenciones fiscales para servir a sus comunidades— que venden la deuda en acuerdos privados a empresas de cobros que, a su vez, persiguen a los pacientes.

"Se acosa a las personas a toda hora. Muchos acuden a nosotros sin saber de dónde procede la deuda", explicó Eric Zell, abogado supervisor de la Sociedad de Ayuda Legal de Cleveland. "Parece una epidemia".

En deuda con los hospitales, las tarjetas de crédito y los familiares

La crisis de la deuda en Estados Unidos se debe a una simple realidad: la mitad de los adultos estadounidenses no tiene dinero para cubrir una factura médica inesperada de $500, según la encuesta de KFF.

Como resultado, muchos simplemente no pagan. La avalancha de facturas impagas ha convertido la deuda médica en la forma más común de deuda en los registros de crédito de los consumidores.

El año pasado, el 58% de las deudas en los registros de cobros eran por una factura médica, según la Oficina de Protección Financiera del Consumidor (CFPB). Eso es casi cuatro veces más que las deudas atribuibles a facturas de telecomunicaciones, la siguiente forma de deuda más común en los registros de crédito.

Pero, en la investigación de KHN-NPR, se muestra que la deuda médica en los informes de crédito representa solo una fracción del dinero que los estadounidenses deben por atención de salud.

Es difícil saber cuántas deudas médicas tienen los estadounidenses en total, porque muchas no se registran. Pero un análisis anterior de KFF de los datos federales estimó que la deuda médica colectiva totalizó al menos $195 mil millones en 2019, más grande que la economía de Grecia.

Los saldos de las tarjetas de crédito, que tampoco se contabilizan como deuda médica, pueden ser sustanciales, según un análisis de los registros de tarjetas de crédito realizado por el Instituto JPMorgan Chase. El grupo de investigación financiera halló que el saldo mensual del titular típico de una tarjeta se disparaba un 34% después de un gasto médico importante.

Después, los saldos mensuales se reducen a medida que se pagan las facturas. Sin embargo, durante un año, se mantuvieron un 10% por encima de su nivel anterior al gasto médico. Los saldos de un grupo comparable de titulares de tarjetas sin un gasto médico importante se mantuvieron relativamente estables.

No está claro qué parte de los saldos más elevados se convirtió en deuda, ya que los datos del instituto no distinguen entre los titulares de tarjetas que pagan su saldo cada mes y los que no. Pero alrededor de la mitad de los titulares de tarjetas de todo el país tiene un saldo en sus tarjetas, lo que suele añadir intereses y comisiones.

Deudas grandes y pequeñas

Para muchos estadounidenses, las deudas por atención médica o dental pueden ser relativamente bajas. Aproximadamente un tercio debe menos de $1,000, según la encuesta de KFF.

Pero incluso las deudas más pequeñas pueden pasar factura.

Los cobradores persiguieron por años a Edy Adams, una estudiante de medicina de 31 años, de Texas, por un examen médico al que se sometió después de haber sido agredida sexualmente.

Adams se había graduado recientemente de la universidad y vivía en Chicago.

La policía nunca encontró al agresor. Pero dos años después de la agresión, Adams empezó a recibir llamadas de cobradores diciendo que debía $130,58.

La ley de Illinois prohíbe facturar a las víctimas por este tipo de pruebas. Pero no importaba cuántas veces Adams explicara el error, las llamadas seguían, y cada una la obligaba, según ella, a revivir el peor día de su vida.

A veces, cuando los cobradores llamaban, Adams rompía a llorar por teléfono. "Estaba desesperada", recordó. "Me perseguía esa factura zombi. No podía pararla".

Las deudas de salud también pueden ser catastróficas.

Sherrie Foy, de 63 años, y su marido, Michael, vieron cómo su jubilación, cuidadosamente planificada, se truncó cuando hubo que extirpar el colon de Foy.

Después de que Michael se jubilara de Consolidated Edison en Nueva York, la pareja se trasladó a la zona rural del suroeste de Virginia. Sherrie disponía allí de espacio para cuidar de sus caballos rescatados.

La pareja había ahorrado y contaban con un seguro médico para retirados a través de Con Edison. Pero la intervención quirúrgica de Sherrie provocó numerosas complicaciones, meses de hospitalización y facturas médicas que superaron el límite de un millón de dólares del plan de salud de la pareja.

Cuando Foy no pudo pagar los más de $775,000 que debía al Sistema de Salud de la Universidad de Virginia, el centro médico la demandó, una práctica que en su día era habitual y que la universidad dijo haber frenado. La pareja se declaró en quiebra.

Los Foys cobraron una póliza de seguro de vida para pagar a un abogado especializado en quiebras y liquidaron las cuentas de ahorro que la pareja había creado para sus nietos.

"Nos quitaron todo lo que teníamos", contó Foy. "Ahora no tenemos nada".

Alrededor de 1 de cada 8 estadounidenses endeudados por facturas médicas debe $10,000 o más, según la encuesta de KFF.

Aunque la mayoría espera pagar su deuda, el 23% dijo que tardará al menos tres años; el 18% dijo que no espera pagarla nunca.

El amplio alcance de la deuda médica

La deuda lleva mucho tiempo acechando en las sombras de la atención de salud estadounidense.

En el siglo XIX, los pacientes masculinos del Hospital Bellevue de Nueva York tenían que transportar pasajeros por el East River y las madres primerizas tenían que fregar suelos para pagar sus deudas, según una historia de los hospitales de Estados Unidos escrita por Charles Rosenberg.

Sin embargo, los acuerdos eran en su mayoría informales. En la mayoría de los casos, los médicos se limitaban a perdonar las facturas que los pacientes no podían pagar, según el historiador Jonathan Engel. "No existía el concepto de estar en deuda médica".

En la actualidad, las deudas por facturas médicas y dentales afectan a casi todos los rincones de la sociedad estadounidense, y suponen una carga incluso para quienes tienen cobertura de seguro a través del trabajo o de programas gubernamentales como Medicare.

Casi la mitad de los estadounidenses de hogares que ganan más de $90,000 al año han contraído deudas de atención médica en los últimos cinco años, según la encuesta de KFF.

Las mujeres son más propensas que los hombres a tener deudas. Y los que son padres tienen más deudas de salud que las personas sin hijos.

Pero la crisis se ha ensañado con los más vulnerables y con los que no tienen seguro.

La deuda está más extendida en el sur, según un análisis de los registros de crédito realizado por el Urban Institute. Las protecciones de los seguros son más débiles, muchos de los estados no han ampliado Medicaid y las enfermedades crónicas están más extendidas.

En todo el país, según la encuesta, los adultos negros no hispanos tienen un 50% más de probabilidades de deber dinero por atención médica, y los adultos hispanos un 35% más de probabilidades que los blancos no hispanos. (Los hispanos pueden ser de cualquier raza o combinación de razas).

En algunos lugares, como la capital del país, las disparidades son aún mayores, según los datos del Urban Institute: la deuda médica en los vecindarios predominantemente minoritarios de Washington D.C. es casi cuatro veces más común que en los barrios blancos no hispanos.

En las comunidades de minorías que ya enfrentan menos oportunidades educativas y económicas, la deuda puede ser agobiante, señaló Joseph Leitmann-Santa Cruz, director ejecutivo de Capital Area Asset Builders, una organización sin fines de lucro que ofrece asesoramiento financiero a los residentes con bajos ingresos de Washington. "Es como tener otro brazo atado a la espalda", añadió.

Las deudas médicas también pueden impedir a los jóvenes ahorrar, terminar sus estudios o conseguir un empleo. Un análisis de los datos crediticios reveló que la deuda por atención médica alcanza su punto máximo para un estadounidense promedio a finales de los 20 años y principios de los 30, y luego disminuye a medida que envejecen.

La deuda médica de Cheyenne Dantona hizo descarrilar su carrera antes de que empezara.

A Dantona, de 31 años, le diagnosticaron un cáncer de la sangre cuando estaba en la universidad. El cáncer remitió, pero cuando Dantona cambió de plan de salud, tuvo que pagar miles de dólares en facturas médicas porque uno de sus proveedores principales estaba fuera de la red.

Se inscribió en una tarjeta de crédito médica, pero tuvo que pagar aún más intereses. Otras facturas fueron a parar a agencias de cobro, lo que dañó su puntaje de crédito. Dantona sigue soñando con trabajar con animales salvajes heridos y huérfanos, pero se ha visto obligada a volver a vivir con su madre en las afueras de Minneapolis.

"Ha quedado atrapada", dijo Desiree, la hermana de Dantona. "Su vida se ha detenido".

Barreras para la atención

Desiree Dantona dijo que la deuda también ha hecho que su hermana dude a la hora de buscar atención para asegurar que su cáncer siga en remisión.

Los proveedores de servicios médicos dicen que éste es uno de los efectos más perniciosos de la crisis de la deuda en Estados Unidos, ya que aleja a los enfermos de la atención médica y acumula estrés tóxico en los pacientes cuando son más vulnerables.

La tensión financiera puede ralentizar la recuperación de los pacientes e incluso aumentar sus probabilidades de muerte, según los investigadores del cáncer.

Sin embargo, el vínculo entre enfermedad y deuda es un rasgo definitorio de la atención sanitaria estadounidense, según el Urban Institute, que analizó los registros de crédito y otros datos demográficos sobre pobreza, raza y estado de salud.

Los condados de Estados Unidos con la mayor proporción de residentes con múltiples enfermedades crónicas, como diabetes y enfermedades cardíacas, también tienden a tener la mayor deuda médica. Esto hace que la enfermedad sea un factor de predicción de deuda médica más poderoso que la pobreza o el seguro.

En los 100 condados de Estados Unidos con los niveles más altos de enfermedades crónicas, casi una cuarta parte de los adultos tienen deudas médicas en sus registros de crédito, en comparación con menos de 1 de cada 10 en los condados más saludables.

El problema es tan generalizado que incluso muchos médicos y líderes empresariales admiten que la deuda se ha convertido en una lacra para el sistema de salud estadounidense.

"No hay ninguna razón en este país para que una deuda médica destruya a las personas", indicó George Halvorson, ex director general de Kaiser Permanente (KP), el mayor sistema médico integrado y plan de salud del país. KP tiene una política de ayuda financiera relativamente generosa, pero a veces demanda a los pacientes. (El sistema de salud no está afiliado a KHN).

Halvorson citó el crecimiento de los seguros de salud con deducibles elevados como un factor clave de la crisis de la deuda. "Los pacientes se arruinan al recibir atención médica", añadió, "aunque tengan seguro".

El papel de Washington

ACA reforzó las protecciones financieras para millones de estadounidenses, no solo aumentando la cobertura sanitaria, sino también estableciendo normas que se suponía debían limitar cuánto pagarían los pacientes de su propio bolsillo.

En alguna medida, la ley ha funcionado, según estudios. En California, se produjo un descenso del 11% en el uso mensual de préstamos basados en el salario después de que el estado ampliara la cobertura a través de ACA.

Pero los límites de la ley en cuanto a los gastos de bolsillo han resultado ser demasiado elevados para la mayoría de los estadounidenses. La normativa federal permite que los gastos máximos de los planes individuales sean de hasta $8,700.

Además, ACA no detuvo el crecimiento de los planes con deducibles elevados, que se han convertido en la norma en la última década. Esto ha obligado a un número cada vez mayor de estadounidenses a pagar miles de dólares de su propio bolsillo antes de que su cobertura entre en vigencia.

El año pasado, el deducible anual de un trabajador soltero con cobertura a través de su empleo superó los $1,400, casi cuatro veces más que en 2006, según una encuesta anual de empleadores realizada por KFF. El deducible para una familia puede llegar a los $10,000.

Mientras los planes de salud exigen a los pacientes que paguen más, los hospitales, las farmacéuticas y otros proveedores médicos están subiendo los precios.

De 2012 a 2016, los precios de la atención médica aumentaron un 16%, casi cuatro veces la tasa de inflación general, según un informe del Health Care Cost Institute, una organización sin fines de lucro.

Para muchos estadounidenses, la combinación de precios elevados y altos costos de bolsillo significa casi inevitablemente una deuda. La encuesta de KFF reveló que 6 de cada 10 adultos en edad de trabajar, con cobertura, se han endeudado para recibir atención médica en los últimos cinco años, una tasa solo ligeramente inferior a la de los no asegurados.

Incluso la cobertura de Medicare puede dejar a los pacientes pagos de miles de dólares por medicamentos y tratamientos, según estudios.

Aproximadamente un tercio de las personas mayores ha debido dinero por cuidados médicos, según la encuesta. Y el 37% dijo que ellos o alguien de su hogar se ha visto obligado a recortar gastos en comida, ropa y otros artículos de primera necesidad debido a la deuda; el 12% afirmó haber tomado un trabajo extra.

El creciente costo de la deuda ha suscitado un nuevo interés por parte de los políticos, los reguladores y los líderes del sector.

En marzo, tras las advertencias de la Oficina de Protección Financiera del Consumidor (CFPB), las principales empresas de información crediticia comunicaron que eliminarían de los informes de crédito de los consumidores las deudas médicas inferiores a $500, y las que se hubieran pagado.

En abril, la administración Biden anunció una nueva campaña de la CFPB contra los cobradores de deudas y una iniciativa del Departamento de Salud y Servicios Humanos para recopilar más información sobre la forma en que los hospitales proporcionan ayuda financiera.

Estas medidas fueron aplaudidas por los defensores de los pacientes. Sin embargo, es probable que los cambios no aborden las causas fundamentales de esta crisis nacional.

"La razón número 1, y las razones número 2, 3 y 4, por las que las personas se endeudan por motivos médicos es que no tienen dinero", aseguró Alan Cohen, cofundador de la aseguradora Centivo, quien ha trabajado en el ámbito de las prestaciones de salud durante más de 30 años. "No es complicado".

Buck, el padre de Arizona al que se le negó la atención, lo ha visto de primera mano al vender planes de Medicare a personas mayores. "He tenido personas mayores llorando al teléfono conmigo", dijo. "Es horroroso".

Ahora, con 30 años, Buck se enfrenta a sus propias luchas. Se recuperó de la infección intestinal, pero después de verse obligado a ir a la emergencia de un hospital, recibió miles de dólares en facturas médicas.

Y se acumularon más cuando la esposa de Buck tuvo que acudir a urgencias por quistes en los ovarios.

Hoy, los Buck, que tienen tres hijos, calculan que deben más de $50,000, incluidas las facturas médicas que cargaron a las tarjetas de crédito y que no pueden pagar.

"Hemos tenido que recortar en todo", contó Buck. Sus hijos visten ropa usada. Escatiman en material escolar y dependen de la familia para los regalos de Navidad. Cenar fuera es un lujo.

"Me duele cuando mis hijos me piden ir a algún lugar y no puedo complacerlos", se lamentó Buck. "Me siento como si hubiera fallado como padre".

La pareja se prepara para declararse en bancarrota.

ACERCA DE ESTE PROYECTO

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

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

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

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

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

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Watch: She Almost Died. The $250K Debt Took Their House.

Cindy Powers needed 19 surgeries over the course of five years for abdominal problems and life-threatening infections. “I knew of at least three times where she died on the operating table and they had to restart her heart,” her husband, Jim Powers, told investigative consumer correspondent Anna Werner on the CBS Evening News.

Cindy’s illnesses led to $250,000 in bills, bankruptcy, and eventually foreclosure on the couple’s house in Texas.

The Powers, now living in Colorado, are among more than 100 million people in the U.S. burdened with health care debt, according to an investigation by KHN and NPR. Jim described Cindy’s illness as five years of hell. The financial consequences for the couple lasted even longer.

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Medical Bills Can Shatter Lives. North Carolina May Act to ‘De-Weaponize’ That Debt.

RALEIGH, N.C. — When Erin Williams-Reavis faced a $3,500 surgery bill, the hospital offered to let her pay in $300 monthly installments. It was too much, said Williams-Reavis, 44, who lives in Greensboro, about an hour west of the state capital. Her hours as a personal assistant had been cut, and she and her husband were behind on bills, even requesting a forbearance on their mortgage.

In Charlotte, Patrick Oliver was stunned to receive a nearly $30,000 bill after a trip to the emergency room for numbness and burning in his hands and feet. When Oliver, 66, and his wife, Mary, couldn’t pay, the hospital sued them. The couple feared they’d lose their home.

In Asheville, Emmaleigh Argonauta’s $25.72 medical bill was sent to collections. She said that she’d paid the bill but that the hospital system hadn’t recorded it. It took Argonauta eight months, a slew of calls and emails, and a full day at the billing office to resolve the debt.

Now, they’re all waiting to see whether North Carolina’s lawmakers will make good on a bill that its sponsors say will “de-weaponize medical debt.”

About 100 million people in the U.S. — 41% of adults — have some form of health care debt, according to a KFF poll conducted for a new KHN-NPR investigation. The problem is driving millions of people into bankruptcy, depleting savings and retirement accounts, and leaving black marks on credit scores that make finding housing or employment difficult, the investigation found.

But federal protections remain weak. And the widespread burden has spurred efforts by at least a dozen state legislatures in recent years to better protect patients. California, Maine, and Maryland have enacted measures that compel hospitals to expand financial aid, crack down on debt collectors, and curb extreme practices such as placing liens on patients’ homes.

Many of these states have expanded Medicaid coverage through the Affordable Care Act, providing critical financial protections to millions of previously uninsured people.

But some states with the highest levels of medical debt, such as Texas, South Carolina, and Tennessee, have few protections. Low-income, Black, and Indigenous people in these Southern states are among the hardest hit. But even in more liberal states such as California, the health care and debt collection industries have foiled more ambitious reform efforts.

The debt problem in North Carolina is among the most acute in the nation, according to credit bureau data analyzed by the nonprofit Urban Institute. Only five states have a higher share of residents with medical debt on their credit reports.

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North Carolina lawmakers are debating two measures to tackle the state’s debt problem: one to expand Medicaid, a government insurance program for low-income people, and another to strengthen financial protections for patients. If both pass, policy experts say North Carolina could emerge as a national leader in protecting residents against medical debt and aggressive collection practices.

“Medical debt can drive people into poverty and prevent people and their families from getting out of poverty,” said Mark Rukavina, a program director with the nonprofit health advocacy group Community Catalyst. These bills could provide “significant protection” against that.

Currently, North Carolina ranks 28th on a national scorecard of medical debt policies developed by the Innovation for Justice lab at the University of Arizona and the University of Utah. If North Carolina’s legislature passes both bills, the state would jump to second, said Gabriela Elizondo-Craig, a lead investigator on the scorecard project. That would put it ahead of California and just below Maryland, which, according to the scorecard, is the only state that prohibits hospitals from selling medical debt to other companies.

The North Carolina Senate passed the bill that includes Medicaid expansion after Republicans, who had previously opposed the move, threw their support behind it. Senate leader Phil Berger said in a news conference that an increase in federal funds to encourage states to expand the program, along with a recent overhaul of the state’s Medicaid program to make it more efficient, ensured that doing so would no longer hurt the state’s budget. Although the bill faces an uphill battle in the House, it could provide insurance coverage to more than 500,000 people.

“Medicaid expansion would go beyond hospital costs,” said Jenifer Bosco, an attorney at the National Consumer Law Center who has co-authored a model state law on medical debt. “It would touch all health care costs and pharmacy costs, which really does have the potential to reduce or eliminate a lot of medical debt for the lowest-income people.”

The second piece of legislation, known as the Medical Debt De-Weaponization Act, would require hospitals to offer financial assistance to patients based on their income and limit the way large medical facilities and debt collectors can pursue unpaid bills. It features a host of provisions championed by consumer advocates, including:

Requiring hospitals to provide free care to patients whose household income is at or below 200% of the federal poverty level and sliding-scale discounts for patients with higher incomes. (Currently, that means a single person making less than $27,180 or a family of four making less than $55,500 would qualify for free care.)
Offering patients payment plans that span at least two years, with installments that don’t exceed 5% of their monthly income
Capping the annual out-of-pocket expense for most patients at $2,300
Capping the maximum interest rate on medical debt at 5%
Shielding family members from medical or nursing home debt incurred by a spouse or parent
Delaying reporting of unpaid medical debts to credit bureaus until one year after a patient is billed
Prohibiting home foreclosures related to medical debt
Requiring the attorney general to enforce the law and giving patients the ability to sue health care facilities for violations

At least a dozen states have passed laws with similar provisions in recent years, said Quynh Chi Nguyen, a senior policy analyst at Community Catalyst. As of 2021, 10 states — including California, Illinois, and Maine — required hospitals to provide free or discounted care to patients who meet certain income thresholds. Thirteen states and Washington, D.C., limit various debt collection practices. In New Mexico, hospitals are prohibited from suing patients with incomes below 200% of the federal poverty level, placing liens on their property, or garnishing their wages. In Nevada, debt collection agencies are required to provide written notice to patients at least 60 days before any collection action is taken. Other state policies have focused on price transparency or limiting the impact of debt on people’s credit scores and livelihoods.

Earlier this year, the three big credit-reporting agencies announced they will remove medical debts of less than $500 and those that have been repaid from consumer credit reports. The Biden administration advised federal lenders to no longer consider medical debt when evaluating loan applications.

Together, these policies can decrease the number of people driven into poverty by medical bills or kept there generation after generation because of medical debt, Nguyen said.

North Carolina’s medical debt legislation was spurred by multiple reports from the treasurer’s office, which found that hospitals sent nearly $150 million in bills to patients who should have qualified for free or discounted care under the hospitals’ policies. A previous KHN investigation found similar trends nationwide.

“People in North Carolina are not able to see themselves out of poverty, not because of the war in Ukraine or inflation,” said state Treasurer Dale Folwell, “but because of medical debt.”

State Rep. Ed Goodwin, a Republican who sponsored the bill and represents two of the North Carolina counties with among the highest shares of residents with medical debt, said he believes there is bipartisan support to tackle the issue. Goodwin suggested that perhaps this bill will be easier to sell than Medicaid expansion — which he said has been discussed for years “and not a whole lot has happened.”

But that doesn’t mean it’ll be smooth sailing.

At a committee hearing in early June, Republican state Rep. John Szoka said “a number of things” in the bill “greatly disturb” him. He questioned whether a credit score could substantially harm someone’s upward mobility and noted that federal laws already require nonprofit hospitals to provide financial assistance. “I would not want to see any hospital turned into social services,” he added.

Similar laws in other states have faced opposition from powerful hospital associations, and groups representing debt collectors often criticize these types of protections.

The North Carolina Healthcare Association, which represents hospitals in the state, said it has not taken an official position yet. But spokesperson Cynthia Charles said existing federal and state laws address many issues related to fair billing and collections.

Hospitals do “more than any other part of the health care field to assist vulnerable patients,” she wrote in a statement to KHN. They try to make it easy for patients to learn about financial assistance through counselors, call centers, virtual chat tools, and more, she said, but it’s “a two-way process,” and patients must provide financial information to be qualified.

The North Carolina Collectors Association declined to comment.

For people with onerous medical bills, the legislation can’t come fast enough and can’t go far enough.

Emmaleigh Argonauta, who was sent to collections over that erroneous $26 bill, said the law should also require hospitals to provide an itemized bill to every patient, without waiting for them to request it.

Patrick and Mary Oliver, who were sued by a hospital, said health systems need to be clearer about the cost of services upfront and justify those costs.

Erin Williams-Reavis, who was offered the $300 monthly payment plan for her surgery bill, said lawmakers should speak with more “normal people” when revising the legislation “because we’re the ones who are affected.”

The medical debt bill is currently under review by the House banking committee, where it is likely to be revised. To pass into law this session, the bill has just two weeks left to make it through the North Carolina House and Senate.

KHN senior correspondent Noam N. Levey contributed to this report.

About This Project

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

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

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

The JPMorgan Chase Institute analyzed records from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses.

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

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Watch: Still Paying Off Bills From Twins’ Birth. The Kids Are 10 Now.

Marcus and Allyson Ward carefully planned their finances before having children — but they owed $80,000 after their twins were born prematurely. Years later, after exhausting savings and retirement accounts, they are still paying off that debt. The family is among 100 million people in America systematically pushed into medical debt, according to an investigation by KHN and NPR. CBS consumer investigative correspondent Anna Werner interviewed the Wards for “CBS Mornings.”

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Double Shifts, Credit Card Debt, and Family Loans When Twins Were Born Early

We had a plan that we were not going to be homeless.
Allyson Ward

Allyson Ward, 43, Chicago

Approximate Medical Debt: $80,000

Medical Issue: Childbirth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

About This Project

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

The JPMorgan Chase Institute analyzed records from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses.

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Five Quick Takeaways From a Yearlong Investigation of Medical Debt in America

KHN and NPR embarked on a project to understand how widespread medical debt is in America. Here are the most important takeaways of that yearlong investigation:

The problem is large. Very large. More than 100 million people, including 41% of adults, are saddled with debt from medical or dental bills, according to a KFF poll conducted for the project. Much of that debt is hidden on credit card balances, in payment plans to hospitals and other medical providers, and through loans patients take out from friends and family. Hospitals, some of them nonprofit or public university systems, often fuel the problem, shuttling patients into loans or selling debt to collection companies.
The debt is upending millions of lives. About half of adults with health care debt say they have had to make difficult sacrifices. The most common is cutting spending on food, clothing, and other basic household items. But millions of Americans are also taking on extra work, draining retirement accounts, moving out of their homes, or delaying education for themselves or their children. The debt is deepening racial disparities and preventing patients from getting care.
Health care debt is hard to pay off. One in 8 people with health care debt owe $10,000 or more, the KFF poll found. And although most people with debt expect to repay it, 18% say they don’t believe they’ll ever pay it all off.
Debt and illness are linked. Debt is more common among low-income and uninsured Americans, but the strongest predictor of whether a community will have high medical debt is how sick its residents are. That’s according to the Urban Institute, which analyzed county-level debt data for this project: In the 100 U.S. counties with the highest levels of chronic disease, nearly a quarter of adults have medical debt on their credit records, compared with fewer than 1 in 10 in the healthiest counties. View this interactive graphic to learn more.
Patient debt is pervasive for a reason. The KHN-NPR investigation finds that despite more people having health insurance — as a result of the Affordable Care Act — medical debt is pervasive. There is a reason: Over the past two decades, health insurers have shifted costs onto patients through higher deductibles at the same time that the medical industry has steadily raised the prices of drugs, procedures, and treatments. The 2010 health care law didn’t curb that.

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100 Million People in America Are Saddled With Health Care Debt

Elizabeth Woodruff drained her retirement account and took on three jobs after she and her husband were sued for nearly $10,000 by the New York hospital where his infected leg was amputated.

Ariane Buck, a young father in Arizona who sells health insurance, couldn’t make an appointment with his doctor for a dangerous intestinal infection because the office said he had outstanding bills.

Allyson Ward and her husband loaded up credit cards, borrowed from relatives, and delayed repaying student loans after the premature birth of their twins left them with $80,000 in debt. Ward, a nurse practitioner, took on extra nursing shifts, working days and nights.

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

The three are among more than 100 million people in America ― including 41% of adults ― beset by a health care system that is systematically pushing patients into debt on a mass scale, an investigation by KHN and NPR shows.

The investigation reveals a problem that, despite new attention from the White House and Congress, is far more pervasive than previously reported. That is because much of the debt that patients accrue is hidden as credit card balances, loans from family, or payment plans to hospitals and other medical providers.

To calculate the true extent and burden of this debt, the KHN-NPR investigation draws on a nationwide poll conducted by KFF for this project. The poll was designed to capture not just bills patients couldn’t afford, but other borrowing used to pay for health care as well. New analyses of credit bureau, hospital billing, and credit card data by the Urban Institute and other research partners also inform the project. And KHN and NPR reporters conducted hundreds of interviews with patients, physicians, health industry leaders, consumer advocates, and researchers.

The picture is bleak.

In the past five years, more than half of U.S. adults report they’ve gone into debt because of medical or dental bills, the KFF poll found.

A quarter of adults with health care debt owe more than $5,000. And about 1 in 5 with any amount of debt said they don’t expect to ever pay it off.

“Debt is no longer just a bug in our system. It is one of the main products,” said Dr. Rishi Manchanda, who has worked with low-income patients in California for more than a decade and served on the board of the nonprofit RIP Medical Debt. “We have a health care system almost perfectly designed to create debt.”

The burden is forcing families to cut spending on food and other essentials. Millions are being driven from their homes or into bankruptcy, the poll found.

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Medical debt is piling additional hardships on people with cancer and other chronic illnesses. Debt levels in U.S. counties with the highest rates of disease can be three or four times what they are in the healthiest counties, according to an Urban Institute analysis.

The debt is also deepening racial disparities.

And it is preventing Americans from saving for retirement, investing in their children’s educations, or laying the traditional building blocks for a secure future, such as borrowing for college or buying a home. Debt from health care is nearly twice as common for adults under 30 as for those 65 and older, the KFF poll found.

Perhaps most perversely, medical debt is blocking patients from care.

About 1 in 7 people with debt said they’ve been denied access to a hospital, doctor, or other provider because of unpaid bills, according to the poll. An even greater share ― about two-thirds ― have put off care they or a family member need because of cost.

“It’s barbaric,” said Dr. Miriam Atkins, a Georgia oncologist who, like many physicians, said she’s had patients give up treatment for fear of debt.

Patient debt is piling up despite the landmark 2010 Affordable Care Act.

The law expanded insurance coverage to tens of millions of Americans. Yet it also ushered in years of robust profits for the medical industry, which has steadily raised prices over the past decade.

Hospitals recorded their most profitable year on record in 2019, notching an aggregate profit margin of 7.6%, according to the federal Medicare Payment Advisory Committee. Many hospitals thrived even through the pandemic.

But for many Americans, the law failed to live up to its promise of more affordable care. Instead, they’ve faced thousands of dollars in bills as health insurers shifted costs onto patients through higher deductibles.

Now, a highly lucrative industry is capitalizing on patients’ inability to pay. Hospitals and other medical providers are pushing millions into credit cards and other loans. These stick patients with high interest rates while generating profits for the lenders that top 29%, according to research firm IBISWorld.

Patient debt is also sustaining a shadowy collections business fed by hospitals ― including public university systems and nonprofits granted tax breaks to serve their communities ― that sell debt in private deals to collections companies that, in turn, pursue patients.

“People are getting harassed at all hours of the day. Many come to us with no idea where the debt came from,” said Eric Zell, a supervising attorney at the Legal Aid Society of Cleveland. “It seems to be an epidemic.”

In Debt to Hospitals, Credit Cards, and Relatives

America’s debt crisis is driven by a simple reality: Half of U.S. adults don’t have the cash to cover an unexpected $500 health care bill, according to the KFF poll.

As a result, many simply don’t pay. The flood of unpaid bills has made medical debt the most common form of debt on consumer credit records.

As of last year, 58% of debts recorded in collections were for a medical bill, according to the Consumer Financial Protection Bureau. That’s nearly four times as many debts attributable to telecom bills, the next most common form of debt on credit records.

But the medical debt on credit reports represents only a fraction of the money that Americans owe for health care, the KHN-NPR investigation shows.

About 50 million adults ― roughly 1 in 5 ― are paying off bills for their own care or a family member’s through an installment plan with a hospital or other provider, the KFF poll found. Such debt arrangements don’t appear on credit reports unless a patient stops paying.
One in 10 owe money to a friend or family member who covered their medical or dental bills, another form of borrowing not customarily measured.
Still more debt ends up on credit cards, as patients charge their bills and run up balances, piling high interest rates on top of what they owe for care. About 1 in 6 adults are paying off a medical or dental bill they put on a card.

How much medical debt Americans have in total is hard to know because so much isn’t recorded. But an earlier KFF analysis of federal data estimated that collective medical debt totaled at least $195 billion in 2019, larger than the economy of Greece.

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The credit card balances, which also aren’t recorded as medical debt, can be substantial, according to an analysis of credit card records by the JPMorgan Chase Institute. The financial research group found that the typical cardholder’s monthly balance jumped 34% after a major medical expense.

Monthly balances then declined as people paid down their bills. But for a year, they remained about 10% above where they had been before the medical expense. Balances for a comparable group of cardholders without a major medical expense stayed relatively flat.

It’s unclear how much of the higher balances ended up as debt, as the institute’s data doesn’t distinguish between cardholders who pay off their balance every month from those who don’t. But about half of cardholders nationwide carry a balance on their cards, which usually adds interest and fees.

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Debts Large and Small

For many Americans, debt from medical or dental care may be relatively low. About a third owe less than $1,000, the KFF poll found.

Even small debts can take a toll.

Edy Adams, a 31-year-old medical student in Texas, was pursued by debt collectors for years for a medical exam she received after she was sexually assaulted.

Adams had recently graduated from college and was living in Chicago.

Police never found the perpetrator. But two years after the attack, Adams started getting calls from collectors saying she owed $130.68.

Illinois law prohibits billing victims for such tests. But no matter how many times Adams explained the error, the calls kept coming, each forcing her, she said, to relive the worst day of her life.

Sometimes when the collectors called, Adams would break down in tears on the phone. “I was frantic,” she recalled. “I was being haunted by this zombie bill. I couldn’t make it stop.”

Health care debt can also be catastrophic.

Sherrie Foy, 63, and her husband, Michael, saw their carefully planned retirement upended when Foy’s colon had to be removed.

After Michael retired from Consolidated Edison in New York, the couple moved to rural southwestern Virginia. Sherrie had the space to care for rescued horses.

The couple had diligently saved. And they had retiree health insurance through Con Edison. But Sherrie’s surgery led to numerous complications, months in the hospital, and medical bills that passed the $1 million cap on the couple’s health plan.

When Foy couldn’t pay more than $775,000 she owed the University of Virginia Health System, the medical center sued, a once common practice that the university said it has reined in. The couple declared bankruptcy.

The Foys cashed in a life insurance policy to pay a bankruptcy lawyer and liquidated savings accounts the couple had set up for their grandchildren.

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

About 1 in 8 medically indebted Americans owe $10,000 or more, according to the KFF poll.

Although most expect to repay their debt, 23% said it will take at least three years; 18% said they don’t expect to ever pay it off.

Medical Debt’s Wide Reach

Debt has long lurked in the shadows of American health care.

In the 19th century, male patients at New York’s Bellevue Hospital had to ferry passengers on the East River and new mothers had to scrub floors to pay their debts, according to a history of American hospitals by Charles Rosenberg.

The arrangements were mostly informal, however. More often, physicians simply wrote off bills patients couldn’t afford, historian Jonathan Engel said. “There was no notion of being in medical arrears.”

Today, debt from medical and dental bills touches nearly every corner of American society, burdening even those with insurance coverage through work or government programs such as Medicare.

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Nearly half of Americans in households making more than $90,000 a year have incurred health care debt in the past five years, the KFF poll found.

Women are more likely than men to be in debt. And parents more commonly have health care debt than people without children.

But the crisis has landed hardest on the poorest and uninsured.

Debt is most widespread in the South, an analysis of credit records by the Urban Institute shows. Insurance protections there are weaker, many of the states haven’t expanded Medicaid, and chronic illness is more widespread.

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Nationwide, according to the poll, Black adults are 50% more likely and Hispanic adults 35% more likely than whites to owe money for care. (Hispanics can be of any race or combination of races.)

In some places, such as the nation’s capital, disparities are even larger, Urban Institute data shows: Medical debt in Washington, D.C.’s predominantly minority neighborhoods is nearly four times as common as in white neighborhoods.

In minority communities already struggling with fewer educational and economic opportunities, the debt can be crippling, said Joseph Leitmann-Santa Cruz, chief executive of Capital Area Asset Builders, a nonprofit that provides financial counseling to low-income Washington residents. “It’s like having another arm tied behind their backs,” he said.

Medical debt can also keep young people from building savings, finishing their education, or getting a job. One analysis of credit data found that debt from health care peaks for typical Americans in their late 20s and early 30s, then declines as they get older.

Cheyenne Dantona’s medical debt derailed her career before it began.

Dantona, 31, was diagnosed with blood cancer while in college. The cancer went into remission, but when Dantona changed health plans, she was hit with thousands of dollars of medical bills because one of her primary providers was out of network.

She enrolled in a medical credit card, only to get stuck paying even more in interest. Other bills went to collections, dragging down her credit score. Dantona still dreams of working with injured and orphaned wild animals, but she’s been forced to move back in with her mother outside Minneapolis.

“She’s been trapped,” said Dantona’s sister, Desiree. “Her life is on pause.”

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Barriers to Care

Desiree Dantona said the debt has also made her sister hesitant to seek care to ensure her cancer remains in remission.

Medical providers say this is one of the most pernicious effects of America’s debt crisis, keeping the sick away from care and piling toxic stress on patients when they are most vulnerable.

The financial strain can slow patients’ recovery and even increase their chances of death, cancer researchers have found.

Yet the link between sickness and debt is a defining feature of American health care, according to the Urban Institute, which analyzed credit records and other demographic data on poverty, race, and health status.

U.S. counties with the highest share of residents with multiple chronic conditions, such as diabetes and heart disease, also tend to have the most medical debt. That makes illness a stronger predictor of medical debt than either poverty or insurance.

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

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The problem is so pervasive that even many physicians and business leaders concede debt has become a black mark on American health care.

“There is no reason in this country that people should have medical debt that destroys them,” said George Halvorson, former chief executive of Kaiser Permanente, the nation’s largest integrated medical system and health plan. KP has a relatively generous financial assistance policy but does sometimes sue patients. (The health system is not affiliated with KHN.)

Halvorson cited the growth of high-deductible health insurance as a key driver of the debt crisis. “People are getting bankrupted when they get care,” he said, “even if they have insurance.”

Washington’s Role

The Affordable Care Act bolstered financial protections for millions of Americans, not only increasing health coverage but also setting insurance standards that were supposed to limit how much patients must pay out of their own pockets.

By some measures, the law worked, research shows. In California, there was an 11% decline in the monthly use of payday loans after the state expanded coverage through the law.

But the law’s caps on out-of-pocket costs have proven too high for most Americans. Federal regulations allow out-of-pocket maximums on individual plans up to $8,700.

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Additionally, the law did not stop the growth of high-deductible plans, which have become standard over the past decade. That has forced many Americans to pay thousands of dollars out of their own pockets before their coverage kicks in.

Last year the average annual deductible for a single worker with job-based coverage topped $1,400, almost four times what it was in 2006, according to an annual employer survey by KFF. Family deductibles can top $10,000.

While health plans are requiring patients to pay more, hospitals, drugmakers, and other medical providers are raising prices.

From 2012 to 2016, prices for medical care surged 16%, almost four times the rate of overall inflation, a report by the nonprofit Health Care Cost Institute found.

For many Americans, the combination of high prices and high out-of-pocket costs almost inevitably means debt. The KFF poll found that 6 in 10 working-age adults with coverage have gone into debt getting care in the past five years, a rate only slightly lower than the uninsured.

Even Medicare coverage can leave patients on the hook for thousands of dollars in charges for drugs and treatment, studies show.

About a third of seniors have owed money for care, the poll found. And 37% of these said they or someone in their household have been forced to cut spending on food, clothing, or other essentials because of what they owe; 12% said they’ve taken on extra work.

The widespread burden of medical debt has sparked new interest from elected officials, regulators, and industry leaders.

In March, following warnings from the Consumer Financial Protection Bureau, the major credit reporting companies said they would remove medical debts under $500 and those that had been repaid from consumer credit reports.

In April, the Biden administration announced a new CFPB crackdown on debt collectors and an initiative by the Department of Health and Human Services to gather more information on how hospitals provide financial aid.

The actions were applauded by patient advocates. However, the changes likely won’t address the root causes of this national crisis.

“The No. 1 reason, and the No. 2, 3, and 4 reasons, that people go into medical debt is they don’t have the money,” said Alan Cohen, a co-founder of insurer Centivo who has worked in health benefits for more than 30 years. “It’s not complicated.”

Buck, the father in Arizona who was denied care, has seen this firsthand while selling Medicare plans to seniors. “I’ve had old people crying on the phone with me,” he said. “It’s horrifying.”

Now 30, Buck faces his own struggles. He recovered from the intestinal infection, but after being forced to go to a hospital emergency room, he was hit with thousands of dollars in medical bills.

More piled on when Buck’s wife landed in an emergency room for ovarian cysts.

Today the Bucks, who have three children, estimate they owe more than $50,000, including medical bills they put on credit cards that they can’t pay off.

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

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

The couple is preparing to file for bankruptcy.

About This Project

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

The JPMorgan Chase Institute analyzed records from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses.

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This story can be republished for free (details).

from Health Industry – Kaiser Health News

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