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