By 9 a.m., more than two-dozen people were crowded into the room for what has become the busiest legal docket in rural Butler County.

“Lots of medical cases again today,” the judge said, and then he called court into session for another weekly fight between a hospital and its patients, which neither side appears to be winning.

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So far this year, Poplar Bluff Regional Medical Center has filed more than 1,100 lawsuits for unpaid bills in a rural corner of Southeast Missouri, where emergency medical care has become a standoff between hospitals and patients who are both going broke. Unpaid medical bills are the leading cause of personal debt and bankruptcy in the United States according to credit reports, and what’s happening in rural areas such as Butler County is a main reason why. Patients who visit rural emergency rooms in record numbers are defaulting on their bills at higher rates than ever before. Meanwhile, many of the nation’s 2,000 rural hospitals have begun to buckle under bad debt, with more than 100 closing in the past decade and hundreds more on the brink of insolvency as they fight to squeeze whatever money they’re owed from patients who don’t have it.

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The result each week in Poplar Bluff, a town of 17,000, has become so routine that some people here derisively refer to it as the “follow-up appointment” — 19 lawsuits for unpaid hospital bills scheduled on this particular Wednesday, 34 more the following week, 22 the week after that. Case after case, a hospital that helps sustain its rural community is now also collecting payments that are bankrupting hundreds of its residents.

“Think of me as the referee,” the judge explained, as he called the first case. “It’s my job to be fair. I’m not going to be chugging for either side.”

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On one side of the courtroom was a young lawyer representing the hospital, and he carried 19 case files that totaled more than $55,000 in money owed to Poplar Bluff Regional. Three nearby hospitals in Southeast Missouri had already closed for financial reasons in the past few years, leaving Poplar Bluff Regional as the last full-service hospital to care for five rural counties, treating more than 50,000 patients each year. It never turned away patients who needed emergency care, regardless of their ability to pay, and some people without insurance were offered free or discounted treatment. In the past few years, the hospitals’ total cost of uncompensated care had risen from about $60 million to $84 million. Its ownership company Community Health Systems, a struggling conglomerate of more than 100 rural and suburban hospitals, had begun selling off facilities as its stock price tanked from $50 per share in 2015 to less than $3 as the lawyer approached the judge to discuss the first case.

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“We’re seeking fair payment for services we’ve provided. Nothing else,” he said.

Behind him in the courtroom were some of Poplar Bluff Regional’s patients — a population that was on average sicker, older, poorer and underinsured compared with the rest of the United States. More than 35 percent of people in Butler County have unpaid medical debt on their credit report, about double the national rate. Most of the 19 people on the morning docket had been treated in the emergency room and then failed to pay their bill for more than 60 days before receiving a summons to court. Many of them had insurance but still owed their co-pay or deductibles, which have tripled on average in the past decade across the United States. One patient owed more than $12,000 after being treated for a heart attack. Another was being sued for $286. If the hospital won a judgment, it had the right to garnish money from a patient’s paycheck or bank account or it could put a lien against a house.

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“I’m hoping to negotiate a payment plan, but I can only afford $20 a month,” one patient told the court.

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“I’m late for work, so if there’s someplace I can sign, I guess I’ll just sign,” said another patient, who owed more than $3,000 after spending six hours in the emergency room for chest pain.

“How am I supposed to pay $4,000 to see a doctor if I’m barely making $2,000 a month?” asked another.

One by one the patients came up to plead their cases until the judge called Gail Dudley, 31, who was sitting with her mother in the third row. She had gone to the emergency room at Poplar Bluff Regional in 2017 after passing out because of complications from Type 1 diabetes. The hospital had given her medication to stabilize her blood sugar, kept her overnight for observation, and then sent her home with a bill for $8,342, of which she was still responsible for about $3,000 after insurance. She’d tried to appease the hospital’s billing department by sending in an occasional check for $50, but with accumulating interest and penalty fees, the balance on her account had remained essentially the same for two years.

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“I’m grateful for what they did for me, and I know I owe it, but I don’t have that kind of money,” she said.

The judge gestured in the direction of the hospital’s attorney and then looked at Dudley. “Would you like a chance to talk to this gentleman for a moment and see if you two can work something out?”

“Okay,” she said. “We might as well try.”

Matthew McCormick, 27, led Dudley into the hallway to begin the same negotiation he’d been having with dozens of hospital patients each week. On Thursdays he was listed as a hospital attorney for the court docket in Doniphan, population 1,997. Mondays it was Kirksville, Tuesdays were Bloomfield, and Wednesdays often brought him here, to a 95-year-old courthouse in Butler County, where he’d represented Poplar Bluff Regional on more than 450 billing cases so far in 2019.

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“We’d like to find a way to work with you on this,” he told Dudley as they sat down together in the courtroom lobby. He reached out to shake her hand. He smiled and offered his business card. For the past year, he’d been working on behalf of the hospital as the newest attorney for a law firm called Faber and Brand, which promised to “use the judicial system to recover money owed.” McCormick’s cases hardly ever went to trial. More than 90 percent of the people being sued weren’t represented by an attorney and at least half failed to show up in court, resulting in default judgments in the hospital’s favor. The rest of the patients McCormick met came into court with little to offer in their own defense except for apologies and stories of poverty, poor health, unemployment and bad luck.

“I’m real sorry about this,” Dudley said. “If I’d been thinking straight, I would never have let them take me to the emergency room. I know I can’t afford that. I wish I could pay you all of it right now.”

“Let’s make this as easy as we can,” he told her. “Is there something you can pay? A little each month?”

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“I don’t have anything extra,” she said, thinking about the paycheck she earned for a full-time job as a clerk at Goodwill, which totaled $736 every two weeks. After paying for rent and utilities on a subsidized three-bedroom apartment, groceries, and child care for her 6-year-old son and 3-year-old daughter, she sometimes ran out of money by the end of the month.

“How about $15 out of every paycheck?” she offered, even though she doubted she could afford it. When McCormick didn’t immediately respond, she revised her offer. “Thirty? How’s that?”

“Let’s say thirty,” McCormick said.

He had more patients waiting to negotiate, so he thanked Dudley and led her back into the courtroom to sign her judgment. It said she had agreed to a total claim of $3,021, plus $115 in court costs and 9 percent annual interest. She would send the hospital $60 each month until the balance was paid in full, and if she failed to make a payment the hospital could pursue garnishment of her wages.

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“I’m glad you worked something out,” the judge said as he signed off on the agreement.

The court clerk handed Dudley a copy of the judgment, and once she was back outside the courtroom she took out her phone to run the math. If everything went right, and she somehow managed to save and pay $60 each month, she’d be sending checks to Poplar Bluff Regional for the next 5½ years.

In order to make 66 monthly payments, she had to somehow come up with the first, but her bank account was almost empty and payday was still a week away. Dudley left the courthouse, got into the car with her mother, then changed into a polo shirt for work. They drove away from the cobblestone streets of downtown and headed toward Goodwill.

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“Could’ve been worse,” said her mother, Norma Garcia, 48. “Sixty isn’t so terrible.”

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“It is if you don’t have it,” Dudley said. “Who do you know that’s sitting on an extra sixty each month?”

They drove past a dollar store, a payday lender and a fast-food restaurant advertising “full-time career opportunities” starting at $7.80 an hour.

“Maybe you can borrow it?” Garcia suggested.

“I don’t do credit cards or lenders,” Dudley said. “That’d just be another debt I couldn’t pay.”

“I meant from somebody.”

“Who?” Dudley asked. “Everyone we know is paying the hospital already.”

Their family had lived for three generations in Poplar Bluff’s predominantly black neighborhood just north of downtown, where according to credit records more than half of adults had debt in collections for unpaid auto loans, credit cards or medical bills. Dudley’s aunt had been sued twice by Poplar Bluff Regional and was forfeiting 15 percent of her paycheck to a court-ordered hospital garnishment. Her cousin was being sued for $1,200. Her sister owed $280.

But none of them had cycled through the emergency room as often as Dudley during the past several years. Her two pregnancies had complicated her diabetes, and she’d tried to save money by skimping on insulin. Instead of paying $50 every few months for a preventive medication, she had collapsed at work and been rushed to the emergency room, where she was sent home with thousands of dollars in now-unpaid bills. Poplar Bluff Regional was an ambitious rural hospital — a $173 million facility with a cancer center, a cardiac center, dozens of specialists and state-of-the-art surgical suites — and Dudley believed she was alive because of it. But during the past five years, the average amount that rural patients owed for hospital visits nationwide had doubled, and Dudley was earning $11 an hour at Goodwill as new hospital bills kept arriving in her mailbox.

She owed a $100 co-pay from another hospital visit in November 2018 that had already been sent to collections.

She owed $485 from another trip to the ER in April.

She owed $159 for lab tests, $85 for a doctor’s visit and now $60 for her first court-mandated payment, which was due at the end of the month.

“I’m trying to make peace with the fact that this debt could sit on me forever,” she said.

“Maybe I can help,” Garcia offered, even though she was on disability and avoiding her own billing notices from the hospital, seeking $365 in unpaid deductibles.

“It’s my bill to pay,” Dudley said. She’d been saving a little money for back-to-school supplies, and she said it was enough for her first month’s payment. “I’ll handle it,” she said. “There’s no other choice.”

There was one person in town who did believe patients had another choice, and over the past several years Daniel Moore had begun encouraging his clients to make it.

“Don’t pay one cent,” the lawyer had advised dozens of clients. “I don’t care how much the hospital says you owe. Fight them over it.”

Moore had been working for almost five decades as a self-described “old hillbilly lawyer” out of a converted house downtown. He specialized in criminal defense, with more than 400 cases pending all over the state, and he liked to align himself with the underdog. He’d been unable to afford a doctor himself while growing up on a farm with no running water, so when clients began coming to his office with bills from Poplar Bluff Regional that they could neither pay nor understand, he had agreed to take a look.

What Moore found in some of those itemized receipts didn’t make sense to him either: $75 for a surgical mask; $11.10 for each cleaning wipe; $23.62 for two standard ibuprofen pills; $592 for a strep throat culture; $838 for a pregnancy test. He searched through court records and discovered that the hospital was collecting hundreds of monthly garnishments from hourly employees at places like Quickstop, Earl’s Diner, Wendy’s, Instant Pawn and Alan’s Muffler.

He decided to represent several hospital patients free, and went to court against the hospital for a jury trial for the first time late in 2015. Moore’s client was a Poplar Bluff police officer with decent insurance, an Army veteran who went to the emergency room one afternoon because of chronic stomach problems. He’d been given a battery of tests in the ER, then treated with three IV medications before being discharged after three hours with a bill for $6,373. His insurance had paid some, but the hospital was suing him for co-pays totaling about $1,650, plus interest.

“The facts show that he came to the hospital and received treatment that alleviated his symptoms,” the hospital’s lawyer at the time told the jury. “He received three separate bills. He just didn’t pay the balance.”

“These charges are outrageous,” Moore told the jury. “He doesn’t owe the hospital anything.”

A billing manager from the hospital took the stand and said Poplar Bluff’s prices were in line with other hospitals in rural Missouri. She mentioned the high cost of providing care at rural hospitals, which must pay higher salaries in order to recruit doctors, nurses and specialists while also suffering more from federal cuts to Medicaid and Medicare compared with urban hospitals.

Moore began to question her about each charge on his client’s itemized receipt. Why, he asked, did it cost $800 to spend approximately 40 seconds with a doctor? Why was the hospital charging $211 for an oxygen sensor that was on sale for $16 at Walmart? Then Moore asked about three identical charges on the bill labeled “IV Push,” which each cost $365.

“An IV push, if I understand it, that’s the act of sticking the needle in that little port and then squeezing it,” Moore said. “Is that right?”

“Yes,” the billing manager said.

“So that takes maybe five seconds, right?”

“Yes.”

“So you, the hospital, think that act alone, not counting the drugs inside the IV, which cost thousands of dollars more — that act alone is worth $365.38?”

“Yes,” she said again.

“It makes me so mad,” Moore told the jury, in his closing argument. “If you’re content to let the hospital just crush people, then go on and give them their measly $1,650. But what you can do today is say, ‘Hey, we’re tired of this.’ How many times are we going to let working people take the shaft?”

“In reality, this is a simple bill,” the hospital’s lawyer countered. “All we’re asking for is his co-pay and his deductible. The hospital provided treatment. He still owes.”

The jury deliberated for less than an hour and then found in favor of Moore’s client, wiping away his hospital debts. But whatever sense of victory Moore felt was mitigated over the next months as Poplar Bluff Regional’s lawsuits continued to spread across the civil courts of Southeast Missouri, and he agreed to take on more free cases. “The hospital circuit,” Moore called it, which meant Mondays in Caruthersville, Tuesdays in West Plains and Wednesdays in Poplar Bluff.

On Thursdays it was Doniphan, a town of fewer than 2,000 people, where Poplar Bluff Regional had filed more than 300 lawsuits during the past several years. Moore drove past horse farms and timber plants, parking near an abandoned hospital. Ripley County Memorial had closed six months earlier, and there were locks on the doors and a sign taped above the ambulance bay.

“For Nearest Emergency Services, go 29 miles to Poplar Bluff Regional,” it said, and now several of those Poplar Bluff patients had been summoned right back to downtown Doniphan, to a red brick courthouse at the center of the town square.

They crowded next to each other on a wooden bench in the lobby, waving their hospital bills as fans against the late July heat while they waited for the courtroom to open and then entered one by one: a husband and wife who went for cancer treatments at Poplar Bluff Regional each week but couldn’t afford the co-pays. A community college student who owed more than $7,000 for treatment of a chronic heart condition. And then the judge, who had presided over hundreds of hospital cases during his career and also recused himself from one case a few years earlier, when the patient being sued was his wife.

“How are we all doing today?” he asked, as he looked down at a docket with 14 more cases between a hospital ownership company that couldn’t afford to keep losing money and patients who couldn’t afford to pay. Both sides were drowning in debt, fighting to stay above water, and pulling each other back down.