The medical debt advocacy organization Undue Medical Debt released a toolkit to help doctors address patients’ financial needs – a role doctors said they did not train or want, but feel thrust into amid what they see as a worsening crisis.
More than 90% of Americans carry some form of health insurance. Still, an estimated 41% of US adults, or more than 100 million people, also have medical debt – whether held on a credit card, paid off to a provider over time, borrowed from a family member or with a collections agency, surveys show.
Medical debt can result from a wide array of interactions with the US health system. From patient “cost-sharing” such as high deductibles, to “out-of-network” care such as a ground ambulance ride, to insurance denials, to the sheer volume of appointments needed for diseases such as diabetes or cancer – in many cases, the patients must pay.
“The healthcare financing system is undermining that trust, and it’s something physicians have a big stake in,” said Eva Stahl, vice-president of public policy and program management at Undue Medical Debt.
Since 2014, Undue Medical Debt has bought and forgiven $10bn worth of medical debt. The organization often buys debt for pennies on the dollar from debt collectors and hospitals, and then retires it.
The new toolkit for doctors comes alongside the release of survey and focus group results, where doctors said they believed the medical debt crisis was worsening. Doctors in focus groups also reported that many do what they can to prevent debt, such as ordering fewer tests, but that they don’t always feel financing should be in their purview.
“The top line is that the business of medicine is overshadowing what they were trained to do, and that really means people are showing up not fully understanding their insurance or very fearful of accruing medical debt,” said Stahl.
Increased scrutiny of the US medical debt crisis has pushed some politicians to take action. In Joe Biden’s waning days in office, his administration finalized a rule that bans credit agencies from including medical debt in reports.
But healthcare providers’ billing departments can still sue patients, deny care and hire aggressive debt collectors. Those outcomes, alongside impenetrable hospital and insurance bureaucracy, means many patients remain fearful of medical debt.
Additionally, the Trump administration is expected to cut health insurance coverage by shrinking government programs, which could exacerbate medical debt. In confirmation hearings, a cabinet-level nominee has expressed support for adding work requirements to Medicaid, the health insurance program for low-income Americans, which would likely force people off the program without meaningfully increasing employment. Other reforms seek to control spending by cutting health programs.
“There is this uptick in intensity that is really front and center right now,” said Stahl. “The frustration ripples through not just the clinician population, but the patient population.”
Dr Karen Kinsell is a primary care doctor in rural Georgia, where the closest specialist center is five hours away in Alabama. She said patients, “not infrequently, refuse to go to the ER”, for fear of both more debt and long waits.
Others have ended up on what amounts to lifelong payment plans. One of Kinsell’s patients is a widower whose wife was spent roughly a year in the hospital before she died – amassing untold debt. Unable to pay the bills, the man agreed to a payment plan, one of a number of patients, “who are on, like, a $25 a month plan for the rest of their lives … He was dutifully paying this off, what he could every month,” she said.
Another pain point, though not strictly related to debt, are the cost of prescription drugs. She said many of her patients ration prescriptions – failing to take the prescribed dose. Others are unable to pick them up at all.
“Pharmaceuticals are not a debt situation – they just don’t get it,” Kinsell said. “The days of [pharmacies] extending credit are way gone.”
Far away from Georgia’s country roads, attending physician Dr Anand Habib at Yale School of Medicine in Connecticut said: “When you start asking individuals as patients and their families about the ways in which healthcare does not meet their needs – not only medical but financial – if you seek you will find.”
Habib learned about medical debt firsthand as a resident, when he got into a bike accident in San Francisco and was taken to the city’s only trauma center. Soon after, he was hit with an ambulance ride from the local fire department (his insurer said he did not obtain “prior authorization”), the entire hospital visit (which was “out-of-network”) and later the realization that, upon intake, he signed paperwork waiving the statute of limitations for a debt collection lawsuit.
“It feels absurd,” Habib said. “I am providing care to people within the city of San Francisco, and also being taken to the cleaners, to the bank, simultaneously.”
Among his many cases involving medical debt, Habib said he cared for a mother with breast cancer worried not about her imminent death – but freighting her children with medical bills. He said elderly patients are frequently worried, and sometimes rightly, that an ambulance ride home will end in a bill, and said he often speaks to insurance company’s “utilization review” doctors daily – arguing about whether a claim should be denied.
“That person has the power to determine whether my patients are exposed to financial pecuniary and potentially poverty and medical debt,” said Habib. “That is not a system anybody would design de novo.”
Habib, who has joined multiple efforts to educate physicians on medical debt, said, “Time and again, you see these issues and you realize, ‘I can either be a bystander or I can attempt to advocate’ – even if the political winds are against us.”
English (US)