Primum non nocere. From our very first days as fledgling physicians, we make a promise to do good by our patients, but what does it mean to do harm? Should we include socioeconomic harm to the list of things we aim to avoid when offering help to our patients?
This question seems increasingly relevant as more and more hospitals and physicians are beginning to file lawsuits against patients who fail to pay their bills. Prior to the passage of the Affordable Care Act (ACA), these patients would likely have been uninsured. However, in recent years, lawsuits filed by hospitals and physicians have begun to target patients who have insurance but cannot meet their deductible or cover their copays.1 In some states, debt collectors can force patients to go to court and testify about their poverty on a regular basis — using that information to garnish wages, bank accounts, or put liens on individuals’ properties.
When people get sick, they rarely have a choice in the matter. There is not a free market in which they can shop around for better or cheaper care.
This may seem reasonable on its surface — financial debts ought to be paid, after all. Yet, medical debt is different from other kinds of debt. When one buys a TV, car, or house on credit, they are choosing to purchase something. When one pays for medical care, the notion of choice is often minimal, if absent entirely. One could always rent within one’s means, use public transportation, or forego the TV. Health care, on the other hand, is more often than not a necessity. If a patient is diagnosed with a lymphoma, they can either choose to receive treatment or risk an almost certain death. This lack of choice places patients in a position of profound vulnerability, one that is already emotionally taxing by virtue of their being sick. It is no surprise that most people would amass unconscionable medical debt in the pursuit of survival. Thus, is it consistent with the principle of doing no harm to hold patients in contempt, arrest them, and imprison them on bail, which is then used to cover the unpaid medical debt?
In Coffeyville, Kansas, for example, there’s a lawyer, judge, and network of hospitals and physicians who think the answer is yes. In this particular town, when individuals default on a bill, no matter how small, they’re forced to make court appearances or they may find themselves in contempt of court. The prosecution’s lawyer may use this opportunity to get the judge to issue a bench warrant. The result of this is that ordinary people are arrested for the crime of being too poor to pay their medical bills. Though failure to pay a civil debt is not grounds for arrest in the United States, many cases in Coffeyville still lead to arrest due to the loophole of holding patients in contempt of court for failing to appear.
Lizzie Presser from pro-publica.org has spent time studying this phenomenon — exploring how a system that harasses and imprisons individuals for being unable to pay exorbitant medical bills came to be. In one example, a woman who was 4 months pregnant went to her local sheriff’s office to report a money order scam only to be arrested because there was an outstanding warrant for her arrest for failing to appear in court over a $230.00 medical bill. In another case, a man caring for a son with leukemia and a wife struggling with seizures was arrested over outstanding medical bills during routine police check for a hunting license.
There’s no outstanding balance too small to prevent a debt collector from wielding the power of contempt if there is a judge willing to allow it because there are no laws requiring that courts use contempt when a court order is not followed. Thus, the use of contempt is dependent on the discretion of the judge.2
This close relationship between lawyers, judges, and hospital systems is, unfortunately, not unique to Coffeeville, Kansas. The University of Virginia health system, a nonprofit hospital system, filed nearly 36,000 lawsuits over a 6-year period, leveraging its relationship with local courts to seize wages, bank accounts, and property, a practice that has forced many families into bankruptcy (Hancock and Lucas, khn.org). In fact, it is not uncommon for courthouses to reserve days for their local hospitals to file suit. Fredericksburg, Virginia, for example, has a local hospital that sues so many patients that the hospital has a dedicated day in court each month.3
Taking all of these factors into account, what we have is a healthcare system in crisis. It is no surprise that individuals find themselves with massive amounts of unexpected medical debt when they get sick.
When people get sick, they rarely have a choice in the matter. There is not a free market in which they can shop around for better or cheaper care. Invariably when someone enters the hospital, they lose all control of their care and consequently the cost of treatment. Unnecessary tests may get ordered, out-of-network physicians may be consulted by the in-network physician, and, in some cases, the hospital might just bill the whole episode of care improperly, which may be difficult, or impossible, for patients to resolve on their own. Compounded with this is the lack of transparency about the actual cost of care, resulting in patients being sued over a predetermined percentage of what their insurance company has privately negotiated with the hospitals and providers. The real cost or value of certain services remains unknown to the patient. Patients who are uninsured may face additional consequences over hospital and provider bills that are multiples of what was actually expected to be collected. Further, most Americans do not realize that their health insurance is unlikely to adequately protect them against significant financial harm as a result of receiving medical treatment. For example, the Trump administration, in its battle to repeal the ACA, has encouraged individuals to seek insurance from private brokers who can sell health plans that do not cover preexisting conditions or hospital care.4 Taking all of these factors into account, what we have is a healthcare system in crisis. It is no surprise that individuals find themselves with massive amounts of unexpected medical debt when they get sick.
Putting the victims of our broken healthcare system in jail no doubt appears both unjust and inconsistent with the values underlying the medical field, especially if we are starting from the premise of primum non nocere. In fact, embarrassed by the practice lawsuits against patients, several hospital systems backed off from suing their patients after information of the practice was made public.3
While I do not disagree that medical debt ought to be paid back, there is no doubt that the healthcare system can be unjust and unreasonably expensive. Thus, we ought to consider medical debt within that context. There must be some prudence and compassion paid to how we approach collections for medical debt.
1. Kliff S. With medical bills skyrocketing, more hospitals are suing for payment. New York Times, November 2019.
2. Presser L. When medical debt collectors decide who gets arrested. Propublica.org. October 16, 2019.
3. Hancock J, Lucas E. ‘UVA has ruined us’: health system sues thousands of patients, seizing paychecks and claiming homes. Kaiser Health News, September 10, 2019.
4. Abutaleb Y. Critics say ‘junk plans’ are being pushed on ACA exchanges. The Washington Post, November 20, 2019.