Medical Debt Book Talk Reckons With Aggressive Collection’s Consequences

On May 31, 2001, an article, headlined ​“The Predator on the Hill,” appeared in the now-defunct New Haven Advocate. The predator: Yale-New Haven Hospital.

“Paul Bass, the paper’s reporter, had picked up on the hospital’s practice of foreclosing on the homes of patients, some of whom worked low-paying jobs at the hospital, over unpaid debts,” said Dr. Luke Messac at a recent event at the Yale School of Medicine.

The occasion for the event was the book launch for ​“Your Money or Your Life: Debt Collection in American Medicine,” in which Messac, an emergency physician at Brigham and Women’s Hospital and historian of health policy in the United States, chronicles how medical debt has eroded trust in American health care and led countless patients into financial run. 

Messac was in conversation with Lindsey Muniak, a medical debt organizer with the Debt Collective, which is leading national efforts to address medical debt and financialization in the healthcare sector. 

The site of the launch was no accident. 

“New Haven was the epicenter of the practices that I write about in the book, for good and for ill,” said Messac.

The ill: the aggressive tactics practiced by YNHH against low-income patients in the early 2000s — ranging from lawsuits and wage garnishments to home foreclosures and even jail time — for, as he put it, ​“the crime of falling sick without wealth.” 

The good: what happened after Grace Rollins, a then-recent Yale graduate and researcher for SEIU District 1199, the union for YNHH food services workers, read the article. 

“She really got into the forensics of how much money was being collected, what tactics were being used, and how these folks were mostly low-income folks,” Messac said.

The resulting report, ​“Uncharitable Care,” on YNHH’s collection practices, was released in January 2003. It caught the attention of the Wall Street Journal’s Lucette Lagnado. 

In a piece dated March 13, 2003, Lagnado highlighted Quinton White, a 77-year-old Bridgeport retired dry-cleaning worker strapped with a $40,000 debt to YNHH. The bill was for two hospital admissions for his wife’s treatment of cancer 20 years before. 

“They initially owed around $16,000 and signed up for a payment plan, which they continued to pay religiously even on their limited incomes,” Messac said. ​“Ten years later, the debt had actually gotten bigger because the hospital was charging 10 percent interest, including late fees.”

After placing a lien on the Whites’ home, the hospital’s lawyers seized Quinton’s bank account in 1996 — three years after his wife died — even as he struggled with chronic kidney disease. 

“Quinton’s story became a cause celebre, and Yale-New Haven eventually forgave the remainder of his debt,” Messac said. ​“But that didn’t stop them from continuing to take people to court.”

A number of local groups sprang into action. In 2003, the SEIU put up a billboard reading ​“SHAME” so drivers on I‑95 could see its message to YNHH. New Haven clergy headlined demonstrations, calling on executives to ​“repent.” Yale law students filed lawsuits against the hospital and sent formal demand letters to the hospital to forgive debts immediately. 

Messac said that organizing led to a congressional hearing that saw hospital systems in the country announce changes in practice and led to new state laws, including bills that reduced the limit on interest charged on hospital debt. 

If all that agitation ​“drew a ton of attention to the problem, it didn’t solve it,” he said.

One reason has been hospitals’ widespread practice of selling debt to collection agencies. 

“These groups work that debt very hard because they have no connection to the patients,” he said. ​“They’re just numbers on a sheet of paper, and the more they collect, the more money they get.” 

Muniak, the Debt Collective organizer, introduced another factor in the continuing inability to curb hospitals’ relentless debt collection. 

“If you don’t really cement laws that can throw up some walls around protections, they can find these loopholes and wiggle back in.”

In a comment provided to the Independent for this article, Dana Marnane, the director of public relations and communications for Yale New Haven Health, responded to the book talk’s critique and lifted up the hospital’s current practices. ​“Twenty years ago, Yale New Haven Health led the way in changing how medical debt was handled, not only for Connecticut hospitals, but nationally,” Marnane wrote. ​“Today, we have one of the most generous free and discounted care programs in the nation. We invest millions annually into clinics and free care as well as non-traditional investments. These include education, safe housing and food insecurity. All of these investments help to break down barriers to healthcare, create equitable access and reduce medical debt. As Connecticut’s leading healthcare system, last year alone, inclusive of debt forgiveness and under reimbursement, we contributed $849.6 million in community benefit and community building activity.”

“There are so many tools that make it easy for hospitals to determine whether a person qualifies for financial assistance, and qualify them at the point of care, but they still make patients run through this rigmarole,” Muniak said at the recent book talk.

Despite that intransigence, Messac said he was heartened by private actors that are fighting back. 

One is Dollar For, which was started by a former bartender in Vancouver, Wa. who had issues with medical debt in his own family and realized that a lot of the problem was even applying for hospital financial assistance.

“So he started a group that helps people apply for financial assistance for free, and they’ve helped not only to do that, but also point out how crazy the system is, how onerous, how much can and should be done to make this easier,” he said, adding there are hospitals in Portland that now screen patients at the point of care. 

Muniak described the organizing tactics employed by the Debt Collective.

“We just ask do you have debt, then you’re part of the fight,” she said. ​“For a lot of people debt is very shame-inducing because they’ve been taught their whole lives that to have debt is to be immoral,” she said. ​“So we say come into this space with everyone else who’s in the same situation, we can talk about why this isn’t a personal or moral failure but a structural failure of this massive system with plenty of money.” 

The mission, she said, ​“is to show people how grotesque something is and by doing so help them make sense of their own agency in relation to the political landscape.”

Messac pointed out the power of media — specifically, local, independent newspapers—to effect change.

“Paul Bass wrote this article and within a few years you had congressional hearings where these huge hospital administrators were saying ​‘oh please, forgive us, we’ll change everything,’” he said. 

Anand Habib, a post-doctoral fellow at Yale School of Medicine, questioned the role of doctors in a landscape that has groups like nurses and food service workers organizing against hospitals’ billing practices. 

“I don’t think any one of us got involved with this to make a quick buck out of treating people,” he said.

“Physicians are way behind the ball on this,” Messac said.

“I’m not super religious but I think there’s something of the sacred in the bond between the patient and the physician and nurse that the market fundamentalists can’t take from us,” he added. ​“If we become reduced to a transaction, I don’t know what will come of my world view, but I can’t keep doing what I’m doing.” 

He paused. ​“So it was a real jolt for me to find out that in some senses it had. I was already living in that dystopia that I promised myself I would never let happen.”