Tied Together in Sickness and in Debt

As a nurse working for a nonprofit community hospital, Marcia had seen what medical debt can do. One of her patients, terminally ill with cancer, kept asking to be sent home because she worried about the financial burden on her family if she stayed. Her husband fretted that they could lose the house trying to keep up with the medical bills. Marcia showed up on her days off to check on her patient and called around to secure help with groceries, school supplies, and utility bills. It was the least she could do for this 40-year-old mother. This could be any one of us, she thought.

She didn’t realize how soon she would be facing her own mountain of medical debt. It was July 2025 when she convinced her doctor to send her for a colonoscopy screening. She was experiencing bleeding that didn’t feel right, though she was being told it wasn’t serious.

Marcia did her due diligence when scheduling her appointment, confirming with her insurance company and the clinician, who was located inside an in-network hospital, that the procedure was covered under her plan. But two months later, Marcia received a bill for $10,097, including an erroneous charge of nearly $2,000 for sedation and anesthesia that she had declined. The insurance company had refused to pay, reporting that the provider was out of network.

On her modest income, Marcia could not afford the $400 monthly payment on the bill—the lowest the health system agreed to offer—on top of what she was paying for medical expenses incurred earlier in the year. Instead of working with Marcia, the hospital threatened to send the debt to collections.

For months, Marcia spent hours on the phone during her days off, looking for resources to help address her debt. She filed two appeals with her insurance; both were denied. She asked the health system to correct the billing error; they gave her the runaround and ultimately refused. And when Marcia sought financial relief from her hospital’s employee assistance program, she was told “We don’t do medical bills.” She worried that she would also lose her house.

Marcia started working as a tech at this very hospital 20 years ago—before a large private health system took over. Back then, her monthly out-of-pocket expense for medical and dental insurance was $11. Now it’s more than 10 times that, in addition to a high deductible. “I might actually have to leave my job,” she said. “We recently got raises, but our cost for medical insurance, which is terrible, also increased. That’s not a win-win. It’s a struggle-struggle.”  The job that fulfills her calling to care for the sick won’t pay her enough to live.

For too many people in this country, going to the doctor means falling into debt. Today, more than 100 million adults have medical debt, and about 1 in 5 believe they will never be able to pay it off.¹ This is a relatively new phenomenon. Until recently, the great gap in our social safety net was evidenced by the rising ranks of the uninsured. In 2010, nearly 18 percent of all nonelderly Americans lacked health insurance. With the passage of the Affordable Care Act (ACA) and other interventions, the uninsurance rate has been cut nearly in half² (though some of those gains are projected to disappear³ because of the cuts made in President Donald Trump’s One Big Beautiful Bill Act).* And the ACA’s Medicaid expansion offered real relief to those struggling with healthcare bills. Between 2013 and 2020, states that expanded Medicaid in 2014 had a much greater decrease in average medical debt than states that refused to expand it, where average medical debt barely budged.⁴ Today, gaps in the safety net persist, including provider deserts⁵ and disparities in access to and quality of care.⁶ A prominent illustration of those gaps is the rise and persistence of medical debt across the United States.

The heavy burden of healthcare costs and the specter of medical debt afflict the insured and uninsured alike. Approximately 23 percent of US working-age adults—nearly 1 in 4—are considered “underinsured,”⁷ which means that while they have health insurance for the full year, their out-of-pocket medical expenses pose significant strain on both finances and health.

The spread of underinsurance is just one example of how too many workers are not protected from the risks of healthcare costs. Health insurance premiums are going up while coverage is going down. Deductibles and copayments are also going up, which means even the insured must pay hefty prices to access care.⁸ Doctors who used to be in-network are now out,⁹ and the idea of finding a new provider is overwhelming. And patients are constantly stretching the limits of the care they receive. More than half of Black households and 4 out of 10 white households are cutting their pills in half or skipping doses, substituting over-the-counter drugs for their prescriptions, or simply not taking what their doctor prescribed because of cost.¹⁰

These structural problems express themselves with brutal specificity when illness strikes. Most medical debt is triggered by a one-time or short-term medical expense,¹¹ and even small, unexpected medical costs have long-term financial consequences: Garnishments can empty bank accounts and effectively suppress wages; credit-damaging collections and court judgments make it harder to rent an apartment or get approved for a mortgage; and court and interest charges cause debt to grow. A one-time illness can place a lasting burden on building and maintaining wealth.¹²

Overcoming a debt crisis forces difficult choices, often Hobson’s choices such as either receiving medically needed care along with painful debt obligations or forgoing care and risking tragedy. About 2 in 5 Americans report that they ignore symptoms, skip scheduled appointments, and grind on.¹³ Many also report more serious consequences like skipping payments on other bills, delaying college or buying a home, or changing their housing situation as a result of their debt. And medical debt itself contributes to poor health. More than half of underinsured adults avoid necessary medical care because of cost, and 1 in 7 adults with healthcare debt say they have been denied care by a “hospital, physician’s office, or other medical or dental provider” due to unpaid bills.¹⁴ But health problems often do not resolve themselves, and by the time many patients get the care they need, they are struggling with graver conditions and steeper bills.¹⁵ This also impacts clinicians, as they bear the moral distress and injury of caring for patients who are sicker, have higher stress levels, and fear falling deeper into debt.¹⁶

These are not just people who deny the value of preventive medical care. Many work at hospitals, as Marcia does. The health sector simply is not working for many Americans, including for those who tirelessly and devotedly work within it.

How Did This Happen?

One thing that is clear is that the nation is spending healthcare dollars profligately while failing both to protect those vulnerable to illness and to promote our collective well-being. Data collected by the Centers for Medicare and Medicaid Services show that healthcare expenditures have been rising dramatically for generations. In 1980, they were $804.4 billion (in constant 2024 dollars) and roughly $3,491 per capita. They grew to $2.29 trillion in 2000 (also in constant 2024 dollars) and roughly $8,100 per capita, and then to $4.97 trillion or over $14,931 per capita in 2020. We’re now well over $5 trillion. These numbers capture how much was spent on healthcare and on related activities such as insurance administration, medical research, and public health.¹⁷

This is far more than what comparable countries pay for healthcare. The US expenditure per capita is about 50 percent higher than the expenditure in Switzerland or Germany, and we spend more than twice as much per capita as Denmark, the United Kingdom, or Canada.¹⁸ But we are not spending our dollars wisely. Compared to other wealthy nations, life expectancy in the United States is lower, avoidable deaths are higher, and US patients are most likely to skip needed care because of cost.¹⁹ Plus, the prevalence of heart disease, diabetes, and lung disease is significantly higher in the United States than throughout Europe.²⁰

Policies That Neglect Common Sense

The reason our healthcare costs are so high, and the reason we continue to suffer from both poor health outcomes and rising medical debt, is because of the policies we have chosen. We have never prioritized addressing the day-to-day struggles of raising a family and maintaining daily well-being. Instead of providing the basics, such as access to primary care, a reliable supply of necessary therapeutics, and support for elder care and chronic conditions (or even helping families with the stressors of obtaining childcare, housing, and healthy food), we have a system that seizes boatloads of money from workers’ monthly paychecks and offers a feeding frenzy for some of the nation’s most ravenous corporate interests—insurers, health systems, pharmaceutical companies, and the many intermediaries. Thus, we find ourselves mired in a complex, profit-seeking system in which the word “choice” obscures more than it reveals. We rely on employers to provide health insurance to working Americans (largely ignoring the hardships of those who can’t find a job that offers insurance), but employers rarely ask those workers what kind of plan they want. Workers are often left with few choices and with plans that eat away at their wages. Over the past three decades, health insurance premiums have increased about three times faster than earnings.²¹

Our current medical debt crisis is therefore a simple consequence of math, a juxtaposition of wages that rise gradually while healthcare costs rise steeply, and it is no surprise who is hurt most. According to a KFF survey in 2022, 41 percent of adults in the United States had medical or dental debt, and that number went up to 57 percent for adults with household incomes under $40,000. Even among adults with household incomes above $90,000, 26 percent reported medical or dental debt.²² And while more than 80 percent of the uninsured said in an April 2026 KFF poll that it was difficult to afford healthcare costs, 42 percent of those with insurance said the same. It is no wonder that more Americans are worried about healthcare costs than about the price of gas, groceries, or rent.²³

Failures of Accountability

Our health system also makes it impossible for patients to conserve their limited healthcare dollars. Patients cannot shop for affordable care because few providers disclose their prices, because insurers add complexity and institute bureaucratic controls over coverage rather than guiding patients to the care they need, and because policies designed to protect low-income patients are often not followed. Hospitals have largely failed to comply with price transparency requirements that have been in effect for over five years, making price comparisons impossible.²⁴ A recent study revealed that the price of a procedure in a single hospital may be more than 10 times higher for one patient than for another, and between hospitals that variation jumps to as much as 31 times; for example, at Spring View Hospital in Lebanon, Kentucky, the minimum insured negotiated price for an appendectomy is $1,574, while the maximum insured negotiated price is $35,908.²⁵ Patients routinely are befuddled with the bills they receive, even after having asked for clear quotes before receiving care.

Billing errors and overcharges are also commonplace in hospital invoices. One study found that 45 percent of nonprofit hospital organizations were regularly sending bills to patients with incomes that would have qualified them for what the hospitals call “charity care.”²⁶ (Although hospitals are obligated to publicize charity care policies, they can structure those policies however they’d like, and the charity required of them is very minimal; most analyses suggest that charity care constitutes less than 1.4 percent of hospital operating expenses.²⁷) This matters not only for those who meet the income qualifications but also for their children and other loved ones who are called on to help them.

We ask too much of patients, expecting them to act as accountants at precisely the moment they suffer from illness. And we have little sympathy when bills and debt catch them by surprise.

Making a Bad Problem Worse

Our country has compounded these problems by treating those suffering from medical debt as if they have freely chosen their hardships. We blame patients for mismanaging their finances, spending too much for an unnecessary procedure, or failing to shop for affordable care. We focus on what patients chose, paying little regard to how hospitals, insurers, and others ensnare ordinary individuals in a system of hidden prices, billing complexity, and escalating costs—and ignoring the obvious fact that as you’re loaded into an ambulance after an accident or given a cancer diagnosis, researching affordable care may not be possible.

Few patients understand the healthcare prices they confront or the bills they ultimately receive, and many are then further victimized by the court system and the providers that choose to use it. The last 25 years have seen a growing tendency by hospitals to use aggressive legal actions to collect medical debt. One study found that hospital lawsuits over unpaid medical bills increased by 37 percent in Wisconsin from 2001 to 2018.²⁸ An examination of medical debt collections in North Carolina found similar results, including that interest charges and court fees increased patients’ medical debt burden by more than 35 percent.²⁹ And a recent study examining Virginia court records found that medical debt collection lawsuits constituted more than one-fourth of all of the state’s debt collection actions from 2010 to 2024.³⁰ All three studies also reported that a relatively small subset of hospitals were responsible for a vast majority of the lawsuits.

As if illness and its financial consequences were not traumatic enough, many patients must then suffer the stress of receiving court summonses and legal threats. It is easy to lose trust in a health system that is insensitive to the real physical and emotional toll that patients suffer when hauled into court. More than half of adults with medical debt say they have made what they feel to be a difficult sacrifice to pay down their debt, causing them to feel as if they could not provide a good life for their families or despair that they will never extricate themselves from debt.³¹ Harassment from debt collectors and adverse impacts on credit scores lead to additional financial problems, such as difficulty buying vehicles needed for work or buying or renting a home.

Court actions to collect medical debt harm patients in other material ways as well. Once patients are sued for their debt, they then are subject to court fees, attorneys’ fees, and interest charges. The North Carolina study showed that those fees increased their debt by more than one-third; some families owed more than $10,000 in interest alone.³²

Hospitals, courts, and other public institutions that pledge to protect public health and safety need to confront their practices that harm their patients and the health of their communities.

What Should We Do Now?

Julia works as an ICU nurse at a rural hospital in Washington state. Over the years, the hospital administration’s attempts to cut health insurance costs have had the opposite result for employees, who have dealt with repeated changes to insurance plans, sudden disruptions in care, and lots of shocking medical bills. Seeing her coworkers and friends dealing with these problems spurred Julia to take action. “That’s when I started getting involved with the union,” she said.

As a union leader, Julia has heard about many of her colleagues’ hardships, but even she was shocked to learn that some of the CNAs and RNs at a nearby hospital were sent to collections by their employer and were seeing their wages garnished to pay for recent ER visits. Even worse, these members hadn’t let their bills go unpaid—they never received bills at all, or any kind of itemized accounting of the charges. The first they learned of any supposed debt was from the collection agency.

“It’s mind-boggling,” Julia said. “While you are working your tail off, the same company you’re working for sends you to collections and takes money from your paycheck before you even know what you’re supposed to owe. In the meantime, it hits your credit, and that has impacts that can last for years.”

Protecting healthcare workers against the threat of medical debt is a top priority for Julia’s union. They have fought to restore in-network status to preferred physicians and eventually negotiated contract language requiring the hospital to give the union advance notice of plan or benefit changes to protect members from expensive surprises. “We have to be vigilant,” Julia said, “but we know that when we fight back together, we can win.”

The kinds of benefit changes Julia and her coworkers experienced are far from unique—and for too many employers, they go unchallenged. But as Julia has learned in her years of union activism, collective action can help to turn the tide.

In recent years, physicians are also seeing merit in forming unions to combat dominant hospital employers. From 2000 to 2022, physicians filed paperwork to form unions at a rate of about two petitions per year. In 2023 and 2024, the rate spiked to more than 16 per year. Physicians cite the same reasons for unionizing^† as Julia—protecting the integrity of healthcare delivery, redressing unsafe working conditions, and demanding a voice against increasingly corporatized medicine.³³ There is a growing sense across all categories of healthcare workers that the nation’s health system isn’t working the way it should for anyone.

Rethinking Our Choices

Since the medical debt problem has grown so severe, some policymakers have started listening. In 2025, the Virginia state legislature passed the Medical Debt Protection Act, which limits interest collection on medical debt, mandates a 90-day interest-free grace period, and prohibits extraordinary actions like home foreclosures and wage garnishments for certain individuals.³⁴ Other states and the District of Columbia have also worked to eliminate or prevent the injustices of medical debt. Some, like Pennsylvania, have used state healthcare funds to cancel medical debt owed by residents. Others, including Arizona, Colorado, Illinois, Minnesota, and Oregon, have taken measures to cap interest rates for medical debt, stop creditors from garnishing wages or putting liens on homes, or prevent medical debt from hurting credit ratings.³⁵

These policies are commendable, but much more is needed.

Certainly, the causes of medical debt need to be addressed and not just its worst outcomes. At the very least, that means medical bills must be accurate, comprehendible, and issued alongside efforts to ensure that those eligible for low- or no-cost care receive the assistance hospitals promise. It also means healthcare prices should be transparent, and patients should have both some opportunity to shop for affordable care and the agency to understand the financial burdens they assume.

Employers should also take the burdens of medical bills seriously. Because employers play an active role in constructing employee health benefits, they can negotiate on behalf of their employees for accessible physician networks, avoid predatory providers, and offer insurance that genuinely protects from financial ruin. For example, when the human resources team constructs a provider network for employees, they should be aware of which hospitals are suing patients and lean on those providers to cease those litigation activities. It’s also important that employers resist the many intermediaries and monopolies in the health sector, invest genuine effort to deliver value to workers, and direct employees to high-value providers (that, among other things, will not burden their patients with medical debt collections). In truth, these efforts are not discretionary—the law requires employers to put in this work on behalf of their employees.³⁶ Unions can both hold employers directly accountable and demand from policymakers that the purchasers of healthcare are held accountable to those who ultimately need it.

Hospitals and other community institutions—especially those that receive tax exemptions, government subsidies, and other favors from the taxpayer—must also take their responsibilities to their community seriously and recognize the harm they inflict when they sue their patients. This is all the more true for hospitals that sue the very people who deliver lifesaving care and help them achieve their missions. It is time for hospitals to stop suing patients, and legislative changes can make it so—if only we, the voters, demand it.

Our collective choices can also make healthcare more affordable. The nation will continue to suffocate from healthcare costs so long as we continue to spend the most but get the least among all our peer nations. Changing the course of our healthcare system—shifting our focus toward more primary care and less hospital care, expanding preventive and high-value services and becoming less tethered to a reactive system designed to respond to severe illness, and making real advances toward accessible and affordable care for all—will require a nationwide effort, with a reckoning from every stakeholder in the health sector, but it is needed and ultimately will benefit everyone.

Sadly, it will become harder before it gets easier. The recent expiration of the ACA subsidies and imminent cuts in Medicaid will make more Americans newly vulnerable to the financial consequences of illness. Now is the time to demand a compassionate health sector, one that refuses to condone lawsuits against patients and other punitive actions against those struggling with illness. It is also the time to give healthcare workers the respect they deserve and to support unionization efforts that give them the strong voice they need to build a system that truly cares for people. And it’s a time to think deeply about how we can build a healthcare system that serves the daily needs of Americans without the constant threat of financial distress.

There’s no time to lose. 

Barak D. Richman, JD, PhD, is the Alexander Hamilton Professor of Business Law and co-director of the Health Law and Policy Program at the George Washington University Law School. He is also a senior scholar at the Clinical Excellence Research Center at the Stanford University School of Medicine. Previously, while a professor at Duke University, he helped found the Duke Margolis Institute for Health Policy. Frederick F. Wherry, PhD, is the vice dean for faculty development and inclusion in the Office of the Dean of Faculty and the Townsend Martin, Class of 1917 Professor of Sociology at Princeton University. He founded the Debt Collection Lab and the Dignity + Debt Network and has authored or edited numerous books on debt and economic justice. 

*For more on the effects of Trump’s healthcare policies, see “What Donald Trump’s Second Presidency Has Meant for Health” in the Spring 2026 issue of AFT Health Care. (return to article)

^†For a detailed look at why one group of physicians decided to unionize, see “Do No Harm” in the Spring 2023 issue of AFT Health Care. (return to article)

Endnotes

1. N. Levey, “100 Million People in America Are Saddled with Health Care Debt,” KFF Health News, June 16, 2022, kffhealthnews.org/health-care-costs/diagnosis-debt-investigation-100-million-americans-hidden-medical-debt.

2. J. Tolbert et al., “Key Facts About the Uninsured Population,” KFF, June 16, 2026, kff.org/uninsured/key-facts-about-the-uninsured-population/?entry=trends-in-the-uninsured-population-uninsured-trends; and M. Stobbe and A. Swenson, “About 8% of the Country Lacked Health Insurance in 2025, New Data Shows. That Could Rise Next Year,” Associated Press, May 28, 2026, apnews.com/article/uninsured-americans-healthcare-trump-cdc-nchs-40253e8ebb89cf10fa32e4778b7c2722.

3. Stobbe and Swenson, “About 8%.”

4. R. Kluender et al., “Medical Debt in the US, 2009–2020,” JAMA 326, no. 3 (July 20, 2021): 250–56.

5. KFF, “Primary Care Health Professional Shortage Areas (HPSAs),” December 31, 2025, kff.org/other-health/state-indicator/primary-care-health-professional-shortage-areas-hpsas/.

6. See, for example, C. Caraballo et al., “Trends in Racial and Ethnic Disparities in Barriers to Timely Medical Care Among Adults in the US, 1999 to 2018,” JAMA Health Forum 3, no. 10 (October 28, 2022): e223856.

7. S. Collins and A. Gupta, “The State of Health Insurance Coverage in the U.S.: Findings from the Commonwealth Fund 2024 Biennial Health Insurance Survey,” Commonwealth Fund, November 21, 2024, commonwealthfund.org/publications/surveys/2024/nov/state-health-insurance-coverage-us-2024-biennial-survey.

8. G. Claxton et al., 2025 Employer Health Benefits Survey (KFF, October 22, 2025), kff.org/health-costs/2025-employer-health-benefits-survey/#55d346a7-5bff-4d99-840c-a793b6a03320.

9. See, for example, National Alliance on Mental Illness, “The Doctor Is Out,” nami.org/research/publications-reports/public-policy-reports/the-doctor-is-out.

10. G. Sparks et al., “Americans’ Challenges with Health Care Costs,” KFF, April 30, 2026, kff.org/health-costs/americans-challenges-with-health-care-costs.

11. L. Lopes et al., “Health Care Debt in the U.S.: The Broad Consequences of Medical and Dental Bills,” KFF, June 16, 2022, kff.org/health-costs/kff-health-care-debt-survey/#c7f7c77b-dec4-4baf-bed1-78e3522b4f46.

12. B. Richman et al., Medical Debt Ecosystem: The Mechanized Wealth Extraction from America’s Patients (GW Law, Stanford Medicine, and PatientRightsAdvocate.org, 2025), patientrightsadvocate.org/medical-debt-ecosystem-report.

13. S. Collins, S. Roy, and R. Masitha, “Paying for It: How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer,” Commonwealth Fund, October 26, 2023, commonwealthfund.org/publications/surveys/2023/oct/paying-for-it-costs-debt-americans-sicker-
poorer-2023-affordability-survey.

14. Lopes et al., “Health Care Debt.”

15. Collins, Roy, and Masitha, “Paying for It.”

16. P. Pittman et al., “Understanding and Addressing Health Worker Burnout and Moral Injury,” GW School of Medicine and Health Sciences, May 19, 2025, emed.smhs.gwu.edu/news/understanding-and-addressing-health-worker-burnout-and-moral-injury; M. Bailey, “Beyond Burnout: Docs Decry ‘Moral Injury’ from Financial Pressures of Health Care,” KFF Health News, February 4, 2020, kffhealthnews.org/health-care-costs/beyond-burnout-docs-decry-moral-injury-from-financial-pressures-of-health-care; and L. Doggett, “Doctors Have Their Own Diagnosis: ‘Moral Distress’ from an Inhumane Health System,” National Public Radio, August 2, 2023, npr.org/sections/health-shots/2023/08/02/1191446579/doctors-have-their-own-diagnosis-moral-distress-from-an-inhumane-health-system.

17. S. Rakshit et al., “How Has U.S. Spending on Healthcare Changed over Time?,” Peterson-KFF Health System Tracker, January 22, 2026, https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time.

18. I. Telesford et al., “How Does Health Spending in the U.S. Compare to the Other Countries?,” Peterson-KFF Health System Tracker, March 11, 2026, https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#GDP%20per%20capita%20and%20health%
20consumption%20spending%20per%20capita,%20U.S.%20dollars,%202024%20(current%20prices
%20and%20PPP%20adjusted).

19. D. Blumenthal et al., Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System (Commonwealth Fund, September 19, 2024), commonwealthfund.org/publications/fund-reports/2024/sep/mirror-mirror-2024.

20. National Research Council and Institute of Medicine, U.S. Health in International Perspective: Shorter Lives, Poorer Health, ed. S. Woolf and L. Aron (National Academies Press, 2013); and R. Tikkanen and M. Abrams, “U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes?,” Commonwealth Fund, January 30, 2020, commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019.

21. S. Kanimian and V. Ho, “US Medical Prices and Health Insurance Premiums, 1999–2024,” JAMA Network Open 8, no. 12 (December 8, 2025): e2547462.

22. Lopes et al., “Health Care Debt.”

23. G. Sparks et al., “Americans’ Challenges with Health Care Costs,” KFF, April 30, 2026, kff.org/health-costs/americans-challenges-with-health-care-costs.

24. B. Richman and K. Bartlett, “Shopping for Healthcare: Can We Be Good Consumers?,” Health Management, Policy and Innovation 7, no. 2 (April 2022), hmpi.org/2022/04/29/shopping-for-healthcare-can-we-be-good-consumers.

25. PatientRightsAdvocate.org, Price Variation Report (December 2023), patientrightsadvocate.org/pricevariationreport.

26. J. Rau, “Patients Eligible for Charity Care Instead Get Big Bills,” KFF Health News, October 14, 2019, kffhealthnews.org/health-care-costs/patients-eligible-for-charity-care-instead-get-big-bills.

27. Z. Levinson, S. Hulver, and T. Neuman, “Hospital Charity Care: How It Works and Why It Matters,” KFF, November 3, 2022, kff.org/health-costs/hospital-charity-care-how-it-works-and-why-it-matters.

28. Z. Cooper, J. Han, and N. Mahoney, “Hospital Lawsuits over Unpaid Bills Increased by 37 Percent in Wisconsin from 2001 to 2018,” Health Affairs 40, no. 12 (2021): 1830–35.

29. B. Richman et al., “Hospitals Suing Patients: How Hospitals Use North Carolina Courts to Collect Medical Debt,” Duke Law School Public Law & Legal Theory Series No. 2023-49, August 24, 2023, papers.ssrn.com/sol3/papers.cfm?abstract_id=4540657.

30. Richman et al., Medical Debt Ecosystem.

31. Lopes et al., “Health Care Debt.”

32. Richman et al., “Hospitals Suing Patients.”

33. H. Rooke-Ley et al., “Unionization Efforts by Physicians Between 2000 and 2024,” JAMA 333, no. 4 (December 18, 2024): 347–48.

34. Virginia Poverty Law Center, “Virginia Enacts New Protections Against Medical Debt and Junk Fees,” June 16, 2025, vplc.org/news/virginia-enacts-new-protections-against-medical-debt-and-junk-fees.

35. H. Howard and L. Buddenbaum, “The Growing Policy Wave of Medical Debt Cancellation: States Taking Action,” Health Affairs, May 16, 2024, healthaffairs.org/content/forefront/growing-policy-wave-
medical-debt-cancellation-states-taking-action.

36. B. Richman et al., “ERISA and the Failure of Employers to Perform Their Fiduciary Duties: Evidence from a Survey of Health Plan Administrators,” Journal of Law, Medicine & Ethics (September 8, 2025), papers.ssrn.com/sol3/papers.cfm?abstract_id=5292797

[Illustrations By Yasmine Gateau]