In my job leading EOI’s health care affordability work, I have the privilege of talking to people from all around Washington state about their experience with our health care system. Time and time again, I hear worries about the high cost. People try to avoid going to the doctor for fear of price. They forego or delay appointments or medications. They cut back on food, clothing, going on vacation, or contributing to retirement savings to pay for care. They put off having kids. 

But what happens when you have to go to the doctor and simply can’t afford to pay?  

The answer is simple: medical debt. Over 100 million Americans are struggling with medical debt, making it the single largest category of debt in collections in the United States. One in three people have medical debt, whether it’s a medical bill with a payment plan or that has been sent to collections, credit card charges, or loans from banks, friends, or family members.  

Rates of medical debt are even higher for people with chronic illnesses like cancer, with nearly one in two cancer patients and survivors owing on some form of medical debt, according to a survey released this year by the American Cancer Society. For patients with cancer-related medical debt, half of those have more than $5,000 in debt.  

Disparities in medical debt also persist. Thirteen percent of Black Americans carry medical debt, compared to seven percent of White Americans. Women are more likely than men to have medical debt. People with low-incomes, veterans, indigenous people, young adults, older adults, and uninsured people are all disproportionately impacted by medical debt. 

These data are national in scope because Washington doesn’t yet track medical debt. But our state’s Health Care Cost Transparency Board is taking steps to collect better consumer data in a number of ways – especially with the new consumer underinsurance survey that EOI pushed for – and won – during the 2024 legislative session with HB 1508.  

And medical debt isn’t just something that comes and goes. It sometimes never goes away, and its impacts include increased risks of filing for bankruptcy, increased barriers to housing and education, having wages or savings garnished, a seven-year credit score impact, and a heavy mental and emotional toll. One in two people with medical debt say they feel trapped and will never be able to pay off their debt.  

Medical debt is a symptom of skyrocketing health care costs.  

Debt is downstream of prices. And prices are high and going up. While about 95% of people in Washington have health insurance, the amount people spend on health care is still outpacing what we can afford. And while the percentage of Washingtonians with medical debt is lower than in many other states (6.5% of adults in WA compared to states like New Mexico and Mississippi with 9% and 15%, respectively,) it doesn’t mean health care is affordable. 

The average premium on the Washington State marketplace, the Health Benefit Exchange, has increased by a shocking 100% since its inception in 2014. Premiums have increased from a $401 average monthly premium to the proposed 2025 premium of $804. And that’s just to buy insurance.  

To use their coverage, consumers have to meet large upfront deductibles before their coverage kicks in, and then have to pay co-payments and co-insurance on top of deductibles. For people with limited incomes, covering even small medical bills can be out of reach. On top of the high cost of care, unexpected medical bills can add up quickly, especially if insurance claims are denied.  

In short, it’s too expensive to be sick. 

Our system prioritizes profit, not people 

The root of these high costs is our increasingly consolidated health care system that prioritizes high profit and revenue over improved affordability, outcomes, and access for patients. We need solutions that hold mega-industry giants accountable and drive down the overall cost of care. EOI co-founded the Fair Health Prices Washington campaign to do just this. It’s time to tackle big industry so we can keep patients, not profit, at the center of our health care system. 

The good news is that bad behavior from big health systems has gotten the attention of Washington leaders. Attorney General Bob Ferguson sued Providence Hospital in 2022 for violating charity care laws and for sending their most vulnerable patients to collections; the lawsuit resulted in a judgment ordering Providence to repay $158 million to nearly 100,000 low-income Washingtonians. PeaceHealth has also been found guilty of violating charity care laws by not providing financial assistance to low-income patients.  

But providers and hospital systems are still using increasingly aggressive debt collection methods. A Kaiser Family Foundation investigation found that of 500 hospital systems investigated, two in three report debt to collection agencies. Some will even deny non-emergency care for people with medical debt. Hospitals use these aggressive practices, even while 87% of non-profit hospitals in Washington fail to meet community benefit requirements. 

What can be done?  

Health care costs, and their devastating symptom of medical debt, will continue to rise until we can control cost drivers at the root. Solutions like setting or capping rates for drugs and medical services, limiting harmful consolidations, and mitigating effects of existing consolidations are key to long term system health care transformation. 

In the meantime, understanding the impact of medical debt helps us identify who is hurting and how we can stop the bleeding. 

Washington state has taken some steps to protect consumers by requiring hospitals to assist patients in finding out whether they are eligible for health insurance coverage, minimize charity care application requirements, provide charity care information in multiple languages, and to include information about financial assistance in all hospital bills and collection notices.  

But implementation has been a challenge. 

In the meantime, much more can be done to reduce the harmful impacts of medical debt and ensure no one falls into financial ruin for going to the doctor. Solutions include:  

• Improving hospital compliance with charity care eligibility requirements – About half of Washingtonians are eligible for free or reduced cost care, but some hospitals are still failing to make information on financial assistance available to patients. When hospitals keep charity care a secret, patients end up with a stack of bills and being chased by debt collectors.  

• Remove medical debt as a factor in credit ratings – A new proposed federal rule released by the Biden administration last month would remove medical debt from credit reports and wouldn’t allow lenders to use medical debt information in assessing creditworthiness. Washington state has added a waiting period of 120 days before a hospital can send medical debt to collections, but other states have eliminated this altogether.  

• Limit interest on medical debt – Washington limits medical debt interest rate at 9%, but debt collectors can add fees of up to 50% more on the charges for public hospitals, garnish up to 20% of every paycheck, or wipe out all but $2,000 in a bank account. Other states such as Arizona and Colorado limit interest on medical debt to 3%. 

• Halt predatory debt collections practices – Family economic security shouldn’t be destroyed with tactics such as wage and savings garnishment (as WA bill HB 2119 attempted to prevent during the recent legislative session) as well as litigation for inability to pay for care. 

As medical debt reaches untenable highs across the country, we must make protecting patients our top priority. Ultimately, we need systemic solutions that target the root causes of industry consolidation and profit-driven practices. In the meantime, patients shouldn’t face financial ruin for something as simple as going to the doctor. Washington, we have work to do.