More than 100 million people in America are saddled with medical bills they cannot pay. It was the first headline finding of KHN senior correspondent Noam N. Levey’s yearlong investigation into a staggering failure of U.S. health care: It systematically pushes patients into debt.
KHN’s **Diagnosis: Debt** project pulled back the curtain on this crisis, the true scale of which had been obscured even from many policymakers and medical practitioners. The investigation – in digital, audio and broadcast stories – exposed what is now an epidemic of medical debt that is now a defining feature of the nation’s health care system.
**Diagnosis: Debt** has catalyzed a growing national discussion about medical debt. KHN’s findings were cited prominently in a successful November ballot initiative in Arizona to expand patient protections. And federal regulators at the CFPB asked subjects from Levey’s story to provide public testimony about nursing homes suing friends and families of residents and then stepped up investigation of the industry’s debt collection practices.
The stories prompted good Samaritans to come forward to help relieve the debts of people profiled by KHN, several of whom had their entire debt settled, KHN learned. In December, Aledade, a physician-led company that supports primary care providers, cited the project when it paid to help retire the debt of more than 85,000 patients in Louisiana and Mississippi. In the announcement, Aledade founder Dr. Farzad Mostashari called the series “a complete and utter indictment of the financial structures in our health care system.”
The project found a large and engaged readership. As a public service, KHN provides all of its coverage to any news outlet to re-publish. And hundreds of media outlets picked up our **Diagnosis: Debt** stories. The stories frequently appeared in the “Top Stories” in Apple News. Our coordinated social media posts with NPR garnered hundreds of thousands of views and thousands of comments. Key stories were translated for Spanish and Chinese audiences.
Levey’s findings informed an episode of Tradeoffs, a health care podcast. A callout to readers pulled in hundreds more heart-wrenching stories, which we expect to inform further reporting this year.
The guiding imperative of **Diagnosis: Debt** was to bring to light the sacrifices of Americans victimized by a system that is supposed to take care of them. Building on hundreds of interviews with patients and families, KHN and our partners at NPR and CBS News gave voice to families forced from their homes, new parents driven to take on extra work, and retirees pushed to bankruptcy because of debt. They were people like Monica Reed, a Knoxville woman whose cancer left her with $10,000 in bills. “I just don’t buy a lot of food, just plain and simple” she said. Or Penelope Wingard, a North Carolina woman who could not book appointments when she fell behind on bills. “My hair hadn’t even grown back from chemo,” she said, “and I couldn’t see my oncologist.”
The project drew on a nationwide poll designed with KFF, new research into debt and hospital finances, and original investigations by KHN reporters. These included a review of thousands of court records to expose debt collection by nursing homes, an analysis of hospital contracts obtained through public records requests, and a yearlong examination of billing policies at hundreds of U.S. hospitals, many of whom resisted public disclosures.
Context about the project:
One of the health systems – Atrium Health, a public hospital system based in Charlotte – threw up multiple barriers to our requests, bringing in an outside counsel and threatening that our records request would cost thousands of dollars to fulfill.
Our investigation of nursing homes that sue the friends and family of residents was based on a database KHN constructed from New York court records. Working over many months, Levey looked at four years of records in one New York county, searching for cases in which nursing homes in the county filed debt collection cases. Each case was entered into a database with key pieces of information, including the debt, who was sued, what allegation was made and how the case was resolved.
We also built a database with public records we obtained from public university hospital systems to analyze how these health systems were using a patient financing company. We entered data from several years’ worth of biweekly reports filed by the company that outlined which loan products patients were in at each hospital. We then analyzed this data to explore how growing numbers of patients were ending up in higher-interest loans the longer each hospital system used the financing company.
The largest database KHN created was built with information gathered about the financial assistance and collection policies of more than 500 hospitals nationwide. We looked at thousands of pages of hospital policies to find what standards hospitals were using to grant assistance and what kind of things hospitals would do to collect unpaid bills, such as suing patients or denying them care. Thousands of pieces of information were entered into the database and analyzed to better understand the prevalence of aggressive collection actions and the wide variation in hospital policies. The database also informed an online interactive map that allows readers to see information about each of the hospitals we researched.
What can other journalists learn from this project?
Collecting and verifying the data in the project’s databases was extremely laborious and time consuming. While it relied on deep thinking and a lot of digging, the tools of the data work were not technically sophisticated. Asking the right questions and methodically organizing the answers can create powerful reporting tools.