For 15 years ending in 2024, Virginia health systems, hospitals and physician practices hid prices from patients, imposed inflated bills and fees after delivering care and referred patients with unpaid bills to debt collectors, according to a report in May.
The report, “Medical Debt Ecosystem. The Mechanized Wealth Extraction from America’s Patients, shows how Virginia providers took advantage of hidden prices and opaque billing practices to establish a collection system that exploited low-income patients starting in 2010. For a decade and a half, providers worked with law firms, banks and employers to exploit those who could not afford to pay the full cost of their care even if they had health insurance, the report shows.
The report reaffirms the need for in-depth reporting on how well hospitals, physicians and other providers assess patients who cannot afford their bills. From this angle, reporters can investigate how well hospitals explain their financial assistance policies to patients in need and whether health systems and hospitals comply with the 2021 federal Hospital Price Transparency Rule. Under that rule, the federal Centers for Medicare and Medicaid Services issued new guidelines last year, as an article in STAT News explains.
Another angle journalists can investigate is whether and how well hospitals and other providers take advantage of hidden prices and opaque billing practices, as the report notes. Those practices and hidden prices “create a multi-layered, coordinated and highly exploitative collection system that disproportionately plagues lower-income Americans unprotected by Medicaid billing restrictions on hospitals and providers,” the report shows.
This is my nightmare come true. … People are having to choose between going to the hospital and staying home and dying. Because at least my family won’t be burdened with a lawsuit if I die at home.
Anonymous patient sued by Sentara Health,
quoted from “Medical Debt Ecosystem” report
When seeking care, few patients know how much they may need to pay, and many are unprepared for the high cost of care when bills arrive weeks or months later, according to the report. Such harms drive up health care costs and medical debt. Also, many Americans lack health insurance under measures the Trump administration and Congress enacted last year, leaving many unable to afford their care.
The power of public exposure
In the report, the authors cite multiple examples that highlight the effectiveness of reporting on hospital debt-collection practices, including Jay Hancock and Elizabeth Lucas’s eight-part series in 2019 on the debt-collection methods the University of Virginia (UVA) Health System used when pursuing patients unable to pay their medical bills. At the time, Hancock and Lucas worked for Kaiser Health News, now KFF Health News. In 2020, the Pulitzer Prize Committee named Hancock and Lucas finalists for the Pulitzer for their series, as we explained.
The report also cites an in-depth report that same year on the nonprofit Methodist Le Bonheur Healthcare in Memphis by ProPublica and the nonprofit newsroom MLK50: Justice Through Journalism.
From July 2019 through October 2020, ProPublica and MLK50 published a five-part series titled “Profiting from the Poor: Inside Memphis’ debt machine.” In that series, Wendi C. Thomas and Deborah Douglas reported that the Methodist Le Bonheur system filed more than 8,300 debt-collection lawsuits against patients between 2014 and 2018. Many of those lawsuits were filed against low-income residents and the hospital’s own employees. Shortly thereafter, the hospital system changed its debt-collection policies, stopped filing new lawsuits and canceled the debt. “Ultimately, the system erased medical debt for more than 6,500 patients and reduced or eliminated debts for roughly 7,500 individuals,” the report notes.
Those two examples of strong reporting are just part of the report, which shows that from 2010 through 2024, Virginia hospitals and medical providers brought 1.15 million lawsuits against patients, seeking to collect $1.4 billion in medical debt. Representing 27.1% of all debt-collection actions in the state’s District Court, those cases resulted in 812,948 judgments for providers, averaging $1,753 per judgment, and many cases (84.6%) added 6% annualized interest when average interest rates were about 1.5%, the report notes.
Another significant angle to report is how much nonprofit hospitals spend on charity care as they litigate against those who cannot afford their care. From 2010 through 2024, Virginia’s nonprofit hospitals filed more than half (52.7%) of those 1.15 million lawsuits, and among the nonprofit hospital systems that sued more than 1,000 patients each year, fewer than half (44%) spent less than 3% on charity care from 2011 to 2023, the report notes.
Do hospitals ignore price transparency rules?
Another angle journalists can investigate is whether and how well hospitals and other providers take advantage of hidden prices and opaque billing practices. Those practices and hidden prices “create a multi-layered, coordinated and highly exploitative collection system that disproportionately plagues lower-income Americans unprotected by Medicaid billing restrictions on hospitals and providers,” the report shows.
For the report, researchers at the George Washington University Law School, Patient Rights Advocate and Stanford Medicine documented not only the harsh treatment of poor patients but also how attorneys and law firms used the debt-collection system to sue patients and get court judgments with little scrutiny of the integrity of the underlying bills.
Using wage-garnishment orders, lawyers for the plaintiffs required large employers and banks to extract wages and savings from their low-income employees and customers, the report documents.
Multiple patient stories to cover
Some of the best stories journalists can write feature patients who consented to unknown prices and hidden fees, including interest charges as high as 18% annually, the report states. Patients reported not having access to up-front prices before receiving care and were unable to understand their hospital bills or verify whether they had been sued over a fair market rate.
Another story to cover is how medical debt and the resulting lawsuits inflict severe financial and emotional distress on patients and families. “After being sued by Sentara Martha Jefferson Hospital (in Charlottesville, Va.,) for care given without an upfront price, patients reported selling possessions, borrowing high-interest loans, struggling to pay for rent and groceries, and avoiding future medical care,” the report notes. “Several patients believed they could lose their jobs or be jailed over nonpayment.”
After Sentara Health sued one patient, she felt helpless, the report notes. “This is my nightmare come true,” the patient told the report’s authors. “People are having to choose between going to the hospital and staying home and dying. Because at least my family won’t be burdened with a lawsuit if I die at home.” Sentara Health is a nonprofit health system in Norfolk, Va., that serves 125,000 members in Virginia, North Carolina and Florida.
In addition to Milstein, the other authors on the report were Cynthia A. Fisher, Julie Havlak, Margaret Nikolov, Ph.D., Barak Richman, J.D., Ph.D., Ilaria Santangelo, Sujin Song and Onisuru Ojegba, J.D..
Resources
- “Researchers flag a medical-debt ‘vortex,’” Megan R. Wilson, The Washington Post, March 26, 2026.
- “Could a hospital sue you? In Virginia, it happened 1 million times,” Ken Alltucker, USA TODAY, March 27, 2026.
- America’s Predatory Medical Debt Ecosystem, a guest commentary, Barak Richman and Cynthia Fisher, Richmond Times-Dispatch, March 26, 2026.
