‘Making peoples' lives hell': When he couldn't pay for cancer treatment, the hospital sued

In 2012, Terry Belk’s beloved wife, Sandra, died after a yearslong battle with breast cancer. The car salesman in Charlotte, North Carolina, had quit work to take care of his wife, and the bills for her treatment were more than he could pay, even with health insurance. Adding to his burden, he was diagnosed with prostate cancer that year, generating additional bills for his own treatment.

Atrium Health, the nonprofit hospital treating the Belks, pursued them aggressively for their debts. Without fully understanding the consequences, Belk said, he agreed to what’s known as a deed of trust under which the hospital will receive roughly $23,000 when he sells his home, an amount that will cover outstanding amounts owed for his wife’s treatments. “We weren’t trying to abscond from the bills,” he said. “I wanted to pay but I couldn’t.”

It didn’t end there. In 2022, the hospital sued Belk for the roughly $6,000 he still owed for prostate cancer care. Belk said he knew he couldn’t win in court so he agreed to pay off the debt, which has grown to around $8,000 with interest. Belk said he is paying $100 a month to whittle it down and keep bill collectors away.

“I’ve been battling this for over 20 years,” Belk, 68, said of his medical debt. “This has been like an albatross around my neck, like an anvil I’m dragging around every day.”

Americans owe at least $220 billion in medical debt, according to KFF, a nonprofit health policy research, polling and news organization. The top three states for medical debt are South Dakota, where 18% of the population is affected, followed by Mississippi at 15% and Belk’s home state of North Carolina at 13%, KFF says. The burden of medical debt has contributed to financial anxiety among voters and has become an issue in the 2024 presidential campaign.

Medical debt is a “problem that is uniquely American,” said Berneta Haynes, senior attorney at the National Consumer Law Center, a nonprofit organization, and an expert on the topic. “Even if you have insurance, if you have chronic health conditions that require you to interface more often with the health care system, you are putting yourself at greater risk for medical debt every single time you make" an appointment.

Asked about Belk’s situation, a spokesman for Atrium Health said it has used litigation against patients “as a last resort.” Belk signed both the deed of trust and the other judgment voluntarily, the spokesman said, “and presumably on the advice of his attorney.”

The Atrium spokesman also provided a statement saying: “As the leading, nonprofit health system in the Southeast, Atrium Health works to ensure access to high-quality care for everyone in each community we’re privileged to serve. For us, there are no profits — just outcomes, in the form of improving health, elevating hope and advancing healing — for all.” 

Incorrect bills and a lack of help

Almost 18% of our nation’s gross domestic product goes to health care — far more than other developed countries--with roughly one-third of those dollars spent on hospital care, according to National Health Expenditures data.

With costs so elevated, it’s no surprise that medical expenses are a leading cause of bankruptcy in the United States, according to a 2019 study published in the American Journal of Public Health. Residents of southeastern states have been especially hard hit by medical debt because their state governments have often blocked the expansion of Medicaid.

Nonprofit hospitals are supposed to offer financial assistance programs to patients who can’t afford care, according to a provision of the Affordable Care Act. But patients don’t always receive information about these programs, experts say.

Compounding the challenge posed by medical debt is the fact that hospital or health care bills are hard to decipher and often incorrect, according to Cynthia Fisher, founder of PatientRightsAdvocate.org, a nonprofit seeking transparency in health care prices. Fisher’s organization routinely analyzes patient records and told NBC News: “We have not yet had an accurate bill.”

A new study by The Commonwealth Fund, an independent research organization focusing on health care, confirmed that inaccurate bills are a big problem. Some 45% of U.S. adults say they’ve received a medical bill that they were surprised was not covered by their insurance, the research found. Many of those polled did not challenge the bills, the report said, but 38% of those who questioned them had the bills reduced or eliminated. 

Even when bills are accurate, prices can vary significantly for the same service in the same hospital, Fisher’s organization found. For example, last year PatientRightsAdvocate.org studied costs of five common services, including appendectomies, cesarean sections and cataract surgery, at hospitals in 10 states. The research found an appendectomy in the same hospital can cost as much as 32 times on the upper end what that facility’s lowest cost is for the service; cataract surgery can cost nine times and cesareans eight times the lowest cost at the same facility. The average variation in price across the procedures at the same hospital was almost 11 times, the research determined. 

8% interest rates

In 2023, Darcy Guill, 52, underwent emergency hernia surgery. She had health insurance with a marketplace plan but later that year received a $4,000 bill from the hospital for the amount her plan didn’t cover. Guill, who has multiple sclerosis, lives in Aiden, North Carolina, a rural community just south of Greenville. She said she is paying approximately $123 a month on the bill. 

“I didn’t ask to have a hernia,” she said. “I used to be an elementary school teacher and have not had a lot of money in recent years.”

Guill said she is especially grateful that North Carolina recently expanded Medicaid coverage for residents, which she can now access. She volunteers with a nonprofit called Down Home North Carolina to help her neighbors gain access to Medicaid. “We have a ton of people with medical debt in the state because our insurance plans didn’t cover our medical bills,” she said. 

Guill’s view is confirmed by 2021 research from the Urban Institute, which found that three of the top 10 U.S. counties with residents holding medical debt were in North Carolina. In those counties, more than 40% of residents carried medical debt, versus 13.9% nationwide, the study said.

North Carolina residents shoulder high amounts of medical debt because recent mergers among hospitals in the state have curtailed competition among facilities, said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform. As hospitals consolidate, he said, their increased market power drives up the costs of care, especially in rural areas. “When hospitals merge, prices go up,” he said.

Adding to the burden are North Carolina laws allowing hospitals to sue patients for medical debts with legal judgments lasting up to 20 years. In addition, those judgments can carry 8% interest rates and can automatically act as liens against patients’ homes.

“When you have medical problems, there’s a whole cascade of consequences,” said Ed Boltz, a lawyer who represents North Carolina patients being sued for medical debt. “It takes people who have been on the knife’s edge and pushes them over. People end up losing their homes.” 

From January 2017 through June 2022, North Carolina hospitals sued 7,517 patients and their family members to collect medical debt, according to a recent study by Duke University School of Law faculty and North Carolina’s Office of State Treasurer. Many of the legal actions resulted in default judgments in state district courts; interest charges and other added fees accounted for an astounding 35% of the $57.3 million in total judgments owed by patients.

“Part of what we’re seeing is a real court failure where inaccurate bills are automatically compounding themselves and wreaking financial havoc on patients,” said Barak Richman, visiting professor of law at George Washington University Law School and a researcher on the study.

Another problem for patients who are being pursued is one Belk experienced, said Sara Sternberg Greene, a professor at Duke Law and one of the study’s researchers. “A lot of these people were eligible for charity care and didn’t get it,” she said. 

‘Paying into the afterlife’

In mid-August, North Carolina Gov. Roy Cooper, a Democrat, said 99 of the state’s eligible hospitals had signed on to a medical debt relief program he recently initiated. The hospitals participating in the program, including the largest systems in the state, agreed to forgive medical debts dating back to Jan. 1, 2014, for Medicaid beneficiaries, as well as medical debt considered uncollectible for patients whose income is at or below at least 350% of the federal poverty level. Past medical debt that exceeds 5% of a person’s annual income will also be relieved under the program. Democratic presidential candidate Kamala Harris praised the North Carolina program when she held a rally in the state in July.

Unfortunately, Belk said, the program will not help him. Guill said she has not yet determined whether it will affect her.

In June, the Consumer Financial Protection Bureau proposed a rule that would remove medical debt from most consumers’ credit reports, aiming to solve the problem of lower scores associated with the obligations. Almost $50 billion in medical debt would be removed under the rule.

Haynes of the National Consumer Law Center said many states aren’t waiting for the federal government to address the medical debt burdens among their residents. Delaware recently passed a law prohibiting interest and late fees on medical debt and Maryland requires hospitals to reimburse patients who were eligible for financial assistance but did not receive it. In 2023, Oregon passed a law requiring patients to be screened for financial assistance if they owe more than $500.

“There’s a lot of interest in resolving the medical debt crisis,” Haynes said. “A lot of states have been tackling medical debt and going far beyond what the federal government is doing.”

Belk is hopeful that Americans everywhere will benefit from people speaking out about medical debt. “This is a national problem, people are getting millions and millions of these bills,” he said. “They are making peoples’ lives hell. I’ll probably be paying this into the afterlife.”

This story first appeared on NBCNews.com. More from NBC News:

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