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The Healthy Project Podcast is your go-to source for thought-provoking conversations on health equity, public health, and social determinants of health. Hosted by Corey Dion Lewis, each episode explores the intersection of community health, policy, and innovation, offering insights from experts and changemakers who are leading the charge in creating healthier, more equitable communities. Whether you're a healthcare professional, public health advocate, or simply passionate about making a difference, this podcast equips you with the knowledge and inspiration to drive meaningful change. Join us on the journey to build a healthier, more just world—one conversation at a time.
Corey Dion Lewis (00:01.354)
Hello everybody. Welcome back to another episode of the Healthy Project Podcast. I'm your host, Corey Dion Lewis. And today we're going get into a topic that affects millions of Americans, especially those in under-resourced communities. Medical debt, know, and medical bills can be crippling, not just financially, but in terms of access to healthcare, quality of life, long-term stability, and to help us unpack some of the complexities of medical debt and its impacts.
I'm excited to be joined by Jennifer Bosco. She's a senior attorney at the National Consumer Law Center, focusing on financial issues that affect low income consumers, including medical debt issues. She co-wrote the NCLC's Model Medical Debt Protection Act and is a contributing author to NCLC's collection actions treaties, unfair and deceptive acts and practices treaties.
and other NCLC publications. And today we'll explore how medical debt disproportionately affects low income communities and what we can do about it. So again, Jennifer, thank you so much for being here. I really appreciate it.
Jenifer Bosco (01:14.778)
sure, thank you for having me.
Corey Dion Lewis (01:16.712)
Yeah, so before we get into this very important topic today, can you tell the people maybe a little bit more about yourself and what gets you up in the morning?
Jenifer Bosco (01:27.051)
sure. So, yeah, my name is Jennifer Bosco. Most people call me Jen. I am a senior attorney at the National Consumer Law Center, and we're a nonprofit organization that's been around for over 50 years. We're based in Boston, Massachusetts, but we're national. And we work on advocacy on behalf of under-resourced consumers, low-income consumers, consumers of color, in all kinds of different
financial issues that impact consumers. I work on medical debt issues at NCLC. I also work on energy and utility issues. And I have colleagues who cover a wide range of issues, student loan debt, criminal justice system debt, mortgage and foreclosure issues, all kinds of areas that impact folks. So that's what gets me up in the morning, I guess, is looking at,
ways that we can help make life easier for folks who are under some pretty serious financial burdens.
Corey Dion Lewis (02:35.25)
No, that's great. know, I am, and correct me if I'm wrong, because this is, you know, obviously you're in this work a lot. But when we're thinking, when I think about, I don't really think about medical debt, you know, all that much. So, you know, what are some of the most common causes of medical debt?
Jenifer Bosco (02:55.573)
Well, that's great that you don't have to think about medical debt so much. Yeah, I mean, it's one of the most common types of consumer debt, unfortunately. And there are a lot of different causes of medical debt. That's a pretty big question. I guess like any question about our health care system, there are so many different factors, so many different, the ways that people's situation in life affects the outcomes for them.
Corey Dion Lewis (02:58.113)
Definitely a privilege, for sure.
Jenifer Bosco (03:25.923)
you know, some researchers point to just rising healthcare costs that impact everyone. as part of the driver, there are, you know, people who lack insurance, maybe because they live in a state that has an expanded Medicaid, maybe for other reasons, they are having trouble finding affordable insurance. There are people who have really high cost sharing burdens because they have, you know, high co-pays and deductibles or a lot of out of network providers who they may end up seeing either.
you know, on purpose or by accident. Hospital costs tend to make up a large portion of medical debt that people have. Some people end up with medical debt because they're insured, they have insurance and their doctor recommends that they need a particular kind of treatment, but the insurance company denies the claim. So that can be a source for some people. Drug costs.
Certainly we've heard a lot about the cost of insulin for folks and other medications that people need for chronic conditions. That can really drive a lot of healthcare expenses and medical debt. So yeah, are some of the factors that we see also. People who have serious illnesses or chronic health conditions, as you would expect, guess it's kind of intuitive, might end up with.
higher amounts of medical debt.
Corey Dion Lewis (04:53.94)
Right. You know, when we first spoke to Jen, is it okay if I call you Jen while we have this conversation? When we first spoke and I was telling you kind of what prompted my idea for having this conversation and it being speaking with a patient who was so afraid of getting a bill that they were refusing to take the ambulance when they needed to or going to the emergency room.
Jenifer Bosco (04:59.623)
of course. Yeah. Yeah.
Corey Dion Lewis (05:22.824)
And I'm sure that's kind of a common thing for people of that fear. Can you talk a little bit about the consumer's fear of this medical debt and what, if there's any research that shows what that fear, what happens when that happens?
Jenifer Bosco (05:43.167)
Yeah, that's a good question because it's definitely a serious concern. Over the last few years, I've seen a number of different reports in academic journals and I think maybe health affairs had covered this, that the fear of medical debt that people have sometimes is worse than their fear of the illness or the healthcare condition. People are very afraid of having significant medical debt.
Corey Dion Lewis (06:06.848)
Mmm.
Jenifer Bosco (06:13.191)
And so that's a big deterrent when people need care. you know, they're unfortunately we do see people delaying needed care or going without care because they're afraid of having medical debt. And I've, you know, certainly heard of all sorts of hacks that people try. Like I, I think on social media, there had been someone posting about how, well, if you just go to the emergency room and sit in the waiting room and see if you
get better, then you can walk out and you don't have to worry about having healthcare costs from that. it's scary to think that people might, someone who might really be in an emergency situation might avoid calling an ambulance, like you'd said, and try to get to the hospital another way or might avoid going to the hospital at all. And I...
Corey Dion Lewis (06:50.196)
Jenifer Bosco (07:09.373)
I certainly, I understand that we're all healthcare consumers. We've all had to deal with the healthcare system and you're in a very vulnerable situation at that point. I guess I understand that people are fearful. I think we just need to do a better job to make sure that people don't end up with unsustainable burdens of medical debt.
Corey Dion Lewis (07:33.888)
No, 100%. Man, the internet's a gift and a curse, man, because I just know there's somebody who heard that and tried it. You know what I mean? gosh. Okay. But kind of going back to, you kind of mentioned, obviously, when we're talking about medical debt, there are many, it's just a big gumbo pot of
Jenifer Bosco (07:39.668)
Yeah.
Corey Dion Lewis (08:03.668)
many different reasons. In healthcare, you kind of talked about healthcare prices being one of those problems. But what role can healthcare systems play in alleviating some of this medical debt for patients, especially those in under-resourced communities?
Jenifer Bosco (08:25.771)
Well, I guess one of the biggest things that would help is something that's to some extent out of the hands of healthcare providers, and that's expanding Medicaid in the remaining states that have not, because those are the states where you tend to see some of the highest burdens of medical debt. But, you know, for a hospital or a healthcare provider, you know, there certainly are things that they could do. So,
Nonprofit hospitals in the United States are required to provide financial assistance. It's an affordable care provision that, you know, is part of the community benefits that nonprofit hospitals provide. They also need to have a financial assistance policy and make that available to patients. There's not a lot of specificity in the federal rules about what has to be in a financial assistance policy.
There aren't, you know, like specific rules about you have to have income below this amount and the financial assistance has to be a certain amount. So hospitals have a lot of flexibility and, you know, I would recommend that's one thing that hospitals can do is look at their financial assistance policies and see, you know, what can they really, can they do more to help their lower income patients who qualify for financial assistance? Can they,
Can they extend financial assistance to people who are not just very low income, but maybe more moderate income as well? Can they provide a higher amount of financial assistance? And if these are patients who wouldn't be able to pay and would end up with medical debt anyway, and the hospital might end up chasing them for medical debt, probably not get money for that. Isn't it more fair and equitable to just
Corey Dion Lewis (10:18.675)
Right.
Right.
Jenifer Bosco (10:23.671)
Right, provide the care, not potentially bankrupt these patients and provide better financial assistance. you know, it's some states also have requirements that say it's not just nonprofit hospitals that need to provide financial assistance, for-profit hospitals do as well. So, you know, if there's a hospital that doesn't actually have a legal requirement, they could look at voluntarily providing financial assistance.
Corey Dion Lewis (10:29.93)
Right.
Jenifer Bosco (10:53.683)
And then once there's a financial assistance policy in place, make it easier for patients to access that because we've heard time and time again about patients who they never heard that there was a financial assistance policy or they asked and nobody ever gave them an application or told them to go and talk to someone about a payment plan instead. patients who should be getting financial assistance are not always doing
So in fact, there's a whole nonprofit organization called Dollar4. Their website is dollarfor.org. they take inquiries from people about how to get access to financial assistance. so it's great. They're a great organization. And it's really really cool idea. But unfortunate that that's needed in the first place, that it's hard for people to access those.
Corey Dion Lewis (11:38.444)
very cool.
Corey Dion Lewis (11:47.104)
100%.
Jenifer Bosco (11:50.217)
you know, and hospitals can do certain things like look at, you know, to the extent that they know who their lower income patients are, you know, maybe like, just assume, maybe presume that they're eligible, unless proven otherwise. So just have like kind of some presumptive rules about, you know, these, these folks who needed assistance in the past, you know, may still need assistance. So let's, you know, let's streamline the process for them, or let's, you know, assume that they are.
Corey Dion Lewis (12:12.384)
Right.
Jenifer Bosco (12:19.017)
just opting into financial assistance. So yeah, making that accessible for patients. think also, you know, some hospitals might more proactively like help screen patients for insurance that they could be eligible for. There are some people who may not realize they're eligible for Medicaid in their states. So.
you know, helping to screen patients for whatever benefits they could be eligible for that will help them with their health care. And I think, you know, another area, and we've written a lot about this in our model, Medical Debt Protection Act that you mentioned at the start, there are, once a patient has medical debt, there are a number of things you can do to,
protect patients from kind of the most aggressive debt collection practices. So hospitals could choose to, you know, maybe be more thoughtful in how they do try to collect medical debt. And, you know, some hospitals have done things like they stopped filing liens on patients' homes. You know, there had been like a big, a series of articles several years ago about hospitals in Virginia that had filed thousands of liens on patients' homes.
Corey Dion Lewis (13:31.072)
Mm.
Jenifer Bosco (13:40.439)
and to the point that the hospitals couldn't even keep track of all the liens. And so those hospital systems, UVA hospital system, and another one in Virginia, they changed their rules. They stopped filing liens, and they actually then had tried to go back and eliminate some of those. So yeah, so I guess looking at what the debt collection practices are and what really is necessary and what's not and what's really just punitive.
Corey Dion Lewis (13:41.18)
Jenifer Bosco (14:09.835)
and making changes to help your patients.
Corey Dion Lewis (14:11.424)
Right. Right. What is an overreaction? Like, come on, we're gonna take somebody's house. Lord Jesus. I wanna kinda talk about, I know that's something that the healthcare system can do, but I really wanna kinda talk about insurance companies. know there are, know, and most of them, I'm thinking about those in under-resourced communities. And I know this might not be everybody, but.
I'm sure there are a lot in the people in those communities that maybe are uninsured or underinsured and they may have insurance, but it just doesn't cover everything. It's just not enough. And I'm sure that, I mean, that's frustrating. I mean, I'm sure that can be very, very frustrating for someone to have insurance, but not feel like if they go, they're going to get a bill and, they're already paying for this insurance and they can't use it.
What can we do or what is now, what is the role of the insurance company? I know that is a huge, that can go up. We can probably have a whole podcast conversation on just that one piece, but what needs to change for some of these employers or employees in these communities to be able to get equitable access to insurance where they can.
go to the hospital and not feel like they're gonna leave with a huge bill.
Jenifer Bosco (15:47.083)
Yeah, absolutely. Insurance companies are big part of the picture. And before I came to the National Consumer Law Center, I'd actually mostly worked on the health insurance side of things. And often, as you said, helping patients who had run into trouble, even though they did have insurance. So I think one of the pieces that
I guess I did already mention is expanding Medicaid. for the states that haven't expanded Medicaid and states that do have Medicaid programs, like kind of continually looking at how can those be improved to address the health care needs of folks who qualify for Medicaid. For private insurance, I think a lot of employers offer
insurance that has, you know, has pretty high cost sharing responsibilities for patients. And, you know, I've seen a lot of people who ended up with pretty significant medical debt because they didn't realize that, you know, how much cost sharing you have with a high deductible health plan. you know,
not really a fan of those for lower income people, but I understand sometimes someone might be in a position where they feel like that's the only plan they can afford, even though it doesn't provide great coverage. I think there had, I would say in the previous administration, there'd been an expansion of things that weren't really insurance, but were fake insurance plans like association.
health plans and religious sharing ministry plans that people signed up for thinking it was actual insurance. And it's not. Yeah, and they provide very limited coverage. They don't have to follow the Affordable Care Act rules about what needs to be covered. to avoid signing up for those, guess, and I think that's also where state insurance commissioners can...
Corey Dion Lewis (17:46.717)
wow.
Jenifer Bosco (18:06.645)
kind of have an active role is looking out for those plans and warning consumers in their states about that those are not actual insurance plans. There's also the problem of people getting care that's recommended by their doctor and the insurance claim being denied. And that can be for either paperwork reasons or sometimes a determination that
the insurance company decides the care was not medically necessary according to their rules, even though the doctor and the patient certainly thought it was medically necessary. When that happens, patients do have the right to appeal usually to challenge those decisions. So I think insurance companies can...
Corey Dion Lewis (18:42.047)
Right.
Jenifer Bosco (18:58.867)
try to make sure that patients have that information, have accurate information about their appeal rights and make that process as consumer friendly as possible. Better to not deny the care in the first place. having reasonable rules about medical necessity are pretty important. yeah, there's probably a lot more about insurance companies that
Corey Dion Lewis (19:13.827)
Right.
Jenifer Bosco (19:28.331)
could be done. are just, I don't know, some of the ideas based on things I've worked on in the past.
Corey Dion Lewis (19:33.376)
100%. And you know, we are in, you know, in an election year. a lot of, you know, my conversations right now are around civic engagement and, and, all of that. So it kind of brings up the question is, know, how do we give the power back to the people to speak up about, about this and what are those powers that be that they can.
you know, say, hey, I don't like that I can't go to the hospital without feeling like I'm gonna have to, you know, give my left kidney just to be able to pay for something that is supposed to save my life. You know, what does that look like giving the power back to the community to speak up about what they feel like is wrong when it comes to medical debt?
Jenifer Bosco (20:24.843)
Ooh, I think a of state legislatures are taking steps to really try to protect people in their states from medical debt. Some states have passed laws that limit the kind of debt collection practices that hospitals can use that have eliminated.
credit reporting of medical debt, which is certainly a concern for a lot of people. People are worried that medical debt is going to ruin their credit reports. And I should mention that a couple of years ago, the three major credit bureaus, because of pressure from a lot of different places, they stopped reporting most medical debt, not all of it, but most of it. But now on top of that, some states have said no credit reporting of medical debt.
So I think, you know, getting involved with those efforts to try to, you know, pass laws to protect consumers. You know, Maryland has done a great job passing health care consumer protection laws. New Mexico, Colorado, New York. So, you know, look and see is there, you know, what activity is going on in your state to try to reform health care laws. And I think when
Folks have, you know, if you have like a bad situation, you end up with a lot of medical debt or you feel you've been treated unfairly by a debt collector or the debt collector for hospital. There are government agencies that you can complain to and actually the Federal Consumer Financial Protection Bureau, the CFPB, they have a whole public complaint database. So they, on their website,
which is CFPB.gov, you can enter information about a complaint about any debt collection or financial issue. And it goes into the CFPB complaint database so folks can look and see what are the types of complaints and number of complaints that have been filed. And it may also contribute toward
Jenifer Bosco (22:50.161)
know, if there's an issue that people are complaining about a lot, then the agency may be able to investigate it and take some steps. So I think, you know, consumer complaints to CFPB to your attorney general's office, you know, your state Division of Insurance, kind of making noise, don't just you know, if something if something happens to you, and it feels like it's wrong, it probably is wrong. think some people who end up it with
you know, with medical debt or in like with a medical debt collection lawsuit filed against them, they might feel really alone in it and not realize this is unfortunately this is happening to thousands and thousands of people across the country. You're not alone and you know, there are things you can do.
Corey Dion Lewis (23:28.853)
Right.
Corey Dion Lewis (23:35.36)
No, that's great. That's great. And you you've been doing this work for a very, very long time. And I'm sure you've seen the highs and the lows, ups and the downs from all of this. you know, if you were to look in the future of, you know, medical debt and the work and the policies you've been able to support and do, how does the future look for, you know, in this realm of medical debt?
Jenifer Bosco (24:03.435)
You know, I think there's increasing awareness and I think it's touched so many people, unfortunately. there, you know, there's a lot of media coverage about medical debt lately and a lot of stories of, you know, people who thought they had good insurance and, you know, they go to the hospital for a necessary healthcare procedure for surgery. They go to have a baby and they end up with, like, you know,
Corey Dion Lewis (24:17.461)
Mm.
Jenifer Bosco (24:33.055)
tens of thousand dollars in medical bills. you know, I think that the public awareness and the public appetite to do something about it keeps building. You know, that a lot of policymakers seem really receptive to it. I think that, you know, the reforms we've had so far have been helpful and, you know, have helped some consumers. I hope that in the future, you know, maybe it's the long term future, I hope we
have more comprehensive solutions because we can kind of chip away at the problem. But I mean, my personal opinion is that until we have some sort of single payer system or universal coverage, medical debt is just going to continue to be a problem for folks.
Corey Dion Lewis (25:22.188)
100%. Jen, thank you so much for being on the podcast with me today. In this little bit of time, I've learned more than what I knew, so I'm appreciative of that. If anybody listening wants to learn more about what you're doing or connect with you, where can they find you?
Jenifer Bosco (25:42.699)
Well, the website for my organization is nclc.org and my email address is JBosco at nclc.org. But we have, you know, number of documents and resources on our website. We also we have this book that I'll show you real quick actually called Surviving Debt that is available
for free on our website for consumers. So we publish a lot of documents that are aimed at helping other lawyers who are representing consumers or like kind of documents for policymakers, but this, surviving debt book is actually for consumers. it's, there's a chapter on medical debt and things you can do about medical debt, but there's also other chapters about student loan debt and utility debt and how to deal with the...
harassment from debt collectors and that sort of thing. So, you you can go on our website and take a look at that.
Corey Dion Lewis (26:45.406)
You had me asked through the loan debt. I'm... So I will be going onto the website immediately.
Jenifer Bosco (26:47.787)
I'm sorry. So many, so many of us.
Jenifer Bosco (26:57.833)
We actually have a whole student borrower assistance page too. yeah, my student loan debt colleagues do amazing work, I have to say.
Corey Dion Lewis (27:03.675)
fantastic.
Corey Dion Lewis (27:08.996)
that's so cool. Well, Jen, again, thank you so much for being here. I really appreciate your time. Everybody, thank you for listening to the Healthy Project podcast. I'll highlight you next time.