How Ohio Cities Showed Kamala Harris the Way Forward on Medical Debt

Cleveland—Medical debt is a national crisis, and Kamala Harris has a plan to deal with it; she just needs to tell people about it. And to do that, she should first talk about Ohio.

About 41 percent of working-age Americans carry medical debt, according to surveys by the Commonwealth Fund and the Kaiser Family Foundation. The figures vary depending on how medical debt is defined—whether a hospital is owed the money or the debt is on a credit card or owed to another lender—but somewhere between 79 to 100 million Americans owe a total of more than $220 billion. Most people with debt have health insurance, and medical debt is one of theleading causes of bankruptcy. Daniel Lempert, the vice president of communications for the nonprofit Undue Medical Debt, pointed out that half of adults in the US don’t even have $500 for an emergency expense. “With all that in mind,” he told me, “it’s unsurprising that almost anyone is one accident or illness away from financial crisis.”

In August, Kamala Harris announced a plan for federal medical debt forgiveness, saying, “No one should go bankrupt just because they had the misfortune of becoming sick or hurt.”

The Harris plan was light on details about how precisely the debt jubilee would be enacted, but Ohio provides a road map on how a Harris administration could work with local governments, hospital systems, and nonprofits to wipe out medical debt for millions of Americans. Ohio is ranked 44th among the 50 states for “health value,” according to the Health Policy Institute of Ohio, meaning residents “live less healthy lives and spend more on health care than people in most other states.”

Nearly 2 million Ohioans have medical debt, and as the Covid-19 pandemic shut down the economy, local politicians were worried about this debt pushing people deeper in poverty. “This isn’t vanity debt,” Kris Harsh of the Cleveland City Council told me. “For people with insurance, their plans are not covering the entirety of the costs, and for those without insurance, the debt is usually the result of an emergency.”

In late 2022, the city of Toledo set aside a portion of America Rescue Plan Act (ARPA) funds to forgive medical debt. It used the money to buy up the debt portfolios of two local hospital systems that they had sold to third-party collectors. Once the portfolios were purchased, they were marked as paid. It was Michele Grim, then a city councillor and now a Democratic state representative, who led the initiative

Toledo did not do this on its own, though. It followed Cook County, the area surrounding Chicago, and partnered with the nonprofit Undue Medical Debt. The group began its work in 2014, and Lempert told me that, at first, “the idea that debts are bought and sold for pennies on the dollar, especially medical debt, was foreign and frankly confusing for many people.” He said a 2019 segment on John Oliver’s Last Week Tonight helped; it explained the process, and the show even bought and forgave $15 million of medical debt for 9,000 Texans.

Hospital systems will sell the debt knowing that patients will unlikely be able to cover the costs left over after insurance companies cover their portions of accrued bills. Third-party collections agencies will buy the debt for cheap, but once it has been sitting with them for some time, they often give up attempting on collecting on it, too. That’s when Undue Medical Debt is able to buy the debt portfolios for pennies on the dollar. It gives the third-party collectors some compensation for the portfolio and allows patients much-needed relief. The bills will be marked as paid.

How much these portfolios cost vary by hospital system, number of patients, and the amount of time the debt has been in collection, Lempert said.

When Harsh learned about this, he jumped on the chance to help Clevelanders, too.

The ARPA funds were meant to provide relief in the wake of the pandemic, but the money wasn’t specifically intended for medical debt forgiveness. As Lempert put it, Ohio cities found ”a creative use for these funds.” Columbus, Cincinnati, and Akron would eventually join Toledo and Cleveland in using federal funds to forgive medical debt.

According to the Urban Institute, medical debt both in Ohio and across the country is more common in communities of color. In Cuyahoga County, which includes Cleveland, majority non-white communities have twice the rate of medical debt of white communities. And across the country, more than 20 percent of residents in communities of color have medical debt in collections.

In Cleveland, Harsh and the rest of the city council worked with the Metro Health hospital system, one of the largest in the city, to forgive $200 million in debt for nearly 300,000 patients.

There are some caveats with these kinds of deals. Undue Medical debt can’t select specific people, but it can, Lempert said, “target zip codes for debt forgiveness and basically ensure that we were helping Cleveland residents first and foremost. Of course, some debt was held by people who’ve moved away since the debt was initially incurred. and there was some natural overlap into our surrounding suburbs.”

The group also focuses on patients who are four times or below the federal poverty level and those whose debt is 5 percent or more of their annual income, as Lempert explained. He said the nonprofit’s process is appealing to officials because of the “ROI [return on investment] of medical debt abolishment and the ability to help burdened citizens without any red tape or application process.”

Lempert said that “the main challenge has just been shedding light on this crisis which can be highly stigmatizing and therefore underexplored.” But by sharing personal stories and with more and more municipalities and cities reaching out, there has been increased visibility and more people helped. Undue Medical Debt has forgiven more than $14 billion in debt across the country.

Jenny, whose name has been changed at her request to protect her anonymity, was a patient of Metro Health and said she has had “approximately 14 surgeries since 2015.” She said had employer healthcare until 2015 but was not eligible for Medicare until 2019. In the intervening years, her medical debt piled up. The pandemic and a 2020 breast cancer diagnosis made it impossible for her to work and pay off that debt.

She said that when she was 62, she couldn’t find a job and was forced to take smaller Social Security payments. With her ongoing tests and having to move to be closer to family members, she could barely keep up with the calls and letters coming from the collection agency. Thankfully, Undue Medical Debt bought her debt from the third-party collection agency, and as of early 2024, her bills were considered paid.

Now 71, she still sometimes struggles to make ends meet on her fixed income, but she doesn’t feel forced to go back to work. She told me, “I’d like to see more people get the same kind of help to put their minds at ease. When you have a critical condition, you got enough on your mind without having to worry about getting help.”