$24,000 for a broken arm: Dallas-Fort Worth residents have highest medical debt in nation

As soon as her daughter was getting ready to get into the second ambulance to go to a second hospital, Charlie Brusko was thinking about the bill.

In January, Brusko’s 7-year-old daughter had broken her arm while playing at school. Getting it fixed required a long day: An ambulance ride to a hospital in Argyle, where Brusko and her family live, and then a second ride to a hospital in Fort Worth, where eventually Brusko’s daughter Penelope Segovia-Brusko got her arm reset and bandaged in a cast.

But that long day was nothing compared to the bills that followed: Brusko has been charged about $16,000 for her daughter’s care at the Fort Worth hospital, plus a charge from the first hospital in Argyle and both ambulance trips. In all, Brusko estimates she has been billed $24,000 for the care her daughter received on Jan. 5, according to copies of the billing statements she shared with the Star-Telegram. Brusko, her daughter, and her husband don’t have health insurance, and they’ve have had no luck negotiating the cost with the hospitals, Brusko said.

The family is one of thousands in Dallas-Fort Worth who grapple with steep medical bills every year. Among the country’s most populous counties, Tarrant County has the highest concentration of medical debt in the nation, according to an analysis by Kaiser Health News and the Urban Institute. Among county residents with credit reports, about 27% have medical debt, according to the analysis. Neighboring Dallas County is second in the nation, with 22.5% owing money for their health care.

There are many reasons why medical debt is so common in the Metroplex, but a key reason, experts and policy analysts said, is that Texas has the highest rate of uninsured residents in the nation. The state is one of 11 that has not expanded Medicaid, the joint state and federal health insurance program, to low-income adults. Adults in Texas are only eligible for Medicaid if they are pregnant or disabled. (A small share of parents are eligible for Medicaid if they make less than $285 a month for a family of four.)

But health insurance alone doesn’t protect against medical debt, and one reason behind the large bills patients face is that it’s simply the way the U.S. health care system is designed, experts said.

This is a “uniquely American problem,” said Allison Sesso, the CEO of RIP Medical Debt, a nonprofit that erases medical debt by purchasing it from debt collectors.

The cost of health care

The U.S. is an outlier among wealthy countries when it comes to how much it spends on care and the overall health of the population.

Although anyone, even those with health insurance, can incur medical debt, the bills often hit people without health insurance the hardest, because they are charged the “sticker” price for the care. For people with health insurance, the price of hospital care usually works like this: A hospital will negotiate with insurance companies over the rate the insurer will pay for a certain service. So a hospital’s listed price of care might not actually reflect its true cost, said Sara Collins, the vice president for health care coverage and access at the Commonwealth Fund.

“Prices in hospitals are really highly variable, depending on that negotiation process,” Collins said. “But if you are uninsured, you don’t have the benefit of an insurer, negotiating prices on your behalf.”

So the Bruskos’ bill doesn’t necessarily reflect how much it cost to get Penelope’s arm mended. The hospital where Penelope ultimately got her arm put in a cast says the family owes $16,103.34. The hospital did discount because it labeled Penelope as a “self-pay” patient; many health care providers will offer a discounted price for patients who pay some or all of the cost upfront in cash, instead of billing their insurance company.

A smaller step than expanding Medicaid would be to require hospitals to do more to let patients know when they qualify for discounts or to automatically screen all patients for financial assistance. Under federal and state laws, nonprofit hospitals are required to do so. For-profit hospitals are not required to offer financial assistance, but many do. Public hospitals, like those run by counties or hospital districts, are also required to offer financial assistance.

Brusko, who works as an independent hairstylist in Fort Worth, and her husband, who works at a day care center and as a coach in Argyle, make too much to qualify for Medicaid. Neither parent can sign up for health insurance through their jobs. The only other option for them would be to purchase a health insurance plan through the Affordable Care Act Marketplace. But Brusko said she chose not to buy health insurance before her daughter’s accident because she didn’t really see the benefit: Many health insurance plans don’t pay for mental health care, and checkups for minor illnesses were affordable to pay out of pocket at local clinics or urgent cares, she said.

Brusko said she didn’t know how much her daughter’s care would cost, or what exactly was happening when her daughter was in the hospital.

“My biggest problem with everything was how little communication there was,” she said. “I’ve never experienced this. I don’t know what I’m supposed to ask.”

After her family left the hospital, Brusko said she tried to negotiate a payment plan with the hospital’s financial office. Brusko offered a cash payment of $10,000, more than half of the total bill she owes. She asked for more explanation on her bills, and for any wiggle room to negotiate a repayment plan that was feasible for her family. Over the course of various phone calls and offers, Brusko said, the hospital either said no or didn’t return her calls and messages.

As Penelope waits for her arm to fully heal, Brusko is waiting for the bill to be sent to collections.

“I know that collections will accept a payment that isn’t $600 a month,” she said. “That’s not the best case scenario, but that’s kind of what I have to do.”

At a recent follow-up appointment, Penelope got the green light from her doctor to go to soccer practice

In the meantime, Penelope is waiting until she gets the green light from her doctors to play soccer and softball with her dad. In all, Brusko still sees her family as lucky: Both she and husband have good jobs and savings to rely on. But needing emergency care for their daughter has affected their finances so much, that she’s grateful she didn’t pay off the rest of her car payment

“If I had done that, I don’t know,” she said. “I don’t know what we would have done. I guess it would have just gone to collections, and it would have just sat there forever.”