Dear friends,

As a NYTimes investigation demonstrated last month, there is a lot of profiteering happening in health care. The investigation unpacked efforts by one of the country’s largest nonprofit hospital chains to turn patients who qualified for free care into sources of revenue. 
 

We are shocked, but sadly not surprised by these new reports. The practices uncovered are part of a larger health care trend of healthcare profiteering, which extracts wealth from socially and economically marginalized communities and has long been recognized as a macroeconomic driver of rising U.S. healthcare costs and medical debt. As I’ve said before to outlets like NPR, “Debt is no longer just a bug in our system. It is one of the main products. We have a health care system almost perfectly designed to create debt.”
 

In a moment where mission-driven healthcare leaders and providers are trying to advance health equity and address the social and structural drivers of health equity, their good work is being undermined by internal institutional practices and business models that harm the very patients and communities they’re trying to help. Hospitals can’t tout their health equity and social determinants work on a Monday and then unfairly extract wealth from marginalized patients on a Tuesday. This hypocrisy is underscored by research that demonstrates the ways medical debt fuels poor health outcomes and increases the risk of social needs like housing and food insecurity. 
 

If you are someone who feels like healthcare profiteering undermines your work for patients and toward health equity, here are four things you can do inside your hospital and community:
 

1) Review: See How Your Hospital Measures Up

The Lown Institute Hospital Index measures and ranks healthcare institutions according to how socially responsible they are. You can review where your hospital ranks on the index, and use their questions, along with resources from Families USA and Community Catalyst, to assess whether your local hospital’s financial practices are predatory and inequitable.

2) Reform: Push for Changes to Your Hospital’s Financial Practices 

Community Catalyst has published a set of practices and reforms hospitals can enact to ensure their financial assistance, billing, and collection policies are equitable. Encourage and, where needed, pressure hospital boards and leaders to reform or end collection actions (e.g., legal actions, freezing bank accounts, garnishing wages, liens on property, credit reporting, etc.) that inflict unwarranted damage on families and historically marginalized populations. 

 
3) Redress: Help People Harmed by Healthcare Profiteering and Medical Debt

Hospital leaders must acknowledge and apologize for the economic and health harms their institutions’ financial practices may have caused to their patients. In addition to asking impacted patients and communities about how best to provide redress for healthcare profiteering, health systems should cancel existing medical debt, compensate those harmed, and connect patients to financial and social assistance programs and models like Medical-Financial Partnerships. 

 
4) Reimagine: Advocate for Policy Changes Around Pricing And Debt

To truly prevent harmful and predatory financial practices, we need to place equity at the center of policymaking. To start, state and federal policies can: 

• Rein in abusive prices to lower health care costs, using approaches like hospital global budget payment models and cost containment commissions.
• Challenge hospitals’ nonprofit status to ensure these entities are not allowed to engage in healthcare profiteering.
• Eliminate abusive debt collection, stop credit reporting of medical debt, and prevent medical debt at the outset using policies outlined by the National Consumer Law Center.

 
Lastly, since nearly half of all Americans with insurance can’t afford their deductible, advocate for progressive value-based and wage-based insurance benefits in workplaces to protect patients and communities from out-of-control health care prices.
 
None of this will be solved with a single policy reform or practice. Nor is it about a few “bad apples.” It is about counteracting healthcare profiteering — a form of structural violence — by helping hospitals, health systems, and health plans to reckon with the ways they drive inequities through abusive prices and debt. For those committed to moving upstream and advancing health equity, we should expect and call upon hospitals to first do no harm.

In solidarity,

Rishi Manchanda, MD, MPH.                                         Sadena Thevarajah, JD