Terry and Sandra Belk’s medical bills began to pile up after a series of illnesses – including breast cancer, prostate cancer and gallbladder surgery – repeatedly sent them to the largest hospital system in Charlotte, North Carolina, Atrium Health.
Despite having commercial insurance, the Belks received bills for tens of thousands of dollars. When the couple couldn’t pay, Atrium sued them through North Carolina’s civil courts.
Like millions of Americans, Terry Belk – Sandra died in October 2013 – is stuck in medical debt. Unlike so many others, because of North Carolina’s debt system, it also means that when the hospital successfully won a judgment against him, they claimed ownership of part of the equity on Belk’s home.
“This is putting tremendous pressure on my health,” said Belk from the dining room of his three-bedroom, two-bath one-story ranch that sits atop a small hill. “On one end, they help you get well. On the other, you get sick again.”
In North Carolina, a successful debt lawsuit automatically places a lien on real property, a kind of collection method that secures a debt against the value of a home. For most people, that property lien is on the family home.
Belk, 67, cannot retire because of the debt. Sandra nearly refused to see doctors in her dying days because of the debt. The lien will need to be paid before the home can be sold or transferred to Belk’s heirs – he has five children and 10 grandchildren. For Belk, medical debt is nothing short of “bondage”.
“I’ll probably die before it’s paid out,” said Belk. “We are married,” he said of himself and the hospital. “It’s till death do us part.”
Medical debt and the burden it places on Americans has come under increasing scrutiny following the pandemic. A recent investigation by Kaiser Family Foundation news found the majority of the nation’s 5,100 hospitals probably use “extraordinary” collection measures, including suing patients.
In North Carolina, the practice received heightened attention after the state’s treasurer, the Republican Dale Folwell, published a report finding “litigious” hospitals in the state had filed more than 7,500 lawsuits in just five years. The most litigious, in sheer volume, was Atrium. Officials there said they stopped suing patients in November 2022, “as part of our journey in making health care more affordable”.
However, the non-profit stopped short of providing relief to patients such as Belk, who both has liens on his home and was encouraged to take on credit card debt to pay the hospital, because he worried about future lawsuits.
“They’re making indigent and poor people and people of color’s life hell,” said Belk, who is Black, about hospital debt collections.
He wants only one thing: “Release the liens” – not for himself, but for others whom hospitals “hold in bondage”.
Atrium said that it had a “generous financial assistance policy” and that it did not turn patients away “regardless of their ability or inability to pay”.
Thanks to a recent merger, Atrium is the third-largest non-profit health system in the country. It serves 6 million patients a year across 67 hospitals and more than 1,000 other clinical sites located in several states in the midwest and south-east. The non-profit reported $15.2bn in revenue in the first half of the year, with nearly $998m in excess revenue after expenses.
“As a leading, non-profit health system, Atrium Health is working to ensure access to high-quality care for everyone in the communities we serve,” said a spokesperson for Atrium Health. “For us, there are no profits – just outcomes, in the form of improving health, elevating hope and advancing healing – for all.” Atrium said it could not comment on Belk’s specific case, citing patient privacy laws.
Sandra Belk was working in the shoe department in Macy’s when she was diagnosed with breast cancer. She and Terry each had insurance, but still racked up bills. In 2005, to secure a debt of $23,311 from Sandra’s treatment, a lawyer for the hospital convinced the couple to sign a deed of trust to their home. It required Atrium’s debt and attorneys’ fees to be paid before the home could be sold, transferred or refinanced.
In 2010, Belk was diagnosed with prostate cancer. Suddenly, he owed another $6,792, which he could not pay. In 2012, the hospital sued to collect its money and succeeded. Another lien was placed on the family home, with an 8% annual interest rate and more attorneys’ fees on top. Worse, Sandra’s cancer returned.
“She was the most wonderful person,” Belk said, and repeated it twice more, shaking his head. “She had months to live, and they were suing her right along with me.”
In 2013, Sandra died at 61. That did not stop the hospital from refiling the debt lien from her initial treatment, when it would have otherwise expired in 2022. That has allowed the hospital to retain a stake in Belk’s home to this day.
By 2023, Terry again needed hospital care, but was well aware of Atrium’s collections practices. He did not want to return to Atrium, but felt he had no choice. Not only was Atrium the only hospital his health insurance covered, but it also dominated the area with 52% of the healthcare market share in the 13-county region surrounding Charlotte.
According to the US government, Atrium used that very dominance to gain an “anti-competitive” advantage, insisting insurers send patients to them and limit information about price and quality.
This time, instead of waiting to be sued, Belk took out a credit card through the medical financing company AccessOne to pay Atrium. He owes $1,707 on the card, and as of late September was 30 days behind on his payments.
Belk is hardly alone.
“Most every one of my clients has six or eight or 12 [bills],” said Ed Boltz, a bankruptcy attorney based in Durham, North Carolina. “They owe this doctor $900 or $600,” or, perhaps, “$10-, $20-, $30,000 on some catastrophic medical event they were hit with.
“A large number, particularly of private hospitals, are very aggressive in bringing lawsuits for those balances and getting judgment liens so they can collect on those debts,” said Boltz. Hospitals rarely initiate foreclosure proceedings, though they could choose to. Instead, he said: “They’re willing to be patient to wait and collect on those debts.”
The US has the highest healthcare prices in the world, and an insurance system that has pushed more and more costs on to patients in the last 10 years. It’s a system that has increasingly concerned Folwell, whose agency is the largest provider of private health insurance in North Carolina – providing care to 750,000 teachers, police and other public servants.
“What I’ve observed in dealing with this healthcare cartel is the biggest transfer of wealth in my lifetime,” said Folwell, “especially from low- and middle-income individuals to these multibillion-dollar corporations who describe themselves as non-profits.”
Notably, assessing the true scope of medical debt is difficult. A 2019 survey by KFF suggests it could total $195bn in 2019. What is clear is who is most affected. The US Consumer Financial Protection Bureau (CFPB) confirms Belk’s observations that collection practices hit Black, Latino and young and poor people of all races hardest.
“Over the course of the years, it became clear this was a major issue,” said Corine Mack, the president of the Charlotte NAACP. Because property is the most common way Americans pass on wealth, “What is happening now will affect generations of people,” said Mack.
Folwell has vociferously pushed for change – advocating for the passage of the Medical Debt De-Weaponization act in North Carolina, a bill that would enact a raft of consumer protections, including shouldering the burden of a family member’s medical debt. The bill sailed through North Carolina’s senate, but died in committee in the house.
Hospitals have lobbied against the bill, but Folwell points out that nothing is stopping them from lifting liens on people’s homes today.
“The hospital executives without a law could snap their fingers and make most of this go away,” said Folwell.
Until liens are lifted on people’s homes, Belk said he has no intention of staying quiet.
“I’m not special. I’m not even smart – but what I am is committed,” said Belk. In an effort to lift liens from medical debt, he exhorts others: “Come join me.”
