Across the region and the country, significant numbers of patients find themselves in situations where they can't-or won't-pay their medical bills.
According to Altru Health System in Grand Forks, that was the case last year for more than $14.5 million in billing that the system either absorbed as an expense or sent to collections agencies.
Bonita Kuntz, Altru's patients account manager, said that pool is divided between what the industry calls "charity care" and "bad debt."
"We do write off some for people who have shown they cannot pay for it," said Kuntz, adding that the system has "changed our policies and now we can put more into that charity care."
Altru says it filed more than $5 million in billing as charity care for 2017, with the remaining $9.4 million filed as bad debt. So far this year, Altru has written off more than $4.8 million to charity care against slightly more than $4 million in bad debt.
The line between can't-pay and won't-pay isn't always clear.
"For us, choosing not to pay might be not filling out the application for financial assistance," said Kuntz.
That application and other relevant billing information can be found online at Altru's website, as required of health care providers by the Affordable Care Act. In accordance with that, patients can also find billing and collections policy on the website for Sanford Health, a national health care provider with a major footprint the region.
But even with more information now in the public eye, medical debts are still a major source of financial worry for patients across the country. A 2016 study done in collaboration by the New York Times and the Kaiser Family Foundation, estimated that about a quarter of U.S. adults say "they or someone in their household had problems paying or an inability to pay medical bills" during the previous year.
The research suggested payment difficulty came from a range of socioeconomic backgrounds, with about 37 percent of those with trouble paying coming from households that earned $50,000 or less in a given year. A slight majority of households that struggled with medical bills reported that they were uninsured, with the rest covered either by private insurance or Medicaid.
Josh Huffman is the program manager of financial counseling at The Village Family Service Center, a regional nonprofit social services provider. As part of his role, Huffman oversees counseling for people considering filing for bankruptcy. He said it's "not uncommon" for clients to seek help from the Village in response to medical debts.
It was difficult for Huffman to quote any averages for the levels of medical debt his office might hear from any given client.
"It runs the gamut," he said. "We'll see people with anywhere from a couple thousand to $100,000."
But Huffman said the typical client is usually in crisis. They are either low-income individuals or those who otherwise live paycheck to paycheck. And when an unexpected medical cost hits, it may push them into a downward spiral, especially when collection agencies begin to ramp up efforts to collect debts.
Source of stress
Earlier this year, many speculated that such a pattern had played a factor in the case of Astra Volk, a Grand Forks mother believed by police to have killed her three children before killing herself in their home. In the weeks before her death, Volk, who spoke often online of her battles with mental illness, had sought donations online to cover medical costs incurred after psychiatric care in local facilities.
In the year prior, she'd been taken to court by a collections agency on three occasions for debts apparently stemming from Altru services. She paid a total of $3,700.
Huffman, who is based in Fargo, had heard of the case. Though he said it seemed to have had multiple factors in play, he emphasized the effects financial stress can have on the clients he sees, especially once a bill is sent to collections.
"People come in so burnt out," he said. "It's a huge stressor in people's lives."
To avoid that, Huffman recommended patients start communicating early and often with their health care provider after receiving services. He said most of the health care providers in the area are "pretty good" about making plans with patients to pay off their debts through an extended period of time.
That gets to what Kuntz said about financial assistance. According to her, in some cases Altru has allowed patients to pay off their bills over the course of "years." More often the system is looking for full repayment through installments made within a year of service provision.
Representatives of the health system didn't respond directly when asked whether the Volk case had made an impact on how Altru communicates financial expectations to patients. Kuntz said Altru does notify patients when a bill is going to a collections agency, a step that typically comes when there's little or no communication between system and client.
Echoing Huffman, she said patients with billing concerns will find the best results by being proactive in starting talks with their provider.
"Before even filling out the application, contact us and have that conversation," said Kuntz. "In our area, people are proud and they dont always want that help, but they also can't always pay on the rate our guidelines expect. But just by calling us and having that conversation, we may find the method that's best for them too."