that is the sternest you can imagine about confidentiality. it is an incredibly strong norm in the court because it is fraught enough without having to worry about these things. i would say two things. i clerked before the pandemic when most people work from their offices. we had laptops, but were not necessarily working from home. there is a greater possibility that the leak was maybe not intentional, or at least not the result of someone setting out to do this. more of a leak of opportunity. that leads to the second thing, i do worry that the leak overshadows the importance of the decision that was leaked. >> your second point was mine. the fact of the leak is so much less consequential than the content of the leak. to the extent that anyone is questioning the supreme court is not the fact that an opinion got out, but the fact that it is willing to remake the law in its own conservative image. >> i might take a different take on it. the norms and the processes are trend substantive. if you are willing to leak this, what about lower courts? what about confidentiality anywhere? i am an institutionalist enough to know that, to think that yes, it should not distract from the fact that dobbs is a major decision revoking a right that existed for 50 years, but if essentially the supreme court can no longer actually do its work, it does not matter what the issue is. that affects the entire term. if we end up with a scenario in the future where only little clicks are writing opinions and disposing those to others, that is a breakdown of a magnitude that we have not seen before. >> let's end on that in a timely fashion, thanking both acs for having organized this and thanking each of the panelists and all of our audience both online and through c-span. we have a new justice on the court as of today. we have a huge number of challenges before the court next term, including related to affirmative action. the -- doctrine which will have enormous effect on voting rights. matt -- major decisions on the voting rights act. it is certain we will be back here again next year. hopefully with somewhat better news. no doubt, with a course that has the same majority and probably the same aggressive posture. next, a look at what congress can do about health care costs and medical debt. patient advocates and health care officials testify this is. about an hour and 20 minutes. >> the committee of banking housing and urban affairs will come into order. today's hearings a hybrid format. our witnesses will testify in person. thanks to all five of you for making the effort to be here. some of you came as far from cleveland, so thank you for that. the members will -- virtually. thinking of saying a loved one brush to the hospital in an ambulance or learning you have a chronic disease that is going to require years of k are and monitoring, these kind of medical ordeals or some of the scariest moments in a family's life. they can happen at anytime to anyone without warning. suddenly, you are coordinating doctors visits and calls with insurance companies. you are nervously checking your savings account. you're spending hours on in turnable phone calls trying to get answers. you're dealing with it all while worrying whether your husband or your mother or your child will make it out of the hospital, and whether their health problems will continue. as the cost of prescription drugs rise, hospital bills skyrocket, death collector start calling, families are forced to figure out how to make ends meet instead of focusing on their health. families all over the country are telling us that we heard from penelope wind guard in after school teacher from north carolina who lost her health coverage while battling breast cancer while her medical bills began to pile up, her doctors eventually stops in her. soon after, she had an aneurysm in addition sedition loss, both required the surgery because of the financial situation caused by her diagnosis, miss wynne guard was forced to wait. and then seek care from a limited list of providers who were allowing side and payments. that collectors called her, they harass her every single day. now her credit soaring cause of her health. now she needs additional testing to ensure that cancer does not return, which has added another $2,000 to her debt. so instead of focusing on battling her illness, she has to figure out how to handle debt collectors. miss wing guard is far from alone. in the united states, 43 million americans hold 88 billion dollars of medical debt, and this problem is growing. it can happen to anyone, low income families, black and hispanic, households, the veterans, young adults, and older adults are hit particularly hard. debt collectors make this already exhausting experience worse. they call over, and over, and they make threats, even contact patients employers. take for example many hedges from delaware county, ohio. she's so type one diabetes when she was five. for most of her adult life until the passage of the affordable care act, she was unable to get health and 14 shirts because she had a pre-existing condition. after losing her business and the 2008 reception, her medical bills pageup, she was unable to pay them. that's when the debt collectors started calling, and calling, and calling, and calling. miss hedges did her best, she tried to negotiate, even begged for relief, and the harassment continued. at one point, she said she was afraid to leave her house. this harassment is part of the business model. a counselor medical debt collector agency owned by hudson, toys were about harassing patients, they said they found the first 20 to 30 calls to be, quote, highly effective. if the calls don't work, debt collective often move on to even more aggressive tactics like litigation, forcing people to go through lengthy expensive emotionally draining court proceedings, often while still battling cancer grieving loved one. for patients, litigation can result in garnished -- property leaves. we've seen people thrown in jail because they couldn't afford to pay. it's the return of debtors prison. people in the united states of america, i think of that today, are in jail right now because of medical debt. of course, whenever we find suffering, wall street finds opportunity. private equity firms are making inroads in the medical debt collection market between 2015 and 16, and one third of all debt collection agency acquisitions were bought by private equity. those firms exist, clearly, to maximize investor profits no matter the cost of society. maybe that's why private equity own death collection agencies are responsible for an outsized number of consumer complaints, many concerning attempts to collect it from people who do not owe them. we must address the growing crisis of medical debt, burdening american families. president biden has administration working to remove barriers to medical debt forgiveness for veterans and make it easier and cheaper for them to get care. no one who serves this country should be saddled with debt, for illness or injuries incurred in the line of duty. the biden administration wasted no time in implementing the no surprises act which took effect on january 1st. the bipartisan law finally ben surprise medical bills, one way to provide prevent the collection harassment is to protect people from that in the first place. against the cfpb is also doing important work, exposing abuses americans face well just trying to get health care. and after increasing scrutiny and pressure of the three credit reporting agencies, equifax, experience, trans union, all announced that they would significantly changed how medical debt collection -- death is reported. these changes are expected to remove nearly 70% of medical debt and collections from credit reports. it's a positive first step, but just a step. this first step gets to a basic fact that we too often ignore, medical debt does not correlate with credit risk. it correlates with illness. it should be obvious anyone can get sick, anyone can get in a car accident. it doesn't have anything to do with your ability to pay your bills or at least it shortened. no one should be forced into poverty, no one should be harassed by shady debt collectors because of a medical emergency or sick family member. we have taken important steps to protect americans, but we can do more. i'm asking the cfpb to create a position for consumer medical debt. it's also why expanding medicaid coverage to those who live in the 12 states who refused to expand medicaid under the affordable care act is long overdue. i'm appreciative of two members of this committee, senators who warren and ossoff who were willing to get this done either here or in their safe. of course, meeting these challenges can be done by the government alone. this country needs private institutions to meet their obligations, financial assistance and the no surprise act. we are hearing from two advocates for consumers as well as one of my constituents, robyn king, from cleveland, miss king will tell her story of battling medical debt she never owed after a nursing care home for her mother. i'm looking for to hearing more about how we can protect americans from medical debt and debt collector harassment. no one should have their financial future ruin simply because they got sick. so -- we >> thank you, mister chairman. pressing risk accurately is critical for the safety and soundness of the financial institutions and to consumers ability to access affordable credit. because one by orders, default -- lenders generally look at information about credit history, it helps them estimate the risk of default and price loans. lenders who cannot access information that they consider predictive of risk are likely to restrict their lending to the borrowers -- seek out relevant proxies with the credit information they are not able to obtain. or increase the price of loans to all by owners to capture the uncertainty in the risk. this hurts all consumers, especially low income families and those with a long credit history. for all those reasons, the government should not suppress the reporting of accurate credit information. unfortunately, so called consumer groups and allies have sought to remove information from credit reports and thereby make them less accurate. i'm afraid such actions will have adverse unintended consequences. today's hearing is titled, quote, growing burden of medical debt, and quote. it's interesting, but inaccurate title. because evidence suggests that medical debt is actually falling, not growing. according to the cfpb's own estimate, which the chairman side did, medical collection was 88 billion dollars last year. that's a nominal reduction of 10% over the last three and a half years. another study shows the average medical debt in collection fell by 40% in the last decade. and that is despite the fact that over the same period, medical spending increased by 70%. 70, and over 50% per capita. this is all illustrated on chart one behind me. now there are likely many reasons for a decline in medical debt, the primary driver was the improving economy. after the tax reform of 2017, those with the lowest wages, those most likely to have medical debt, we're making the biggest gains in income. another driver of the decline was the enactment of obamacare and medicaid expansion. researchers estimate that for every $25 spent on medicaid expansion, medical debt and collections decreased by $1. there are many aspects that have made me question the wisdom and efficacy of medicaid expansion, including its cost and the lack of evidence that it -- unsurprisingly, if you are willing to spend massive amounts of other people's money, you can transfer other individuals debts onto another taxpayer, that is illustrated uncharted. to all available evidence suggest that there is no growing burden of medical debt, in fact, the scale of medical debt is often misunderstood as chart three illustrates, medical debt in collection represents less than 1% of all household debts. two thirds of medical debt collections are under $500. and bankruptcy from medical debt is extremely rare as illustrated in charge for. 31 hundredths of 1% of the population suffers bankruptcy each year as a result of hospitalization. and medical debt is not strictly an american phenomenon, any medical system in the developed world, according to the world health organization, even before medicaid expansion, the likelihood that out of pocket expenses would exceed a quarter of one's income was roughly, as rare in the united states, eight tenths of 1%, as canada or the uk, about five tenths of 1%. and considerably rare than italy, spain, korea, switzerland, and other countries in the developed world. recently, credit reporting agencies are announced changes that will reduce the amount of medical debt that appears on consumer credit reports going forward. now, for credit reporting agencies to exclude this information, i don't think it's the government's role to meddle with that decision. however, if credit reporting agencies had collectively decided the opposite, if every one of them had gotten together and decided they would begin at the same time to add consumers medical debt information on to reports, i suspect the house and protests about greed and collusion would have been deafening. what appears to have occurred here is a political campaign, which included the cfpb, bullied lenders and credit agency into removing disinformation. this kind of misuse of power by the administrative state has grown all too common. it's an example of how congress has become far too comfortable with the executive branch seizing the article one lawmaking authority of congress. we need to be careful that any actions consider to address symptoms, in this case, death from a health condition, don't make matters worse. this new credit reporting agency policy doesn't actually lower the cost of medical care, in, fact it raises costs and reduces access. it may end up discourage people from paying medical bears. it could give health care providers to not treat individuals without the obvious means to pay. and by eliminating one metric in the credit rating, it may cause credit agencies, credit rating agencies, to use other metrics, or proxies that are less accurate and which could actually hurt low income populations more. these kinds of downstream effects wouldn't be shocking given that the entire effort to micromanage credit ratings is coming from an agency that has no expertise on complex medical billing and health care systems. it should remind us that intervention into the market, no matter how noble advocates may think they are being, we'll have consequences, usually unintended consequences. and second, intervention should come after careful deliberation by the peoples representatives, not tic tacs from unelected bureaucrats. thank, you mister chairman. >> thank you sir. i will introduce five witnesses, robin, king of former second grades teachers assistant in cleveland, that works part-time in volunteers when she's not caring for her family. miss king uses her voice to shed light on the terrible toll that medical debt is taking on average americans. and restored is the executive director of the committee overseeing the advocacy of consumer health care rights and the organization's finances and operations. she has two decades of experience and health care advocacy. doctor benedict, but legal, studies health care financing the pharmaceutical market and its regulations on the effect of health care costs on the personal finances of americans. he's a senior fellow and economic policy studies at the american enterprise institute. david hymen is a scott ginsburg professor at georgetown, is an abject scholar at the cato institute, a doctor as well as a lawyer. he has served most recently as the rawsonville and work terror law professor of medicine and illinois. bernard haines is the -- law center, working on a portfolio that includes consumer medical debt policy and energy policy. she recently published a reporting and the intersection between the racial health gap and the racial wealth gap and the harms of aggressive and -- in the harm of aggressive medical debt collection. thank you all for coming and joining us today. i will begin with miss king, welcome. >> good morning. it's an honor to be here and a privilege to be able to share my story with this committee. i am here to speak about my experience with medical debt. it's something that affects thousands and thousands of people in this country every year. and i know firsthand that the consequences of these burdens can be debilitating. i was lucky enough to get help from attorneys illegal aid in cleveland, but not many people are so lucky. for them and for others who have yet to be victimized, i share my story. i'm a mother of three children. i worked as a teachers assistant for ten years and recently transition to working part-time, and a learning center. i still volunteer with children, and older adult summertime. i also am the youngest of six siblings who all cared deeply about our mom. if you ever bought a parent or a loved one to a nursing home, knowing that they will live out their final days there, knowing you are trusting all of their care and covers two strangers, that's a thing you will never forget. because mom was suffering from alzheimer's and had difficulty understanding what's happening, my siblings and i decided i would be moms representative for the nursing home admission and signed all the paperwork that allowed my mom to be admitted into the facility. moms social security checks were used to pay for her portion of the nursing home pill, and medicaid covered the west. knowing my finances were all very tight, i made sure to check the box at the nursing home admissions form that said i did not agree to be personally liable it finances for my mom's red medical care for an out. i have a household of my own to take care of and i knew i couldn't afford to pay any nursing home for my mom's medical expenses. in november 2019, the nursing home staff told me my mom's medicaid needed to be reinstated. so i went to the office and filled out some more forms. i did not hear anything from them about medicaid for months. so i assume that everything had been taken care of. i was shocked but when the nursing home told me in may 2020 the mom's medicaid had been -- had not been re-approved, and that i was now responsible for paying a huge bill. why haven't they told me this months ago? how could they have kept this information from me when i always did everything the nursing home asked me to do? maybe we could've figured out a way to prevent it from them coming after me for this debt. it cost a nursing home it took so long that medicaid stop payments bills, the amount had grown huge. they were not trying to collect almost $70,000. and while i tried frankly to fix the situation, the nursing home started sending bills each month, each bill larger than the last. my mom passed away when october 3rd, 2020, just two days earlier, i had received a notice that i was being sued by the nursing home for close to $80,000. i never had time to leave. i kept so much aside, the stress was unbearable. i thought i won't be able to fix my -- afford my mortgage, and definitely i'm going to lose my house, i could face a garnishment on my paycheck and be forced to live on a reduced income, when my money was tied to begin with. what would i tell my kids? what does it mean to have this kind of judgment against? you have with that impact the rest of my life? i don't, point i even thought, i'd rather be with my mom. i felt defeated, i had nothing to give. the lawsuit made no sense to me since i told the nursing home that i would not be personally responsible for any of my mom's medical expenses. on my sister's advice, we called cleveland legal aid. i am so grateful for my attorneys help because they freed me from having to pay the nursing home debt with my own money. the nursing home is still pursue my mom's estate for wet it's owed, so it's still impacting my life, while i'm not personally on the hook for the, death are still going after my family's assets. i hope you can take action to protect people like me and not allow medical debt to upend peoples lives. medical care is not something we can out out of. getting sick or having a family member get sick should not force people to face crushing amounts of debt. i thought i had done everything where i'd been taking care of my mom, but without cleveland legal aid, i would've had an enormous judgment against me and my family's financial future. i would've been devastated. there must be a better way to take care of each other, and not leave people like me facing life-changing amounts of debt. there is just no excuse for this in america. i hope that my testimony today will help you turn my story into something positive. thank. you >> thank you, miss king. mr. wood of community catalyst, welcome. >> thank, you and good morning chairman brown, and ranking members to me, and members of the committee. thank you for having. we community catalyst is a national nonprofit organization that is dedicated to building the power of people to build a health system that is race equity and justice in a society where wright is a right for all. for nearly 25, years we have worked at the forefront of local state and national conversations to make the health system more responsive to people. and over the course of that time, one of the major takeaways from our work has been the deep connection and troublesome connection between peoples health and their overall financial well-being. there is no issue that science shines bright light on this we are lucky as medical dead. medical debt should be put in its context. our health system is cost, the is imbued with inequity, and it harms. all building collection is complicated and confusing even to experts, but it's patients, individual people, who are put in the position of resolving that complexity. whether it being figure it out whether or not they were some of the bill to begin with, or not getting a dispute between their health plan and their health care provider. they're many sources of medical debt, but the largest share from er visits, dental, care and diagnostic tests such as x-rays and mris. it's such a concerning issue that 40% of americans say that they are more fearful of medical debt then a serious illness. the census bureau estimates that 17% of u.s. households hold medical debt. there are other studies that have higher estimates, and it's entirely plausible that the most people know someone knows who has -- i decided to survey my siblings. i have seven of them. five of us have had medical debt in the thousands, ranging from er visits, pregnancy related care, and surprise bills. of course, medical dead impacts some more than others. people who are uninsured or more likely to have medical debt, and importantly, many of them are living in states that have not expanded medicaid under the affordable care act. and dispute of -- there's a disproportionate effect on people of color, with 27% of black households and just other 17% of latin households reporting medical. that families with children are far more likely to have medical debt than those without. and families with a member who has a disability are nearly twice as likely to have medical. that medical debt can have a profound impact on peoples health and well-being. 37% of people with medical debt have used up all their savings to pay off their bills, 31% took on your credit card debt, and 11% took out a mortgage against their income or another type of loan. people report spending on food, clothing, and other household items. it should come as no surprise that people with medical debt are much more likely to report experiencing stress, anxiety, and depression. and the covid-19 pandemic has exacerbated the issue for many. for example, through our work with coalition partners and illinois, a story resurfaced with a man with work with the rise a shun in the state, he was rushed to the emergency room with covid-19 complications. and subsequently charged $11,798. the hospital denied him any financial assistance even though he was eligible under state law, and even federal assistance was already in place for covid-19 related care. he paid over $1,000 each month for a number of months because he was afraid that his bill would impact his immigration status or his ability to buy a home. whether a person's medical bill problems alleviated or aggravated hinges on who holds the debt. many hospitals offer extended payment plans directed at the patience and in fact, nonprofit hospitals are required to offer financial assistance under federal community benefit standards. however, many people are unaware of these programs. and not adequately informed them about them upon receiving the first bill. for many people, the headache begins when their bills are sent to their agencies. the agencies have paid a percentage of the that they collect. they typically report that accounts to the carriage of boroughs, and if not paid promptly, they pursue legal action. numerous press reports have detail people having their wages garnished, bank accounts frozen, orleans put on their homes. medical debt can ruin peoples credit rating. and in to make matters worse, the data is often inaccurate or out of date. and analysis by cfpb show that nearly two thirds of collection complaints assert that the debt was never owed, never verified as a consumer's debt, already paid, or discharged in bankruptcy. proposals to address this issue are necessarily multi faceted, but they are a few to highlight. senator, brown community catalyst supports here proposal for sea of ppe -- complaints. it's important to also eliminated unpaid medical billing reports, and to hold credit -- it's important to strengthen nonprofit community standards weber, hip it leans of property, and to apply those protections to hospitals. it also, extending medicaid coverage to people who are living in states that have yes to expand medicaid. thank you for hearing this testimony and i look for to hearing your questions. >> thank you,. mr. and dr. alito? >> thank you very much for having me. i'm gonna echo some of the comments we just. third medical debt is different than other forms of consumer debt. a lot of consumers aren't actively pursuing this that. they are not taking on a dead intentionally. more, than that it reflects the futures -- it's very expensive. quite complex. certainly, the extra tension we pay to medical debt is certainly understandable. that's, as policy makers continue the issue, it's important to have an affirmed rest of the empirical reality surrounding medical debt in the united states. -- this unexpected catastrophic health shocks that can give rise to very large bills. while those deaths absolutely do exist, they don't if, you look at the late, appear to be representative of the typical experience in the u.s.. instead, medical debt is a very common phenomenon. it seems to reflect much more typical common interactions with a health care system. for, example 16 or 17% of adults were immigrants have medical collections of the credit report. the average medical collection itself is about $300. i think for a lot of people that's relatively modest. i don't mean modest in the sense that it is an imported, modest in the sense that the kind of bills we know can happen in the health care system, certainly that we heard about. today in aggregate, concern are -- but numbers a little higher if we include other forms of medical debt. about 92% of those medical collections, however, are never reported as paid on credit reports. these that's gonna affect household finances in a few ways. perhaps more centrally, they can lower credit scores. that makes it harder or more expensive for consumers to borrow. many have called that practice into question. it's worth considering with policy changes are warranted and what trade-offs who might need to consider. obviously, credit score summit summarize credit worthiness. if they are doing that accurately, if they're penalizing consumers for things they can control or -- those are the kind of things we have to address. i think some medical debts fit that category. for example, a medical debt initially incurred because of confusion over the billing process but later repaid surely carries less predictive risk about future credit risk than a bill that is willingly incurred and that goes on paid for a long time. policies that would distinguish between things versus paid versus unpaid medical collections would help consumers incorrectly penalized in the current market. some argue in fallacies that go further, -- the major credit bureaus have announced a policy that would do that for the majority of medical collections recently. those kinds of policies come with more potential unintended consequences that i do think are at least important to flag for policymakers interested in this area and these policies actually achieving their stated goals. in particular, while medical collections are certainly less predictive of some future repayment risk, that doesn't mean they are not predictive. we have to think about, from the perspective a lot of lender, there is a risk that they play some value on it that is now not eliminated, it is obscured. how are they going to respond to the fact they cannot observe this anymore? i think there are potential ways -- [inaudible] that aren't medical collections. are indicative of a similar risk. other kinds of collections, other kinds of delinquencies, for example. it's not as obvious that the distributional consequences of that kind of reaction are better than the status quo. if they don't think they can find a clear proxy, they may instead just increase the cost of borrowing across all consumers or in, some cases, you may change your lending habits, particularly in populations where there isn't a high-end observed every square it's hard to proxy. young consumers carry a lot of medical debt in the united states. they tend to have it in their credit files. that's the kind of population where you might be more concerned about that kind of adverse reaction. finally, -- academic a theoretical, but very reminiscent of real world issues we see certainly in the health care market where we try and achieve similar things through regulatory redistribution. for example, health insurance premiums can't fire very with health expenditures. that is motivated by equity concerns. it has a similar flavor to what we are talking about today. we are trying to help people have this unexpected health shock that they can't necessarily prevent. that said, it distorts pricing signals in the market, it creates a lot of instability. we constantly have to be vigilant over risk polling issues in these markets, we constantly have to be vigilant about unraveling incentives that distort the actual stability of the fundamental market itself. them if the market isn't stable, if we don't have insurance products readily available to consumers, that really attenuates the benefit of all these policies. and, so that is not to say this is an important topic, and it's not worth addressing. it is to say, however there are important potential unintended consequences we should be aware of and emphasize. thank you for having me, i look forward to the questions. >> thank you doctor. professor hymen. >> chairman brown and ranking member toomey and members of committee, thank you for inviting me to speak to you. i'm a vessel or a georgetown where, among other classes, i teach consumer protection on a course entitled how to regulate. this is very much something i think about a lot. i primarily we am a health law and policy person. i have been the victim of identity theft and have had to deal with medical bills for myself and my kids. the difficulty of going forth when we've got such a distinguished lineup of speakers is to say, well, a lot of what i wanted to say has been set already. i will focus on a couple issues that have not been flagged yet. the first is, you hear numbers thrown around. those numbers are very widely -- figures ranging from 89 billion dollars to 195 billion dollars in medical debt. when you see a range that wide, you should conclude there is uncertainty as well as variation in the way in which people are measuring things. that's exactly what's going on here. methodological choices and the definition of uncertainty matter. the most common approach to quantifying the problem of unpaid medical debt involves looking at credit reports. those credit reports flag certain things as from coming from medical providers that are in collections. that is a series of limitations you ought to at least be aware of, right? because most of the studies involve data from a single credit reporting agency. the same information is not necessarily reported to all of the agencies. second, the accounts in collection aren't necessarily a subset of all accounts, particularly given the time lag in reporting. the additional problem that's often not appreciated is the decking the designation of medical debt that obscures the reality that patients use a variety of strategies to pay for their health care bills, including paying for traditional credit cards -- medical credit cards taking out home equity loans and if those go into collections, they are truly beatable to an underlying medical cost, they won't be flagged as medical debt. the alternative approach uses surveys, including data gathered by the census that has some advantages and some disadvantages. i'm happy to talk about in the q&a. but the short version is the numbers that you hear reflect a very specific set of assumptions about what's does and doesn't count as medical debt >> the second point i want to make a sudden medical debt is the functional result of multiple interactive factors. you can start with whether somebody receives health care or, not second how much they're built for, us how much is paid for or discounted of this price from various sources. and that includes insurance, it includes self payment, includes charity care policies. and all of those are moving parts to the fact whether any given individual, with any given set of circumstances has medical debt, and if so, how much. the third point i want to make is that modifications to credit reporting and medical debt may provide some relief, but as dr. up alito ready said, you should be wary of some of the unintended consequences. it's a solution to a symptom, it is not a solution to the underlying problem. that's a last point i want to end with and emphasize which is the reason why we have medical debt because health care and the united states is expensive. and, if you want to address the problem of medical debt, you should treat the underlying cause, i.e., the disease, rather than the symptom, and focus on ways of making health care less expensive. i flagged two possible strategies, but there are many others. one of which is pushing hospitals to more fully implement their charity care obligations, specifically nonprofit hospitals, which at long had an obligation to do that under both state and federal law. i think, to the extent, hospitals are major sources of these bills that resulted in medical debt, that's going to be an important tool that already exists. second, i want to acknowledge that congress is already taken an important step in addressing some aspects in addressing medical debt, with the no surprises act that both dr. up alito and i helped on -- consulted on on the context of that legislation. and there are additional strategies as well, but it's important to keep your eye on the ball. the ball hair is high health care costs that result in these problems. and those problems are disproportionately borne by certain portions of the population. thank you very much for your attention. >> thank you professor hymen. miss haines, welcome. the >> chairman, brown senator toomey, members of the committee, i appreciate you having me testify on medical debt. i provide my testimony on behalf of the national consumer law center. medical debt disproportionately affects black and latin families. we as that you provide consumer protections to prevent medical debt at the outset, and to shield consumers from harmful debt conduction practices and long term impacts on your well-being. according to the cfpb, medical debt represents more than half of all deaths in collection, and remains a leading cause of bankruptcy. i live in georgia, where i have worked directly with consumers and seen up close the real life impacts of the medical debt crisis. 19% of georgians have medical debt in collections, 17% of white georgians, and 21% of non white georgians. likewise, 17% will of the high -- medical debt collection. 17% of white ohioans, 23% of non white ohioans. similar disparities exist across the country. consumers with medical debt face aggressive debt collection. to avoid that collection, families drain their savings, increase their credit card debt, they turn to deceptive financial products like medical credit cards and high interest loans to pay off medical bills. because medical debt often appears as other forms of debt and individual credit history, it likely has an even larger impact and data currently shows. aggressive debt collection takes so many forms, hospitals sometimes turned bills over to third-party debt collectors who may use frequent, abusive and harassing communication to pressure consumers to pay. medical debt is consistently the most common type of debt about which people are contacted by death collectors. that collectors contact black homes at twice the rate of white households. according to the ftc. in some cases, health care providers profit will -- file lawsuits against the consumer. they may use these lawsuits to we -- garnish wages and -- seized back accounts, and even seek warrants when a debtor -- between 2009 in 2018, hospitals in maryland file nearly 40,000 lawsuits that resulted in which garnishment, often from their own employees according to national nurses united. john hopkins also saw $4 million in wage current schmidt lawsuits between 2009 in 2018. it has a service area that is 45% black. the university of virginia hospital system has a history of relying on property -- to collect medical bills, as qatar hill news report in 2020. as a result of that expose a, the system cancel decades of leans placed on low-income patients. vcu medical system enrichment, a majority black city, filed the most lawsuits of any single hospital from 2018 to 2020. according to researchers from johns hopkins. worse yet, the aclu documented cases of arrest for medical debt in several states including maryland, tennessee, and arkansas. in maryland, they of the practice of -- less than $1,000. the result of these practices essentially revives debtors prisons which should be illegal in this country. these that collection tactics for obvious reasons, affecting consumers well-being, psychological -- consumers may forego and delay medical care because they fear medical debt, which can form your physical health and lead to greater medical expenses in the future. carrying dead and being subjected to these debt collection practices also causes psychological distress. increasing anxiety, depression, substance use disorders, and other mental health use -- disorders. all of these things can lead to medical bills down the road, a vicious cycle. so to address this epidemic of medical debt, we ask that you focus on ways to prevent medical debt so that seeking health care doesn't send individuals into a financial tailspin. we ask that you consider consumer protections that address the racial disparities in medical. debt ban wage garnishment, bank account, seizure properly, and foreclosure homes based on medical debt means, and civil arrest warrants for medical debt. prohibit debt collection during health insurance appeals in the practice of turning over medical debt to their party collectors. prohibit providers and debt collectors from reporting all medical debt to credit reporting. bureaus universal privately funded -- administered at the state and local levels. and there is more detail on these recommendations found in my written testimony. i do thank you for the opportunity to testify. i would love to answer any questions you have. >> we will begin the questioning with senator warnock, who's been advocating for in medicaid expansion. as miss hanks stated, she knows -- you are recognized. >> thank you so very much. it is good to see all our witnesses, particularly miss haines from georgia. thank you mister chairman for letting me go early due to my presiding obligations. the affordable care act allowed states to expand medicaid to over 13 million americans. this is transformational legislation for our country. sadly, there is still 646,000 georgians unable to access free and affordable health care because state politicians continue to prioritize politics over people. i have been fighting for medicaid expansion longer for i came to the senate. when i arrived, i fought really hard to get further incentives for georgia to expand medicaid, which we won in the american rescue plan and the state continues state, politicians continue to refuse to expand medicaid. that loss to the state, the 646,000 georgians in the medicaid gap. after that i introduced the medicaid saves lives act, which would give folks in states like georgia access to health care. but -- ensure everybody everywhere, no matter your zip code, has access to health care. miss haines, do we tend to see more medical debt in states like georgia? that have not expanded medicaid we, then states that have expanded medicaid? >> that's absolutely correct. households in the south, the region with the highest concentration of black folks, carry more medical debt than other regions. this is exactly the reason where medicaid expansion hasn't happened. the 12 states that have not expanded medicaid, eight of them are in the south. that's left many people uninsured, particularly black folks, also many of those southern states have a high percentage of for profit hospitals that are not subject to the care provisions of the aca. that said, the uninsured rate in the south is definitely connected to the lack of medicaid expansion and connected to the increasing levels of medical debt in that region. >> you see a direct link between medical indebtedness in states like georgia and its refusal to expand medicaid? >> absolutely. the last that i believe said georgia has the fourth or third highest uninsured rate in the country. i have worked with clients directly in georgia who are under insured are uninsured, facing medical debt and trying to figure out whether they need to file bankruptcy, trying to figure out how they can negotiate some sort of payment plan. it's definitely a crevice crisis level in states like georgia. >> medicaid expansion is something i am focused on. i will keep pushing for that. but also capping the cost of prescription drugs would be helpful. according to the kaiser family foundation, nearly one in ten adults, or roughly 23 million people, oh medical debt. as of 2020, american families collectively owed over 140 billion dollars in medical debt. in georgia, there is over 120 million million dollars -- in medical for folks. this is unacceptable. people should not have to choose between getting that prescription drugs they need and groceries. this is why i introduced the capping prescription drug costs act. and the affordable insulin now act which will cap out of pocket drug costs for americans. mr., how would proposals that cap out of pocket drug costs like a mine alleviate or help to alleviate the medical debt crisis in our country? >> thank you senator warnock. -- supports both pieces of your legislation. thank you for that. it is quite clear, based on the testimony of many people here, that it's underlying health care costs and peoples inability to afford health care as a major driving factor. the kaiser family foundation also found that of people who have incurred medical bills they have they cannot afford, -- prescription drug costs. absolutely, efforts like the one you are undertaking with your bill would help the underlying issues and help affiliate the burden of medical. that >> kaiser has done work, as i recall, in the past on the impact of georgia's refusal to expand medicaid, on the georgia economy. it's a drag on peoples health care and it's a drag on the georgia economy, is that? correct >> absolutely. correct many studies showing the connection between medicaid expansion and improving overall economic well-being. >> we would do well to expand medicaid in the 12 non expansion states for us to have federal legislation to ensure people in those states gun access and medicaid like program and we would do well to cap the cost of prescription drugs, a net gain for the georgia economy and for peoples health care? >> absolutely. it would help millions of people across the country. >> thank you so much. >> thank you. >> thank you senator warnock. senator julie is recognized. >> thank you mister chairman. let me address this question to the two of you. i think you touched on this. i just want to be clear. can credit reporting in that collection policies actually solve the underlying problem of higher unexpected medical debt? with that require some health care policy change? doctor apple eat out, you go first. >> yeah, i'm gonna echo something professor hind said but, the challenges we're dealing with a clear symptom. medical that reflects something. something mechanical the bill wasn't paid, obviously, but it reflects a bill that was potentially quite expensive and a four chalian trying to address this through credit reporting changes, if we haven't changed the underlying risk that the landings are responding to in that case the leaders are gonna respond we -- have to assume they're gonna respond to the -- organizing some response. that's where i worry more about the end consequences. >> professor hymen? >> i would echo that. i think you should think separately about the bills already accumulated versus the bills going forward but i don't think changes in credit report practices meaningfully change the debt that is owed. although they may change in the visibility of that debt. if you don't do something about the cost of health care you should expect future medical debt to compound itself rather than, as i said, previously, addressing the root cause of the problem. >> this is one of the reasons i'm concerned the cfpb seems to be running a point on this. they have no authority to make changes to health care policy, they don't have any expertise in health care policy. they are certainly not going to address the underlying problems. let's talk a little bit, if we could, about the effects of suppressing information. i understand that there might be categories of medical debt that may not be particularly predictive about a person's credit worthiness. i don't know, something like hospitalization for a car accident is something that is obviously completely involuntarily, extremely unusual, could be very expensive if you don't have insurance. on the other hand, i think somebody, doctor if alito, might have been you, we pointed out that a very large majority of unpaid medical debt is under $500, a few hundred dollars, which seems to suggest something closer to a more routine medical expense. failure to pay that maybe that tells us something different about, maybe that has a different predictive value with respect to credit worthiness. can you talk about the differences between different kinds of medical debt in terms of their predictive value? and the unintended consequences that could emerge if that which has some predictive value is suppressed and simply obscured to creditors. >> i think there is two things there. the first thing is he points to one of the big challenges when we look at the data on this topic. the distribution of medical debt doesn't look like what you are expecting because so many of us are thinking the car accident because it generates a huge bill. that is a really typical when you look at their credit profiles -- >> atypical? >> atypical, that's. right the typical experience is the median collection is $300, $310, i believe, in 2020. $310 can be generated in a lot of health care interactions that aren't the catastrophic situation. your question speaks to the way i think about this topic which is that we are seeing something that is an interaction between two things. one is there is a health care component, obviously. but there's also a personal finance component as well. if you are seeing 300 dollar bills, 200 dollar bills, 100 dollar bills not getting paid, it's not completely obvious to me that the answer is, well it's a health care problem, per se. the cost point is notwithstanding. it seems to me we have a broader personal finance program, that suppressing information on a credit panel isn't going to get rid of that risk it's just going to hide it. we know people are gonna respond because we see it in other markets. that's the core tension i see. >> professor hyman, do you want to comment on that? >> i want to add, it's hard to infer much about the credit worthiness of a particular individual simply based on the size of the medical bill they received. especially if you're looking at bills in isolation when a single encounter with the health care system can result in multiple bills, each of which might be collection. and so, the dollar amount is informative of the distribution, but it doesn't tell you that much about whether there has been an income shock or ability to repay has been affected or not. you need more information on that. >> thank you. thanks, mister chairman. >> senator warren, of massachusetts, is recognized. >> thank you mister chairman. this is an important hearing. medical debt is the most common form of debt on consumer credit records. it represents about 60% of all consumer debts listed on credit reports. it totals as much as 140 billion dollars. for the nearly one in five americans with medical debt in collections who are, by the way, disproportionately black and hispanic, it means facing aggressive and often predatory collection practices that can ruin your credit, garnish your wages, and drive you into bankruptcy. it also means that, when it damages your credit score, it drives up costs for mortgages, credit cards, and other financial products. medical providers often outsource their debt collection to other businesses. in recent years, one of the big players to pop up in this space is, surprise surprise, the private equity. giant private equity firms have slipped their tentacles across the health care industry, spending about 750 billion dollars over the last decade to buy up everything from hospitals to ambulances, to the companies that bill patients and track them down to collect those debts. miss haines, you are an expert on medical debt collection practices and their impact on families. let me ask you, how would you characterize private equities collection practices? does it have a good track record of following the law and doing right by consumers? >> private equity hospitals and the debt collection are as much a part of the problem in the medical debt crisis as the other players. they are very aggressive in intellectual practices. they filed lawsuits against patients, they harass them via phone, report their debt to see our ace, even when the debt is not out. they are as big a player in the medical debt crisis as any other player in this crisis and i should say that these aggressive debt collection practices involving leans on homes are particularly damaging. hospitals, once they actually seek a lean on a home, it can really damage the person's current asset value. their housing stability, ultimately. >> i want to underline one of the phrases you used in there. including when the debt is not even out. i would like to know how much of those 300 dollar medical bills are not actually even owed. but that collection is an ideal business for private equity, because their whole business model rests on squeezing companies and people dry. and the standard playbook is to buy up a company by loading it up with that, squeeze the company to extract profit, then take the money and run after a few years. in the medical debt collection business, that means doing whatever it takes to collect as much money as possible from patients and doing it as fast as they can. it is no wonder that private equity is gobbling up medical debt collection firms right and left, rolling them up into consolidated debt collection giants. in recent years, private equity has been behind as much as one third of the acquisitions of these companies. miss stewart, as the executive director of community catalyst, a consumer health advocacy center headquartered in boston, you have worked to protect consumers across the country from predatory medical debt collections. in your view, it is the consolidation of medical debt collectors under private equity ownership likely to be in consumer's best interests? senator, as you noted, the objective of private equity is, generally speaking, to make big profits and to attract investors. the world of health care delivery, private equity has usually meant rising health care costs, particularly for people. if past practice is a predictor of the future, it is highly unlikely that private equity consolidating medical collection practices is gonna be a good thing for people. >> thank you. you know, medical debt is one of the biggest threats to family financial security. i'm glad that cfpb has taken steps to reduce this risk, including by pressuring the big three credit reporting agencies to clear up to 70% of medical debt from credit reports. this is going to boost scores for millions of americans. but we also need to crack down on the role that wall street private equity firms are playing in the medical debt crisis. whether that is providing care, billing, or debt collection. my stop wall street alluding act would better align incentives between private equity and the companies they take over, in order to protect patients and their lives, financial and otherwise. and make sure that they aren't ruined by corporate greed. i think this is a scenario we need to work on. thank you, mister chairman. >> thank you, senator warren. senator tillis, from north carolina, is recognized. >> thank you mister chairman. thanks to all the witnesses for being here. i know there are some people that think that cfpb wading into this space make sense. i'm not one of them. i think we have seen there expansion of influence through the hostile takeover of the -- by the director. now we see them wanting to move into the health care space. i do think it's a problem we need to address. i just don't necessarily think it's for this committee to deal with. if you listen to senator warnock, virtually every salacious and he had to this problem dealt with committing subject matter after side our jurisdiction. doctor ippolito and professor hyman, senator toomey mentioned a few statistics. i just want to make sure i'm right and see if there are other indicators we should be following. a little bit less than 1% of medical debt is in collections, is that right? >> i'm not sure what percent of medical debt in total. >> i think it is somewhere around 0.9 3% of all households that. only about 8% ultimately gets collected. one number i am curious about is the medical debt is reduced substantially about 40% since 2009. you would logically think some of that tax with the implementation of the -- expansion of medicaid. are there any other things that would've potentially contributed to the reduction in medical debt over that period of time? >> broadly speaking, i am sure that the economy from 2010 to now has to have improved but we are seeing there, and other outcomes on credit reports. >> professor hyman, when you are talking about if his credit reporting is no longer taken into account as a predictive indicator, i think you said something to the effect of they would respond, that lenders would have to respond to that risk. what would that look like? give me some examples of unintended consequences. >> it's hard to make predictions, especially about the future. to quote yogi bera. for me it was mark twain. in any event, you know, as i indicated in my written testimony, i would increase in in credit scores to happen. the question would be whether credit agencies would make adjustments, as doctor ippolito indicated. >> setting the bar for wet may or may not be good? >> exactly. basically either modifying the formula to come up with numbers that actually match or close the ability to pay, or moving the bar for what counted as a good risk versus a bad risk. with my health care at on, the, i would point out that there are potential consequences within the health care system. a health care provider may become less willing to take patients that are unable to pay in full at the time of service. i would also expect, as i indicated in my written testimony, some increased consolidation. because larger providers are better able to weather this storm then a small or individual practice might be. >> what's other significant potential unintended consequences could come from addressing this symptom versus the underlying problems you mentioned in your opening testimony? >> i apologize for not addressing that. the other problem, of course, is this is a feedback loop, indicating the problems with the american health care system. it's no different than turning off the fire alarm. the fire is still going. you just no longer have the same evidence of the underlying problem. you may not feel the same urgency to put the fire out. >> miss haynes, i was more curious than in anything you mentioned that the black and hispanic community is disproportionately hit by this. i think you also mentioned they are likely to be contacted twice as many times as a white a person who might be in medical debt. have you looked at it along socioeconomic lines? is there much disparity, for example, between black, hispanic, and white poor families? do you understand the question? >>. that's a fantastic question. -- the data shows that in zip codes predominantly black, no matter income, they are more likely to be contacted by debt collectors than white zip codes than non blacks zip codes. the data shows across incomes, black folks are still more likely to be contacted by debt collective. >> okay. thank you. thank you, mister chair. >> thank you senator tillis. i will ants my questions. now i'll start with miss king -- in may 2020 received your alarmingly high bill. i think you said this in your testimony, $69,000 from the nursing home that cared for your mother. october 2020, shortly after passing the nursing homes review, close to $80,000. what's impacted this enormous amount of medical debt? did you imagine to ever be free of this? >> that amount, i could not. it was just really more than i could take him at the time. i was grieving or my mom had just passed. i was just trying to figure it all out. like, how could they do this? i said i would not be responsible? how am i getting sued? i had no idea how i would handle, how i would take care of paying that amount. what were they going to do to me? no, i had no idea. like, it was unbelievable. i felt terrible. it was tough. it was ridiculously tough. >> unfortunately, you found legal services and they found you? >> i found legal services and they helped me. >> cleveland has a particularly good legal services, legal aid society. >> very much so. they are amazing. >> thank. you miss stewart, as we pointed out, medical debt doesn't mean someone is a credit risk, it means they got sick. accidents and sickness, as all five of our witnesses pointed out, can happen to anyone at any time. yet, people with medical debt are made to feel like a bird into society. obviously, medical debt isn't the fault of the person who gets sick. would you say that -- my question is this -- would you say our financial system treats medical debt like a moral failing? >> yes, i would say that our medical, our financial system treats it as an individual moral failing, when it's a failing of the financial system, the health system, taken together as we discussed during this hearing so far. the health care system is not regulated in terms of health care cost. people are bearing the brunt of rising costs, being forced to pay higher deductibles, higher co-insurance, and the financial system, in terms of billing and collection around medical that, doesn't take any of that into account, which is why we are really grateful at community catalyst that you are holding hearings like this to have can -- both on the financial system sector as well as the health system sector. >> thank you, miss stewart. my last question, miss haynes. under pressure, equifax and transunion -- wipe 70% of medical debt off credit reports. these changes will help the financial lives of millions of consumers. however, that means 30% is left, obviously. you said in the past that medical debt is not predictive of credit risk. since medical debt is not a good indicator of credit risk, should medical that even be part of a credit report? should all medical debt be prohibited from being reported? >> yes. as i suggested in my recommendations and testimony, ideally, we should, in the practice of turning over any debt to debt collectors, consider how involuntary and unpredictable debt from medical emergencies tends to be. i should also add the credit bureaus and the changes they made, while meaningful, there's a couple of categories of medical debt that will be removed from credit reports. a lot will remain on peoples credit reports. that's of less than $500, for instance, will be removed. debt that has been paid off. that will help 15% of americans. but if you look at the stats from the urban institute, the average medical debt americans have been collections is $797. 854 for non-white communities. those individuals will still be left on the hook and still see those debts in their credit histories. >> thank. you with these changes to how medical that is reported, i think it's worth considering what's next potential steps of the cfpb and others might take to further lighten the medical debt burden. senator ossoff is from georgia, recognized from his office. >> i extend a particularly warm welcome to you, haynes. think you for joining us and representing the state of georgia. i would like to begin with you as well and ask you, miss haynes based upon your knowledge, and then i'm gonna turn to professor hyman, with the same question. how does the american experience of incurring massive debt because of a medical emergency, because you or a family member needs a medical procedure, how does that compare with the experience of folks in other wealthy countries around the world? >> yes. as i noted in my testimony, in terms of the recommendations, and acting a publicly funded universal national single parent plan administered at state and local levels would go a long way to remedy this problem in various countries. outside the united states, they do have some version of a public option, a public payer system. i won't speak to that any more detail because i have to get back to you about how that would actually look. medical debt in this country is a uniquely american problem. we need to address it. as it stands currently. >> professor hyman, in the course of your research, whether you've undertaken a full comparative analysis with other countries, nevertheless, what is your impression, your reaction to the same question? how the american experience of medical that contrasts with the folks in other oecd or industrialized advanced countries? >> thank you, senator, for the question. that's not been the primary focus of my research. my sense, based on having done this for quite awhile, is that the united states is an outlier, to say the least. relative to other countries. the cost of its health care system, which has predictable consequences for medical debt. other countries vary in their delivery systems as well as their financing. but the united states is nonetheless an outlier. >> thank. you miss haynes i spoke with a fellow georgian named felicia who took care of her father after he recently suffered a stroke. the family faced steep medical bills. the impact of that debt has lowered her credit score and imposed a huge burden on the family as a result. she was unable to take out a loan necessary for home repairs. this is, of course, not an uncommon story. miss haynes, folks don't use to incur medical expenses for the most part, correct? >> that is correct. medical debt tends to be very unpredictable and involuntary. it usually forces people to drive up their credit on credit cards, taking out personal loans. medical debt really can drill people into a financial tailspin. >> as a fellow georgian, miss haynes, you are well familiar with the ongoing saga of the state of georgia's refusal to expand medicaid under the affordable care act, one of just 12 states that made that decision. 80% of medical debt is held by households with zero or negative net worth. how can medicaid expansion in the state of georgia, which senator reverend warnock and i have fought for, we delivered resources to make it an even better deal for the state of georgia, georgians are already paying federal taxes at the same level as folks in other states. but not getting this investment in public health, forcing low income and middle income georgians in the emergency room instead of the preventative health care. miss, haynes, in your opinion it, what would be the impact of medicaid expansion in georgia on the burden of medical debt that is faced by so many of our fellow georgians? >> thank you very much for that question. georgia, as you know, has one of the highest uninsured rates in the country. it desperately impacts black and latinx -- in georgia. expanding medicaid -- it would also help reduce the medical debt crisis that is facing many black and -- families, making sure that they are not lost within the -- >> thank you, miss haynes. miss stewart, as has been discussed, aqua facts, experian transunion recently announced a change for the way they score medical debt. as i understand it now, medical collection under $5.01 appear on consumer credit reports. the average amount of medical debt, according to my staff's research is approximately $2,400 for those carrying it. miss stewart, how will the rip credit reporting agencies announcement of this change impact image duels who have more than $500 a medical debt? >> for people who have debt more than $500, they will have an extra year to resolve their debt. that's the good news of the policy. beyond that, people with that over $500, it would not be removed from their credit report. that is something we would encourage cfpb to pursue and explore. >> thank you all for your well informed and concise questions. mister chairman, thank you for holding this hearing. i will close with this note. it is a travesty that millions of americans suffer not just from illness that they are unable to treat or prevent in the way that most of us would want and expect because they can't get health insurance. but then the burden of debt at these moments of stress and crisis for their families. we have widespread medical debt in this country. we have children with school lunch debt in this country. we have to stop burning working people across the united states with debt from the necessary's of life, like food and health care. i thank you, mister chairman, for holding this meeting to shine light on this issue. >> -- >> thank you mister chairman, thank you for holding this important hearing. thank you to the panelists for joining us this morning. when issue i want to raise here is the issue of medical debt in -- four generations, the federal government has had a trust in treaty responsibility to provide care to sovereign tribal nations. the volume of medical debt across tribal communities is evidence we have fallen well short of meeting those obligations. in 2019, the new york times report found that indian health services declined to pay medical bills for more than 500,000 patients, saddling them with more than two billion in medical debt over the proceeding three years. miss stewart and miss haynes, how will these changes in reporting affect native americans? >> -- >> i will start with miss haynes. >> i can't speak to that particular issue, unfortunately. if we're talking about federally held debt, you may be aware of some of the changes related to federally held medical that recently that may go a long way toward helping the consumers avoid some of the credit downfall of medical debt. >> thank you. miss stewart? >> i would agree with miss haynes. just to highlight one of the big issues with respect to medical debt and its impact on native americans is a lack of data. it is something that community catalyst is really focused on making sure there is more investment in this aggregated data that it's much more clear on the impact on native american populations. >> i said on the indian affairs committee, this is one area, there's a lack of data. because of the lack of data, we are missing out on important services to our communities, including our tribal communities across the country. we really have to start focusing on those being left behind. let me jump to another area, which is a lack of communication i find here in some of this important information that needs to get out there that isn't at times. in the recent cfpb report, it was illuminating because it said 50% of black respondents in a survey did not know that hospitals provide free and reduced cost care for low income patients. do we know at the level of awareness of these programs is among spanish speaking and other non-english speaking communities? this is a travesty. let me just stop there and ask maybe miss king or miss stewart, or miss hayes, i'm concerned that the information is not getting out there. we have a report there showing members of the black community are being hit. what about those with a language barrier? how do we ensure they're getting access to this information that's important for their health? >> i will start, senator. first of all, there are no requirements that hospitals, including nonprofit hospitals, that are 501(c) (3) nonprofit organizations, proactively ski people for financial assistance programs. there are responsibilities to make information publicly available. for many, many people, they report they had no awareness they were eligible for financial assistance. for people for whom english is not their primary language, that is a very critical issue. you can imagine how that issue is expanded when somebody has a language barrier. it's deeply concerning overall, especially concerning for people who face language barriers. >> what should we be doing about it? what can congress do about this to make sure this information gets out there? >> there could be a changes to the nonprofit community benefit standards to require nonprofit hospitals to proactively screen people for financial assistance programs prior to billing them. in addition there, could be financial support for consumer assistance programs and other community based organizations that could be available with resources to offer that kind of assistance to people. >> thank you. yes, please. >> i would just add that the affordable care act included requirements for nonprofit community hospitals to develop a plan and report on the plan but it did not include parallel requirements to disclose the patients, along with all the other things that they do just close to patients, hate, we have a charity care program and here are the details on how you should apply for. you could do that with either legislation or regulation it seems to me, as a condition of participation. >> thank you. yes, miss haines? >> i wanted to answer those great comments as well that in addition to improving the folks required to screen patients before collecting. there is no right of action that patients have currently under the affordable care act to enforce that requirement. allowing patients to actually enforce state and federal f ap -- until violating hospitals liable would go a long way toward improving this. >> thank you. thank you, mister chairman. >> thank you, senator cortez. we will wrap the hearing at. thank you for the final of you for being here. as senator toomey's charts pointed out, the affordable care act especially, medicaid expansion not only proves it could help americans but it's also improved their financial health as well. thanks to the aca states that expanded medicaid programs. we know georgia is an expansion with states that expanded medicaid programs. medic gold debt fell by 44%. almost in half. i would add parenthetical e i, know senator cortez care so much about this. the implementation of the child tax credit also dropped the poverty rate by about that number, 40% for america's children. the aca medicaid expansion helped produce medical that much more needs to be done, i look forward to working with colleagues in congress and at the cfpb to reduce medical debt, including by creating a medical debt ombudsman. americans should be able to focus on the health, not worry about their financial. held as miss king pointed, out some of those particularly difficult times to highlight the need for congressional action i would like to submit for the record three testimonials from mandy hodges of ohio, senator tillis estate from senator toomey's state. without objection, the order. thanks to the witnesses. four senators who wish to submit questions these questions are due one week from today, on tuesday april 5th. to the five of you, if you get questions submitted, please submit your response for the record within 45 days to the day you received them. the hearing is adjourned.

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