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      Abolishing Medical Debt in the United States with RIP Medical Debt

      Healthcare Rethink - Episode 13

      According to the 2020 Survey of Income and Program Participation the collective US Medical Debt totaled $195 Billion in 2019 alone. This figure is expected to grow by healthcare economists and finance experts. How can we help those with very unstable economic lives who need it most? Eva Stahl and Priscilla Keith of RIP Medical Debt join the podcast to discuss how the intersections of philanthropic innovation, policy and research will produce next generation solutions for healing the fractures in our healthcare economy.

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      Healthcare Rethink: Hear From Leading Changemakers

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      Brian Urban: [00:01:00]    
      Yes, this is the Healthcare Rethink podcast. I am your host, Brian Urban, and today joining me is a dynamic duo of philanthropic innovators from RIP Medical Debt. Joining us today, we have Vice President of Public Policy, Eva Stahl, and Vice President of Program Management, Priscilla Keith. If you don't know about RIP Medical Debt, I'll make it simple for you. 6.7 billion of medical debt wiped away for 4.2 million families in the U.S. Now, both ends of that stat I listed are growing, but we're going to learn about what RIP Medical Debt is doing to abolish medical debt in the U.S. So without further ado, Eva, Priscilla, thank you for joining our little show.

      Eva Stahl:    
      Thanks for having us.

      Priscilla Keith:    
      Same here.

      Brian Urban: [00:01:30]  
      Awesome. Well, I'd like to introduce our guests to our audience on every episode, and I thought what better way of doing that than having you both tell us a little bit about your story, your journey to RIP Medical Debt and the amazing work that you're leading here. Then we can really get down to current state and how do we start to fix some of the structural challenges we have with our healthcare system in the U.S. So if we could, Priscilla, can you kick us off?

      Priscilla Keith: [00:02:00]
      I'm happy to do that. I am based in Indianapolis, Indiana, and I think you will find that half of RIP staff is remote. I'm originally, excuse me, from South Carolina and I bleed blue, which is Spelman College in Atlanta University. If you've not heard of Spelman, it's a school for African American women. I received my biology degree from Spelman and had the opportunity to attend Atlanta University where I received my master's in biology as well. I'm a Hoosier by a transplant and attended IU McKinney School of Law here in Indianapolis. So when I meet you, my first thing is, "Who's your family?" So that's how we got the word Hoosier here, so very happy to be here. I will say quickly here, I've taken jack of all trades route to RIP. I've worked in academia. I've had the opportunity to work at a large pharmaceutical company as well, and made my bones in public health by being general counsel of the largest public health entity here in Indiana. So I'm doing very well and just a pleasure to be here. So I will pivot to Eva to talk a little bit about her background.

      Eva Stahl: [00:03:30]    
      All right. So I'll pick up on that because Priscilla is my Midwestern sister. So I actually grew up in St. Louis, so we're actually both from the Midwest, but I'm now actually based in Boston, Massachusetts. My journey to RIP, so I ended up headed to the East Coast for college and met my partner there. But we ended up going to Texas for graduate school where I did a degree in public policy at the LBJ School and then ended up back in Massachusetts actually to do my PhD work at Brandeis University at the Heller School of Social Policy.

      I think for me, my journey here has been really about advocating for patients. I spent over a decade working at National Consumer Health Advocacy Organization, working on behalf of patients to make sure that they had access to the healthcare they need. So in continuing that journey, had this opportunity this year to actually join RIP Medical Debt and build out their public policy portfolio. That's just been really exciting work when we think about the millions of individuals and families across the country that we're able to provide immediate help to acknowledging that we have so much work to do to really address the root causes of medical debt.

      Brian Urban: [00:05:00]
      I love hearing about both of your backgrounds, how they're rooted in, I think the common theme, helping people that need help. Priscilla as a educator, lawyer, public health official, Eva, as a community advocate, really, I feel like aside from your strong academic background, it seems like you've really put your hands in the dirt of different communities and work closely with different leaders to change and advance policy. So it's just exciting. We're going to get into the pharmaceutical side, a little bit of the medical debt correlated to determinants of health and policy. What can we do to move us in the right direction in a speedy way? So I'd like to get a little bit more into RIP Medical Debt. So if Priscilla, you can walk me through a little bit about who you are and how you do what you do, which is buying debt at really pennies occasionally on the dollar at the family level, individual level. So who are you all, and how are you doing what you do, 'cause you've made such an amazing impact?

      Priscilla Keith: [00:06:00]
      Well, we're a relatively young organization. We were founded in 2014 by two former debt collectors, one who just happens to be a veteran. So we want to give a shout-out to Jerry who's one of our founders. So we've been in existence since 2014 and what we do is relatively, I won't say easy, but it's pretty straightforward. We receive donations from various entities. It can be from individual giving, from foundations, from group organizations who come together to say, "We're going to abolish medical debt." I will say for every dollar that is donated, we abolish approximately $ 100 in medical debt.

      So we started out working with secondary market buyers, which is another name for debt collectors in terms of buying their debt because that's how we started. We've transitioned now to working with hospitals to buy their debt and that's been a great experience. We've recently pivoted to working with local governments in terms of working with them to abolish medical debt for their communities. So we have a proprietary formula that we use to look at what we will pay for that debt. But as you say, Brian, it's pennies on the dollar, but the end result is that we are able to abolish much more medical debt than what a person in a normal instance would be able to do.

      Brian Urban:    
      Thank you for giving us that strong grounding on who you are and exciting to see your growth. I think there was an event recently at the White House with the Biden Administration, your other leader there, Allison was on stage. So just exciting to see the visibility and also tracking the impact. So it's just amazing.

      Priscilla Keith: [00:08:00]    
      Well, actually Eva can talk a little bit about that because she was instrumental in helping us to be on the playing field at the White House. So I'll let my colleague take a lot of the credit for having us be there at the White House.

      Brian Urban:    
      Good segue way. So-

      Priscilla Keith:    

      Brian Urban:    
      Eva, tell me, how is the experience, first of all, and how do you think the, I think, future ripple effect of being there and having publicity and having the message and mission known? So tell me a little bit about that experience and what's in store from that event.

      Eva Stahl: [00:08:30]
      Sure. So I think that there were rumblings at the beginning of the year growing interest in medical debt. Certainly, I think people that follow the issue can see its tick up in the media. Particularly in this moment, it's really been amplified and a spotlight shines on the issue of medical debt. We were contacted by the White House as a key player in this space specifically because of our work, our abolishment work to provide some input and be a part of an event to increase the visibility even more using that platform. I think that the administration is keenly interested in addressing a variety of different dimensions. The event included not just the health side, but also the lending side and also veteran affairs and looking for administrative pathways that they could ease the burden of medical debt for individuals, so it was a really exciting event.

      I think for us, we really saw it as a launchpad to have deeper conversations about medical debt. We see a lot of the work that we do. We actually have an in-house anthropologist who's able to collect and collate thousands of stories from our beneficiaries. So in that ethnography work that she leads, we really are learning so much about the medical debt experience. So it really gives us, I think, a lever to amp up the conversation and really humanize that experience for the media, for stakeholders, for policy makers that patients and people are just suffering and we need to get together and find some solutions.

      Brian Urban: [00:10:30]
      You bring up such a good point, and thank you for sharing all of that insights, Eva, medical debt as a connection to mental health hiding in plain sight for the U.S. and as a U.S. specific injustice with our healthcare structure in our systems. So the connection of that was highlighted, and this is a study that I'm sure you've seen as a retrospective analysis on credit reports back from 2009 to 2020. It was done by Dr. Wong, Kluender and Mahoney and they did an amazing insight overview. They found that medical debt was highest among individuals who live in the South, of low-income deciles and more concentrated in lower income states that did not expand Medicaid, so there was a little bit of the political determinants of health in there as well. From a policy perspective, it's becoming more known the connections of medical debt as a determinant of health.

      Priscilla, this is your public health wheelhouse and Eva, this is your policy wheelhouse. So first question to Eva, in terms of policy, it seems like in our country we're strategically placed in the right timing to make big leapfrog advancements. Do you think with change in administration, anything like that pending in the future elections, do you think we're going to get slowed down from having medical debt disassociated with credit reports and disassociated with determinants of health over time? Are we ever going to catch up policy to the growing medical debt, or is it going to be a continual struggle for the rest of the time? Not to have a grim outlook, but what's your forecast in terms of policy impact?

      Eva Stahl: [00:12:30]    
      Sure. Look, medical debt is a drag. It's a drag on the economy and it's a drag on your physical and mental health and your financial well-being as an individual and that there's a lot of finger pointing about who's to blame for it. But the reality is that it's stressful for individuals and it hampers our growth as a nation and it really demands solutions. Whether or not we'll be able to move some of those solutions is unclear. We have a very partisan environment and some of these solutions require bold and big ideas about addressing under insurance and coverage, but at the same time that we all become more accountable for the rising cost of healthcare and how we can contain those costs in a way that systems can still be successful and patients are still free from harm and health harmless.

      So in terms of forecasting what can happen, big bold ideas are pretty challenging given our environment. But there are a lot of incremental and positive policy changes that could and should happen, and I think the momentum is there. So I think that the more that the pressure is building from constituents that they want medical debt solved, the more that it will force folks to come to the table and make some of these even small incremental changes that could be quite meaningful in reducing debt for people. I think you just saw it probably last week when there's now a committee to look at ground ambulances. That's an outgrowth of pressure but also an outgrowth of the No Surprises Act, and so it's really saying we need to look at all dimensions of medical debt, so I'm hopeful.

      Brian Urban:    
      That's what I wanted to hear. To your point, it's incremental, it's a journey, but maybe an underlying point you're making here is don't let up on the pressure. We need an army of-

      Eva Stahl:    
      That's right.

      Brian Urban:  [00:14:00]  
      ... of good bullies in government and all levels.

      Eva Stahl:    
      That's right.

      Brian Urban:    
      If we don't let up, we're going to achieve a lot of success, and I just-

      Eva Stahl:    
      I would just say too, that people need to remember that this an everyone issue. You know someone, we all know someone if it's not even our family. But at the same time as the data points to is that this disproportionately harms some more than others, and we also need to be very clear-eyed about that and make sure that we prioritize it in our solutions.

      Brian Urban: [00:15:00]    
      Absolutely. I think economic stability in terms of generational poverty, that's starting to become a trend in some research with socioeconomic data. I love some of the things I'm seeing and some research getting pumped out. One interesting thing, Priscilla, that I wanted to spin off from what Eva's comments were is that this medical debt is, it's affecting everyone at different levels. That same JAMA article back from 2021 that I had referenced, they talked about medical debt associated with reduced healthcare use. So the higher medical debt you have, the lower probability of you seeking care for appropriate services that you need-

      Priscilla Keith:    
      Right. Right.

      Brian Urban:    
      ... thus delaying the care you need-

      Priscilla Keith:    

      Brian Urban: [00:15:30]    
      ... and exacerbating issues, and that creates even more of a divide. So from a public health perspective, are you seeing new opportunities fill in from social health services? So you've worked in Indiana local government, have you seen the evolution of community health programs taken place in your own now home state of Indiana or even from South Carolina, but have you seen some evolution at the public health like county and community level start to take form?

      Priscilla Keith:    
      In terms of medical debt, Brian?

      Brian Urban:    
      In terms of financial assistance programs, social health services, have you started to see more innovations pop up and more nonprofits pop up and shine, put their hand in to help?

      Priscilla Keith: [00:16:30]
      Well, I know from a public health perspective, public health departments have always been at the forefront in terms of public health for many of your public health departments in the last few years have declared racism as a public health emergency. So we can take from that the issues stemming from racism and how it impacts the health of an individual and/or family. I will say, I would like to just pinpoint here in terms of social determinants of health and how that's getting to be more of a factor or being recognized as a factor with regard to medical debt. Let's just talk about that in terms of what organizations are looking at or having to grapple with with regard to medical debt. When we think about social determinants of health, let's think about what's the access to care. You've already mentioned that when people have medical debt, there's a tendency not to access the healthcare system.

      Part of that is because number one, they feel as though that they won't get the care or will be turned down because they have medical debt. Secondly, there is a stigma or shame to having medical debt more so then just having regular consumer debt. So just in terms of access, we have to deal with that and the downstream impact that when you don't take care of an issue, it tends to rear it head later on. The impact is that the patient is sicker and it costs more to heal that patient. Secondly, let's look at it from another social determinant of health. When a patient has medical debt, oftentimes they have to determine what trade-offs going to use in terms of, "Do I buy food for my family or do I pay this medical debt?" "Do I pay my rent and/or mortgage or do I pay this medical debt?"

      Also, just in terms of from a mental health perspective, patients are three times more likely to suffer from mental health issues in terms of, "Wow, I really have to pay this medical debt. I don't have the money for it. I really need to see a doctor," and there's hesitancy in terms of calling on the medical system in terms of working with them to address certain health issues. So what studies have shown over time is that the mental health stress from not being able to pay your medical debt is tremendous. In terms of looking at what institutions are doing, I think first and foremost and what's prominent is that the attention that medical debt and the impact that medical debt has on families has on individuals in terms of mental health, in terms of their economic viability, financial viability and access to care has taken more of a prominent role.

      More people are talking about it and giving it the same status as we are now giving student loan debt because they recognize the impact, the negative impact that medical debt has on individuals in terms of not only just accessing the healthcare system, but also just in terms of being able to have the financial stability to move forward. The one last thing that I did mention is in terms of the negative credit rating that's often attributed to people who unfortunately can't pay their medical debt bill and receive a negative mark on that. Sometimes that can impact your employment status, that can impact you buying a house, that can impact you renting an apartment. So those are the sometimes unseen impact that's associated with medical debt.

      Brian Urban: [00:20:30]    
      I love where you went there, Priscilla, because if you are accumulating medical debt because you have healthcare needs, you're less likely to get healthcare services because you don't want to have more debt. If you can't pay off your debt, you get negative marks on your credit report. Even if you go to a debt relief program that, I understand, stays on your credit report for up to-

      Eva Stahl:    
      Seven years.

      Brian Urban:    
      ... seven years.

      Priscilla Keith:    

      Brian Urban: [00:21:00]    
      So your lending power, your buying power, if you're down, you will stay generationally down and start to become impoverished from family to family in local communities across the United States. It seems like we're in a place that there's so many contributors that could help, but they just do the standard process of, "Hey, you got a bad credit score, nah, you can't get a loan, we're not going to help you." Even if you help remove your debt, "Nah, we don't like that you went to a debt relief program. We don't trust you. You're not going to get access to buying a home or a car." It's obnoxious and it is absolute new determinant of health and it's racism in that as well, so gets me all boiled up. I'm going to move on from this subject before I go down this path further, but-

      Eva Stahl: [00:22:00]    
      I would just say really quick, Brian, but there are good ideas out there, but it goes back to that whole issue around building power and demanding solutions. There are a number of, I think, the fact that public health is even interested in medical debt as it emerges and the pressure grows raises issues around surveillance and the issue of the credit agencies seeking to segment and think about medical debt differently. So you remember over the summer that the national credit agencies, rating agencies, said that they would take marks off people's credit reports, but you still haven't lifted the car hood to look underneath to realize that there are a lot of systemic issues that need to be addressed to really prevent people from accruing that debt in the first place.

      There's a lot of work that needs to be done, but there are a lot of good rumblings and a lot of good ideas out there, whether it's helping people enroll in coverage and making sure that those entities are well-supported and navigators can help people navigate what is a highly-complex system in gaining access to coverage or bolstering that type of coverage like the Inflation Reduction Act did, so that your subsidy is worth more and your coverage is better so that you have lower out-of-pocket costs, there are still lots of pathways to improve upon.

      Brian Urban: [00:23:00]    
      The positive outlook that you have, Eva, it calms me down immediately, so thank you for taking us there. Actually, to go under the hood for a second, data is centric to a lot of your work-

      Eva Stahl:    

      Brian Urban: [00:23:30]  
       ... for RIP Medical Debt. So I was hoping we could talk about data for a little bit in terms of how you identify people in need, defining the people in need in terms of how you want to abolish their medical debt at a particular healthcare group or system. How has data, and I guess your continual maintenance of data and use of data been so core to your success? Just tell me a little bit about how that's utilized in your model.

      Eva Stahl:    
      I can punt it to Priscilla in a second, but I just want to make a general statement about data and medical debt. So the general statement is that we don't have a lot of data and that when you talk about that JAMA study, that's based on credit reports. Now-

      Priscilla Keith:  
       That's right.

      Eva Stahl: [00:24:00]    
      So a lot of what is troubling is all of the advice that flies around across the internet of how to deal with your medical debt bills or your medical debt period. A lot of it's around negotiation and one-on-one strategies with your hospital or your provider entity or strategies around borrowing from family, friends or putting it on your credit card or doing some of these new financial pieces around medical credit cards or buy now, pay later. They all run risks, but as soon as you move it from that column of healthcare service medical into another column, it's no longer medical debt.

      We can't see it from a data perspective, and there is no national database, there is no national surveillance of medical debt. So what you're seeing on the credit reports is only a slice of what actually exists. That's all that we have access to as an entity that purchases medical debt. So with that, I will actually pass it off to Priscilla to talk a little bit about the data because she's deeply involved in our structures as well as keeping data safe and secure. But I think it's important to note that we have no national surveillance of medical debt, and it's a really big problem that needs to be addressed.

      Brian Urban:    
      Great point. Yeah, Priscilla, take us deeper.

      Priscilla Keith: [00:25:30]
      Thank you, Eva. Eva is exactly right. In terms of the amount of data that we have, the level of data and the scrutiny surrounding the data, I will just say that when we work with individual entities or corporations, the first thing that we look at and what we usually have is a non-disclosure agreement or business associate agreement. What I've learned is that when you are working with PHI that ism you really want to make sure that you are protecting the data that you receive from hospitals that you receive from credit collection agencies. So in terms of that, we want to make sure that the data we have is stored in a manner that is completely protected and that we do all that we can to make sure that we protect that data from outside sources or nefarious sources related to that.

      In terms of what we'd like to do going forward with that data, we'd like to be able to, as we take the data in and as you've heard Eva talk about, we have an anthropologist to help us look at the data to tell us exactly from the numbers because you can be data rich and research poor. We'd like to be able to look at it and quantify the data to say, what does this actually tell us? What is the number of persons who are, I would say, single mothers who have to deal with medical debt on a daily basis? Let's look at families who may have insurance. But as we know, high deductibles tend to wipe out all of the gains that you think that you may be able to gain in regard to having insurance. Let's look at from a race perspective, we already have numbers with regard to that, but can we dig just a little bit deeper?

      I will also talk about, just very briefly, we were able to work with a group in Atlanta, Georgia known as ARCHI where we worked with [inaudible 00:27:20] to just take a qualitative look at medical debt in the Atlanta area. In terms of that study, we looked at four groups. The first group were white, consisted of white individuals, the second African American, the third Hispanic, and then the fourth group dealt with I would say constituents whose debt had been abolished by RIP. What we found with that is that the issue of medical debt transcended race and that some of the things that we found from them is that they didn't know how to navigate the health system. They felt as though the health system had abandoned them. They didn't trust the health system, and that was in the three groups. With the group that whose debt had been abolished by RIP, we found what we normally hear from our constituents on a daily basis was, "Wow, I did know that RIP existed, but I'm glad that it does exist."

      Two, "This is too good to be true. Are you really kidding me in terms of what you actually do?" Third, I think they intuitively know that they may have other medical bills, but just in terms of abolishing that one specific medical bill tends to help them in terms of mental health stress. This is a bill that they no longer have to worry about. They're able to navigate the system a little bit better and they just feel really better about themselves as we talked about in terms of the shame associated with medical debt. So as Eva talked about in terms of the data, we're hoping to look at that data as we get more data and be able to quantify it and be able to tell the stories in a different way that people will begin to appreciate what the impact of medical debt has on families and also by alleviating medical debt, what that does for individuals and families in a positive manner.

      Eva Stahl: [00:30:00]    
      Then I would just turn to also just the criteria piece, which I think you wanted to talk a little bit about too, Brian, which is that when this data comes in-house for us, once the purchase is made with donated dollars, that we have two main criteria at RIP Medical Debt, which is 400% of the poverty level or 5% of income. Really, the goal of this is to capture people that are feeling the stress and strain of medical debt. If you look at data on medical debt, when you hit about 400% of poverty, there's a small slight drop in medical debt. So the goal here is really to capture as many individuals as we can that are struggling and provide them the assistance of abolishment. That really aligns partly, we lifted our threshold this year from, what was it, Priscilla, from 250 to 400? Part of that too, was also to better and more robustly align with our goals around health equity to make sure that we're capturing as many people who need our help that we can in a really responsible way. So once the data match, we purchase data from a credit agency to match up with our debt files so that we can run those criteria, and then we only purchase debt that actually meets those criteria. Then once we've done that, then that's when we use what we call our debt engine to push our letters out to let people know that they're free and clear of that debt.

      Priscilla Keith:    
      Exactly. Thank you, Eva.

      Brian Urban: [00:31:30]   
      That is a good both sides of the story and I think from both of you in research, we tend to focus so much on the findings and the insights gleaned and what is it telling us, but we often forget about each data being a story, about someone's struggle, someone's life. When we're talking about that in terms of medical debt, you all elevate that story so well. So I love that you're doing the research in a quantitative statistical manner, but then you're also elevating it to storytelling, like this is about someone's life, family, and why they're struggling every day and the ripple effect on mental health, on maybe their existing conditions, on their employment status and family relations.

      It's amazing that you've taken the responsibility to do the full story and not just like the model of reducing debt. You've done the whole thing, and I love that, and I commend you both for doing that. I want to take us a step into the future, a compelling question for you both here. So Eva, you mentioned the touch of your work to health equity. What do you both feel, and I'll start with Eva here, your greatest impact in the health equity movement will be over the next two or three years going forward that might extend past medical debt abolishment? Is there anything that you see in the creative risk taking horizon that medical RIP Medical Debt will step into as well, expand upon?

      Eva Stahl: [00:33:00]
      I guess from a policy perspective, it's actually just creating a new conversation and doorway to Medicaid expansion. It's very, very clear that all the research points to Medicaid expansion as a key policy change that will really lift people up and is really about racial and health equity. I think the more that we can elevate the narrative around medical debt and humanize the experiences of medical debt, that my hope is that it will influence and spark different conversations about taking this step, particularly for the 11 states that still need to do this. So I think, for me, really it's an obvious but important role that we can play in amplifying the need to make that change.

      Brian Urban:    
      I love it. Priscilla, same question for you. What's on the horizon from your perspective for RIP Medical Debt?

      Priscilla Keith: [00:34:00]
      I think I probably would echo Eva's sentiments in terms of Medicaid expansion. I'm a daughter of the South and so sometimes you become a little bit sad because you see the indicators, the health indicators have not changed. Some of that is attributed to the mere fact that some of the states have not expanded Medicaid and which can account for the numbers that you see equated to the lack of access to healthcare. So I would like to see much more discussion and movement in that direction because when your health indicators improve, what that means is that your children are healthier. Your educational systems are better. Your economic development is better. Your communities are healthier. The state as a whole is healthier. When your states are healthier, that means that your nation is in a much better position. So I'm just going to piggyback off my colleague and friend, Eva's comments and sentiments with regard to Medicaid expansion.

      Eva Stahl: 

      Brian Urban:    
      I love it. Amen, indeed. It's a perfect way to bring us to a nice close here. So thankful to have you both on our little show. Priscilla Keith, Eva Stahl of RIP Medical, love what you're doing, love the mission. I love that I could be a part of it for 30 minutes here in a dialogue. I wish you both a happy holiday season here ahead and for more insights on our show, please visit finthrive.com.

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