A rising epidemic of slow-pay and no-pay patients for medical bills has caused problems throughout the healthcare system.
Cleveland Clinic, for example, recently instituted a policy that patients have to pay first before getting treated, and then rescinded the policy. the clinic said that in 2024 more than half of its co-pays were not paid for Clinic services.
A Texas doctor said that in a primary care practice, the copays, deductibles, and difficulty identifying uncovered services are “the death march that has led to our demise.“
The cofounder of a radiology company that collects payments up front in advance said that in their experience if they don’t collect in advance, they collect 10 cents on the dollar with a lot of effort and expense on the back end.
“In 2022, about four in ten adults (41%) reported having debt due to medical or dental bills including debts owed to credit cards, collections agencies, family and friends, banks, and other lenders to pay for their health care costs, with disproportionate shares of Black and Hispanic adults, women, parents, those with low incomes, and uninsured adults saying they have health care debt,” the Kaiser Family Foundation reported in a recent study.
“Those who are covered by health insurance are not immune to the burden of health care costs. Almost four in ten insured adults under the age of 65 (38%) worry about affording their monthly health insurance premium and large shares of adults with employer-sponsored insurance (ESI) and those with Marketplace coverage rate their insurance as ‘fair’ or ‘poor’ when it comes to their monthly premium and to out-of-pocket costs to see a doctor.”
Rising deductibles
Why are so many people not paying? In defense of patients, one big trend in healthcare in recent years has been rising deductibles: Often patients have to pay first dollar up to their deductible, which could be $1,000 or $6,000.
Another rising trend is coinsurance. It used to be that a copay was a common thing — a fixed rate, like $25, for a visit to see a general practitioner. But now many insurance policies require what’s called coinsurance — that’s a percentage of the bill that is the patient’s responsibility. It’s not uncommon to see 10%, 20%, even 30% coinsurance requirements. This of course means money out of the patient’s pocket — even after they have met their deductibles.
It’s also true that there have been recent limitations on how much medical debt can be reported on a patient’s consumer credit accounts. There’s the Federal requirement — now overturned, as of July 2025 — and then also state by state there are different regulations. The upshot is the an unpaid medical bill may no longer ding your credit — so maybe not paying has fewer consequences (except that often hospital systems decline to treat people with outstanding bills).
Pre-pay policy
In May, Cleveland Clinic announced that some appointments would be canceled or rescheduled if patients could not pay upfront, starting on June 1. But after an uproar of criticism that they were turning patients away, the clinic rescinded the policy, and instead “will allow those with commercial insurance or Medicare Advantage, who can’t pay their co-pay at the time of their non-emergency outpatient visit, to set up a 0% interest payment plan,” according to a report in cleveland.com.
The system reported that half of all co-pays were not paid at time of service, resulting in $70 million in unpaid copays in 2024, cleveland.com reported.
Dr. Cristin Dickerson is founding partner of Green Imaging, a national network of cash-pay imaging for individuals and self funded health plans. She wrote: ”In our experience, we collect 10 cents on the dollar (with a lot of effort/expense) of anything we are owed by patients if we don’t collect at [time of service].
“We are a bit different than ongoing care, but some of their care is episodic as well. We are also now legally prohibited to send patients to collections for debts in the imaging range so there is no threat of recourse to not pay.”
Primary care woes
Dr. Guy Culpepper is a board-certified family physician in full-time private practice for 37 years, and I am also the leader of Jefferson Physician Group, a Dallas-based independent physician association supporting over 250 physicians since 1995.
“Within a primary care practice, the copays, deductibles, and difficulty identifying uncovered services are the death march that has led to our demise,” he wrote in an email on the topic. “We have 3 staff who do nothing but verify insurance and try to define what’s covered in both preventive care and disease care.
“The information we get from insurance cards and online verification is wrong or inadequate about 25% of the time. Patients are often surprised to learn that a $3 urinalysis, $15 lipid panel, or a $40 EKG is not covered under their preventive care.
“If we don’t collect at the time of visit, there is a huge likelihood that the patients will ignore our repeated billing of $15. Or even be angry at us because it’s not covered.
“‘Greedy family physicians trying to charge me $15! That’s what is wrong in medicine!’
“Family Medicine was a wonderful profession until Co-pays and Prior Authorizations started the death march. If we don’t collect up front, we won’t be able to collect later because we closed.”
Credit reporting
The Biden administration set into place a ban on the reporting of medical debt on consumer credit reports, with a prohibition to lenders from considering medical debt when making credit decisions. But a federal judge ruled in July 2025 that the ban could not be instituted.
A growing number of states have enacted their own bans or restrictions on medical debt reporting, with some laws applying broadly and others targeting specific types of debt or setting requirements before reporting is allowed.
Among the states with such statutes are Maine and Oregon, newly forbidding reporting of medical debt. Previously, California, New York, Connecticut, New Jersey, Rhode Island and others had laws that mostly prohibited such reporting. Several other states have partial restrictions on such reporting.
“Healthcare debt in the United States is a significant problem, affecting millions of Americans,” the authors of a paper in the Annals of Medicine and Surgery wrote in January 2025. “Many people struggle to pay for healthcare, and approximately 9% owe over $250 due to health costs.
“Nearly half of U.S. adults find it difficult to afford healthcare, with uninsured individuals and those with lower incomes facing the most significant challenges. Healthcare debt in the United States is a problem with profound consequences. … Healthcare debt casts a long shadow, adversely affecting physical and mental well-being and increasing stress, anxiety, and depression.
“Unpaid bills lead to the avoidance of necessary care, perpetuating health issues and straining the healthcare system.” Beyond health implications, it affects credit history, limits access to credit facilities, and hampers employment opportunities. So, comprehensive healthcare reform emerges as a potential remedy, by expanding access to affordable health insurance, regulating healthcare costs, and addressing coverage gaps could alleviate the impact of healthcare debts.”
