Medical debt is a critical point of intersection between the national struggle for Medicare for All and the individual, often atomized struggles for survival and dignity in healthcare. In 2018, Boston DSA’s Healthcare Working Group took on that struggle with a city-wide program to assist individuals navigating medical debt.

“If history shows anything,” writes anthropologist David Graeber, “it is that there is no better way to justify relations founded on violence… than by reframing them in the language of debt.” We are taught to view indebtedness as a personal failing that justifies the material hardships inflicted on debtors. This lie crumbles in the face of medical debt, which forces sick people and their families to scramble for money to stay alive. A system in which the sick are expected to price-compare hospital beds while being loaded into ambulances strikes the conscience intuitively as both illogical and immoral.

Yet medical debt is ubiquitous in the United States, where around one in every five people has unpaid medical debt, and where women and people of color are disproportionately affected. Despite a relatively strong public safety net, Massachusetts residents still owe tens or hundreds of millions for past medical treatments, and our “moderate” Republican governor continues to roll back protections for poor and immigrant residents.

All of this debt emerges from violence and perpetuates it. Illness can seem “natural,” but its causes are often systemically produced, through environmental contamination, food deserts, or stress and overwork, and refusals of coverage or care amplify that violence by depriving patients of the potential for recovery.

In particular, medical debt is rooted in America’s failure to create a just healthcare system. The absence of universal care sustains a vampiric insurance industry that generates convoluted and expensive plans, which are liable to change and often predicated on shifting employment status. The resulting absence of affordable insurance pushes many into desperate measures to acquire medical care. These challenges can produce a vicious cycle: most home foreclosures in the United States are linked to medical debt, and many with debt forego care. Medical debt drives people to take out risky loans or open new lines of credit, which magnify psychic and economic anxiety.

While our long-term goal is universal care and the abolition of debt, organizing against medical debt in the short term can offer crucial assistance, bring awareness to the violence of capitalist healthcare, and build momentum toward health justice in the United States and beyond. Thus in 2018 our working group began planning a medical debt relief project.

Our goal was twofold. First, we wanted to give aid to people struggling to pay medical bills, in the form of both general support and, in more complex cases, free legal aid. Second, we wanted to assemble and educate a network of debtors who could mobilize collectively against a domineering health-debt system. Co-hosting our initial programs with City Life/Vida Urbana, a housing justice organization, we hoped to mirror their “Sword and Shield” approach: The “shield” of legal assistance becomes more powerful when individuals join together to fight back against collectors with the “sword” of collective action.

Training volunteers from Boston DSA to read and interpret confusing medical bills, we planned bimonthly clinics oriented around three messages:

  1. You are not alone.

  2. This is not your fault. 

  3. This system should not exist.  

The clinics themselves are straightforward. We begin by speaking about the problem of medical debt and connecting it to broader issues: our healthcare system, the debt economy and capitalism. Drawing again from CLVU’s efforts to center the voices of marginalized individuals, we encourage attendees to speak directly about their experiences. We offer Spanish translation for discussions and handouts. Finally, we partner with local legal service groups to bring a lawyer with debt expertise to speak with any individuals facing emergencies (foreclosure, court appearances).

Attendees not facing an immediate emergency are paired with a Boston DSA member who works with them one-on-one. In order to help our volunteers become well-informed and confident in this role, we offer a basic step-by-step guide, host monthly new volunteer trainings, and pair new volunteers with more experienced members of the working group during their first clinic.

During their one-on-one conversations with clinic attendees, our volunteers collect information about their cases. Conversations have ranged from questions like “Is there a fine for not having insurance?” to locating hospital double-billing on paper records and advising how to negotiate down a large heart-monitor charge. Volunteers are then responsible for following up on these cases as debtors navigate a process that one of our legal advisors described as “billing ping-pong” with hospitals and insurance providers. By tracking the status of cases in a spreadsheet shared among our clinic admin team, we ensure timely follow-up and allow for collaboration among volunteers. In situations requiring legal expertise, we connect with local attorneys at Health Law Advocates.

A few lessons emerging from our early events may be helpful to those embarking on similar projects:

  1. Medical debt is an opportunity for data-gathering. Both the origins and effects of medical debt are difficult to track due to their complexity and association with shame. We want to use our clinics as opportunities to identify bad actors and plan targeted actions. Prioritizing confidentiality in the data we collect and always confirming the permission of attendees, we aim to analyze the information collected from clinics in order to build a more complete picture of medical debt in Boston. 

  2. Medical debt is an opportunity for new coalitions. We find that participating in CLVU meetings allows us to develop stronger partnerships with local activist groups. The concrete existence of our clinics builds our credibility among local organizations, and our non-reformist mutual aid effort appeals to the progressive values of many activist groups. In late April, for instance, we brought stories from the clinics to a protest with the Right Care Alliance against pharma greed in Massachusetts. At the request of several groups, we are planning educational events and trainings to further distribute knowledge about medical debt.

Small victories are important. The material aid we are able to provide in these clinics is often limited, but every bit matters: Discovering a $100 overcharge, for instance, could save nearly nine hours’ worth of minimum wage work in Massachusetts. Even in cases in which no overcharges are discovered, clinic attendees often express gratitude for help in interpreting their bills and, even more essentially, for bearing witness to their lived experience in an absurd and crushing system. We view our effort to raise the confidence of patients in the face of the insurance and billing industry as a crucial element of political education, pushing people to question our system and enabling collective action in the future.

Written by Sheridan Aspinwall and Brad Bolman. To learn more about Boston DSA, visit their website and follow them on Twitter.