By Mitchell Black and Noam N. Levey. Cross posted from KFF Health News.
It took little more than an hour for Deborah Hackler to dispense with the tall stack of debt collection lawsuits that McAlester Regional Medical Center recently brought to small-claims court in this Oklahoma farm community.
Hackler, a lawyer who sues patients on behalf of the hospital, buzzed through 51 cases, all but a handful uncontested, as is often the case. She bantered with the judge as she secured nearly $40,000 in judgments, plus 10% in fees for herself, according to court records.
It’s a payday the hospital and Hackler have shared frequently over the past three decades, records show. The records indicate McAlester Regional Medical Center and an affiliated clinic have filed close to 5,000 debt collection cases since the early 1990s, most often represented by the father-daughter law firm of Hackler & Hackler.
Some of McAlester’s 18,000 residents have been taken to court multiple times. A deputy at the county jail and her adult son were each sued recently, court records show. New mothers said they compare stories of their legal run-ins with the medical center.
“There’s a lot that’s not right,” Sherry McKee, a dorm monitor at a tribal boarding school outside McAlester, said on the courthouse steps after the hearing. The hospital has sued her three times, most recently over a $3,375 bill for what she said turned out to be vertigo.
In recent years, major health systems in Virginia, North Carolina, and elsewhere have stopped suing patients following news reports about lawsuits. And several states, such as Maryland and New York, have restricted the legal actions hospitals can take against patients.
But with some 100 million people in the U.S. burdened by health care debt, medical collection cases still clog courtrooms across the country, researchers have found. In places like McAlester, a hospital’s debt collection machine can hum away quietly for years, helped along by powerful people in town. An effort to limit hospital lawsuits failed in the Oklahoma Legislature in 2021.
In McAlester, the lawsuits have provided business for some, such as the Adjustment Bureau, a local collection agency run out of a squat concrete building down the street from the courthouse, and for Hackler, a former president of the McAlester Area Chamber of Commerce. But for many patients and their families, the lawsuits can take a devastating toll, sapping wages, emptying retirement accounts, and upending lives.
McKee said she wasn’t sure how long it would take to pay off the recent judgment. Her $3,375 debt exceeds her monthly salary, she said.
“This affects a large number of people in a small community,” said Janet Roloff, an attorney who has spent years assisting low-income clients with legal issues such as evictions in and around McAlester. “The impact is great.”
Settled more than a century ago by fortune seekers who secured land from the Choctaw Nation to mine coal in the nearby hills, McAlester was once a boom town. Vestiges of that era remain, including a mammoth, 140-foot-tall Masonic temple that looms over the city.
Recent times have been tougher for McAlester, now home by one count to 12 marijuana dispensaries and the state’s death row. The downtown is pockmarked by empty storefronts, including the OKLA theater, which has been dark for decades. Nearly 1 in 5 residents in McAlester and the surrounding county live below the federal poverty line.
The hospital, operated by a public trust under the city’s authority, faces its own struggles. Paint is peeling off the front portico, and weeds poke up through the parking lots. The hospital has operated in the red for years, according to independent audit reports available on the state auditor’s website.
“I’m trying to find ways to get the entire community better care and more care,” said Shawn Howard, the hospital’s chief executive. Howard grew up in McAlester and proudly noted he started his career as a receptionist in the hospital’s physical therapy department. “This is my hometown,” he said. “I am not trying to keep people out of getting care.”
The hospital operates a clinic for low-income patients, whose webpage notes it has “limited appointments” at no cost for patients who are approved for aid. But data from the audits shows the hospital offers very little financial assistance, despite its purported mission to serve the community.
In the 2022 fiscal year, it provided just $114,000 in charity care, out of a total operating budget of more than $100 million, hospital records show. Charity care totaling $2 million or $3 million out of a $100 million budget would be more in line with other U.S. hospitals.
While audits show few McAlester patients get financial aid, many get taken to court.
Renee Montgomery, the city treasurer in an adjoining town and mother of a local police officer, said she dipped into savings she’d reserved for her children and grandchildren after the hospital sued her last year for more than $5,500. She’d gone to the emergency room for chest pain.
Dusty Powell, a truck driver, said he lost his pickup and motorcycle when his wages were garnished after the hospital sued him for almost $9,000. He’d gone to the emergency department for what turned out to be gastritis and didn’t have insurance, he said.
“Everyone in this town probably has a story about McAlester Regional,” said another former patient who spoke on the condition she not be named, fearful to publicly criticize the hospital in such a small city. “It’s not even a secret.”
The woman, who works at an Army munitions plant outside town, was sued twice over bills she incurred giving birth. Her sister-in-law has been sued as well.
“It’s a good-old-boy system,” said the woman, who lowered her voice when the mayor walked into the coffee shop where she was meeting with KFF Health News. Now, she said, she avoids the hospital if her children need care.
Nationwide, most people sued in debt collection cases never challenge them, a response experts say reflects widespread misunderstanding of the legal process and anxiety about coming to court.
At the center of the McAlester hospital’s collection efforts for decades has been Hackler & Hackler.
Donald Hackler was city attorney in McAlester for 13 years in the ’70s and ’80s and a longtime member of the local Lions Club and the Scottish Rite Freemasons.
Daughter Deborah Hackler, who joined the family firm 30 years ago, has been a deacon at the First Presbyterian Church of McAlester and served on the board of the local Girl Scouts chapter, according to the McAlester News-Capital newspaper, which named her “Woman of the Year” in 2007. Since 2001, she also has been a municipal judge in McAlester, hearing traffic cases, including some involving people she has sued on behalf of the hospital, municipal and county court records show.
For years, the Hacklers’ debt collection cases were often heard by Judge James Bland, who has retired from the bench and now sits on the hospital board. Bland didn’t respond to an inquiry for interview.
Hackler declined to speak with KFF Health News after her recent court appearance. “I’m not going to visit with you about a current client,” she said before leaving the courthouse.
Howard, the hospital CEO, said he couldn’t discuss the lawsuits either. He said he didn’t know the hospital took its patients to court. “I had to call and ask if we sue people,” he said.
Howard also said he didn’t know Deborah Hackler. “I never heard her name before,” he said.
Despite repeated public records requests from KFF Health News since September, the hospital did not provide detailed information about its financial arrangement with Hackler.
McAlester Mayor John Browne, who appoints the hospital’s board of trustees, said he, too, didn’t know about the lawsuits. “I hadn’t heard anything about them suing,” he said.
At the century-old courthouse in downtown McAlester, it’s not hard to find the lawsuits, though. Every month or two, another batch fills the docket in the small-claims court, now presided over by Judge Brian McLaughlin.
After court recently, McLaughlin, who is not from McAlester, shook his head at the stream of cases and patients who almost never show up to defend themselves, leaving him to issue judgment after judgment in the hospital’s favor.
“All I can do is follow the law,” said McLaughlin. “It doesn’t mean I like it.”
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Pretty much the same old Courthouse Crowd you will encounter in any small town or city across the nation. Human nature being what it is, the “debt collectors” rely on fear, distrust, and basic ignorance of “the System” to deter push back against their efforts.
It all comes down to education. These are fairly simple social systems. They can be understood and manipulated with a little effort. That the average person in a society does not do so is not an indictment of the people involved themselves, but of sections of the overall social system that control the public’s education about their “rights and responsibilities” concerning said system. One will not assert a “right” one knows little to nothing about.
This is where what passes for “the Left” in America falls down on the job. A robust Left would have parallel institutions of public ‘education’ set up to increase the ranks of the pool of potential activists within the society. Storefront lawyers and public ‘rabble rousers’ should be stirring up the locals in this Oklahoma community. Power, as presently represented by the aforementioned “Courthouse Crowd,” needs to be challenged, both in the courtroom and on the street. It is a truism that no Elite gives up power voluntarily. A Demand must be made, and made forcefully.
Rant over. Now back to our regularly scheduled programming.
Who’s voting for “the left” you imagine? Not people in Oklahoma, even when offered this vision. Perhaps they should look internally
What you often see in small towns is a “good old boys” club whereby the relatively well-to-do lord over the less well off. Connections mean everything. Often a wink and a nod is all it takes to obtain favors. The people being sued by the hospital aren’t in “the club” so they get screwed over repeatedly. I don’t see a way out for these poor people unless those lording over them suddenly develop some personal integrity and a sense of fairness.
I often wonder just how bad “things” have to become to instigate ‘real’ civil insurrection.
Yup, looky here: “James Bland who has retired from the bench, now sits on the hospital board”.
Where I live hospital billing is very inconsistent. You may be billed right away or months later receive a bill for a service. I told the local hospital I won’t pay any bill unless it is detailed. The date of service as well as what the service was. A big problem is the hospitals contract out certain services. Months later you may get a bill from a provider for their service. I believe they complicate billing so the patient has a hard time knowing if they are being billed for a service they actually got.I also don’t pay until the process a claim through my insurance and I see what has been paid.
I just recieved a small bill for imaging in the fall very specifically very past due and set to go to collections within 10 days if not paid.
Meanwhile, I’d been watching this on my insurance and the insurance portion was paid almost immediately.
It does seem they wanted to collect late fees. Or somehow every single routine bill was lost for months on end.
And of course, I’m the kind of person who isn’t going to panic about threats on a 20 dollar bill because of “access” to lawyers.
‘ “All I can do is follow the law,” said McLaughlin. “It doesn’t mean I like it.” ‘
Eichmann would be proud of this defense.
Malcomn Kyeyune (i.e. “Tinkzorg”, famous swedish shitposter and analyst, I guess) recently wrote an interesting little thread that seems to summarize the question in my view:
Made a mistake with the link. Here it goes corrected.
May the odds be ever in your favor!
I always liked the “don’t ask me, I’m only the CEO” thing.
How can this be happening? I distinctly recall being told with condescending certainty by the folks at DailyKos and their similars on FB during that brief period ACA was being zipped thru Congress at the speed of light over several years (2008-2010?), that the ACA would reduce medical bankruptcies and debt.
Meanwhile, Seward Medical which one is just blocks from me, is in “talks” with the State of Massachusetts regarding it being on the brink of closing due to no money. Further – as yesterday’s NC linked article noted – other Seward hospitals facing the same fate in Pennsylvania got undisclosed amounts of tax $$$ rushed to them within days/weeks/months.
Point being, for-profit corporate medicine = debt free tax $$ without appropriation, patients = debt collection.
What happened, Mr Obama? If Michelle runs for President to Save Our Democracy from you know who, maybe a reporter might ask her what’s up with all this? I wouldn’t be surprised that what comes from this is a new profit venue – privately run medical debt prisons.
New York just announced it will be closing Downstate Medical Center, a major teaching hospital and health care provider in Brooklyn. Some of the services will be foisted on Kings County, the overburdened public hospital nearby. Incredibly, in justifying the closure, officials announced they will be opening a center for the study of healthcare disparities, so they can “study” the outcomes of their own policies.
IIRC this is the primary teaching hospital of (SUNY) Downstate Health Sciences University. Not good. Not surprising. We are not a serious nation.
WellStar closed Atlanta Medical Center last year, undoubtedly with the idea of converting the second hospital in downtown Atlanta (one of two Level I trauma centers in the city) to residential real estate. Last I heard, approval of that zoning change remains “pending” until the money is spread around widely enough among the “deciders.” Just a matter of time.
You should educate yourself more – perhaps the easy answer or what the tevee tells you isn’t exactly accurate. Oklahoma didn’t expand Medicaid as is available to them under the ACA, so their citizens don’t get the benefits under the law. Oklahoma needs better local politicians which can only be gotten from informed active citizens.
Perhaps YOU should educate YOURSEF on how to read.
I don’t watch “teevee” and haven’t for about 15 years and you need to educate yourself that you completely ignored that I am referring to Massachusetts – which does access Medicaid – and Pennsylvania – which I would guess also access Medicaid but I didn’t look it up because your comment doesn’t justify spending the time.
Hmm. Easy to condemn the hospital’s behavior, but it seems the problem likely lies upstream:
“The hospital, operated by a public trust under the city’s authority, faces its own struggles. Paint is peeling off the front portico, and weeds poke up through the parking lots. The hospital has operated in the red for years, according to independent audit reports available on the state auditor’s website.”
Under capitalized and underfunded public hospital serving a poorly insured population, subjected to denial of reimbursements and lack of political will at any level to solve the problem. No, the solution isn’t bleeding Grandma to keep the doors open, but one can also wonder how badly the nurses are paid.
But the authors also note
«In the 2022 fiscal year, it provided just $114,000 in charity care, out of a total operating budget of more than $100 million, hospital records show. Charity care totaling $2 million or $3 million out of a $100 million budget would be more in line with other U.S. hospitals.»
With “$2 million or $3 million” a year going missing, it’s not surprising the paint is peeling. One ought to expect the CEO and the ‘public trustees’ know exactly what they are doing, and one ought to expect them to be indicted.
It’s a leap to go from not given to missing. Agreed, one would expect the CEO and trustees to know – or admit to – what they are doing. But there is much the article doesn’t tell us. Like CEO pay. Like how big the hospital is, and how much of a population and geographic area it is expected to serve. Never mind outcomes. $100 million is not necessarily a well capitalized hospital, depending on what it is expected to do with that money.
My point is that the entire health care system is broken top to bottom, and public hospitals are near the bottom.
We can expect little relief in the future. We have both likely presidential candidates opposed to Medicare for All. Both Biden and Trump were involved in the revamping of Medicare to insert private groups ( often private equity ) to manage Medicare payments to patients for up to 40% of the Medicare budget. Medicare Advantage is another rip off a majority senators and congressmen of both parties support. Everything will be financialized.
I wonder how much the CEO/board are paid.
google tells me that 15 years ago, they were quite well compensated (Kansas prices are not the same as the Bay).
https://www.mcalesternews.com/news/local_news/mrhc-s-top-team-paid-1-million-plus/article_79a97f12-2a3e-576f-aa7f-0bfee00d31f8.html
Funny, KFF didn’t investigate or report on where the money is actually going (obviously not to cut a break for the poor). And since when is a free clinic only free for those the hospital deems worthy?
“Deborah Hackler, who joined the family firm 30 years ago, has been a deacon at the First Presbyterian Church of McAlester and served on the board of the local Girl Scouts chapter, according to the McAlester News-Capital newspaper, which named her “Woman of the Year” in 2007.”
Such an upstanding “Citizen and Christian”. “Thou shalt not bite the hand that feeds you” is somewhere in the New Testament…
I’m sure Jesus ensured that the proper copays and coinsurance fees were paid before he cured the sick. I just can’t seem to find the verse in any of the 4 Gospels.
I think more and more conservative Christians are believers in the Prosperity Gospel so getting rich off your neighbors is not an issue.
A few words from someone who taught medical history for 30 years.
I find it very compelling that this article is about the state of affairs in Oklahoma.
For, it was in that very state that a most amazing chapter in American medical history took place. I find it completely unsurprising that this story has been suppressed and purposely forgotten by our current medical leaders and politicos.
https://en.wikipedia.org/wiki/Michael_Shadid
I do not know at all if this McAlester OK hospital got its start as a medical co-op but I would not be surprised. The vast majority of rural hospitals in OK and that entire part of the USA most certainly did. If Dr. Shadid knew what was going on in these places now, he would most likely throw a rod.
I possess and have read multiple biographies about this man’s life and his work. I have taught medical students about him for my entire life. I just checked. All three of the books I have are celebratory biographies from the Univ of Oklahoma Press from decades ago – hailing him as a courageous doctor, a man of the people and a favorite son. He has grandchildren and great grandchildren as MDs all over that state and beyond. We all must remember there was a time that states like OK were the New Deal FDR blue states. The backbone of the Democratic Party. Will Rogers and Woody Guthrie did not come out of a vacuum.
In essence, he was the father of the medical co-op system in this country. In its basic terms, it was a plan where normal average families would pay a certain and reasonable amount monthly to the co-op. They would then get all the medical care they needed for their entire families free of charge. The money was used to build “community” or “regional” hospitals in every county seat. Also, there was a HUGE emphasis on preventive care and healthy lifestyles. The name of this place in McAlester suggests to me it was likely at one time in this type of plan.
It worked beautifully for decades. But that was a time when no one would dream of profiting from health care. There was not a remote inkling of 30 – 40 employees to each HCW doing nothing all day but sitting around and playing with forms and paper. Everyone in that era would have looked askance at Pharma products costing more than pennies a day.
But Big Insurance could not tolerate the loss of profits. They did EVERYTHING they could to undermine this system starting around 1950 or so. By the late 1960s, It was finally destroyed. Blue Cross, that bastion of morality, was the big offender here. Now most of these little rural hospitals, the ones left still standing, are either gobbled up by big “non profit” hospitals, are struggling to survive on a daily basis, or are already bankrupt.
Dr. Shadid, bless his soul, would be absolutely horrified at this kind of story and what his system has become.
Beat me to it, IM Doc! I plan to use the story of Dr. Michael Shadid on our medical students this year. For those with the time, here is a recent video (21:21) of a presentation to the Oklahoma Historical Society.
As for Oklahoma, Fred Harris was a US Senator from Oklahoma in the living memory of some of us! Harris was the only Senator to vote against the appointment of Lewis Powell of the Powell Memo, often mentioned here, because he was “an elitist” who “has never shown any deep feelings for little people.” Yes. He could also have added that Powell made his bones as the lawyer for Big Tobacco.
This certainly caught my interest, and I will also be viewing the video posted by KLG as well. I am currently reading Dr. Jim Bisset’s, Agrarian Socialism in America: Marx, Jefferson, and Jesus in the Oklahoma Countryside, 1904–1920 It kind of gave me a Wow Moment to learn about Shadid.
Several states, notably California and Michigan, bar lawyers or paralegals from representing litigants in Small Claims Court. This has done quite a bit to reduce the abuses displayed in this excellent reporting.
In Silicon Valley our Small Claims Court also budgeted for mediators recruited from local law schools and the community who were trained to draw out the underlying facts and embarrass litigants into settlements. Some (not all) of the judges were also sticklers about service of process, as “sewer service” process servers are part of the problem of absent litigants and default judgments.
But the real problem on display is the only “health care system” in the civilized world that is nothing less at its hollow core than a Rube Goldberg rent-extraction machine. Shameless narcissism and greed have replaced charity as the American religion.
Re: ‘ …. the only ‘health care system’ in the civilized world that is nothing less at its hollow core than a Rube Goldberg rent-extraction machine.’
David, you realize that, and I realize that, but we have people like David Samuels, writing yesterday in Unherd (I was browsing through Moon of Alabama’s compilation of his past week’s links this morning) who are apparently experiencing a different reality: “American life expectancy — perhaps the most basic gauge of how people are actually doing — is also experiencing a sharp decline, despite (or because of) the fact that America adopted a universal health care system more than a decade ago. ”
So, there you have it: America has had a ‘universal health care system’ for more than a decade! We apparently have not been looking hard enough.
In reading the Samuels piece, I detected more than a whiff of both sarcasm and irony in that passage. Samuels is not an Obama fan — nor am I. Thanks for the link!
Hah, David, I did wonder if that was irony. But the rest of the piece seemed so earnest. Maybe he should have inserted the ‘/s./. Or, I needed more caffeine.
https://fred.stlouisfed.org/graph/?g=1erjq
January 15, 2018
Life Expectancy at Birth for United States, United Kingdom, France, Germany and Italy, 2007-2021
https://fred.stlouisfed.org/graph/?g=1erk0
January 30, 2018
Infant Mortality Rate for United States, United Kingdom, France, Germany and Italy, 2007-2021
I had the “opportunity” to stay in McAlester a few days on business. I drove through the city center just to see what was there. Not a single business in the five block area was open. Nothing. The usual big box outfits and motels were on the main bypass outside of town. Not busy there. Mostly catering to out of town trade. few places to eat. I looked like a classic midwest dying town. From this article, nothing has changed for the better. The hospital barely survives by suing poor folk for noncollectable dept. It is the national med/drug scam in a microcosm.
This article forms an important overview, but I did not properly post the abstract. I will try to post a part of the abstract again:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796358
September 16, 2022
Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US
By David U. Himmelstein, Samuel L. Dickman, Danny McCormick, David H. Bor, Adam Gaffney and Steffie Woolhandler
Abstract
Importance
Cost barriers discourage many US residents from seeking medical care and many who obtain it experience financial hardship. However, little is known about the association between medical debt and social determinants of health (SDOH).
Objective
To determine the prevalence of and risk factors associated with medical debt and the association of medical debt with subsequent changes in the key SDOH of food and housing security.
Design, Setting, and Participants
Cross-sectional analyses using multivariable logistic regression models controlled for demographic, financial, insurance, and health-related factors, and prospective cohort analyses assessing changes over time using the 2018, 2019, and 2020 Surveys of Income and Program Participation. Participants were nationally representative samples of US adults surveyed for 1 to 3 years.
Exposures
Insurance-related and health-related characteristics as risk factors for medical debt; Newly incurred medical debt as a risk factor for deterioration in SDOHs.
Main Outcomes and Measures
Prevalence and amounts of medical debt; 4 SDOHs: inability to pay rent or mortgage or utilities; eviction or foreclosure; and food insecurity…