MEDICINE LODGE, Kansas — Sarrah Miller and her husband, Kyle, live in a rambunctious household filled with children in a rural town of about 1,700 people.
Last month a knock on the door interrupted dinner. It was the Barber County sheriff serving Kyle papers.
Their local medical clinic, Medicine Lodge Memorial Hospital, was suing him for $230 of unpaid debt from a nonroutine visit. In all caps and bold letters, the words “court summons” stood out at the top of the page.
“My husband travels. He’s gone most of the week for work. There was just no way that he was going to be able to attend that court date,” Sarrah said. “I just kind of had to jump in, and honestly, they did not make it easy.”
Because Kyle travels for work, he missed the hospital trying to contact him, and Sarrah was unaware. But they are not alone.
Kansas hospitals are increasingly suing patients for small sums of money. District court records show some cases seeking as little as $104. These lawsuits also mean patients may be on the hook for court fees and interest.
Sarrah said that there were a lot of confusing hoops to jump through for that amount of money.
“I understand rural hospitals, they need their money and they’re trying to stay open, and I respect that,” Sarrah said. “But at the same time they definitely go about it kind of more like a bully than like a neighbor.”
The Millers have health insurance. But it’s not always clear how much you should pay out of pocket, even with insurance.
The end result for some families is either coughing up this month’s rent to avoid a court hearing, or having your wages garnished. Sarrah said the family with four kids already struggles with bills.
Exact data on hospital lawsuits is hard to find.
The Kansas District Courts’ public access portal lists past lawsuits. But hospitals are in litigation so often that the system warns users it can’t pull up every case.
But legal nonprofit Kansas Legal Services does have some data on hand.
In a six-year period, Hays Medical Center sued 1,041 county residents. Meanwhile, Southwest Medical Center in Seward County sued 3,012 county residents, in a county with a population of 22,000. The Pratt Regional Medical Center sued 657 local residents in four years.
Newman Regional Health in Emporia sued 2,648 local residents in 2024 alone. One-fourth of those cases were for amounts less than $500.
Cathy Pimple, CEO of Newman Regional Health, said her money-losing hospital can’t afford to stop suing people over even relatively small amounts of unpaid bills. Although she expects a 25% reduction in collections cases going to legal, she said the hospital needs the money to stay in business.
“We were talking about the immediate loss of services,” Pimple said. “Health outcomes in Kansas would go in the wrong direction.”
Process of lawsuits
Matt Keenan, executive director of Kansas Legal Services, said one major reason these lawsuits keep happening is because hospitals are not following charity care guidelines.
IRS rules say hospitals need to make clear what discounts exist in care, and hospitals can make more people eligible for charity care if they say they can’t afford the treatment.
Keenan said hospitals aren’t having conversations about alternative payment options and that information isn’t clearly stated on bills. He has represented clients who had no idea they could have received free care.
Because those patients didn’t apply for free care, it’s assumed they aren’t eligible and they end up in court. That might not have happened if someone had informed the patient.
“It’s a don’t ask, don’t tell,” Keenan said.
Sometimes hospital staff members honestly don’t know, he said. They’ve told him that in court proceedings. But other times the information isn’t clearly listed on a bill or it’s hard to find the webpage that explains it.
The sheer number of lawsuits is another reason Keenan thinks charity care options aren’t widely discussed.
The hospital in Emporia was averaging seven lawsuits a day in 2024. The Pratt Regional Medical Center averaged a new lawsuit about every two days.
Community Benefit Insight is a website that analyzes hospital tax forms. It tracks what percentage of charity care is paid out when compared to a hospital’s operating expense.
Pratt Regional paid out $96,672 in charity care in 2022. That’s 0.16% of the hospital's operating expenses. The Hiawatha Community Hospital and Community Memorial Hospital in Marysville — both in counties with nearly identical population totals to Pratt — paid out 0.88% and 1.01% in charity care payment rates.
The Hays Medical Center was at 0.73% charity care payments while the Coffeyville Regional Medical Center paid out more than twice as much at 1.64%. Stormont Vail in Topeka had a 2.34% charity care payment rate.
HaysMed said it has paid $77 million in charity care over the past six years.
“We encourage anyone facing difficulty to reach out to us,” a hospital spokesperson said. “Our goal is always to avoid (legal action) whenever possible, while still maintaining the financial stability we need to keep essential, quality healthcare available in our rural region.”
Southwest Medical Center and Pratt Regional didn’t respond to requests for comment.
Keenan said it’s a complicated system that leads to too many lawsuits.
“There are very few villains here,” he said. “The clinicians are working hard … and these patients are getting good care. The hospitals are a huge asset to these communities.”
Todd Butler, a lawyer and managing partner of Butler & Associates in Topeka, has represented hospitals in these cases. While Keenan says there’s not enough vetting, Butler said there are multiple rounds of it before a lawsuit ever gets to his desk.
Hospitals check patients’ eligibility for free or reduced-price care. Then the collections agencies do another round of checking. Butler’s team talks more with patients about their ability to pay. Newman Regional officials said they offer people no-interest payments or connect them with a bank for low-interest payments for longer repayment windows. HaysMed also has payment plans, interest-free loans and other programs.
Butler said he also waits 42 days before bringing the suit so patients have time to avoid court. In total, he said patients have had 240 days to take care of the bill by the time he files the case.
Butler said there is an advantage to going after the smaller claims because they are the “easier ones for everyone to pay and to collect.”
Needing medical attention and then being stuck with a bill you can’t afford is tricky. But Butler said if hospitals let everyone with a few hundred dollars in medical debt get off the hook, then nobody would pay their bill.
“In a small town people talk. And if the hospital never pursues someone who has a $300 or $400 bill, then what’s the incentive to pay yours?” Butler said.
He said rural hospitals are closing down because they can’t pay staff. Others are cutting services. Some hospitals need all the money they can get.
Rural hospital closure
In Kansas, 67% of rural hospitals are at risk of closing, the third highest rate in the entire country. Rhode Island has just one rural hospital, and it’s at risk of closing. Connecticut has four rural hospitals with three at risk of closing.
The Center for Healthcare Quality and Payment Reform said in an October report that 30% of rural Kansas hospitals are at “immediate risk” of closing.
The center said almost half of the rural hospitals in the country lose money when offering services. Those hospitals don’t make enough money elsewhere to offset losses and don’t have large financial reserves.
KFF reported that there were more Medicare patients at rural hospitals than urban hospitals — 53% in rural settings to 45% in urban settings. Medicaid discharges had a 19% rural to 21% urban split.
Medicaid only pays 65 cents for every dollar of treatment provided. That leaves hospitals, like Newman Medical, taking a loss on a majority of its Medicaid patients. Comparatively, Medicare covers 80 cents for every dollar of expenses.
Private insurance usually pays better for services, but private insurance covered 19% of rural discharges compared to 24% of discharges in urban hospitals.
Pimple, of Newman Regional, said the system isn’t working for rural hospitals.
These hospitals are in a tough spot. In Emporia, Newman Regional doesn’t have the financial reserves to offer more free care — 41% of the people in the city are living in poverty, Pimple said. She also said insurance companies pay rural hospitals less than urban hospitals, and just 20% of the people with medical debt at Newman Regional have private insurance.
“If you look at our urban hospitals,” she said, “they’re not seeing those negative margins.”
There also are certain patient-to-staff ratios that hospitals need to maintain. An emergency room needs doctors and nurses. An urban hospital may see 100 patients in an hour, which brings in enough revenue to pay for that staff. Rural hospitals may see a few patients, which means the hospital is taking a loss on a service it has to offer.
Then comes collecting the money.
Suing patients, especially for small sums of money, isn’t profitable because collections agencies and lawyers need to be paid. But Pimple said it’s about minimizing losses.
Newman Regional provided more than $8 million in uncompensated care last year — $4 million in reduced-cost treatment and $4 million in completely free care. Charitable write-offs of the free care help, but Newman Regional has a negative 2% operating margin. Recovering what they can makes a difference.
Pimple knows the burden medical debt puts on people. She wants everyone to be healthy, to get the care they need and not worry about collections agencies. But the financials of the industry simply don’t allow for vast sums of unpaid bills.
“Even though the burden is heavy on hospitals,” she said, “we also recognize the hardship it is on patients too.”
A KFF poll found that 49% of people couldn’t pay an unexpected $500 medical bill. Nineteen percent of people couldn’t pay it at all and another 30% of people would need to go into debt.
Ruth Landé, vice president of provider relations at Undue Medical Debt, worked in a hospital billing department for years. She isn’t a fan of suing over medical debt.
Medical debt is one of the most common reasons for bankruptcy.
In a 2024 study, 65% of people surveyed said medical issues, both medical debt and not working because of medical reasons, contributed to bankruptcy. Loss of income contributed to 78% of bankruptcy cases.
Landé said suing could also make overall health outcomes worse. There’s no real way for patients to avoid medical debt.
“It’s pretty much … don't get sick. Move to Canada,” she said.
So patients may avoid health care in general.
The KFF poll said 36% of respondents said they delayed medical care in the past year because of cost concerns. In the same poll, 18% of people said their health got worse because they skipped care.
Landé doesn’t want to make villains out of the hospitals because the system is also hurting them, but hospitals shouldn’t be going after patients.
“There should never be lawsuits in this area,” she said. “Medical debt is not like other debt. It's not a debt of choice.”
Billing departments
Rick Gundling, senior vice president at the Healthcare Financial Management Association, said suing a patient is the last thing hospitals do because it’s easier and cheaper to settle the debt out of court.
He said patients and providers should talk about costs. If there’s time, they should talk about price estimates and insurance plans. After any treatment, there should be conversations about charity care.
Gundling said rural hospitals are operating on thin margins, and hospitals have to be good financial stewards for the community.
Cindy Samuelson, senior vice president for the Kansas Hospital Association, explained that rural hospitals not only have smaller budgets, they have smaller staffs than their urban counterparts.
Samuelson said that the lack of Medicaid expansion in the state also contributes to more uninsured people struggling to pay.
“We have a bigger population either uninsured or underinsured, because we didn't have a chance to expand that Medicaid into that population,” she said.
Urban hospitals “have more people that can sit down and talk to patients, that can reach out and call them, more times,” Samuelson said. “Whereas a rural hospital may not have that depth of staff and resources to do those things.”
That can lead to more rural residents being sued by their hospital. But Samuelson said that rural hospitals face a difficult choice — choosing between holding patients accountable for bad debt, or losing the services they provide to their communities.
“Every penny counts, every single thing they can capture counts because they just don’t have a lot of it. It’s always important to collect what you're owed,” Samuelson said.
When hospitals close, patients travel farther for treatment.
The U.S. Government Accountability Office said rural closures mean patients travel 20 miles more for inpatient care and about 40 miles more for less common services like drug and alcohol addiction treatment. Prices at nearby hospitals also rose in the following years by 3.6%, an average of $500, a University of Minnesota study found.
The U.S. Centers for Disease Control and Prevention found that largely due to this difference in access to health care, rural residents are more likely to die early than urban residents. They’re also more likely to die from overdoses and suicide without quick access to emergency services.
How does the future look?
There are some ways to protect patients.
Legislation could prevent medical debt from being reported to credit card companies. Bills could also prevent hospitals from putting liens on someone’s house or garnishing wages. There are also more controversial policies like expanding Medicaid, something Kansas didn’t do before pending Medicaid cuts from the Trump administration’s budget bill that was passed earlier this year.
Kansas is projected to lose almost $4 billion in Medicaid funding over the next 10 years because of that bill. The federal Rural Health Transformation program was passed as a $50 billion program to help mitigate those losses. The Kansas health department is seeking $1 billion in federal funding for rural health care over the next five years. That will be decided at the end of the year by The Centers for Medicare & Medicaid Services.
Back in Medicine Lodge, Sarrah Miller and her family will still need to find ways to find an extra $100 in their budget for a few months.
She said she hopes her example could help others avoid being in the tight spot her family is facing.
“I think there are softer ways of handling it. I think they can give people more information and what steps to take,” Sarrah said. “Right now it’s just like kind of kicking people when they’re down.”
Note: One of the authors of this story has been sued by Southwest Medical Center for $500. The bill had been paid before publishing this story
Blaise Mesa with The Beacon contributed to this story.
Calen Moore covers western Kansas for High Plains Public Radio and the Kansas News Service. You can email him at cmoore@hppr.org.
The Kansas News Service is a collaboration of KCUR, Kansas Public Radio, KMUW and High Plains Public Radio focused on health, the social determinants of health and their connection to public policy.
