Quizás, pensaron, se trataba de unos zapatos que no le quedaban bien.

Los familiares describían a la niña amante de los unicornios como inteligente, cariñosa y a veces un poco traviesa. Antes de aprender el alfabeto, ya había descubierto cómo encontrar su programa favorito, Blippi, en un teléfono. También era conocida por sacar mantequilla del refrigerador a escondidas para disfrutarla lamiéndose los dedos.

Pero luego sus extremidades empezaron a sacudirse. Una punción lumbar reveló sarampión en su líquido cefalorraquídeo. El virus que probablemente tuvo cuando era bebé había llegado en secreto a su cerebro. Ahora, con 8 años, Deepanwita está paralizada y no puede hablar.

El sarampión causa complicaciones —que van desde diarrea hasta la muerte— en infectadas, según la Sociedad de Enfermedades Infecciosas de América (IDSA, por sus siglas en inglés). Algunas aparecen de inmediato, mientras que otras tardan semanas o meses en manifestarse. La que está experimentando Deepanwita es la encefalitis esclerosante subaguda (PEES); por lo general, tarda años en aparecer.

“Muchas personas piensan: ‘Si nos da sarampión, estaremos bien, porque conozco a un vecino que lo tuvo y está bien’”, dijo , quien dirige la Sociedad de Neurología Infantil (Child Neurology Society) a nivel nacional, pero habló con Â鶹ŮÓÅ Health News en su papel como doctora en Nueva York con experiencia en enfermedades neurológicas.

Porque el sarampión puede ser peligroso. Un tendrá que volver a aprender a caminar después de sufrir una de las complicaciones más inmediatas: inflamación del cerebro.

Y, a veces, el virus deja una bomba de tiempo en el sistema nervioso.

Una persona puede recuperarse del sarampión y continuar con su vida normal, ya no contagiar y no presentar síntomas identificables —a veces durante una década o más— antes de que aparezcan problemas. Aunque algunos pacientes quedan gravemente discapacitados por un tiempo, Khakoo dijo que la enfermedad casi siempre es mortal.

Antes de la aparición de vacunas eficaces y de uso masivo, esta complicación ocurría con suficiente frecuencia en Estados Unidos como para que, en la década de 1960, un doctor creara un de pacientes con PEES.

Los que aproximadamente 1 de cada 10.000 personas que contraen sarampión desarrollará PEES, pero el riesgo es mucho mayor para quienes se infectan antes de los 5 años. En países muy poblados donde el virus es endémico, como India, los casos se ven con regularidad.

Ahora, doctores e investigadores temen que, a medida que bajan las tasas de vacunación y el sarampión se propaga en Estados Unidos, los casos de esta complicación debilitante también aumenten.

Desde el inicio de 2025, los Centros para el Control y la Prevención de Enfermedades (CDC) —más que en toda la década anterior— en su mayoría en personas no vacunadas. Muchos eran niños.

El año pasado, doctores en Connecticut y, en California, otro en edad escolar que había tenido sarampión cuando era bebé .

“Es probable que veamos más casos de PEES en el futuro, especialmente si no controlamos esto”, dijo , miembro del Comité de Enfermedades Infecciosas de la Academia Americana de Pediatría y autor del libro .

La preocupación por la PEES fue lo suficientemente grande como para que en enero la Child Neurology Society para educar a los médicos estadounidenses sobre la enfermedad. Los doctores que han visto estos casos también están advirtiendo a sus colegas.

“No tenemos una forma de saber quién la va a desarrollar, ni una manera muy efectiva de tratarla”, señaló , profesor de neurología en la Escuela de Medicina de la New York University Grossman. “Lo mejor que podemos hacer, idealmente, es evitar que los niños tengan que pasar por esto en primer lugar”.

La vacuna contra el sarampión recomendada en dos dosis reduce el riesgo de que una persona expuesta contraiga el virus contagioso del  y, por lo tanto, disminuye la posibilidad de desarrollar PEES.

Las vacunas tienen pequeños riesgos de y un , pero el sarampión tiene un riesgo mayor de causar ambos.

Casos en Estados Unidos

Un sobre niños en California que desarrollaron PEES después de un brote de sarampión ocurrido años antes determinó que se diagnostica 1 caso por cada aproximadamente 1.400 casos conocidos de sarampión en niños menores de 5 años, y 1 por cada 600 bebés infectados.

Los investigadores también encontraron que, con los años, los doctores habían pasado por alto algunos casos en pacientes que murieron con enfermedades neurológicas no diagnosticadas.

La posibilidad de que casos futuros pasen desapercibidos llevó a y a sus colegas a publicar un comunicado en septiembre cuando un niño del condado de Los Ángeles .

“Hemos tenido muy pocos casos de sarampión en los últimos 25 años en este país”, dijo Yeganeh, directora médica del Vaccine Preventable Disease Control Program del departamento de salud pública del condado de Los Ángeles, quien ha tenido dos pacientes con PEES. “Desafortunadamente, eso está cambiando y queríamos asegurarnos de que todos supieran de esta complicación a largo plazo”.

El niño de California que murió había contraído sarampión cuando era bebé, dijo Yeganeh, antes de que pudiera recibir la vacuna.

El sarampión es altamente contagioso, por lo que al menos el 95 % de la población debe ser inmune para proteger a las personas vulnerables de la infección, incluidos bebés demasiado pequeños para vacunarse y personas con sistemas inmunológicos debilitados.

“Este es un ejemplo de alguien que hizo todo bien, que quería proteger a su hijo contra esta infección y, lamentablemente, terminó perdiendo a su hijo porque no teníamos inmunidad colectiva”, agregó Yeganeh.

Poco después de que el grupo de Yeganeh publicara el comunicado en California, Nelson también estaba tratando de difundir la información.

Recientemente había visto a un niño de 5 años cuya familia había viajado a Estados Unidos para recibir atención médica después de que el pequeño empezara a tropezar, a tener sacudidas, a alucinar con insectos y animales y a sufrir convulsiones. El niño había contraído sarampión cuando era bebé, cuando todavía era demasiado pequeño para vacunarse. Nelson le diagnosticó PEES.

“Imagínese: tener un hijo sano y feliz que empieza a hablar cada vez menos y finalmente ya no puede caminar”, dijo Nelson. “Es algo muy triste”.

Pensó que solo encontraría esta enfermedad en los libros de texto de la escuela de medicina, como una reliquia del pasado. Sin embargo, en octubre terminó presentando el caso en la conferencia nacional de la Child Neurology Society y participó en el video de la organización sobre la enfermedad.

“Ahora he visto algo que nunca debería haber visto en toda mi carrera”, dijo.

Señales de advertencia desde India

A nivel mundial, el número de brotes de sarampión en los últimos años, y médicos en lugares como el e han visto recientemente grupos de casos de PEES.

El alto costo humano de la propagación del sarampión es especialmente evidente en India. Aunque el número total de casos no se registra, alrededor de 200 familias que cuidan a personas con PEES, incluida la familia de Deepanwita, participan en un mismo grupo de chat en el área de Bangalore.

En Nueva Delhi, Sheffali Gulati estudia y atiende a unos 10 nuevos pacientes al año con esta enfermedad, lo que ella llama el “eco tardío” de los brotes de sarampión. El paciente más joven que ha visto tenía 3 años.

“Las edades y la muerte o un estado vegetativo pueden desarrollarse entre seis meses y cinco años después del inicio”, dijo Gulati, quien dirige el programa de neurología pediátrica del y hasta hace poco dirigía la .

Gulati no ha encontrado tratamientos que reviertan el curso de la SSPE, solo algunos que pueden ralentizar su progreso. A menudo termina aconsejando a los padres: es una situación catastrófica, no es culpa de ellos y no pueden hacer nada más que aceptarlo.

Los familiares de Deepanwita tratan de encontrar momentos de alegría donde pueden. Creen que la niña sonrió cuando su primo favorito la llamó recientemente. Anindita Dasgupta, su madre, dijo que Deepanwita mueve las manos y los pies por sí sola y a veces gira la cabeza, especialmente cuando su padre entra a la habitación.

La niña se comunica con sus padres con los ojos y algunos sonidos.

Pero está muy lejos de cómo estaba en 2022. En el cumpleaños de un primo, unos meses antes de que empezaran los síntomas evidentes, Deepanwita fue quien cantó la canción de cumpleaños más fuerte.

En su propia fiesta de cumpleaños número ocho el año pasado, Deepanwita, con un vestido rosa y un tubo nasal, solo podía parpadear y mover los ojos mientras estaba sentada frente a dos pasteles que no podía comer. Ya no puede tragar, así que su mamá le puso un poco de glaseado en la lengua.

Investigación que no debería ser necesaria

, biólogo molecular de la Clínica Mayo en Rochester, Minnesota, ha estudiado la PEES durante años. Recientemente utilizó tejido cerebral obtenido después de la muerte para mapear cómo el virus del sarampión puede propagarse desde la corteza frontal hasta colonizar todo el cerebro.

Aun así, dijo que sigue siendo una “caja negra” entender exactamente qué hace el virus durante los años en que permanece inactivo entre la infección inicial y la aparición de síntomas de daño neurológico.

Es posible que el virus se replique en el cerebro durante todo ese tiempo sin ser detectado y vaya destruyendo neuronas. Pero con tantas neuronas en el cerebro humano —10 veces más que el número de personas que viven en el planeta— el cerebro puede encontrar formas de adaptarse, dijo Cattaneo, hasta que finalmente ya no puede.

Ahora ha solicitado financiamiento para continuar investigando la enfermedad y posibles tratamientos, aunque en realidad desearía no tener que hacerlo. Las herramientas para eliminar esta enfermedad ya existen.

“El problema podría resolverse con la vacunación”, dijo Cattaneo. “Estados Unidos no debería tener ningún caso de PEES. Es simplemente doloroso”.

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Relatives described the unicorn-loving child as smart, affectionate, and occasionally rascally. Before she learned the alphabet, she had figured out how to find her favorite show, Blippi, on a phone. She was known to sneak butter from the fridge to enjoy a few finger licks.

But then her limbs started jerking. A spinal tap revealed measles in her cerebrospinal fluid. The virus she probably had as an infant had secretly made its way to her brain. Now 8 years old, Deepanwita is paralyzed, unable to talk.

Measles causes complications — ranging from diarrhea to death — in , according to the Infectious Diseases Society of America. Some are immediate, while others take weeks or months to appear. The one Deepanwita is experiencing, subacute sclerosing panencephalitis, or SSPE, typically takes years to rear its head.

“People think, ‘Oh, you know, if we get measles, then we’ll be fine, because I know my neighbor had it and they’re fine,’” said , who leads the national Child Neurology Society but spoke to Â鶹ŮÓÅ Health News in her capacity as a New York City doctor with expertise in neurologic conditions.

Measles, though, can be dangerous: A will have to relearn how to walk after enduring one of the more immediate complications, brain swelling. And every so often, the virus plants a ticking time bomb in the nervous system. A person can recover from measles and continue life as usual, no longer contagious and without any identifiable symptoms — sometimes for a decade or more — before problems appear. While some patients end up severely disabled for a while, Khakoo said, the condition is almost always fatal.

Before the advent of widespread and effective vaccines, the complication occurred enough in the U.S. that in the 1960s a doctor created of SSPE patients. Researchers about 1 in 10,000 people who get measles will develop SSPE, but the risk is significantly higher for those who contract measles before age 5. Populous nations where the virus is endemic, including India, see cases routinely.

Now, doctors and researchers fear that as vaccination rates drop and measles spreads in the U.S., cases of this debilitating complication will also rise here. Since the start of 2025, the over 3,500 measles cases — more than in the entire preceding decade — mostly people who were unvaccinated. Many were children. Last year, Connecticut doctors with SSPE, and in California, a school-age child who’d had measles as an infant .

“We are likely to see SSPE cases going forward, especially if we don’t get this under control,” said , a member of the American Academy of Pediatrics’ Committee on Infectious Diseases and author of the book .

Concern about SSPE was great enough that in January, the Child Neurology Society to educate U.S. clinicians about the condition, and doctors who have seen such cases are warning their peers.

“We don’t have a way of knowing who’s going to get it, and we don’t have a way of very effectively treating it,” said , a professor of neurology with the New York University Grossman School of Medicine. “The one best thing that we can do, ideally, is to prevent children from having to go through it in the first place.”

The recommended two-dose measles vaccine slashes an exposed person’s risk of getting the contagious virus from — and thus reduces the chance of SSPE. The vaccines carry small risks of and a , but measles itself has a higher risk of causing both.

Cases in the U.S.

A of California children who developed SSPE after a measles outbreak there years ago determined that 1 case is diagnosed for about every 1,400 known cases of measles in children under age 5, and 1 for every 600 infected babies.

The researchers also found that, over the years, doctors had missed some cases among patients who had died with undiagnosed neurologic illness.

The possibility that future cases could go undiagnosed spurred and her colleagues to publish a news release in September when a Los Angeles County child .

“We’ve had very few cases of measles in the last 25 years in this country,” said Yeganeh, who is the medical director with the Vaccine Preventable Disease Control Program at the Los Angeles County public health department and has had two patients with SSPE. “Unfortunately, that’s changing, and so we wanted to make sure that everyone was aware of this long-term complication.”

The California child who died had gotten measles as an infant, Yeganeh said, before the child could receive the vaccine. Measles is highly contagious, so at least 95% of the population must be immune to it to protect vulnerable people — including babies too young to vaccinate and people who are immunocompromised — from infection.

“This is an example of someone who did everything right, wanted to protect their child against this infection, and unfortunately ended up losing their child because we didn’t have herd immunity for them,” Yeganeh said.

Shortly after Yeganeh’s group published the news release in California, Nelson was working to get the word out, too.

He had recently seen a 5-year-old whose family had traveled to the U.S. for medical care after the child started stumbling, jerking, hallucinating about bugs and animals, and having seizures. The child had contracted measles as an infant and had been too young to be vaccinated. Nelson diagnosed the child with SSPE.

“Imagine that: Having a child who is healthy and happy, moving to talking less and less, eventually not able to walk,” Nelson said. “It’s a very sad thing.”

He thought he would encounter the condition only in medical school textbooks, as a relic of the past. Instead, in October he found himself presenting the case at the Child Neurology Society’s national conference and participating in the society’s video about the condition. “I’ve now seen something I shouldn’t have ideally seen ever in my career,” he said.

Warning Signs From India

Globally, the number of measles outbreaks in recent years, and physicians in places including and have recently seen clusters of SSPE.

The high human cost of measles’ spread is especially evident in India. While total cases aren’t tracked, about 200 families caring for people with SSPE, including Deepanwita’s, are in a single chat group in the Bangalore area.

In New Delhi, Sheffali Gulati and sees about 10 new patients a year with the condition, what she calls the “delayed echo” of measles outbreaks. The youngest she has seen was 3 years old.

“The ages are , and a death or a vegetative state can develop as soon as in six months to five years of onset,” said Gulati, who leads the pediatric neurology program at the and until recently led India’s .

Gulati hasn’t found any treatments that reverse SSPE’s course, only some that slow its progress. She’s found herself counseling parents: It’s catastrophic, it’s not their fault, and they can do nothing but accept it.

Deepanwita’s relatives try to find joy where they can. They think they noticed the girl smiling when her favorite cousin called recently. Anindita Dasgupta, her mother, said Deepanwita moves her hands and feet on her own and sometimes turns her head, especially when her father enters the room. The girl communicates with her parents through her eyes and a few sounds.

But it’s far from where she was in 2022: At a cousin’s birthday, a few months before noticeable symptoms started, Deepanwita started the birthday song and sang the loudest.

At her own 8th-birthday gathering last year, Deepanwita, wearing a pink eyelet dress and a nasal tube, could only blink and move her eyes as she sat propped up before two cakes that she would not be able to eat. She can no longer swallow, so her mom dabbed a bit of icing on her tongue.

Research That Shouldn’t Be Needed

, a molecular biologist at the Mayo Clinic in Rochester, Minnesota, has been for years. He recently used postmortem brain tissue to map how the measles virus can spread from the frontal cortex to colonize the entire brain. Still, he said it’s a “black box” what exactly measles is doing in those dormant years between the initial infection and when the symptoms of neurologic damage crop up.

It’s possible the virus replicates in the brain that whole time, undetected, killing off neurons. But with so many neurons in the human brain — 10 times as many as people living on the planet — the brain may find a way to adjust, Cattaneo said, until finally it can’t anymore.

He’s applying for funding to continue research on the disease and possible treatments, though ultimately, he wishes he didn’t have to. The tools to obliterate the condition already exist.

“The problem could be solved with vaccination,” Cattaneo said. The U.S. should have no cases of SSPE, he said. “It’s just painful.”

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The legislation introduced in , , , , , , , and builds on efforts made in other states in past years. This latest push for patient protections comes as the Trump administration has backed away from federal debt protections, health care has become , and more people are expected to go without medical coverage or but riskier high-deductible insurance plans that could lead them into debt.

“In the wealthiest country on Earth, people are going bankrupt, suffering wage garnishment, just because they get sick,” said Colorado state Rep. , a Democrat who introduced legislation on Feb. 19 that would, among other measures, ban wage garnishment for medical debt.

That legislation is under consideration after a Â鶹ŮÓÅ Health News investigation found that courts approved wage garnishment requests in an estimated 14,000 medical debt cases a year in Colorado. The investigation also showed that it isn’t just urban hospitals or big health care chains allowing their patients’ wages to be garnished. It’s also small rural hospitals, physician groups, and public ambulance services, among other medical care providers. And the reporting showed that wage garnishment can erroneously target patients. For example, one family lost wages — and subsequently power to their home, because they couldn’t pay their electric bill — after an ambulance company incorrectly billed the family instead of Medicaid.

Wage garnishment is one tool creditors can use in most states to recoup money from people with unpaid bills. In many states, they can garnish someone’s bank account or put a lien on their home, too. To garnish a person’s wages, a creditor must typically get permission from a court to make the person’s employer hand over a piece of the debtor’s earnings.

“The creditor is taking the money directly out of somebody’s paycheck, and so it doesn’t leave people with any choice to say, ‘I need to prioritize food for my children,’” said , legal and policy director for the National Center for Access to Justice. The center, based at Fordham Law School, and the District of Columbia on how fair their laws are to consumers who get sued over debt.

It is legal to garnish patients’ wages for medical debt in all but a , according to the Commonwealth Fund, a nonprofit foundation based in New York focused on health care.

Now, lawmakers in additional states seek to ban the practice entirely. Others want to limit it by exempting debtors whose household income falls under a certain threshold or by upping the amount of earnings immune from garnishment.

Such policies on wage garnishment fit into a larger push around the country to address the effect of medical debt on people’s lives and finances. Those efforts include barring medical debt from credit reports, prohibiting liens on people’s homes, capping interest rates, and limiting the ability to file lawsuits against people with low incomes over unpaid medical bills.

Debt collectors have fought against such measures, arguing they don’t solve the problem of health care affordability and hurt the ability of medical providers to continue to provide care.

“The wage garnishment process is already highly regulated at the federal and state level and includes many consumer protection measures,” said Scott Purcell, chief executive of warning its clients that the legislation “poses an existential threat,” especially to rural health providers. And Bridget Frazier, a spokesperson for the , said Feb. 20 that the bill “could drive up costs and financial risk for health care providers, making it harder to keep hospitals sustainable and ensuring Coloradans have access to care when they need it most.”

The pending Colorado measure would ban wage garnishment for all patients. It also would limit bank garnishments, in which a patient’s financial institution must hand over a chunk of the money in the person’s account. Additionally, among other things, it would prevent payment plans from exceeding 4% of weekly net income, require creditors to check whether uninsured patients are eligible for public health insurance before collecting, bar creditors from collecting on bills that are more than three years old, and leave medical care providers liable to the patient for at least $3,000 if collectors don’t comply.

“No one is saying, ‘Don’t get paid for your services.’ We’re saying getting health care should not lead to financial ruin for people,” said Dana Kennedy, co-executive director at the Denver-based , a health advocacy group that has been working with lawmakers on the Colorado measure.

Kennedy said that Â鶹ŮÓÅ Health News’ investigation drove home how many kinds of Colorado health care facilities are willing to let this collection practice happen to their patients, and that the people whose wages are being garnished are often working at Family Dollar, Walmart, Amazon, or gas stations and restaurants.

“Medical debt is typically different from other forms of indebtedness,” said Colorado state Sen. , a Democrat co-sponsoring the legislation. “You could choose to keep driving your old car or buy a new one and take on debt for that. You could upgrade your home. You could buy consumer appliances. There’s not usually that voluntary element in a health care context.”

, a senior attorney with the National Consumer Law Center, said broad laws that don’t require patients to jump through hoops to access protections are the most likely to be effective. Because of that, she and other consumer advocates prefer state policies that get rid of wage garnishment for all debtors and all types of debt.

“It can be hard to identify medical debt as medical debt,” Carter said. “For example, if you have a medical debt and you put it on your credit card, it’s not going to be easy for a court system to identify that debt as medical debt.”

She said another reason is that complexity is the enemy of effectiveness. Carter pointed to a showing that even though people in the state can keep $10,000 in their bank accounts safe from garnishment, few consumers take advantage of the protection. They must know the protection exists, know where to find the relevant form, get the form notarized, file it, and mail copies to creditors. The same report found that garnishments can also be burdensome for employers, who must process garnishments and can find themselves in court if they make an error.

Jones, at the National Center for Access to Justice, said outlawing wage garnishment fully, rather than limiting it, has other benefits. “It’s also to protect people’s jobs, because in most states, if somebody has two or more orders of garnishment, they can lose their job for it,” she said.

Still, some lawmakers are pushing for the intermediate route. In Washington state, Democratic state Sen. is spearheading legislation to rope off a larger portion of low-wage earnings from garnishment. So, for example, a person making $1,000 a week would be able to keep their whole paycheck, as opposed to the $800 that the law would currently protect.

Mindy Chumbley, owner of a Washington-based collections company and an ACA International board member, testified against the bill on Feb. 2. “Washington has made sweeping changes to medical debt policy year after year without pausing to study the cumulative impact,” she told lawmakers. “Our clients are reporting clinic closures, urgent care centers shutting down, staffing shortages, and rural facilities struggling to stay open.”

The Washington State Hospital Association said it is neutral on the legislation. The American Hospital Association said it does not take positions on state policies.

Liias told Â鶹ŮÓÅ Health News that lawmakers need to ensure health care providers can recoup their costs while also protecting patients. “We don’t want families either to be driven into bankruptcy or to be driven into under-the-table work to avoid these garnishment thresholds,” he said.

Liias said his measure follows the lead of Arizona, which passed similar consumer protections in 2022. “Obviously, the health care system is still functioning in Arizona, and folks are able to make it work.”

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In Alaska and Michigan, legislators are nonetheless advancing bills to keep medical debt off consumer credit reports.

The attorneys general of California and Colorado said they would stand behind credit reporting laws enacted in those states in recent years, even as Colorado faces a lawsuit from debt collectors contesting such laws.

Indiana and Ohio lawmakers have dropped proposals to remove medical debt from credit reports but are pushing legislation that would extend other protections to patients who cannot pay their medical bills.

“ of Alaska voters don’t think credit reports should include medical debt,” said state Rep. , a Democrat there. “I’m not going to wait on the courts on the medical debt issue.”

An estimated 100 million Americans are saddled with health care debt. And a growing number of red and blue states have enacted laws to protect patients.

But federal policy on such debt boomeranged this year when President Donald Trump’s administration chose not to defend federal regulations that would have removed medical debt from all Americans’ credit scores. And in October, Trump’s Consumer Financial Protection Bureau do not have the authority to regulate consumer credit reports.

“It’s sort of a head-spinning, 180-degree reversal,” said , an attorney with the National Consumer Law Center, which advocates for people with low incomes. She called the Consumer Financial Protection Bureau, now led by Project 2025 architect , the “evil twin” of its predecessor under President Joe Biden.

The bureau did not respond to requests for comment.

Eight days after the new federal guidance, debt collectors filed a lawsuit contesting Colorado’s 2023 medical debt credit reporting law, the first to require removal of some or all medical debt from credit reports.

Scott Purcell, CEO of , which is a debt collection trade group and a plaintiff in the Colorado suit, said removing the debt makes it harder to gauge creditworthiness, which he said would lead creditors to assume everyone is a riskier bet.

His also argues the Colorado law violates the First Amendment by suppressing “truthful commercial speech.”

Colorado Attorney General Phil Weiser, a Democrat, called the lawsuit outrageous in a statement to Â鶹ŮÓÅ Health News. His office, he said, “will strongly oppose all efforts to strip away critical medical debt protections.”

In California, Attorney General Rob Bonta, too, is standing firm on his state’s law regardless of how federal officials now interpret state rights. The Democrat told constituents in a : “Let me be clear: This remains the law in California.”

In other states still contemplating credit reporting laws, legislators are adjusting their strategy to account for the lawsuit and the Trump administration’s moves, by either ditching the plan to remove medical debt from credit reports or modifying such legislation.

Wu said her organization saw the federal change coming and had already urged state lawmakers to make pending legislation on credit reporting more lawsuit-proof by looking upstream and downstream of the credit reporting agencies. For example, Wu said, states can tell landlords, employers, or other credit report perusers that they cannot use a person’s medical debt history in their decision-making. And states can require health providers to include, in their contracts with debt collectors, limits on what they can tell credit reporting agencies about the bills they’re collecting.

“You’ll often hear providers say, ‘Oh, well, we don’t want to hurt our patients’ credit,’” she said. “Tell the debt collectors, ‘Don’t report this.’”

Alaska’s legislation has both elements: It bars landlords from making decisions about potential renters based on their medical debt history, and it bars providers and collectors from telling credit reporting agencies about patient debt.

Elsewhere, state lawmakers have opted out of trying to pass credit reporting provisions in proposed legislation. Indiana state Sen. , a Democrat, that tries to, among other things, cap interest rates, limit wage garnishment, and keep people from losing their homes over unpaid bills from medically necessary procedures. But he and his colleagues made a tactical decision to leave out credit reporting, after unsuccessfully including it in a similar bill last year.

“It’s out of legislative pragmatism,” Qaddoura said. “We want to be sure that you don’t get a piece of legislation killed with many benefits to tens of thousands of families just because one provision can’t go in.”

In Ohio, Democratic state Rep. made a similar calculation. She has been working on to ban wage garnishment over medical debt, cap interest rates for such debt at 3%, and scratch it from credit reports. She said she and other lawmakers recently removed the credit reporting portion.

“It’s better to pass something than nothing at all,” Grim said. “It still bans wage garnishment, which is a very aggressive, more-common-than-you-think practice. And it caps the interest rate.”

A recent investigation by Â鶹ŮÓÅ Health News found that, in Colorado alone, thousands of people each year have their wages garnished to pay back medical bills, and some people taken to court for medical debts never actually owed the money.

Legislative efforts to protect people from the effects of medical debt are often bipartisan, but that doesn’t mean they pass easily. Even before the Consumer Financial Protection Bureau reversed its stance on credit reports, several measures hit obstacles in conservative states this year, and legislation failed in Wyoming and South Dakota that aimed to take medical debt off credit reports.

Americans are largely protected from having their credit scores dinged by small medical debts. In 2023, the three big credit bureaus — TransUnion, Equifax, and Experian — to remove medical debts under $500 from their credit reports, and the Consumer Data Industry Association, a trade group for the companies, confirmed they are still doing so.

Even so, lawmakers in several states said they are deciding whether and how to get ahead of the federal guidance with legislation that tackles additional, larger medical debt on credit reports.

“We know that this will need to get beefed up,” said , a Democratic state senator in Michigan, of . She isn’t sure what that will look like, though consumer advocates including Libby Benton hope to see the measure follow Wu’s strategy.

“These aren’t debts that people choose to take on. People might choose to buy a huge pickup truck and that’s a bad financial decision,” said Benton, director of the Michigan Poverty Law Program. “People don’t choose to have emergency heart bypass surgery.”

Yet both can end up on a credit report.

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The texts were part of a pilot run to test technology the Trump administration says will make it easier for some Medicaid enrollees to prove they meet new requirements — working, studying, job training, or volunteering at least 80 hours a month — set to take effect in just over a year.

But only 894 people completed the quarterly wage check, or just under 7% of enrollees who got the text, according to Drew Maranto, undersecretary for the Louisiana Department of Health.

“We’re hoping to get more to opt in,” Maranto said. “We plan to raise awareness.”

The clock is ticking for officials in 42 states — excluding those that did not expand Medicaid at all — and Washington, D.C., to figure out how to verify that an estimated 18.5 million Medicaid enrollees meet rules included in President Donald Trump’s tax and spending law. They have until the end of next year, and federal officials are giving those jurisdictions a total of $200 million to do so.

The policy change is one of several to free up money for Trump’s priorities, such as increased border security and tax breaks that mainly benefit the wealthy.

The nonpartisan Congressional Budget Office has said the millions of people won’t be able to access health insurance over the next decade. It estimates changes to the Medicaid program will result in 10 million fewer Americans covered by 2034 — more than half of them because of the eligibility rules.

For now, state officials, health policy researchers, and consumer advocates are watching the pilot program in Louisiana and another in Arizona. , director of the Centers for Medicare & Medicaid Services, has touted those test-drives and said they will allow people to verify their incomes “within seven minutes.”

“There have been efforts to do this in the past, but they haven’t been able to achieve what we can achieve because we have technologies now,” said Oz, in August.

Brian Blase, the president of the conservative Paragon Health Institute and a key architect of Medicaid changes in the new law, has chimed in, saying during a that with today’s artificial intelligence “people should be able to seamlessly enter how they are spending their time.”

Â鶹ŮÓÅ Health News found scant evidence to support such claims. Federal and state officials have offered little insight into what new technology the two pilots have tested. They do say, however, that it connects directly with the websites of Medicaid enrollees’ payroll providers, rather than using artificial intelligence to draw conclusions about their activities.

Oz said the Trump administration’s efforts started “as soon as the bill was signed” in July. But work on the pilot programs .

And Medicaid is a state-federal program: The federal government contributes most of the funds, but it is up to the states to administer them, not the federal government.

“Oz can say, ‘Oh no, we’re going to fix this. We’re going to do this.’ Well, they don’t actually run the program,” said , a health policy researcher at Georgetown’s Center for Children and Families.

Officials have also offered few details about the pilots’ effectiveness in assisting enrollees in Medicaid or other public benefit programs.

The shortage of information has some state officials and health policy researchers worried that the Trump administration lacks viable solutions to help states implement the work rules. As a result, they say, people with a legal right to Medicaid benefits could lose access to them.

“What actually keeps me up at night is the fear that members that are eligible for Medicaid and are trying to get health care services would fall through the cracks and lose coverage,” said Emma Sandoe, Oregon’s Medicaid director.

Officials involved in the Louisiana and Arizona projects declined to answer many specific questions about their efforts, instead directing Â鶹ŮÓÅ Health News to federal officials.

Spokespeople for Arizona’s Medicaid and Economic Security departments — Johnny Córdoba and Brett Bezio, respectively — did not share data on how many people participated in the state’s pilot test nor describe the outcome. They said the pilot had been used to verify eligibility only for the federal Supplemental Nutrition Assistance Program, a smaller program than Medicaid.

The , a nonprofit that helps people sign up for such SNAP benefits, hadn’t heard of the pilot program.

State officials and health policy researchers said neither pilot program could confirm whether a person meets other qualifying activities — such as community service — or any of the numerous exemptions. The tools being tested can verify only income.

Andrew Nixon, director of communications for the U.S. Department of Health and Human Services, which oversees Oz’s agency, wrote in a statement that the digital tools officials aim to share with states “are largely under development.”

One person is Michael Burstein, who until recently worked at the U.S. Digital Service, which later became known as the Department of Government Efficiency.

As the U.S. Digital Service was turned into DOGE, Burstein and other staffers left and started a nonprofit called to finish supporting the technology to make it easier for people to verify their incomes for Medicaid enrollment.

But without permission from state officials, Burstein would not describe the tool in development, aside from saying that it’s mobile-first, can quickly verify income for a new or returning client, “and we’re pretty happy with it.”

The state agencies that manage benefit programs, such as Medicaid and SNAP, are understaffed, and they use different eligibility systems, many of which need updating, which makes improving them “a challenging task,” he said.

The $200 million in start-up costs the federal government has earmarked for systems to track work requirements equals roughly four times what it cost to administer Georgia’s Medicaid work requirement program alone.

That state, which has the nation’s only active work requirement program, called Georgia Pathways to Coverage, in September was granted a , despite a from a federal watchdog saying it hadn’t received enough federal oversight. A complicated sign-up process has kept enrollment in the program far below Georgia’s own projections.

Trump’s tax and spending law allows states to ask for extra time — until the end of 2028 — to start enforcing the rules, but only with the approval of HHS Secretary Robert F. Kennedy Jr. It also allows counties with high unemployment rates to be exempted, but states must apply for that exemption.

Even with an app that states can use to prove people are eligible for Medicaid, enrollees would still need to know that app existed and how to use it — neither of which is a given, Alker said. There is also no guarantee they’d have reliable cell service or internet access. As Â鶹ŮÓÅ Health News has reported, millions of Americans live in rural areas without reliable internet.

Private vendors also have been working on such apps, said , who researches Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities. Wagner said she has seen several vendors demonstrate products they plan to pitch to states for the work rules. Many are limited in scope, she said, like those in the pilot tests.

“Nobody has a magical solution that’ll make sure eligible people don’t lose coverage,” she said.

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Se había atendido en la sala de emergencias del hospital sin fines de lucro Montrose Regional Health en 2020, pero no recordaba que le hubieran llegado facturas por atención médica.

Por eso se sorprendió cuando, tres años después, su empleador recibió una orden judicial para que le retuviera parte de su salario y comenzara a derivarlo a una agencia de cobro por una factura médica impaga de que, con intereses y costos judiciales, .

El momento no podía ser peor. Luego de salir de un matrimonio problemático y vivir en un refugio, Knoll había conseguido la custodia total de sus tres hijos, una vivienda estable en Montrose, Colorado, y un trabajo en una gasolinera.

“Y justo en ese momento recibí la orden de embargo del tribunal”, contó. “Fue aterrador. Nunca había estado sola ni había criado a mis hijos sola”.

Â鶹ŮÓÅ Health News revisó 1.200 casos —registrados en Colorado entre el 1 de febrero de 2022 y el 1 de febrero de 2024— en los que la justicia había   autorizado embargar sueldos por deudas impagas. Al menos el 30% de esos casos estaban relacionados con servicios médicos, incluso cuando las facturas deberían haber sido cubiertas por Medicaid, el programa  de salud federal gerenciado por los estados para personas con bajos ingresos o discapacidades.

Ese 30% probablemente sea una subestimación, ya que muchas veces la deuda médica , como tarjetas de crédito o adelantos de sueldos. Pero incluso esa cifra mínima equivaldría a unos 14.000 casos al año, en los que los tribunales aprueban embargos de sueldo por deudas médicas en Colorado.

Otros hallazgos

• Se persiguió a los pacientes por facturas médicas que iban desde menos de $30 hasta más de $30.000, y la mayoría era menor de $2.400. A medida que los casos avanzaban en el sistema judicial, acumulando intereses y costos legales, las deudas solían crecer en un 25%. En un caso, se multiplicó por más del 400%.
• Las personas podían ser embargadas hasta 14 años después de haber recibido atención médica, incluso si cambiaban de trabajo.
• Detrás del cobro de esas deudas hay todo tipo de proveedores médicos: grandes cadenas de salud, hospitales rurales pequeños, grupos de médicos, servicios públicos de ambulancia, entre otros. En varios casos, los hospitales obtuvieron autorización para embargar el salario de sus propios empleados por facturas pendientes de pago por haberse atendido en esas mismas instituciones.

Sin embargo, Colorado no es una excepción: es uno de los 45 estados que permiten el embargo de sueldos por deudas médicas. Solo Delaware, Nueva York, North Carolina, Pennsylvania y Texas lo prohíben.

Como ha informado Â鶹ŮÓÅ Health News, la deuda médica es devastadora para millones de personas en todo el país. Y es probable que el problema se agrave aún más a nivel nacional. Se prevé que millones pierdan su seguro médico en los próximos años debido a los cambios en Medicaid introducidos en la ley fiscal y de presupuesto del presidente Donald Trump y si el Congreso permite que expiren algunos subsidios de la Ley de Cuidado de Salud a Bajo Precio (ACA).

Eso significa que, para quienes pierdan el seguro, la crisis de salud también podría convertirse en una espiral de deudas médicas

Y el daño perdurará: las grandes facturas médicas impagas seguirán apareciendo en los informes crediticios en la mayoría de los estados después de que, en julio, anuló una nueva norma destinada a proteger a los consumidores.

“Si no puedes mantener tu salud, ¿cómo vas a trabajar para pagar una deuda?”, dijo , subdirector de Colorado Consumer Health Initiative, una organización sin fines de lucro cuyo objetivo es reducir los costos de atención médica. “Y si, básicamente, no puedes pagar la factura, el embargo de tu salario no te va a ayudar a hacerlo. Te va a poner en una situación financiera aún más difícil”.

A ciegas ante la deuda médica

Cuando una persona no paga una deuda, el acreedor —ya sea que deba la reparación de una puerta de garaje, un préstamo para comprar un auto o atención médica— puede llevarla a juicio. También puede vender la deuda a una agencia de cobro o a un comprador de deuda, que a su vez puede hacer lo mismo.

“En cualquier momento, alrededor del 1% de los adultos con empleo están siendo embargados por alguna razón”, dijo , economista de la University of  Wisconsin-Madison, quien estudió datos de sueldos de ADP, una empresa que procesa las nóminas de alrededor del 20% de los trabajadores del sector privado en Estados Unidos. “Eso es una porción grande de la población”.

Sin embargo, hay pocos estudios específicos sobre la práctica de embargar salarios por deudas médicas. Estudios realizados en , y han demostrado que los hospitales sin fines de lucro frecuentemente embargan salarios y en muchos casos las personas afectadas tienen empleos de bajos ingresos.

Marty Makary, quien dirigió una investigación sobre este tema en Virginia desde la Johns Hopkins University, antes de unirse al gabinete de Trump como comisionado de la Administración de Alimentos y Medicamentos (FDA),

En un estudio que escribió con otros profesionales, Makary encontró que en 2017 el 36% de los hospitales en Virginia —la mayoría sin fines de lucro y en zonas urbanas— embargaban sueldos para cobrar deudas, afectando a miles de pacientes.

Sin embargo, los hallazgos de Â鶹ŮÓÅ Health News en Colorado muestran que los hospitales no son los únicos proveedores médicos que persiguen los cheques de pago de los pacientes.

Investigadores y defensores advierten que, además de la falta de datos en los tribunales, hay otro factor que oculta la magnitud del problema. “La gente siente vergüenza de tener deudas”, afirmó Lester Bird, gerente sénior de , especialista en temas judiciales. “Todo esto ocurre en las sombras”.

Sin datos sobre la frecuencia de esta práctica, los legisladores están tomando decisiones a ciegas, aunque una encuesta de  en 2024 reveló que 4 de cada 5 adultos creen que el gobierno federal debería ayudar a aliviar la deuda médica.

Embargos imposibles

Colorado fue que eliminaron la deuda médica de los informes de crédito. Además, los compradores de deuda no pueden embargar la vivienda de un paciente. Si quienes reúnen los requisitos aceptan pagar en cuotas mensuales, los pagos no deberían superar el 6% de los ingresos familiares y la deuda restante se cancela después de unos tres años de pagos.

Pero si no aceptan un plan de pago, a los habitantes de Colorado se les puede embargar disponibles. El National Consumer Law Center otorgó al estado una por la protección estatal de las finanzas familiares.

Grupos defensores dicen que no tienen certeza de que estas protecciones realmente se estén cumpliendo. Varias personas enviaron cartas a los tribunales advirtiendo que el embargo de salarios empeoraría su ya precaria situación financiera.

“Ya me estoy atrasando con el pago de la electricidad, el gas, el agua, las tarjetas de crédito”, escribió un hombre del oeste de Colorado a un juez, que Â鶹ŮÓÅ Health News obtuvo en los expedientes judiciales. Los registros muestran que trabajaba en construcción y en una tienda de alquiler con opción a compra y debía unos $8.000 por atención médica. Le dijo al juez que estaba pagando cerca de $1.000 al mes.

 “Si esto sigue así, voy a perderlo todo”, explicó.

Las personas demandadas que figuraban en la muestra se desempeñaban en muy diversos rubros: distritos escolares, ganadería, minería, construcción, gobiernos locales e incluso el propio sector de salud. Varias trabajaban en Walmart, Family Dollar, gasolineras, restaurantes o supermercados.

“Están golpeando a la gente cuando ya está en el suelo”, dijo Lois Lupica, exabogada de la organización , con sede en Denver, y del proyecto Debt Collection Lab de la Princeton University. “Básicamente están demandando a gente que no tiene ni un centavo para dar”.

En 2022, los tribunales autorizaron al sistema de salud Valley View, con sede en Glenwood Springs, a embargar el sueldo de una paciente por una factura médica de $400. La paciente trabajaba en una apoyaba como parte de los beneficios comunitarios que ofrece para mantener su estatus libre de impuestos.

Los hospitales sin fines de lucro como Valley View están obligados a proporcionar beneficios comunitarios, que pueden incluir atención gratuita que ayuda a cubrir las facturas médicas de los pacientes.

, directora de relaciones comunitarias de Valley View, dijo que ofrecen opciones como planes de pago sin intereses y atención gratuita o con descuento para familias con ingresos de hasta el 500% del nivel federal de pobreza.

“Como el proveedor de salud más grande de nuestra región rural, es fundamental para la salud y el bienestar de nuestra comunidad que Valley View siga siendo financieramente viable”, señaló. “La mayoría de nuestros pacientes trabajan con nosotros para desarrollar un plan de pago o solicitan asistencia financiera”.

La agencia de cobro que llevó a juicio a esa trabajadora, A-1 Collection Agency, se presenta en su sitio web : “Entendemos que los tiempos son difíciles y el dinero escasea”.

, encargada de operaciones de Healthcare Management —la empresa matriz de A-1— dijo que aceptan pagos desde $50 dólares mensuales y que la mayoría de los hospitales con los que trabajan permiten ofrecer un descuento si el paciente abona todo de una vez.

“Demandar a un paciente es absolutamente el último recurso”, afirmó. “Hacemos todo lo posible para trabajar con ellos”.

En algunas ocasiones, los hospitales embargan el salario de sus propios empleados por atención médica recibida en la misma institución. En un caso, una trabajadora del hospital pasó de ser empleada de limpieza a registradora y luego analista de calidad. Incluso participó en eventos públicos representando a su empleador y apareció en el sitio web del hospital como empleada destacada. Aun así, los tribunales emitieron órdenes de embargo hasta que pagó su deuda médica de $10.000.

“El cuidado hospitalario cuesta dinero”, argumentó Julie Lonborg, vocera de la Colorado Hospital Association, sobre esta práctica. “En cierto modo, me parece gracioso que nos hagan esta pregunta. Entendería si alguien preguntara: ‘¿Por qué no están embargando su salario?’”.

Según abogada sénior del National Consumer Law Center (Centro Nacional de Derecho del Consumidor), los embargos salariales representan solo el 0,2% de los ingresos hospitalarios.

“Y sabemos que hay estados que directamente no lo permiten”, añadió. “Los hospitales siguen brindando atención médica a los pacientes”.

Bueno para unos, malo para otros

Los prestadores de salud aparecieron como demandantes directos en solo el 2% de los casos de deuda médica. Casi todas las demandas fueron presentadas por agencias de cobro o compradores de deuda, siendo BC Services y Professional Finance Company responsables de más de la mitad, seguidos por A-1 Collection Agency y Wakefield & Associates.

Estas empresas ganan dinero comprando deudas que los proveedores ya dieron por perdidas y luego intentando cobrar lo que puedan, con intereses. Cobran un porcentaje de lo que logran recuperar. Algunas compañías hacen ambas cosas.

BC Services no hizo comentarios y Wakefield & Associates no respondió a las preguntas.

Charlie Shoop, presidente de Professional Finance Company, dijo que su empresa inicia embargos en menos del 1% de todas las cuentas que recibe para cobro.

Los proveedores de atención médica de Colorado ya no pueden esconderse detrás de los nombres de los cobradores de deudas cuando demandan a las personas. Lo prohibió una ley estatal de 2024 impulsada por una investigación de en colaboración con un proyecto informativo .

En muchos estados, el proceso de demanda y embargo es relativamente sencillo, sobre todo si la persona demandada no se presenta ante el tribunal.

“Es increíblemente fácil”, dijo Dan Vedra, un abogado de Colorado que representa a consumidores en casos de deuda. “Si tienes un procesador de textos y una hoja de cálculo, puedes generar miles de demandas en horas o minutos”.

En la muestra revisada por Â鶹ŮÓÅ Health News, casi todos los casos de deuda médica terminaron con sentencias en rebeldía, lo que significa que el paciente . Las ausencias pueden deberse a varios motivos: no recibir la notificación por correo, suponer que es una estafa, ignorarla deliberadamente o no poder ausentarse del trabajo.

Vedra y otros expertos dijeron que un alto número de sentencias en rebeldía indica un sistema que favorece a los acreedores por sobre los deudores y que aumenta la probabilidad de que alguien termine perjudicado por una factura incorrecta.

En New Hampshire, por ejemplo, los acreedores deben acudir al tribunal , ya que solo se les permite retener  salarios ya devengados, explicó , profesora investigadora asociada al Center on Health Insurance Reforms de la Georgetown University.

“No parece gran cosa en los papeles”, dijo. “Pero si tienen que regresar al tribunal una y otra vez, no les conviene”.

Demandados por error

El sistema de facturación médica en Estados Unidos tiende a generar errores debido a su complejidad, afirmó , profesor de Derecho en la George Washington University y académico sénior de Stanford Medicine. Richman ha estudiado . “Las facturas no solo son incomprensibles, sino que a menudo están equivocadas”, sostuvo.

De hecho, el Health Care Policy & Financing Department de Colorado, que administra Medicaid en el estado, indicó que durante el último año fiscal envió cerca de 11.000 cartas a proveedores y agencias de cobro que, erróneamente, intentaron exigir pagos a pacientes que estaban cubiertos por Medicaid. Las facturas de estos pacientes deben enviarse a Medicaid, no a ellos directamente, ya que normalmente solo pagan una cantidad simbólica, si acaso.

Shoop, de Professional Finance Company, dijo que su industria le ha pedido sin éxito al estado de Colorado acceso a una base de datos que le permita verificar si los pacientes están cubiertos por Medicaid.

El programa de Medicaid de Colorado no hizo comentarios.

Patricia DeHerrera, residente de Rifle, Colorado, tuvo que demostrar que ella y sus hijos estaban inscritos en Medicaid cuando recibieron atención en Grand River Health. Pero eso fue después de que A-1 contactara a quien era entonces su empleador, la cadena de gasolineras Kum & Go, llevando una orden judicial para retener parte de sus salarios.

DeHerrera contactó al estado, que y a la agencia de cobro notificándoles que estaban llevando a cabo una “acción de cobro ilegal” y ordenándoles detenerse. Las empresas acataron.

Theresa Wagenman, jefa de contabilidad de Grand River Health, explicó que si un paciente presenta un documento de Medicaid que demuestre su elegibilidad, la deuda se retira del proceso de cobro.

Wagenman también dijo que los pacientes reciben al menos ocho cartas por correo y varias llamadas telefónicas antes de que el hospital autorice al cobrador a llevar el caso a los tribunales.

El consejo principal de DeHerrera para otras personas en esta situación es este: “Conozcan sus derechos. Si no, se van a aprovechar de ustedes”.

Pero .

Nicole Silva, que vive en Sanford, un pueblo de 900 habitantes en el sur de Colorado, contó que toda su familia tenía cobertura de Medicaid cuando su hija sufrió un accidente automovilístico. Aun así, los registros judiciales muestran que le embargaron el salario por un traslado en ambulancia que costó $2.181,60  y que, con intereses y tarifas judiciales, .

Silva y se puso en contacto con la oficina de servicios sociales de su condado, pero dijo que no recibió ayuda y que no pudo comunicarse con la persona adecuada en la oficina estatal. El programa de Medicaid del estado confirmó a Â鶹ŮÓÅ Health News que su hija tenía cobertura en el momento del accidente.

Luchar contra la factura era demasiado para Silva y su marido, que tenían que criar a un número cada vez mayor de hijos, uno de ellos con una discapacidad grave. Y, además, trabajan: ella como profesora de preescolar y él en un rancho.

Dejar de recibir aproximadamente $500 al mes, que, según dijo, se le descontaban del sueldo, afectó su capacidad para pagar otras cuentas. “Teníamos que decidir entre comprar comida o pagar la electricidad”, explicó.

Cuando les cortaron el servicio eléctrico, tuvieron que pedir dinero prestado a colegas y amigos para restablecerlo, con un cargo adicional incluido.

Silva dijo que todo este proceso la hace dudar si en el futuro llamaría a una ambulancia.

Fox, de Colorado Consumer Health Initiative, señaló que muchos consumidores piensan que no pueden hacer nada para evitar que les retengan el salario. Sin embargo, pueden impugnar el embargo en el tribunal. Por ejemplo, señalando que deberían haber tenido derecho a una atención médica con descuento o gratuita si el hospital que brindó el servicio es una institución sin fines de lucro.

El economista DeFusco cree que declararse en  bancarrota bajo es una opción subutilizada por los deudores. La bancarrota detiene el embargo de inmediato, aunque no siempre de forma permanente, y tiene otras consecuencias. Pero entiende que es una situación sin salida: es un proceso complejo y usualmente requiere contratar a un abogado.

“Para deshacerse de la deuda, se necesita dinero”, afirma. “Y la razón por la que se encuentra en esta situación es precisamente porque no tiene dinero”.

El pasante de Â鶹ŮÓÅ Health News Henry Larweh, la editora de datos Holly K. Hacker, el editor de Mountain States Matt Volz y la editora web Lydia Zuraw contribuyeron con este informe.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

So she was shocked when, three years after the trip to the hospital, her employer received court orders requiring it to start funneling a chunk of her paychecks to a debt collector for an — which had from interest and court fees.

The timing was terrible. After leaving a bad marriage and staying in a shelter, she had just gotten full custody of her three children, steady housing in Montrose, Colorado, and a job at a gas station.

“And that’s when I got that garnishment from the court,” she said. “It was really scary. I’d never been on my own or raised kids on my own.”

Â鶹ŮÓÅ Health News reviewed 1,200 Colorado cases in which judges, over a two-year period from Feb. 1, 2022, through Feb. 1, 2024, gave permission to garnish wages over unpaid bills. At least 30% of the cases stemmed from medical care — even when patients’ bills should have been covered by Medicaid, the public insurance program for those with low incomes or disabilities. That 30% is likely an underestimate since medical debt is behind other types of debt, such as from credit cards or payday loans. But even that minimum would translate to roughly 14,000 cases a year in Colorado in which courts approved taking people’s wages because of unpaid medical bills.

Among the other findings:

• Patients were pursued for medical bills ranging from under $30 to over $30,000, with most of the bills amounting to less than $2,400. As the cases rolled through the legal system, accumulating interest and court fees, the amount that patients owed often grew by 25%. In one case, it snowballed by more than 400%.
• Cases trailed people for up to 14 years after they received medical care, with debt collectors reviving their cases even as they moved from job to job.
• Medical providers of all stripes are behind these bills — big health care chains, small rural hospitals, physician groups, public ambulance services, and more. In several cases, hospitals won permission to take the pay of their own employees who had unpaid bills from treatment at the facilities.

Colorado has company. It is one of 45 states that allow wage garnishment for unpaid medical bills. Only Delaware, New York, North Carolina, Pennsylvania, and Texas have banned wage garnishment for medical debt.

As Â鶹ŮÓÅ Health News has reported, medical debt is devastating for millions of people across the country. And now the problem is likely to grow more pressing nationwide. Millions of Americans are expected to lose health insurance in the coming years due to Medicaid changes in President Donald Trump’s tax and spending law and if Congress allows some Affordable Care Act subsidies to expire. That means health crises for the newly uninsured could lead them, too, into a spiral of medical debt.

And the hurt will linger: Large unpaid medical bills are staying on credit reports in most states after a July reversed a new rule aimed at protecting consumers.

“If you can't maintain your health, how are you going to work to pay back a debt?” said , deputy director of the Colorado Consumer Health Initiative, a nonprofit aimed at lowering health costs. “And if you fundamentally can't pay the bill, wage garnishment isn't going to help you do that. It's going to put you in more financial distress.”

Flying Blind on Medical Debt

When someone fails to pay a bill, the creditor that provided the service — whether for a garage door repair, a car loan, or medical care — can take the debtor to court. Creditors can also pass the debt to a debt collector or debt buyer, who can do the same.

“At any given point, about 1% of working adults are being garnished for some reason,” said , an economist at the University of Wisconsin-Madison, who studied paycheck data from ADP, a payroll processor that distributes paychecks to about a fifth of private sector U.S. workers. “That's a big chunk of the population.”

But specific research into the practice of garnishing wages over medical debt is scant. Studies in , , and have found that nonprofit hospitals commonly garnish wages from indebted patients, with some studies finding those patients tend to work in low-wage occupations.

Marty Makary, who led research on medical debt wage garnishment in Virginia at Johns Hopkins University before joining Trump’s cabinet as Food and Drug Administration commissioner, has He co-authored a study that found 36% of Virginia hospitals, mostly nonprofit and mostly in urban areas, were using garnishment to collect unpaid debts in 2017, affecting thousands of patients.

The Colorado findings from Â鶹ŮÓÅ Health News show that hospitals are far from the only medical providers going after patients’ paychecks, though.

Researchers and advocates say that, in addition to a dearth of court case data, another phenomenon tends to obscure how often this happens. “People find debt shameful,” said Lester Bird, a senior manager at the who specializes in courts. “A lot of this exists in the shadows.”

Without data on how often this tactic is employed, lawmakers are flying blind — even as a 2024 about 4 in 5 U.S. adults believe it’s important for the federal government to provide medical debt relief.

‘Blood From a Turnip’

Colorado was of to scratch medical debt from credit reports. Debt buyers in the state aren’t allowed to foreclose on a patient’s home. If qualified patients opt to pay in monthly installments, those payments shouldn’t exceed 6% of their household income — and the remaining debt gets wiped after about three years of paying.

But if they don’t agree to a payment plan, Coloradans can have of their disposable earnings garnished. The National Consumer Law Center gave the state a for state protections of family finances.

Consumer advocates said they aren’t sure how well even those Colorado requirements are being followed. And people wrote letters to the courts saying wage garnishment would exacerbate their already dire financial situations.

“I have begun to fall behind on my electricity, my gas, my water my credit cards,” to a judge that Â鶹ŮÓÅ Health News obtained in the court filings. Court records show he was working in construction and at a rent-to-own store, with about $8,000 in medical debt. He wrote to the judge that he was paying close to $1,000 a month. “The way things are going now I will lose everything.”

The people being sued in Â鶹ŮÓÅ Health News’ Colorado review worked in a wide array of jobs. They worked in school districts, ranching, mining, construction, local government, even health care. Several worked at stores such as Walmart and Family Dollar, or at gas stations, restaurants, or grocery stores.

“You're really kicking people when they're down,” said Lois Lupica, a former attorney working with the Denver-based and the Debt Collection Lab at Princeton. “They're basically suing the you-can't-get-blood-from-a-turnip population.”

In 2022, court records show, Valley View health system based in Glenwood Springs was allowed to garnish the wages of one of its patients over a $400 medical bill. The patient was working at a local organization that the as part of the community benefits it provides to keep its tax-exempt status. Nonprofit hospitals like Valley View are required to provide community benefits, which can also include charity care that covers patients’ bills.

, the health system’s chief community relations officer, said it offers options such as interest-free payment plans and care at reduced or no cost to families with incomes up to 500% of the federal poverty level.

“As our rural region’s largest healthcare provider, it is imperative to the health and well-being of our community that Valley View remains a financially viable organization,” she said. “Most of our patients work with us to develop a payment plan or pursue financial assistance.”

The collection agency that took the employee to court, A-1 Collection Agency, as empathetic: “We understand times are tough and money is tight.”

, who oversees operations at A-1’s parent company, Healthcare Management, said it accepts payment plans as small as $50 a month and that most of the hospitals it works with allow it to offer a discount if patients pay all at once.

“Suing a patient is the absolute last resort,” she said. “We try everything we can to work with the patient.”

If you can't maintain your health, how are you going to work to pay back a debt?

Adam Fox, deputy director of the Colorado Consumer Health Initiative

Hospitals sometimes also garnish wages from their own employees for care they provided them. In one case, a hospital employee worked her way up from housekeeper to registrar to quality analyst. She even participated in public events representing her employer and appeared on the hospital’s website as a featured employee — while the court issued writs of garnishment until her $10,000 in medical bills from the hospital was paid off.

“Hospital care costs money to deliver,” said Colorado Hospital Association spokesperson Julie Lonborg about hospitals’ garnishing their own employees’ wages. “In some ways, I think it's funny to be asked the question. I would understand if someone said, ‘Why aren't you garnishing their wages?’”

Studies show that hospital debt collection efforts through wage garnishment bring in only about 0.2% of hospital revenues, said , a senior attorney with the National Consumer Law Center, which advocates for people with low incomes.

"We also know that there are states that don't allow this at all,” she said. “Hospitals are continuing to provide medical care to consumers.”

Smooth Sailing for Collectors — But Not for Patients

Health care providers appeared as the plaintiffs in only 2% of the medical debt cases. Instead, cases were filed almost entirely by third-party debt collectors and buyers, with BC Services and Professional Finance Company behind more than half of the cases, followed by A-1 Collection Agency and Wakefield & Associates.

Debt buyers make money by buying debt from providers who’ve given up on getting paid then collecting what they can of the money owed, plus interest. Debt collectors get paid a percentage of what they recover. Some companies do a bit of both.

BC Services declined to comment, and Wakefield & Associates did not respond to questions.

Charlie Shoop, president of Professional Finance Company, said his company initiates wage garnishment on less than 1% of all accounts placed with it for collection.

Health care providers in Colorado can no longer hide behind debt collectors’ names when they sue people, according to a prompted by a in partnership with a .

In many states, the path for filing a case against a debtor and garnishing their wages is relatively smooth — especially if the debtor doesn’t appear in court.

“It's unbelievably easy,” said Dan Vedra, a lawyer in Colorado who often represents consumers in debt cases. “If you have a word processor and a spreadsheet, you can mass-produce thousands of lawsuits in a matter of hours or minutes.”

Within Â鶹ŮÓÅ Health News’ sample, nearly all the medical debt cases were default judgments, meaning the patient did not in court or in writing. Missing a court date can happen for a variety of reasons, such as not receiving the notice in the mail, assuming it was a scam, knowingly ignoring it, or not having the time to take off from work.

Vedra and other debt law experts said a high rate of default judgments indicates a system that favors the pursuers over the pursued — and increases the chances someone will be harmed by an erroneous bill.

But in New Hampshire, creditors now have to keep going to court for each paycheck they want to garnish, because to garnish only wages that have already been earned, said an associate research professor at the Center on Health Insurance Reforms at Georgetown University.

“It might not look like much on paper,” she said. “It's just not worth it if they have to keep going back to court.”

If you have a word processor and a spreadsheet, you can mass-produce thousands of lawsuits in a matter of hours or minutes.

Dan Vedra

Wrongly Pursued for Bills

The nation’s medical billing setup is already prone to errors due to its complexity, according to , a law professor at George Washington University and a senior scholar at Stanford Medicine who has in several states. “Bills are not only noncomprehensible, but often wrong,” Richman said.

Indeed, Colorado’s Health Care Policy & Financing Department, which runs Medicaid in the state, said it sent out nearly 11,000 letters in the past fiscal year to health providers and collectors that erroneously went after patients on Medicaid. Bills for Medicaid recipients are supposed to be sent to Medicaid, not the patients, who typically pay a nominal amount, if anything, for their care.

Shoop said his industry has pushed Colorado, without success, for access to a database that would allow them to confirm if patients had Medicaid coverage.

Colorado’s Medicaid program declined to comment.

Patricia DeHerrera in Rifle, Colorado, had to prove that she and her children had Medicaid when they received care at Grand River Health — but only after A-1 contacted her employer at the time, the gas station chain Kum & Go, with court-approved paperwork to take a portion of her paychecks.

She contacted the state, which to the hospital and the collector notifying them they were engaging in “illegal billing action” and telling the collector to stop. The companies did.

Theresa Wagenman, controller for Grand River Health, said if a patient can present a letter from a Medicaid caseworker saying they’re eligible, then their bills get removed from the collections pipeline. Wagenman also said patients get at least eight letters in the mail and several phone calls before Grand River gives the go-ahead for the collector to send them to court.

DeHerrera’s main advice to others in this situation: “Know your rights. Otherwise, they’re going to take advantage of you.”

Yet isn’t easy.

Nicole Silva, who lives in the 900-person town of Sanford in south-central Colorado, said she and her family were all on Medicaid when her daughter was in a car crash. Still, court records show, her wages were garnished for a $2,181.60 ambulance ride, which grew to from court fees and interest.

She the bill was wrong, contacting her county’s social services office, but Silva said it wasn’t helpful and she wasn’t able to reach the right person at a state office. The state Medicaid program confirmed to Â鶹ŮÓÅ Health News that her daughter was covered at the time of the wreck.

Fighting the bill felt like too much for Silva and her husband to handle while parenting a growing number of kids, one of them severely disabled, and working — she as a preschool teacher and he as a rancher.

Not receiving the roughly $500 a month that she said came out of her pay was enough to affect their ability to pay other bills. “It was deciding to buy groceries or pay the electric bill,” Silva said.

When their electricity got shut off, she said, they had to scramble to borrow money from colleagues and friends to get it turned back on — with an extra fee.

She said the saga makes her hesitant to call an ambulance in the future.

Fox, of the Colorado Consumer Health Initiative, said consumers often think they cannot do anything to stop their wages from being garnished, but they can contest it in court, for example by pointing out they should have qualified for discounted — or charity — care if the hospital that provided the treatment is a nonprofit.

DeFusco, the economist, believes filing for is an underused option for debtors. It halts garnishment in its tracks, though not always permanently, and it comes with other consequences. But he understands it’s a Catch-22: It’s a and typically necessitates hiring a lawyer.

“To get rid of your debt, you need money,” he said. “And the whole reason you're in this situation is because you don't have money.”

Methodology

We wanted to know how often Coloradans get their wages garnished due to medical debt. Courts don’t compile this information, and researchers and advocates haven’t tracked it systematically.

So we created our own database. We requested a list of all civil cases across the state in which judges gave permission for a person’s earnings to be garnished — known as writs of garnishment in court lingo — from Feb. 1, 2022, through Feb. 1, 2024. The provided a list from all courts except for Denver County Court, which provided its own records. The combined list comprised nearly 90,000 unique court cases. We split up the cases by county population — small (fewer than 10,000 people), medium (10,000 to 100,000 people), and large (more than 100,000 people) — then generated a random sample of 400 cases from each group to ensure we evaluated medical debt across counties of all sizes.

To identify medical debt cases, we looked at the original creditors named in court records, primarily the complaints or affidavits of indebtedness. Often, this information was available through . When it wasn’t available online, we asked county courthouses to send us supporting documents. We counted dentists as medical providers. We excluded 14 cases in which the debt wasn’t exclusively medical.

We looked only at cases in which courts approved money to be garnished from someone’s paycheck, as opposed to from other sources such as their bank accounts. We did not review garnishment cases involving child support, taxes, or federal student loans.

Â鶹ŮÓÅ Health News intern Henry Larweh, data editor Holly K. Hacker, Mountain States editor Matt Volz, and web editor Lydia Zuraw contributed to this report.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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The Department of Health and Human Services in late March canceled nearly 700 Centers for Disease Control and Prevention grants nationwide — together worth about $11 billion. Awarded during the covid-19 pandemic, they supported efforts to vaccinate people, reduce health disparities among demographic groups, upgrade antiquated systems for detecting infectious disease outbreaks, and hire community health workers.

Initially, grant cancellations hit blue and red states roughly evenly. Four of the five jurisdictions with the largest number of terminated grants were led by Democrats: California, the District of Columbia, Illinois, and Massachusetts.

But after attorneys general and governors from about two dozen blue states sued in federal court and won an injunction, the balance flipped. Of the five states with the most canceled grants, four are led by Republicans: Texas, Georgia, Oklahoma, and Ohio.

In blue states, nearly 80% of the CDC grant cuts have been restored, compared with fewer than 5% in red states, according to the Â鶹ŮÓÅ Health News analysis. Grant amounts reported in an HHS database known as the Tracking Accountability in Government Grants System, or TAGGS, often don’t match what states confirmed. Instead, this analysis focused on the number of grants.

The divide is an example of the polarization that permeates health care issues, in which access to safety-net health programs, abortion rights, and the ability of public health officials to respond to disease threats diverge significantly depending on the political party in power.

In an emailed statement, HHS spokesperson Andrew Nixon said the agency “is committed to protecting the health of every American, regardless of politics or geography. These funds were provided in response to the COVID pandemic, which is long over. We will continue working with states to strengthen public health infrastructure and ensure communities have the tools they need to respond to outbreaks and keep people safe.”

The money in question wasn’t spent solely on covid-related activities, public health experts say; it was also used to bolster public health infrastructure and help contain many types of viruses and diseases, including the flu, measles, and RSV, or respiratory syncytial virus.

“It really supported infrastructure across the board, particularly in how states respond to public health threats,” said Susan Kansagra, chief medical officer of the Association of State and Territorial Health Officials.

The Trump cutbacks came as the U.S. recorded its largest measles outbreak in over three decades and 266 pediatric deaths during the most recent flu season — the outside of a pandemic since 2004. Public health departments canceled vaccine clinics, laid off staff, and put contracts on hold, health officials said in interviews.

After its funding cuts were blocked in court, California retained every grant the Trump administration attempted to claw back, while Texas remains the state with the most grants terminated, with at least 30. As the CDC slashed grants in Texas, its measles outbreak spread across the U.S. and Mexico, sickening at least 4,500 people and killing at least 16.

Colorado, which joined the lawsuit, had 11 grant terminations at first, but then 10 were retained. Meanwhile, its neighboring states that didn't sue — Wyoming, Utah, Kansas, Nebraska, and Oklahoma — collectively lost 55 grants, with none retained.

In Jackson, Ohio, a half-dozen community health workers came to work one day in March to find the Trump administration had canceled their grant five months early, leaving the Jackson County Health Department half a million dollars short — and them without jobs.

“I had to lay off three employees in a single day, and I haven’t had to do that before. We don’t have those people doing outreach in Jackson County anymore,” Health Commissioner Kevin Aston said.

At one point, he said, the funding helped 11 Appalachian Ohio counties. Now it supports one.

Marsha Radabaugh, one employee who was reassigned, has scaled back her community health efforts: She’d been helping serve hot meals to homeless people and realized that many clients couldn’t read or write, so she brought forms for services such as Medicaid and the Supplemental Nutrition Assistance Program to their encampment in a local park and helped fill them out.

“We would find them rehab places. We’d get out hygiene kits, blankets, tents, zero-degree sleeping bags, things like that,” she said. As a counselor, she’d also remind people “that they're cared for, that they're worthy of being a human — because, a lot of the time, they're not treated that way.”

Sasha Johnson, who led the community health worker program, said people like Radabaugh “were basically a walking human 411,” offering aid to those in need.

Radabaugh also partnered with a food bank to deliver meals to homebound residents.

Aston said the abrupt way they lost the funds — which meant the county unexpectedly had to pay unemployment for more people — could have ruined the health district financially. Canceling funding midcycle, he said, “was really scary.”

HHS Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist and promoter of vaccine misinformation, a “cesspool of corruption.” At HHS, he has taken steps to undermine vaccination in the U.S. and abroad.

Federal CDC funding accounts for of state and local health department budgets, according to Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News. States that President Donald Trump won in the 2024 election received a higher share of the in fiscal 2023 than those that Democrat Kamala Harris won, according to Â鶹ŮÓÅ.

The Trump administration’s nationwide CDC grant terminations reflect this. More than half were in states that Trump won in 2024, totaling at least 370 terminations before the court action, according to Â鶹ŮÓÅ Health News’ analysis.

The Columbus, Ohio, health department had received $6.2 million in CDC grants, but roughly half of it — $3 million — disappeared with the Trump cuts. The city laid off 11 people who worked on investigating infectious disease outbreaks in such places as schools and nursing homes, Columbus Health Commissioner Mysheika Roberts said.

She also said the city had planned to buy a new electronic health record system for easier access to patients’ hospital records — which could improve disease detection and provide better treatment for those infected — but that was put on ice.

“We’ve never had a grant midcycle just get pulled from us for no reason,” Roberts said. “This sense of uncertainty is stressful.”

Columbus did not receive its money directly from the CDC. Rather, the state gave the city some funds it received from the federal government. Ohio, led by Republican Gov. Mike DeWine and a Republican attorney general, did not sue to block the funding cuts.

Columbus to keep its money, along with other Democratic-led municipalities in Republican-governed states: Harris County, Texas, home to Houston; the Metropolitan Government of Nashville and Davidson County in Tennessee; and Kansas City, Missouri. A federal judge in June blocked those cuts.

As of mid-August, Columbus was awaiting the funds. Roberts said the city won’t rehire staff because the federal funding was expected to end in December.

Joe Grogan, a senior scholar at the University of Southern California’s Schaeffer Institute and former director of the White House Domestic Policy Council in Trump’s first term, said state and local agencies “are not entitled” to the federal money, which was awarded “to deal with an emergency” that has ended.

“We were throwing money out the door the last five years,” Grogan said of the federal government. “I don’t understand why there would ever be a controversy in unspent covid money coming back.”

Ken Gordon, Ohio Department of Health spokesperson, wrote in an email that the $250 million in grants lost had helped with, among other things, upgrading the disease reporting system and boosting public health laboratory testing.

Some of the canceled HHS funding wasn’t slated to end for years, including four grants to strengthen public health in Indian Country, a grant to a Minnesota nonprofit focused on reducing substance use disorders, and a few to universities about occupational safety, HIV, tuberculosis, and more.

Brent Ewig, chief policy and government relations officer for the Association of Immunization Managers, said the cuts were “the predictable result of ‘boom, bust, panic, neglect’ funding” for public health.

The association represents 64 state, local, and territorial immunization programs, which Ewig said will be less prepared to respond to disease outbreaks, including measles.

“The system is blinking red,” Ewig said.

Methodology

Â鶹ŮÓÅ Health News’ analysis of Centers for Disease Control and Prevention grants sought to answer four questions: 1) How many grants have been terminated in the U.S. under the Trump administration since March? 2) Which states saw the most grants cut? 3) What were the grants for? and 4) Did the grant terminations affect blue, red, and purple states differently? This follows a similar analysis by Â鶹ŮÓÅ Health News for an article on nationwide NIH grant terminations.

Our primary data source was a Department of Health and Human Services website showing grant terminations. We compared an initial list of grant terminations from April 3 with one from July 11 to determine how many grants had been restored. The USAspending.gov database helped us track grants by state.

To classify states politically, we followed the same steps from our April coverage of National Institutes of Health grant terminations. States were “blue” if Democrats had complete control of the state government or if the majority of voters favored Democratic presidential candidates in the last three elections (2016, 2020, 2024). “Red” states were classified similarly with respect to the Republican Party. “Purple” states had politically split state governments and/or were generally considered to be presidential election battleground states. The result was 25 red states, 17 blue states, and eight purple states. The District of Columbia was classified as blue using similar methods.

This analysis does not account for potential grant reinstatements in local jurisdictions where the funds were awarded indirectly rather than directly from the CDC; it accounts only for the recipients’ location, and excludes grants terminated from Compacts of Free Association states and other foreign entities that received grants directly from the CDC. At least 40 CDC grants were terminated that were meant for global health efforts or assisting public health activities in other nations following the for the CDC to withdraw support for the World Health Organization.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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Silva’s daughter was on Medicaid, which was supposed to cover the cost of the ambulances. But one of the three ambulance companies, Northglenn Ambulance, a public company since , sent Silva’s bill to a debt collector. It was for $2,181.60, which grew to more than $3,000 with court fees and interest, court records show. The preschool teacher couldn’t pay, and the collector garnished Silva’s wages.

“It put us so behind on bills — our house payment, electric, phone bills, food for the kids,” said Silva, whose daughter recovered fully from the 2015 crash. “It took away from everything.”

Some state legislators are looking to curb bills like the one she received — surprise bills for ground ambulance rides.

When an ambulance company charges more than an insurer is willing to pay, patients can be left with a big bill they probably had no choice in.

States are trying to fill a gap left by the federal , which covers air ambulances but not ground services, including ambulances that travel by road and water. This year, Utah and North Dakota joined that have passed protections against surprise billing for such rides.

Those protections often include setting a minimum for insurers to pay out if someone they cover needs a ride. But the sticking point is where to set that bar. Legislation in Colorado and Montana stalled this year because policymakers worried that forcing insurers to pay more would lead to higher health coverage costs for everyone.

Surprise ambulance bills are one piece of a health care system that systematically saddles Americans with medical debt, straining their finances, preventing them from accessing care, and increasing racial disparities, as Â鶹ŮÓÅ Health News has reported.

“If people are hesitating to call the ambulance because they’re worried about putting a huge financial burden on their family, it means we’re going to get stroke victims who don’t get to the hospital on time,” said , who directs health care campaigns at PIRG, a national consumer advocacy group. “It means that person who’s worried it might be a heart attack won’t call.”

The No Surprises Act, signed into law by President Donald Trump in 2020, says that for most emergency services, patients can be billed for out-of-network care only for the same amount they would have been billed if it were in-network. Like doctors or hospitals, ambulance companies can contract with insurers, making them in-network. Those that don’t remain out-of-network.

But unlike when making an appointment with a doctor or planning a surgery, a patient generally can’t choose the ambulance company that will respond to their 911 call. This means they can get hit with large out-of-network bills.

Federal lawmakers punted on including ground ambulances, in part because of the variety of business models — from private companies to volunteer fire departments — and a lack of data on how much rides cost.

Instead, Congress created an that issued recommendations last year aimed at expanding protections from surprise ambulance bills got a unanimous thumbs-up in both legislative chambers.

Colorado had previously protecting people from surprise bills from private ambulance companies. This new measure was aimed at providing similar protections against bills from public ambulance services and for transfers between hospitals.

“We knew it had bipartisan support, but there are some people that vote no on everything,” said a pleasantly surprised , a Democratic state representative.

A less pleasant surprise came later, when Gov. Jared Polis, who is also a Democrat, vetoed it, citing the fear of rising premiums.

States can do only so much on this issue, because state laws apply only to state-regulated health plans. That leaves out a lot of workers. According to a by Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News, 63% of people who work for private employers and get health insurance through their jobs have , which aren’t state-regulated.

“It’s why we need a federal ambulance protection law, even if we passed 50 state laws,” Kelmar said.

According to data from the Colorado secretary of state’s office, the only lobbying groups the bill were Anthem and UnitedHealth Group, plus UnitedHealth subsidiaries Optum and UnitedHealthcare.

As soon as the legislative session ended in May, , executive director of the Colorado Association of Health Plans, a trade group representing health insurance companies in the state, sent a requesting a veto, with an estimate that the legislation would result in premiums rising 0.4%.

The Colorado bill said local governments — such as cities, counties, or special districts — would set rates.

“We are in a much better place by not having local entities set their own rates,” McFatridge told Â鶹ŮÓÅ Health News. “That’s almost like the fox managing the henhouse.”

, an emeritus research professor with Georgetown University’s McCourt School of Public Policy, said it isn’t clear whether state laws approved elsewhere are raising premiums, or if so by how much. Hoadley said Washington state is expected to come out with an impact analysis of its law in a couple of years.

The national trade association for insurance companies declined to provide a comment for this article. Instead, AHIP forwarded letters that its leaders submitted to lawmakers , , and this year opposing measures in each state to set base ambulance rates. AHIP leadership described the proposals as inflated, government-mandated pricing that would reduce insurers’ chance to negotiate fair prices. Ultimately, the association warned, the proposed minimums would increase health care costs.

In Montana, legislators a minimum reimbursement for ground ambulances of 400% of what Medicare pays, or at a set local rate if one exists. The proposal was sponsored by two Republicans and backed by ambulance companies. Health insurers successfully lobbied against it, arguing that the price was too steep.

Sarah Clerget, a lobbyist representing AHIP, told Montana lawmakers in a legislative hearing that it’s already hard to get ambulance companies to go in-network with insurers, “because folks are going to need ambulance care regardless of whether their insurance company will cover it.” She said the state’s proposal would leave those paying for health coverage with the burden of the new price.

“None of us like our insurance rates to move,” Republican state Sen. said during a legislative meeting as a committee tabled the bill. He equated the proposed minimum to a mandate that could lead to people having to pay more for health coverage for an important but nonetheless niche service.

Colorado’s governor was similarly focused on premiums. Polis said in his that the legislation would have raised premiums between 73 cents and $2.15 per member per month.

“I agree that filling this gap in enforcement is crucial to saving people money on health care,” he wrote. “However, those cost savings are outweighed in my view by the premium increases.”

, policy director at the Colorado Consumer Health Initiative, which supported the bill, said that even if premiums did rise, Coloradans might be OK with the change. After all, she said, they’d be trading the threat of a big ambulance bill for the price of half a cup of coffee per month.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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La hija de Silva tenía Medicaid, que supuestamente cubría el costo de las ambulancias. Pero una de las tres compañías que operaron ese día, Northglenn Ambulance, una empresa pública que había sido adquirida por , envió la factura de Silva a un cobrador de deudas. Era de $2.181,60, pero con los costos judiciales y los intereses aumentó a más de $3.000, según consta en los registros judiciales.

La maestra de preescolar no pudo pagar, y el cobrador embargó el salario de Silva.

“Nos atrasó muchísimo con las facturas: la casa, la luz, el teléfono, la comida de los niños”, contó Silva, cuya hija se recuperó completamente del accidente de 2015. “Nos quitó todo”.

Algunos legisladores estatales buscan reducir facturas como la que recibió Silva: cuentas sorpresa por traslados terrestres en ambulancia.

Cuando una compañía de ambulancias cobra más de lo que una aseguradora está dispuesta a pagar, los pacientes pueden terminar con una factura enorme de la que no tienen escapatoria.

Los estados intentan cubrir el vacío dejado por la ley federal , que cubre las ambulancias aéreas, pero no los servicios terrestres, incluyendo las ambulancias que viajan por carretera y agua.

Este año, Utah y Dakota del Norte se unieron a que han aprobado protecciones contra las facturas sorpresa por este tipo de traslados.

Esas protecciones suelen incluir el establecimiento de un mínimo que las aseguradoras deben pagar si alguno de sus afiliados necesita transporte. Pero el punto de fricción es dónde establecer ese límite. La legislación en Colorado y Montana se estancó este año debido a la preocupación de los legisladores de que obligar a las aseguradoras a pagar más resultaría en mayores costos de cobertura médica para todos.

Las facturas sorpresa de ambulancias son un componente más de un sistema de salud que sistemáticamente endeuda a los estadounidenses, agobiando sus finanzas, impidiéndoles acceder a la atención médica y aumentando las disparidades raciales, como informó Â鶹ŮÓÅ Health News.

“Si las personas dudan en llamar a la ambulancia por temor a sufrir una gran carga financiera para su familia, significa que tendremos víctimas de accidentes cerebrovasculares que no llegarán al hospital a tiempo”, expresó , directora de campañas de atención médica en PIRG, un grupo nacional de defensa del consumidor. “Significa que esa persona que teme un ataque cardíaco no llamará”.

El No Surprises Act, promulgado por el presidente Donald Trump en 2020, establece que, para la mayoría de los servicios de emergencia, a los pacientes se les puede facturar por la atención fuera de la red solo el mismo monto que se les habría facturado si estuvieran dentro de ella. Al igual que los médicos u hospitales, las compañías de ambulancias pueden tener contratos con aseguradoras, lo que las convierte en parte de la red. Las que no lo hacen, permanecen fuera de la red.

Pero a diferencia de cuando se programa una cita con un médico o se planifica una cirugía, un paciente generalmente no puede elegir la compañía de ambulancias que responderá a su llamada al 911. Esto significa que puede recibir grandes facturas fuera de la red.

Los legisladores federales postergaron la inclusión de las ambulancias terrestres, en parte debido a la variedad de modelos de negocio —desde empresas privadas hasta departamentos de bomberos voluntarios— y a la falta de datos sobre el costo de los traslados.

En cambio, el Congreso creó que emitió recomendaciones el año pasado. Su conclusión general —que los pacientes no deberían verse atrapados en el fuego cruzado entre proveedores y aseguradoras— no fue controvertida ni partidista. En Colorado, destinada a ampliar las protecciones contra facturas sorpresa de ambulancias recibió el visto bueno unánime de ambas cámaras legislativas.

Colorado ya había aprobado que protegía a las personas de facturas sorpresa de compañías privadas de ambulancias. Esta nueva medida buscaba brindar protecciones similares contra las facturas de los servicios públicos de ambulancia y para los traslados entre hospitales.

“Sabíamos que contaba con apoyo bipartidista, pero hay quienes votan en contra de todo”, dijo gratamente sorprendida , representante estatal demócrata.

Una sorpresa menos agradable llegó después, cuando el gobernador Jared Polis, también demócrata, la vetó, alegando temor a que aumentaran las primas.

Los estados tienen un margen de maniobra limitado en este tema, ya que las leyes estatales solo se aplican a los planes de salud regulados por el estado.

Esto deja fuera a muchos trabajadores. Según una de 2024 realizada por Â鶹ŮÓÅ, el 63% de las personas que trabajan para empleadores privados y obtienen seguro médico a través de sus empleos tienen , que no están regulados por el estado.

“Por eso necesitamos una ley federal de protección de ambulancias, incluso si aprobáramos 50 leyes estatales”, dijo Kelmar.

Según datos de la oficina del secretario de estado de Colorado, los únicos grupos de presión al proyecto de ley fueron Anthem y UnitedHealth Group, además de las subsidiarias de UnitedHealth, Optum y UnitedHealthcare.

En mayo, tan pronto como finalizó la sesión legislativa, , director ejecutivo de la Colorado Association of Health Plans, un grupo comercial que representa a las compañías de seguros médicos del estado, envió solicitando su veto, con una estimación de que la legislación provocaría un aumento del 0,4% en las primas.

El proyecto de ley de Colorado establecía que los gobiernos locales, como ciudades, condados o distritos especiales, fijarían las tarifas.

“Estamos en una situación mucho mejor al no tener entidades locales que fijen sus propias tarifas”, declaró McFatridge a Â鶹ŮÓÅ Health News.

Jack Hoadley, profesor emérito de investigación de la Escuela de Políticas Públicas McCourt de la Universidad de Georgetown, afirmó que no está claro si las leyes estatales aprobadas en otros estados están aumentando las primas, o en qué medida. Hoadley agregó que se espera que el estado de Washington presente un análisis del impacto de su ley en un par de años.

La asociación nacional de compañías de seguros se negó a comentar para este artículo. En su lugar, la Association of Health Insurance Plans (AHIP) remitió cartas que sus líderes presentaron a legisladores de , y este año, oponiéndose a las medidas de cada estado para establecer tarifas base para ambulancias.

Los líderes de la AHIP describieron las propuestas como precios inflados, impuestos por el gobierno, que reducirían la posibilidad de que las aseguradoras negocien precios justos. En última instancia, advirtió la asociación, los mínimos propuestos aumentarían los costos de la atención médica.

En Montana, los legisladores un reembolso mínimo para ambulancias terrestres del 400% de lo que paga Medicare, o una tarifa local fija, si hay alguna. La propuesta fue patrocinada por dos republicanos y respaldada por las compañías de ambulancias. Las aseguradoras de salud presionaron con éxito en contra, argumentando que el precio era demasiado alto.

Sarah Clerget, lobista que representa a la AHIP, declaró a los legisladores de Montana en una audiencia legislativa que ya es difícil lograr que las compañías de ambulancias se integren a la red de las aseguradoras, “porque la gente va a necesitar atención de ambulancia independientemente de si su compañía de seguros la cubre”.

Agregó que la propuesta estatal dejaría a quienes pagan la cobertura médica con la carga del nuevo precio.

“A nadie le gusta que nuestras tarifas de seguro se modifiquen”, declaró el senador estatal republicano durante una reunión legislativa mientras un comité archivaba el proyecto de ley. Comparó el mínimo propuesto con un mandato que podría llevar a que las personas tengan que pagar más por la cobertura médica de un servicio importante, pero a la vez especializado.

El gobernador de Colorado se centró de forma similar en las primas. Polis afirmó en su que la legislación habría aumentado las primas entre 73 centavos y $2,15 por miembro al mes.

“Estoy de acuerdo en que subsanar esta deficiencia en la aplicación de la ley es crucial para que la gente ahorre dinero en atención médica”, escribió. “Sin embargo, en mi opinión, esos ahorros van a compensarse con el aumento de las primas”.

, directora de políticas de la Colorado Consumer Health Initiative, que apoyó el proyecto de ley, afirmó que incluso si las primas aumentaran, los habitantes de Colorado podrían aceptar el cambio. Después de todo, remarcó, estarían cambiando la amenaza de una gran factura de ambulancia por el precio de media taza de café al mes.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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