When 85-year-old So-Earn Lim was hospitalized recently after an esophageal cancer diagnosis, he and his wife Elligia feared not just for his health, but also for their business.
The couple, owners of the South Lake Union beer and wine store HopVine Patch, said their financial situation is dire. After accumulating thousands of dollars in debt to keep their business afloat during COVID, out-of-pocket medical costs added to that debt could force them to close the business.
"This is our only income," in addition to Social Security, Elligia said in late November.
Without the store's income, Elligia said, they may need to move. They rent the store space and a small apartment above the shop for $3,000 a month.
Although So-Earn has Medicare coverage, the couple join millions of Americans with medical debt. It is a multibillion-dollar nationwide problem, but the burden on individuals is hard to measure statistically. People accrue medical debt for numerous reasons -- from high deductibles to unfortunate life circumstances or being financially unprepared.
"If you're already living paycheck to paycheck, then any kind of surprise expense can be what sets you into debt, whether it is medical or your car breaking down," said Cynthia Cox, a vice president at the Washington, D.C.-based KFF (formally known as the Kaiser Family Foundation). "And so, a lot of the problem here is that Americans don't have a lot in savings."
This is not a new problem. Medical costs have risen dramatically since the 1980s and employers and health plans have been increasing the patients' share of that cost for two decades, Cox said. Washington state has taken several steps to ease the problem of medical debt, such as expanding Medicaid to more low-income earners and requiring hospitals to offer free or discounted services.
But still, thousands of Washingtonians each year accrue a burdensome medical debt, statewide surveys show. Anecdotally, patients and health care advocates say medical expenses and debt causes people to forgo needed treatments and make financial sacrifices, such as tightening food or heating budgets.
"Washington is better than most states, but it's still not great for some patients," said Adam Zarrin, a regional director with the Leukemia & Lymphoma Society.
The cost of medical care can be enormous. Zarrin has seen people with a cancer diagnosis, for example, exhaust their retirement savings within two years of the diagnosis.
"That's your college savings fund, your 401(k), your little nest egg, whatever it is, they use it," Zarrin said.
Tacoma resident Kristopher Shook estimated the total out-of-pocket costs of his cancer treatment at more than $100,000.
In 2013, Shook was diagnosed with two types of lymphoma, and initially given a 15% chance of survival. He beat the odds but is still paying off the debt more than a decade later.
A self-employed real estate agent, Shook, now 54, said before his diagnosis he had bought basic insurance with high deductibles, thinking he would only need insurance for routine checkups. As his debt mounted, he said he had to fend off collection agencies at times but focused on minimizing stress and getting better.
"You have to pick and choose which battle you're going to fight at that moment, and the battle that I took was fighting for my life," Shook said.
Robin Sparks' battle opened her eyes to the broader struggle of patients with medical debt.
Sparks, 63, was diagnosed in 2022 with an incurable form of non-Hodgkin lymphoma. A former executive with Charles Schwab, she came out of retirement after her diagnosis and founded the Marysville nonprofit The C-Suite Center for Hope to provide support services for cancer patients.
"I see people that are just buried in the debt when I'm doing financial navigation, and quite honestly, sometimes I have to say, 'I don't see a way out of this without getting a financial counselor involved,'" Sparks said.
She pointed to her own case as an example of how much treatment can cost. The bill totaled about $365,000 in the first year, of which $50,000 was out of pocket.
"I had really bad coverage, and I had high out-of-pocket deductibles," Sparks said. "We've spent probably $150,000 to $200,000 of out-of-pocket expenses for medical, even with insurance."
Sparks said she and her husband had sufficient savings to pay her bills, but most of her clients don't have that option.
In the U.S., an estimated 20 million people have medical debt, owing a total of around $220 billion, according to KFF. An estimated 14 million of them owe more than $1,000 and about 3 million owe more than $10,000.
From surveys between 2019 and 2021, KFF estimates that an average of 6.5% of Washingtonians, or 380,000 people, carried medical debt in a year. This was lower than the national average of 8.6%.
According to an Urban Institute analysis of August 2023 credit bureau data, the median medical debt in collections in King County was $1,353, identical to the statewide median but lower than the national median of $1,493.
But the data on medical debt can be inconsistent
"You get very different results depending on how you ask the question or what data source you're using," KFF's Cox said. "So, it is hard to track this over time, and it's also hard to give an exact number of how much medical debt is owed."
Cox said medical debt is driven by America's exceptionally high cost for medical care and escalating patient out-of-pocket costs in health plans. The average annual per person out-of-pocket cost increased 23% from 2002 to 2022 based on adjusted inflation figures, KFF estimated, meaning people have been shouldering a bigger share of their medical costs.
"We also ask people how they've gone about paying for these bills, and people make all kinds of sacrifices," Cox said. Some skip vacations or optional expenses, but others tighten food budgets, miss rent or skip mortgage payments, and some turn to GoFundMe.
For John, a 69-year-old truck driver who lives in Renton, racking up about $7,000 in debt due to complications this spring from previous bariatric surgery meant draining his retirement savings.
He was laid off during his medical crisis, and he had to pay the full cost for health coverage, about $800 monthly on a COBRA plan.
"I immediately made a phone call and cashed in my 401(k) and put it into my checking account, about $20,000," he said. "I thought, 'Well, that's going to have to carry me through to whenever I get employed.'"
John asked to withhold his last name, fearing he could lose his new job if his medical history was known. He said he'll likely carry the debt for years, noting he also owes money for extensive dental work costing about $15,000.
"I'm still paycheck to paycheck every week," he said. "I don't have savings."
Several protections are in place to ease medical debt. The federal Affordable Care Act imposes maximum out-of-pocket limits on health plans for covered services. Washington state caps the interest that can be charged on medical debt, although bill collectors can charge debtors a hefty fee for debt accrued at public hospitals.
Providers often offer zero- or low-interest payment plans. In Washington, medical debt also can't be sold to a bill collector for 120 days. However, advocates say patients are pressured to pay their share upfront and they often pay with high-interest credit cards.
In Washington, residents earning up to 138% of the federal poverty level, about $20,783 annually for individuals, qualify for Medicaid coverage. Roughly half the state's population can also qualify for free or discounted treatment at hospitals.
Yet, patients with high deductible plans and gaps in their coverage can have "some really significant out-of-pocket expenses," said Zosia Stanley, vice president and associate general counsel for the Washington State Hospital Association.
She said some patients delay seeking treatment and skip routine checkups, waiting for a medical problem to worsen until they go to an emergency room.
"During the height of the pandemic, we saw people deferring care for various reasons, and then that meant that we were seeing more extreme cases when people were finally getting care," Stanley said. "So, we've seen that pattern play out."
Amanda Martin, executive director of the Northwest Consumer Law Center, said Seattle-area patients seeking legal help with medical debt typically owe around $5,000-$7,000.
NWCLC mostly serves individuals earning $30,000-$45,000 annually. They qualify for discounted treatment at hospitals.
Martin said people may get a huge bill from a hospital or a letter from a debt collector that their wages may be garnished. In some cases, patients aren't screened appropriately by a hospital or notified of potential discounts.
"It all involves medical debt, and usually when folks are coming to us, they're at the point of, 'I have no idea what to do, please help,'" she said.
Stanley said Washington's hospitals are informing patients of charity care as required, but the patient needs to apply for assistance. She said many patients aren't processing the information.
"You're in the hospital because you or your loved one is sick, and that's what you're going to be focusing on," Stanley said. She said everyone periodically should review their health coverage to understand where the gaps may be and what assistance they might qualify for.
A friend of the Lims started a GoFundMe campaign to help with their debt. Co-workers of Elena Franco, 34, who was diagnosed with ovarian cancer in September, did the same for her.
A year ago, Franco, a preschool teacher's aide who lives in South Seattle, never imagined she would simultaneously have to fight for her life against a deadly disease and appeal to strangers for help with her medical bills. But in just a few months she accrued roughly $4,000 in medical debt despite having insurance.
Franco works at The Horizon School in Shoreline, but she had to take paid family leave. She and her partner, a line cook, also struggle with Seattle's high costs, grocery bills and providing for their 3-year-old daughter. They can't afford their own place and have been renting space in his relative's home in South Seattle.
Her treatment involves specialists, chemotherapy, prescription drugs, labs, testing and possibly surgery. Franco is unsure how much debt she'll accumulate but is sure she can't afford to pay it off. She hopes private fundraising will help.
"It is very expensive, and I have to keep going to treatments," she said.