500,000 Americans Will Go Bankrupt This Year from Medical Bills?


On January 12 2020, the Facebook page “Lower Drug Prices Now” shared what appeared to be a screenshot of a tweet, which claimed that “500,000 Americans will go bankrupt this year” due to medical bills:

Claims referencing “this year” can be difficult to fact-check, as images like the one above could circulate for several years in perpetuity, muddying the timeframe of “this year” (or “this week,” or most commonly, “yesterday.”)

A search for the phrasing used in the screenshot led back to its ostensible source, an August 20 2019 tweet by Sen. Bernie Sanders (I-Vermont) on Twitter. The tweet’s origin was unsurprising, as Medicare for All was a major plank of Sanders’ 2020 presidential campaign platform:

Both the tweet and the screenshot contained four lines, and read:

500,000 Americans will go bankrupt this year from medical bills.

They didn’t go to Las Vegas and blow their money at a casino.

Their crime was that they got sick.

How barbaric is a system that says, “I’m going to destroy your family’s finances because you had cancer”?

Although the Facebook post was shared in January 2020, the “this year” clearly referenced 2019 — the year in which Sanders published the tweet. No source was shared alongside the claim, but a fairly specific figure of 500,000 medical bankruptcies was mentioned.

A cursory search revealed both a possible underlying source for the figure, as well as what appeared to be a controversial fact-check. On August 28 2019, a Los Angeles Times op-ed asserted that Sanders had reiterated the “500,000 medical bankruptcies” claim in a debate — and that the Washington Post fact-checked the claim and scored it as “mostly false” or “three Pinocchios.” (The article displays a date of September 4 2019, indicating that it was updated; additional commentary is marked, but changes to the article remained unmarked and impossible to identify via the article itself.)

Diving in, the article explained:

You’ve got to hand it to Sen. Bernie Sanders for his ability to keep hot-button issues in the forefront of the presidential race.

The latest example is his assertion, made at least twice in the last month, that medical bills drive 500,000 Americans into bankruptcy every year. The Washington Post’s fact-checker column examined the numbers and concluded that Sanders deserved “three Pinocchios” for the statement, which means the Post found it “mostly false” and that Sanders was, basically, lying.

The Post blundered, as the authors of the study on which Sanders based his claim point out. In the real world, Sanders’ assertion that “500,000 Americans will go bankrupt this year from medical bills” is “mostly true.” Medical bankruptcy is an American scandal, and possibly even more common than he or the study’s authors calculate.

On the same date as the Los Angeles Times editorial, the Washington Post published a fact-check of Sanders’ assertion. It was indeed rated “mostly false” or “three Pinocchios” as the op-ed said.

We noticed two familiar names in the paper’s examination of the claim — David U. Himmelstein and Steffie Woolhandler. Himmelstein and Woolhandler were researchers credited with a study referenced by our January 13 2020 fact-check about the cost of Canadian healthcare versus that of the United States.

In a section titled “The Facts,” the Washington Post reported:

Sanders said 500,000 people were driven to bankruptcy by medical bills. A Sanders campaign aide said he was relying on an editorial published by the American Journal of Public Health (AJPH) in March [2019].

That study, led by David U. Himmelstein, took a sample of bankruptcy court filings from 2013 to 2016, identified 3,200 bankrupt debtors and mailed them a survey. The response rate was 29.4 percent, with 910 responses and 108 surveys returned as undeliverable.

Debtors were asked whether medical expenses, or loss of work related to illness, contributed to their bankruptcies. Of those who responded, 66.5 percent said at least one of those factors contributed “somewhat” or “very much.”

Sixty-six percent of 750,000 is 500,000, so Sanders’s math adds up at first glance.

The study referenced, “Medical Bankruptcy: Still Common Despite the Affordable Care Act,” was accepted by the American Journal of Public Health in November 2018 and published in February 2019. Sanders’ campaign website also hosted a page (“Medical Bankruptcy is Real, Even if the Washington Post Refuses to Believe it”) about the claim, controversy, and fact-check; the page was written by the study’s authors, Himmelstein et al.

The Washington Post fact-check noted that as an editorial, that particular AJPH article “did not undergo the same peer-reviewed editing process as a research article.” We were unable to find how they were able to make the determination that the article was not peer-reviewed.

The paper also posited that while the 66 percent of bankruptcies cited medical bills as a factor, other factors may have been involved:

This study includes a range of people for whom medical expenses or illness contributed “somewhat” to bankruptcy. What does “somewhat” mean? It’s broad enough to mean “slightly,” “fairly” or “moderately.” Sanders’s claim works only by erasing this ambiguity and taking “somewhat” to mean “mostly.”

In Sanders’ tweet, no qualifiers (like “mostly”) were used. He said “500,000 Americans will go bankrupt this year from medical bills,” a statement that could reasonably be framed to mean either that medical bills were a defining factor in bankruptcies, or that medical bills caused bankruptcies, or that medical bills were a contributing factor in bankruptcies.

Himmelstein was quoted by the paper in its attempt to assign a truth rating to the claim, and he explained that a number of confounding factors made sweeping statements difficult. Of note is that Himmelstein cited circumstances in which illness and mounting medical bills could drive other bankruptcy-exacerbating circumstances, such as work missed due to illness or compounding debt again related to health issues:

“We did not ask about the sole or main reason for bankruptcy, because our past experience indicates that this is a meaningless question,” Himmelstein, a professor at CUNY’s Hunter College who supports single-payer health care, wrote in an email. “The vast majority of debtors suffer multiple problems that bring them to file, and cannot identify a single problem among them. Thus, if an illness led to lost work time (and hence income) and medical bills, debtors cannot separate out these different problems; they are of a piece.”

Critics of Himmelstein and his colleagues’ research into medical bills and bankruptcy proposed different approaches, like “[instead of] looking at a sample of people who go bankrupt and see how many have medical debt, look at a sample of a bunch of people who have medical debt, and how many of them go bankrupt [to get an] idea of causality.” Another study cited a far lower number, while at the same time noting that the figure only involved debtors who had been hospitalized:

“Based on our estimate of 4 percent of bankruptcy filings per year and the approximately 800,000 bankruptcy filings per year, our number would be much closer to something on the order of 30,000-50,000 bankruptcies caused by a hospitalization,” one of the co-authors of the NEJM study, economist Raymond Kluender of Harvard Business School, wrote in an email.

“This would lead us to be skeptical of the 500,000 medical bankruptcies statistic, but that very much depends on how one defines a medical bankruptcy.…  An enormous share of households have some amount of medical debt, so any survey of individuals will report a high share of them have medical debt but this does not imply that the debt caused them to file for bankruptcy.”

Some people could still face high levels of medical debt without ever going through a hospital, and they wouldn’t be counted in the NEJM study.

The Washington Post asked Himmelstein directly if Sanders had accurately represented the findings of his and his colleagues’ editorial, to which he replied in the affirmative:

Himmelstein wrote: “37 percent of filers said medical bills ‘very much’ contributed to their bankruptcy. Even if you use that restricted definition, then Sanders’s statement is accurate — or an underestimate. There are about 700,000 bankruptcy filings each year. Many filings are joint husband/wife filings, and based on our past research, we estimate that on average 2.71 persons reside in each debtor’s household. So the total number of persons who undergo bankruptcy is about 1.9 million annually.

“37 percent of 1.9 million is a bit over 700,000. Even if you only count the husband and wife in a filing, the number suffering a bankruptcy to which medical bills ‘very much’ contributed is about 500,000.”

The fact-check then concluded that the claims constituted politically motivated “cherry-picking” over the researchers’ objections:

This is a classic case of cherry-picking a number from a scientific study and twisting it to make a political point.

An undated response from Himmelstein and Woolhandler appeared at the bottom of the post. The authors pointed out several objections to the fact-check and factors cited in it, writing:

An August 28 [2019] Fact Checker article in the Post assigned a “Three Pinocchios” rating to Sen. Bernie Sanders’ statement that 500,000 Americans are bankrupted by medical bills annually. Sanders’ estimate relied on an editorial by David Himmelstein and colleagues in the American Journal of Public Health (AJPH) reporting findings from a Consumer Bankruptcy Project (CBP) survey that asked debtors about causes of their bankruptcy. The editorial (which the Post falsely implied had not undergone peer review) updated previous CBP studies carried out by Himmelstein, along with then-Harvard Law Professor Elizabeth Warren, Steffie Woolhandler and Deborah Thorne that reached similar conclusions and appeared in leading medical and policy journals.

The Post’s denigration of Sanders’ statement rests on an econometric study that found only a modest uptick in bankruptcy filings among persons hospitalized in California between 2003 and 2007. As Himmelstein, Woolhandler and Warren noted in their response to that study in the New England Journal of Medicine, the study excluded most persons with frequent hospitalizations (a group at high risk of medical bankruptcy); assumed that anyone not hospitalized could not suffer medical bankruptcy; that a child or partners’ illness couldn’t lead to bankruptcy; and that potentially bankrupting illnesses always commence at the moment of hospitalization – an assumption contradicted by the study’s own data.

Rather than checking facts, the Post has chosen one side in an ongoing and unsettled scholarly debate, and labeled those on the other side (and public figures who cite their research) “liars”.

More than 200 readers commented on the fact-check, most objecting to the paper’s dismissal of both the underlying research and the researchers’ responses. One commenter wrote:

I’m not a political supporter of Senator Sanders, I’m a retired former CEO of several significant medical device companies and the former Co-Chairman for eight years of the National Council for Healthcare Technology. The authors of the original editorial and its supporting peer reviewed studies, are the widely acknowledged preeminent experts in the field of medical bankruptcy, which they’ve been studying and publishing peer reviewed articles on for many years. The Washington Post’s reporter has substituted his uninformed judgement for the expertise, acquired over many years, by the authors of the original editorial and its supporting studies. As the authors pointed out in their rebuttal, Senator Sanders’s estimate of medical debt related bankruptcies is, if anything, to conservative. Medical debt related bankruptcies are a huge problem in the US, the only developed country in the world where they occur. The Washington Post is flat out wrong on this issue.

Another echoed:

How hard is it to retract this? I think we are being generous when we say the author made some mistakes here, I think it is pretty clear to anyone who pays attention what the intent of this “fact check” was, and that is to try and discredit Bernie Sanders in any way possible.

But you got called out on it by both Senator Sanders and the authors of the study he cited, now own up to it and retract it. If the WaPo had one shred of journalistic integrity, they would admit they were wrong and seek to correct it. All this does is damage the Post’s credibility going forward the longer they remain obstinate about this.

A third addressed a conclusory claim by the Post that Himmelstein somehow moved the goalposts on his own original claim, remarking on the inferences underlying the “mostly” aspect:

Is the WaPo serious here? The entire article is based on the fact checker’s claim that Sanders implied with his tweets “solely caused” instead of “one of the causes”. But him also saying “people(/Americans)” instead of “cases” isn’t relevant? The study refers to different contributions to bankruptcy. Which one are you proving false? If you are going off of the peer reviewed editorial it is talking about contribution and cases. If you are going off of Sander’s tweet, it’s cause and people. Himmelstein even gave you an easily verifiable fact as to how many people are experiencing bankruptcy per case. This article has many more basic logical inaccuracies, I just wanted to point out this blatant disregard of parallelism in fact checking.

That commenter’s critique was not restricted to one comment:

So…what is your point? Because health care costs may not be the sole reason for a person’s financial difficulties, it is wrong to point to them as a burden? Has WaPo never heard of the straw that broke the camel’s back?

We were unable to find commenters defending the amended fact-check, but we did find an additional comment signed by Himmelstein:

Although the Post agreed to post our brief letter responding to their column, it refused to include the names of the 101 additional colleagues who were signatories of that letter. David U. Himmelstein, MD and Steffie Woolhandler MD MPH

Clearly, Sanders’ claim (depicted in the January 12 2020 Facebook post above) that “500,000 Americans will go bankrupt this year from medical bills” (referencing 2019) was a point of contention, worsened by a widely-disputed Washington Post fact-check originally published on August 28 2019 — after Sanders’ tweet and a Democratic debate in which he referenced the same statistic. Normally, we turn to the source material to verify such debate — in this case, research published in a medical journal.

In a very odd turn of events, the authors of the article in the medical journal spoke up to insist their figures were accurately represented by Sanders in both places. In turn, the Washington Post added some of their objections (but not all), did not correct a claim that the editorial was not subjected to peer-review, and left out important elements of the authors’ response. Although the paper retained its “mostly false/three Pinocchios” rating, we were hard pressed to replicate those findings based on extensive comment from researchers whose peer-reviewed work had been published in medical journals.

The post 500,000 Americans Will Go Bankrupt This Year from Medical Bills? appeared first on Truth or Fiction?.

Read More

Leave a Reply

Do NOT follow this link or you will be banned from the site!