How to Start Fixing a Health-Care System That Creates Medical Debt – The Roosevelt Institute

Report on the Cook County Medical Debt Relief Initiative and its Implications for Sustainable Development Goals

Executive Summary

The Cook County Medical Debt Relief Initiative, a publicly funded program in the United States, was established in 2022 to purchase and cancel residents’ medical debt. As of June 2025, the program has successfully eliminated over $664 million in medical debt for 556,815 residents. This initiative provides a direct and impactful contribution to several Sustainable Development Goals (SDGs), primarily SDG 1 (No Poverty) by alleviating a significant financial burden, SDG 3 (Good Health and Well-being) by reducing financial barriers to health, and SDG 10 (Reduced Inequalities) by targeting debt that disproportionately affects low-income individuals.

Analysis of Program Data and Alignment with SDG 3: Good Health and Well-being

Data generated by the Cook County initiative reveals critical failures within the U.S. healthcare system that impede progress toward universal health coverage, a key target of SDG 3. The findings highlight the inadequacy of existing insurance frameworks and financial assistance policies.

Key Findings on Insurance Coverage Gaps

• 47 percent of beneficiaries had commercial or other health insurance coverage.
• 45 percent were classified as self-pay or had an unknown insurance status.
• 10 percent were covered by Medicare.
• 3 percent were covered by Medicaid.

The fact that a majority of residents whose debt was canceled had some form of insurance coverage demonstrates that the current system fails to provide adequate financial protection, a core component of SDG 3.

Disparities in Financial Assistance and Contribution to SDG 10: Reduced Inequalities

Further analysis indicates that at least 66 percent of residents served by the initiative had incomes below 200 percent of the federal poverty level. This income level should have qualified them for free or reduced-cost care under the stated financial assistance policies of most regional hospital systems. This systemic failure to apply existing aid policies exacerbates economic disparities, running counter to the objectives of SDG 10. The program’s intervention relieved debt that, in many cases, should not have been levied, pointing to a need for stronger institutional accountability as outlined in SDG 16 (Peace, Justice and Strong Institutions).

Strategic Recommendations for Systemic Reform to Achieve Health-Related SDGs

The success of debt cancellation programs highlights the urgency of addressing the root causes of medical debt. A dual approach involving short-term interventions and long-term structural reforms is necessary to build a healthcare system where medical debt is prevented at its source.

Short-Term Strategies for Immediate Impact

1. Enhance Transparency and Accountability (SDG 16): Governments must leverage their authority to collect and publicly report data on healthcare pricing, coverage denials, financial assistance, and collections practices. Models such as state all-payer claims databases and the Los Angeles County initiative, which monitors medical debt as a public health threat, can expose systemic failures and strengthen institutional accountability.
2. Strengthen Public Health Systems (SDG 3): Robust public health insurance programs (e.g., Medicare, Medicaid) and public healthcare providers (e.g., public hospitals, federally qualified health centers) are essential for preventing medical debt. The example of Cook County Health, a large public health system, demonstrates how public provisioning can ensure affordable care and serve as a foundation for achieving universal health access.
3. Leverage Public Funds for System-Wide Action (SDG 17): Public financing can be used to incentivize all healthcare providers to prevent and relieve medical debt. North Carolina’s innovative use of Medicaid payments to encourage hospitals to cancel debt and adopt fairer collection practices exemplifies a partnership approach to deploying public funds for the public good, aligning with SDG 17 (Partnerships for the Goals).

Long-Term Vision for Universal Health Coverage (SDG 3)

While debt cancellation provides immediate relief, a sustainable, long-term strategy requires fundamental system reorientation toward universal health coverage, as seen in numerous other developed nations. These international systems achieve better health outcomes at lower costs by leveraging public sector power to guarantee coverage and control costs. Achieving the goals of SDG 3 in the United States necessitates consideration of proven, globally recognized solutions.

• Standardized healthcare pricing to increase transparency and fairness.
• Enforcement of fair-share spending requirements for non-profit hospitals to ensure community benefits.
• Expansion of robust public provisioning of healthcare services.
• Implementation of a single-payer system to guarantee universal health care and eliminate financial barriers to access.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

1. SDG 1: No Poverty
   • The article directly addresses the financial hardship caused by medical debt, which is a significant driver of poverty. The Cook County Medical Debt Relief Initiative is a measure to alleviate a financial burden that can trap individuals and families in poverty. The text notes that 66% of beneficiaries earned less than 200% of the federal poverty level, explicitly linking medical debt to economic vulnerability.
2. SDG 3: Good Health and Well-being
   • The central theme of the article is the failure of the US health-care system to provide affordable and accessible care, which is a core component of SDG 3. It discusses the need for “universal access to quality health care” and financial risk protection, highlighting how medical debt undermines both physical and financial well-being.
3. SDG 10: Reduced Inequalities
   • The article demonstrates how the current health-care system exacerbates inequality. It points out that low-income individuals are disproportionately affected, even when they should qualify for free care under hospital policies. The initiatives described, such as publicly funded debt cancellation, are policies designed to reduce the economic inequality stemming from unaffordable health care.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. Target 1.3: Implement nationally appropriate social protection systems and measures for all… and achieve substantial coverage of the poor and the vulnerable.
   • The Cook County Medical Debt Relief Initiative is a clear example of a local social protection measure. The article states the program is “the first publicly funded program in the United States to buy and cancel residents’ medical debt,” directly aiming to protect vulnerable residents from financial shocks.
2. Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
   • The article’s entire focus is on the lack of financial risk protection within the US health system. It highlights that even insured individuals (47% with commercial insurance) accrue significant medical debt, demonstrating a failure to achieve this target. The proposed solutions, such as strengthening public health systems and debt cancellation, are steps toward fulfilling the goal of universal health coverage.
3. Target 10.4: Adopt policies, especially fiscal, wage and social protection policies, and progressively achieve greater equality.
   • The article advocates for and describes specific fiscal and social protection policies aimed at reducing inequality. The use of “publicly funded” programs in Cook County and leveraging “state-directed payments under Medicaid” in North Carolina are examples of government policies designed to correct a systemic failure that disproportionately harms low-income populations.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Indicators for Financial Hardship and Social Protection Coverage (Targets 1.3, 3.8, 10.4)
   • Amount of medical debt abolished: The article provides specific figures, such as “$664 million in medical debt” in Cook County and “$6.5 billion” in North Carolina. This directly measures the scale of financial relief provided.
   • Number of beneficiaries of debt relief: The text states the program benefited “556,815 residents of Cook County” and “2.5 million residents” in North Carolina, quantifying the reach of these social protection policies.
   • Proportion of low-income beneficiaries: The finding that “66 percent of residents whose debt Cook County canceled made less than 200 percent of the federal poverty level” is a direct indicator of how well the program targets the poor and vulnerable, as specified in Target 1.3.
   • Proportion of insured individuals with medical debt: The data showing that “47 percent of individuals served had commercial or other health insurance coverage” serves as an indicator for the inadequacy of financial risk protection under existing insurance schemes, relevant to Target 3.8.

4. SDGs, Targets, and Indicators Table

Source: rooseveltinstitute.org