Report on Medical Debt Litigation by St. Louis Universities and its Conflict with Sustainable Development Goals

A recent study published in JAMA Network Open reveals that Saint Louis University and Washington University initiated nearly 1,000 lawsuits against patients for unpaid medical bills between 2020 and 2023. This practice raises significant concerns regarding its alignment with several United Nations Sustainable Development Goals (SDGs), particularly those focused on poverty, health, and equality.

Analysis of Litigation Data in the Context of SDGs

The research, initiated by Mary Shannon after a patient encounter in 2020, highlights a systemic issue that directly undermines key development objectives. The findings present a stark conflict between the actions of these major health institutions and global commitments to social equity and well-being.

Key Findings and Contradictions to SDG Principles

1. SDG 10 (Reduced Inequalities): The litigation disproportionately targets marginalized communities. The data indicates that 41% of the lawsuits were filed against Black patients. Furthermore, dozens of cases involved individuals identified as having a low socioeconomic status, exacerbating existing inequalities within the healthcare system.
2. SDG 1 (No Poverty): The legal actions were often pursued for relatively small sums, with some debts as low as $104 and the majority under $2,000. Such lawsuits can trap vulnerable individuals in cycles of poverty, leading to severe financial consequences like wage garnishment and bankruptcy, directly opposing the goal of eradicating poverty in all its forms.
3. SDG 3 (Good Health and Well-being): The practice of suing patients for medical debt creates a significant barrier to accessing essential healthcare. The fear of financial ruin and legal action can deter individuals from seeking necessary medical care, thereby compromising public health outcomes and the fundamental right to well-being.
4. SDG 16 (Peace, Justice and Strong Institutions): The study found that over half of the 973 lawsuits resulted in a default judgment, where the court ruled in favor of the universities. This suggests a potential lack of access to legal representation and justice for the defendants, raising questions about the role of these institutions in upholding fair and equitable legal processes.

Consequences and Institutional Accountability

Financial and Legal Ramifications for Patients

Legal experts note that ignoring such a lawsuit is the worst course of action. The potential consequences for patients are severe and directly impact their financial stability, a core component of SDG 1 and SDG 10.

• Damage to credit scores, affecting future financial opportunities.
• Potential for wage garnishment.
• Risk of liens being placed on real estate.
• Possibility of being forced into bankruptcy.

Institutional Response

In response to the study, Saint Louis University (SLU) stated that it sold its physician practice, SLUCare, in July 2022. The university claimed its policies at the time limited legal action to larger debts and only for patients who were employed and ineligible for financial assistance. SLU also affirmed its commitment to “reducing health inequities and improving the well-being of the St. Louis region,” a statement that stands in contrast to the study’s findings. Washington University did not provide a comment.

Conclusion: A Call for Alignment with Global Goals

The research underscores a critical disconnect between the litigation practices of major healthcare providers and their stated missions to serve the community. The pursuit of medical debt through legal channels, especially against vulnerable populations, fundamentally conflicts with the principles of Sustainable Development Goals 1, 3, 10, and 16. The study’s author hopes the research empowers individuals by highlighting the availability of financial assistance and other resources, aiming to create a more supportive system that aligns with the global objective of ensuring healthy lives and promoting well-being for all at all ages.

SDGs Addressed in the Article

• SDG 1: No Poverty
• SDG 3: Good Health and Well-being
• SDG 10: Reduced Inequalities
• SDG 16: Peace, Justice and Strong Institutions

Specific SDG Targets Identified

1. SDG 1: No Poverty

   • Target 1.3: Implement nationally appropriate social protection systems and measures for all, including floors, and by 2030 achieve substantial coverage of the poor and the vulnerable. The article discusses the need for “financial assistance and charity care” and mentions university policies that were supposed to protect the “unemployed or earning minimum wage,” which are forms of social protection systems within the healthcare context.
   • Target 1.4: By 2030, ensure that all men and women, in particular the poor and the vulnerable, have equal rights to economic resources. The article highlights how medical debt lawsuits can lead to wage garnishment, damaged credit scores, and liens against real estate, directly impacting individuals’ rights to economic resources.

2. SDG 3: Good Health and Well-being

   • Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services… for all. The central issue of the article is the lack of financial risk protection for patients seeking medical care, as evidenced by the “nearly 1,000 lawsuits” filed over unpaid medical bills. This financial burden can deter people from seeking “emergent medical care,” affecting access to essential services.

3. SDG 10: Reduced Inequalities

   • Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of… race… or economic or other status. The article explicitly points to inequality, stating that “41% of the lawsuits were Black patients” and “Dozens of the lawsuits were identified as low socioeconomic status,” indicating that certain groups are disproportionately affected.
   • Target 10.3: Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory… policies and practices. The practice of suing vulnerable patients for medical debt is a policy that results in unequal outcomes based on race and economic status, which the university’s statement acknowledges by committing to “reducing health inequities.”

4. SDG 16: Peace, Justice and Strong Institutions

   • Target 16.3: Promote the rule of law… and ensure equal access to justice for all. The article reveals a potential lack of equal access to justice, noting that “over half of those [lawsuits] resulted in default judgment where the court rules typically automatically in favor of the plaintiff.” This suggests patients may lack the resources or knowledge to navigate the legal system.
   • Target 16.6: Develop effective, accountable and transparent institutions at all levels. The research study itself is an effort to create accountability and transparency regarding the universities’ debt collection practices. The article’s call for “more accountability, reform and support” directly addresses this target.

Indicators for Measuring Progress

1. SDG 1: No Poverty

   • Implied Indicator: Number of individuals facing legal action due to medical debt. The article provides a specific number: “nearly 1,000 lawsuits from 2020 through 2023.”
   • Implied Indicator: Monetary threshold for legal action on debt. The article mentions lawsuits for debts “as low as $104” and that “most were under $2,000,” which can be used as a metric for how aggressively small debts are pursued.

2. SDG 3: Good Health and Well-being

   • Implied Indicator: Proportion of the population with large household expenditures on health. While not giving a percentage, the article’s focus on lawsuits over medical debt implies that for these individuals, health expenditures have become catastrophic.

3. SDG 10: Reduced Inequalities

   • Specific Indicator: Proportion of lawsuits disaggregated by race. The article provides a clear data point: “41% of the lawsuits were Black patients.”
   • Specific Indicator: Proportion of lawsuits disaggregated by socioeconomic status. The article states that “Dozens of the lawsuits were identified as low socioeconomic status.”

4. SDG 16: Peace, Justice and Strong Institutions

   • Specific Indicator: Proportion of civil cases resulting in default judgment. The article specifies that “over half of those resulted in default judgment.”
   • Implied Indicator: Availability of financial assistance and charity care policies within institutions. The article mentions these policies exist and that the researcher hopes to “compile some resources in a centralized place,” indicating a need to measure their accessibility and effectiveness.

SDGs, Targets, and Indicators Analysis

Source: ksdk.com