Hippocratic Oaf

There are certain phrases Americans keep polished and mounted above the fireplace because examining them too closely might ruin dinner.

Public service.
Family values.
The sanctity of life.

And that magnificent old chestnut:  First, do no harm.

A noble idea. Clean. Reassuring. The sort of thing I imagine woment want floating around in the mind of a man standing between their knees with a medical degree and several thousand dollars' worth of stainless-steel instruments.

But apparently the warranty expires somewhere between the examination room and accounts receivable.

Because Kansas Sen. Roger Marshall — Republican, physician, longtime OB-GYN and professional defender of the sanctity of human life — has suddenly found himself staring down one hell of a medical chart.

According to a new New York Times investigation, Marshall and his medical practice filed lawsuits against more than 700 former patients over unpaid bills.

Some debts ran into the thousands. One was $101.

The practice routinely charged 18 percent annual interest. That is the kind of number that makes you wonder whether your OB-GYN accepts Blue Cross or whether you should just ask for Tony Soprano. At least Tony would have the professional courtesy not to call it health care.

Wages and bank accounts were garnished. And 81 patients were eventually arrested after failing to appear in court in connection with the collection lawsuits.

Sweet Jesus. You could lock a team of political satirists in a Topeka motel with six cases of Red Bull and a whiteboard and they would not improve those numbers.

700 lawsuits.
18 percent interest.
81 arrests.
$101.

This isn't a scandal. It's a billing statement from the Republic. First, do no harm. Then calculate the APR.

The Miracle of Life, Plus Interest

Marshall spent more than 25 years practicing obstetrics in western Kansas and has made his medical career an essential part of his political identity. He has proudly noted that he delivered more than 5,000 babies.

Five thousand.

That is a lot of first breaths, tiny fingers, exhausted mothers and terrified fathers.

It is also, apparently, a hell of a customer base.

Marshall's spokeswoman says he treated patients regardless of their ability to pay and argues that the lawsuits must be understood in the brutal economics of rural medicine — keeping the doors open, keeping doctors available, keeping the hospital lights burning.

And there is truth buried in that defense. Rural medicine is in crisis. Hospitals do not run on prairie virtue. Doctors deserve to be paid.

But then you hit the 18 percent interest rate and the wagon starts losing wheels.

Eighteen percent. On medical debt. In rural Kansas.

This is where the country doctor story starts growing loan-shark teeth.

According to the Times, roughly half the lawsuits were filed under Marshall's own name and the remainder by Heartland Regional OBGYN, a practice he owned or co-owned. Many defendants lived in Barton County, where poverty and lack of health insurance were more common than nationally.

Some of the debts arose from childbirth.

Which gives us one of those uniquely American transactions that would be dismissed as heavy-handed dystopian fiction if it hadn't actually happened.

You have a baby. You go home bleeding, exhausted and terrified that this seven-pound creature will stop breathing if you look away for thirty seconds.

And somewhere across town, a clock begins ticking.

The miracle of life has been delivered successfully, now please remit payment.

The Times reported that Kellie Clutts was sued in 2015 over a $129 postpartum bill. Her baby was nine months old. Her bank account was eventually garnished.

Over one hundred twenty-nine dollars? Members of the United States Senate can spend more than that on dinner without remembering what they ate. But out on the plains, apparently, $129 can become a legal proceeding.

Easter in Kansas

Then we reach Joe Vasquez and his wife. Mrs. Vasquez underwent an emergency hysterectomy. The couple owed $4,561. Marshall sued.

They missed a court appearance. Then came Easter weekend, 2007. Their grandchildren were preparing for an egg hunt when police arrived.

Grandma and Grandpa went to jail.

They stayed there for two days until their son could borrow enough money to post bond.

Stop there.

No embellishment.

No metaphor.

Just look at the picture.

Plastic Easter eggs scattered around a Kansas yard while two grandparents are hauled away after medical debt became litigation, litigation became a missed court appearance, and the missed appearance became a warrant.

Let's be clear that, according to the law, they were not arrested merely because they owed Marshall money. The warrants resulted from failures to appear in court during the collection proceedings. That distinction matters legally and factually.

Morally, however, it reveals something uglier.

Look at the machine: A patient cannot pay a medical bill. Roger Marshall sues. The legal machinery starts grinding. The patient fails to appear. The court issues a warrant. The police arrive.

And suddenly everybody involved can point toward the previous cog and announce that none of this was really their decision.

The doctor didn't make the arrest.

The lawyer didn't issue the warrant.

The judge didn't perform the hysterectomy.

The sheriff didn't set the interest rate.

Everybody's hands are clean.

It's a miracle.

The machinery has somehow produced handcuffs without anybody ever touching the controls.

This is the great genius of institutional cruelty: responsibility disappears one procedural step at a time.

The Eighteen Percent Question

Marshall's former attorney told the Times that Marshall was not personally involved in deciding when attorneys sought warrants, arrests or garnishments. He left collection tactics to the law firm.

That fact belongs here. It matters.

But then comes the other fact: According to the same attorney, Marshall set the 18 percent interest rate.

And there it is. The doctor may not have been driving every vehicle in the convoy, but apparently he helped set the speed limit. 

Eighteen percent is not a clerical error. It is not something that crawled out of QuickBooks at midnight and began reproducing. Someone decided on it.

And medical debt is not ordinary consumer debt. Nobody comparison-shops an emergency hysterectomy.

Nobody says, "Doc, the bleeding is pretty bad, but your financing terms are murder. What can you do if I put twenty percent down?"

Nobody walks into an obstetrics ward because the Labor Day sale looked irresistible.

The transaction begins with vulnerability: You are pregnant. You are bleeding. You are sick.You are frightened.

You need help now.

Then the crisis passes, and the invoice arrives. Then interest. Then lawyers. Then court. Then garnishment.

Then, for some people who fail to appear, warrants.

A lawsuit over $101 is a moral Rorschach test.

You either look at it and see something grotesque or you begin explaining administrative overhead.

And Then the Doctor Went to Washington

Had Roger Marshall retired from medicine and disappeared onto a ranch somewhere, this might be merely an ugly artifact from the subterranean history of American health care.

But Marshall did not retire into obscurity. He went to Washington.

Marshall won a House seat in 2016 and later became a United States senator, carrying his identity as a Kansas country doctor all the way to the Capitol.

The physician-legislator. The man who had seen American health care from the inside. And in 2017, he joined the Republican effort to repeal the Affordable Care Act.

Well, that résumé reads somewhat differently now. Because there are several ways to acquire "firsthand experience with America's health-care system."

You can learn what happens when a working family gets crushed by medical expenses. Or you can learn precisely which forms need to be filed to collect them.

Both technically qualify as experience. Only one looks good in a campaign commercial.

Marshall's campaign says this reporting unfairly transforms the financial realities of rural medicine into an election-year scandal. His spokeswoman argues that he treated people regardless of ability to pay and was trying to keep rural medical care alive.

Fine. Put that defense on the table. Let Kansas voters inspect it.

But while we're inspecting things, perhaps somebody can explain exactly how many $101 lawsuits are required to keep the hospital lights on.

And whether the bulbs get noticeably brighter at 18 percent APR.