MEMPHIS, Tennessee — In July 2007, Carrie Barrett went to the emergency room at Methodist University Hospital, complaining of shortness of breath and tightness in her chest. Her leg was swollen, she’d later recall, and her toes were turning black.

Given her family history, high blood pressure and newly diagnosed congestive heart failure, doctors performed a heart catheterization, threading a long tube through her groin and into her heart.

Her share of the two-night stay: $12,019.

Barrett, who has never made more than $12 an hour, doesn’t remember getting any notices to pay from the hospital. But in 2010, Methodist Le Bonheur Healthcare sued her for the unpaid medical bills, plus attorney’s fees and court costs.

Since then, the nonprofit hospital system affiliated with the United Methodist Church has doggedly pursued her, adding interest to the debt seven times and garnishing money from her paycheck on 15 occasions.

Barrett, 63, now owes about $33,000, more than twice what she earned last year, according to her tax return.

“The only thing that kept me levelheaded was praying and asking God to help me,” she said.

She’s among thousands of patients the massive hospital has sued for unpaid medical bills. From 2014 through 2018, Methodist filed more than 8,300 lawsuits, according to an MLK50-ProPublica analysis of Shelby County General Sessions Court records. Older cases like Barrett’s, which dates back nearly a decade, remain on the court’s docket.

Other hospitals in Memphis and around the country also sue patients. According to a study published Tuesday in the Journal of the American Medical Association, researchers found more than 20,000 debt lawsuits filed by Virginia hospitals in 2017. More than 9,300 garnishment cases occurred that year, and nonprofit hospitals were more likely to garnish wages.

But Methodist’s aggressive collection practices stand out in a city where nearly 1 in 4 residents live below the poverty line.

Its handling of poor patients begins with a financial assistance policy that, unlike many of its peers around the country, all but ignores patients with any form of health insurance, no matter their out-of-pocket costs. If they are unable to afford their bills, patients then face what experts say is rare: A licensed collection agency owned by the hospital.

Lawsuits follow. Finally, after the hospital wins a judgment, it repeatedly tries to garnish patients’ wages, which it does in a far higher share of cases than other nonprofit hospitals in Memphis.

Its own employees are no exception. Since 2014, Methodist has sued dozens of its workers for unpaid medical bills, including a hospital housekeeper sued in 2017 for more than $23,000. That year, she told the court, she made $16,000. She’s in a court-ordered payment plan, but in the case of more than 70 other employees, Methodist has garnished the wages it pays them to recoup its medical charges.

Nonprofit hospitals are generally exempt from local, state and federal taxes. In return, the federal government expects them to provide a significant community benefit, including charity care and financial assistance.

Methodist does provide some charity care — and pegs its community benefits as more than $226 million annually — but experts faulted it for also wielding the court as a hammer.

“If Warren Buffett walks in and needs a heart valve procedure and then stiffs the hospital, then yes, you should sue Warren Buffett,” said John Colombo, a University of Illinois College of Law professor emeritus who has testified before Congress about the tax-exempt status of nonprofit hospitals. “I can’t think of a situation in which thousands of your patients would fit that.”

Several nonprofit hospitals don’t sue patients at all, such as Bon Secours Hospitals in Virginia, which stopped pursuing debt suits in 2007, and the University of Pittsburgh Medical Center, which includes more than 20 facilities.

Some of Methodist Hospital’s cousins — health systems affiliated with the United Methodist Church — also don’t sue patients. That’s the case with Methodist Health System, which operates four hospitals in the Dallas area. The collection policy of the seven-hospital Houston Methodist system states: “At no time will Houston Methodist impose extraordinary collection actions such as wage garnishments,” liens on homes, or credit bureau notification.

“We are a faith-based institution and we don’t believe taking extraordinary measures to seek bill payments is consistent with our mission and values,” a Houston Methodist spokesperson said by email.

Methodist Le Bonheur, which says it is the second largest private employer in Shelby County, boasts on its website that it’s committed to a “culture of compassion.” Last year, Fortune magazine ranked the hospital among the 100 Best Companies to Work For.

Methodist declined repeated requests to interview its top executives.

Instead it sent a statement that said, “Outstanding patient debts are only sent to collections and then to court as a very last resort, and only after continued efforts to work with the patients have been exhausted.”

“We strongly believe in providing exceptional care to all members of the community — regardless of ability to pay.”

Methodist’s collection activities are playing out in the second-poorest large metropolitan area in the nation, where jobs have long been concentrated in low-wage industries such as warehousing and logistics. More than 40% of Memphis workers earn less than $15 an hour, according to one economic development report.

For the rest of this year, MLK50 and ProPublica will explore how hospitals, businesses and others in Memphis make it nearly impossible for low-income workers to make ends meet.

Beverly Robertson, who served on Methodist’s board from 2003 to 2012, said she was surprised to learn from a reporter about the hospital’s collection practices. During her lengthy tenure, she said, board members were never informed about the lawsuits against patients.

“I wish I’d known some of this,” said Robertson, president and CEO of the Greater Memphis Chamber and previously executive director of the National Civil Rights Museum.

The Rhythm of General Sessions Court

On Jan. 16, Barrett appeared in Shelby County General Sessions Court to try to stop Methodist’s latest attempt to garnish her paycheck from her part-time job at Kroger, where she makes $9.05 an hour.

She had plenty of company: All 80 lawsuits on the Division 5 docket that morning had been filed by Methodist.

On this morning, Barrett faced Judge Betty Thomas Moore, who has been on the bench for nearly 21 years. Moore expeditiously moved through cases, pausing occasionally to question defendants or lecture them on money management, and to ask Methodist’s attorneys what judgment amount they sought or the monthly payment they’d accept.

Barrett, a devout woman whose denomination eschews makeup and jewelry, stood when Moore called her name.

She waited as the judge flipped through her file, which contained a record of the case, including a motion she filed to reinstate her payments at $40 a month. That’s the amount a judge approved two years earlier, but Barrett had stopped making payments after she lost her job.

Barrett had submitted a sworn affidavit of income and property, which spelled out her dependents, bank account balances, debts, assets and monthly expenses. Barrett wrote that her checking account had $20 in it. Her monthly income was $750 per month, and her expenses were about twice that.

What caught the judge’s eye, though, was the amount owed to the hospital.

“It’s over a $30,000 balance,” Moore said, incredulously. “It has actually doubled.”

Though Barrett had made sporadic payments, they were dwarfed by the mountains of interest the hospital tacked onto her account.

It wasn’t that she didn’t want to pay, Barrett tried to tell the judge, but that she couldn’t. She had to stop working to care for her sister, who died of cancer in November.

“You gotta pay,” replied Moore tersely. She too is a Christian, and from the bench, she often gives God credit for her journey from humble beginnings in South Memphis to elected office. Barrett began to tell the judge that now that she had a new job, she could pay more reliably, but Moore cut her off.

“That I don’t want to hear. … It’s your fourth motion. One time, you just didn’t show up!” Moore said, as Barrett started coughing — a nervous reaction, she explained later.

“Have a seat, ma’am,” said an irritated Moore. “I’m going to think about it for a minute.”

Lots of lawsuits and garnishments

Between 2014 and 2018, more than 163,000 debt lawsuits were filed in Shelby County General Sessions Court, primarily by debt buyers, auto loan companies and hospitals.

Only one plaintiff, Midland Funding, which buys unpaid debt, sued more frequently than Methodist. (Midland declined to comment.)

Methodist filed more than 8,300 lawsuits, compared with more than 6,700 filed by competitor Baptist Memorial Health Care and just over 1,900 by Regional One Health, the county’s public hospital. St. Jude Children’s Research Hospital, also headquartered in Memphis, doesn’t bill families for care not covered by insurance.

With $2.1 billion in revenue and a health system that includes six hospitals, Methodist leads the market: In 2017, it had the most discharges per year and profits per patient, according to publicly available data analyzed by Definitive Healthcare, an analytics company. Methodist says it has “a hospital in all four quadrants of the greater Memphis area, unparalleled by any other healthcare provider in our region,” plus more than 150 outpatient centers, clinics and physician practices.

The number of lawsuits Methodist files isn’t out of proportion to its size, at least compared to Baptist or Regional One. But where it does stand out is the share of cases in which it seeks a wage garnishment order, an action that can upend the lives of low-wage defendants.

A court-ordered garnishment requires that the debtor’s employer send to the court 25% of a worker’s after-tax income, minus basic living expenses and a tiny deduction for children under 15. The court then sends that payment to the creditor.

Methodist secured garnishment orders in 46% of cases filed from 2014 through 2018, compared with 36% at Regional One and 20% at Baptist, according to an analysis of court records by MLK50 and ProPublica. It is unclear what explains this difference.

Turning to the legal system to settle debts is a choice, not a mandate, said Jenifer Bosco, staff attorney at the National Consumer Law Center, a nonprofit focusing on consumer law for low-income and other disadvantaged people. “A lot of medical debts are just handled through the collections process,” she said. “Certainly some end up in court, but it seems like this hospital is especially aggressive.”

Methodist’s Dogged Pursuit of the Poor

Barrett has worked only low-wage jobs, be it cleaning medical offices or sorting packages at FedEx’s largest distribution facility, known as the hub.

But for the last nine years, Methodist has been on Barrett’s trail, following her from one low-wage job to another.

To successfully garnish a debtor’s paycheck, Methodist, like all creditors, has to clear two hurdles. First, the hospital needs to know where the person works, since garnishment requires the employer’s cooperation.

Next, the debtor must have enough after-tax income to clear the law’s earnings exemption, which protects $217.50 per week of a debtor’s after-tax income – the equivalent of 30 hours at the federal minimum wage of $7.25 an hour.

At first, the hospital couldn’t figure out where Barrett worked. It filed garnishment attempts at FedEx and then at Sodexo, which provides housekeeping and other services for corporations, only to learn from the companies that Barrett hadn’t worked there in years.

By September 2011, Barrett was working at T.J.Maxx, tagging clothes headed for the clearance racks. Methodist served her employer with a garnishment attempt, only to run into the second hurdle: She often didn’t make enough to have her pay garnished.

Time and again over the next six years, the hospital tried to garnish Barrett’s pay. Sometimes it succeeded, once collecting $3.67. Other times it failed. Four times, T.J.Maxx returned the garnishment order to the court, marking “Net Earnings Less Than Exemptions.”

While state law spares the poorest debtors from wage garnishment, it doesn’t stop creditors from adding interest to the underlying debt.

Methodist knew that Barrett was a low-income worker, yet it added interest to her account seven times, in amounts ranging from $46 to $7,340.

Charging that much interest to a low-income patient is “unconscionable,” said Fred Morton, a retired minister of Christ United Methodist Church in East Memphis.

“That’s a 21st-century version of slavery,” said Morton, who serves on the economic justice committee for MICAH, a coalition of community and faith-based organizations. “That kind of indebtedness. … That’s horrible to me.”

By 2017, Barrett had moved in with a friend and her mother, both amputees, and cared for them in exchange for a place to stay.

In April of that year, Barrett filed a motion to stop the wage garnishment and offered to pay $40 per month. She told the court her income was $800 per month.

The judge agreed, but then Barrett’s sister, who was unmarried and never had children, fell ill. When Barrett stopped working to care for her, she fell behind on her payments.

“I went and borrowed money through those payday loans to make those payments,” she said. “It was just a struggle for me.”

Every 30 days, she pays $60 to renew the $300 loan, at an effective annual interest rate of more than 240%.

Financial Assistance Required, but Is It Offered?

The Affordable Care Act, former President Barack Obama’s signature health care legislation, is best known for expanding access to health insurance coverage. But it also imposed new requirements on nonprofit hospitals, namely that they have charity care policies and share them with patients.

But the rules do not specify how generous those policies must be — and Methodist is among the least generous in the state, according to MLK50-ProPublica’s review of policies at Tennessee nonprofit hospitals.

While dozens of hospitals offer free or highly discounted care that helps shield low- and middle-income patients, regardless of insurance status, from crushing debt, Methodist does not.

That’s especially problematic for people with high-deductible health insurance plans, defined by the IRS as those with deductibles over $1,350 for an individual and over $2,700 for a family. The number of adults with employer-based, high-deductible health insurance nearly tripled from 2007 through 2017, according to a 2018 report from the Centers for Disease Control and Prevention.

Methodist said it is required by insurers to collect copayments and deductibles. That said, the hospital added: “We know some insured patients have high copays and deductibles that place a financial burden on the patient. As a mission-driven organization, we will work with these patients seeking assistance.”

Methodist’s financial assistance policy is outdated, said Michele Johnson, executive director of the Tennessee Justice Center, which advocates for expanded health care access.

“Methodist’s rules were written at a time when there was just not this epidemic of underinsured people in the state,” Johnson said. “The reality has changed faster than their policy has changed.”

Methodist said it offers 0% interest payment plans for insured and uninsured patients who have trouble paying their bills, but only offers those before court action commences. Methodist also noted that it provides an automatic 70% discount it provides to those who identify as uninsured and the free care to patients at or below 125% of the federal poverty guidelines, which for a single adult would be just over $15,600. Uninsured patients who earn more than that, but less than twice the poverty limit, are also eligible for discounts.

“We are committed to working with all patients who are struggling with medical expenses. Our desire is to work with patients early in the process to set up a payment plan that meets their individual need,” the hospital said in a statement.

The hospital’s contentions, however, do not match the text of its financial assistance, billing and collections policies or the frequently asked billing questions on the hospital’s website. None of those mention interest-free payment plans.

Methodist, like its peers, also gets assistance from the state of Tennessee to help offset its costs for providing uncompensated care. In the first three months of 2019, the state gave more than $31 million to qualifying hospitals. Of that, Methodist Le Bonheur Healthcare’s hospitals received nearly $5 million, according to a quarterly report submitted to the Tennessee General Assembly.

For years, nonprofit hospitals that sue hundreds of patients have been the subject of investigative reports and lawmakers’ scrutiny.

A 2014 ProPublica report on Mosaic Life Care (formerly Heartland Regional Medical Center) in Missouri revealed that the small hospital filed 11,000 lawsuits over a five-year period. Following the story and a Senate investigation led by Sen. Chuck Grassley, R-Iowa, Mosaic rewrote its financial assistance policies and erased nearly $17 million of patients’ debt.

“We were doing the medically right thing for the person, but on the financial responsibility part, we were doing the wrong thing,” Dr. Mark Laney, president and CEO of Mosaic, told the St. Joseph News-Press at the time.

Aggressive debt collection practices are “contrary to the philosophy behind tax exemption,” Grassley wrote in a September 2017 op-ed for the medical and science news outlet Stat.

“Such hospitals seem to forget that tax exemption is a privilege, not a right. In addition to withholding financial assistance to low-income patients, they give top executives salaries on par with their for-profit counterparts.”

In 2017, Methodist paid its president and CEO, Dr. Michael Ugwueke, $1.6 million in total compensation. That same year, Gary Shorb, the hospital’s CEO from 2001 to 2016, earned more than $1.2 million for serving as Ugwueke’s adviser. In 2018, the hospital brought in $86 million more than it spent, according to an end-of-year revenue bond disclosure statement.

Methodist Sends a Defendant in Circles

Across the country, medical debt is common, but it falls hardest on nonwhite residents and people who live in the South, according to the Debt in America report released by the Urban Institute, a Washington, D.C.-based think tank.

In Shelby County, twice as many nonwhite county residents have medical debt in collections as white residents — 23% compared with 11%.

More than half the county’s residents are African Americans, as were more than 90% of Methodist’s defendants observed by a reporter in court this year.

That includes Raquel Nelson, who appeared in court the same morning as Barrett.

Nelson’s employer-provided health insurance covered the majority of a hospital bill for her 2016 hysterectomy, but she still owes $2,200.

This was not the first time Nelson had been a defendant. Methodist sued her in 2013 for $850 in hospital bills for her children, who are now grown. (She has since paid off that debt.) Three years ago, Baptist sued her for $5,000 after an overnight stay for chest pains. She’s paying $50 a month.

Nelson, 43, doesn’t regret choosing a career in social services, although her bachelor’s and master’s degrees left her with $100,000 in student loans, which are in deferment.

Prescriptions to treat chronic illnesses including hypothyroidism, plus supplies for a machine to treat sleep apnea, total more than $200 a month.

When money is tight, Nelson pays just enough on her utility bill to keep the lights on. Her June utility bill was more than $500, and about $200 is the past due amount.

She can’t bring herself to keep a written budget. “If I do, it’ll be frightening because I’ll be thinking, ’How am I even surviving?’”

When a process server handed her the warrant on Dec. 4, stating she’d been sued by Methodist, he also gave her a card to call Consolidated Recovery Systems, a subsidiary of Revenue Assurance Professionals, the licensed debt collection agency owned by Methodist. She called the hospital’s collection agency and was told that if she didn’t pay $175 per month, she could meet them in court.

So Nelson went to court, where she asked the hospital to send her an itemized bill, so she could verify the debt was hers.

She returned to court in April, agreed the debt was hers and the next week filed a motion to pay $75 a month, the same amount she’d offered the collection agency.

In May, Nelson was back in court, this time before Judge John Donald. “I’m nervous,” she whispered, as Donald raced through the cases.

She stood when the judge called her name. Donald asked Methodist’s attorney if $75 a month would be acceptable.

“That’s fine, your honor,” said Dewun Settle, one of two attorneys Methodist has hired to represent the hospital in court.

“You’re free to go,” Donald said, waving Nelson toward the door.

Outside the courtroom, Nelson tallied her costs, including time off work, parking fees for three trips to court and a $27 filing fee all for Methodist’s lawyers to agree to the same monthly payment the hospital’s collection agency refused.

“They were just being greedy,” she said.

A Familiar Rhythm

Methodist’s attorneys tag team the cases. Settle presents the cases to the judge. R. Alan Pritchard moves between the courtroom and the hallway, where he negotiates payment plans with defendants. Attorney’s fees add 33% to the initial hospital bill in each case, turning a $2,000 bill into a $2,660 lawsuit, before court fees and interest.

The judges’ rulings will follow the defendants for months, years, even decades. But Settle doesn’t need to say much for the judge to be the hospital’s heavy.

He usually asks for more than the defendant offered, and then the judges almost always lean on the defendant.

In February, Judge Deborah Henderson was unmoved as a charter school employee explained that student loans and caring for her ailing mother kept her from paying any more than $40 per month.

“It is admirable that you are helping your disabled mom, but there is a difference between a moral responsibility and a legal responsibility,” Henderson said. “This debt is your legal obligation,” she said, before ordering the educator to pay $75 per month.

The defendant left the courtroom in tears.

Even when a defendant complies with a court order and pays the amount agreed and on time, Methodist often seeks more.

That’s what happened to a FedEx worker and mother of two the hospital summoned to court in April.

Court records show she’d made her $50 per month payments as scheduled for the past year. The sworn affidavit detailing her finances showed that her monthly expenses were $170 more than her income.

Judge Lonnie Thompson, elected in 1998, had these documents before him as he listened to Settle argue that the mother should pay more.

“She is paying on time,” Settle allowed. “We’re seeking an increase for $100 a month so the balance won’t continue to increase.”

The hospital had added more than $400 since September, raising the defendant’s debt to nearly $7,000.

Thompson turned to the defendant. “Can you pay $75?”

“My house is in foreclosure right now,” she replied.

Thompson pressed her and the defendant grew frustrated.

“I can’t agree to it if I can’t pay,” the defendant said.

“If I sign the order,” Thompson said sternly, “you have to pay it.”

“I mean, I don’t have it to pay,” she replied.

Thompson relented and agreed to let her continue paying $50 a month. Three weeks later, she filed for bankruptcy.

Pritchard and Settle referred questions to Methodist. Henderson and Thompson did not return emails seeking comment.

If a defendant had an attorney, the lawyer might be able to negotiate a discount on the debt or maybe a reduction in the attorney’s fees.

Without counsel, defendants navigate the system on their own, often poorly. When a judge asked one defendant if she was represented by counsel, the defendant pointed to Pritchard, who shook his head.

Of 80 cases on the Jan. 16 docket, only one defendant was represented by a lawyer.

Neither the judge nor the court staffers can give legal advice.

“I was telling my daughter, and she was saying, ‘You need to talk to somebody,’” Barrett recalled. She thought about going to a free legal clinic offered by Memphis Area Legal Services, she said, “but when you’re the only sole support in your household, you can’t just take off days.”

When the Tennessee Justice Center gets the rare call from a patient drowning in hospital bills, Johnson or her staff will call their contacts at that hospital.

“We’ll say, ‘This is a really heartbreaking story,’ and a lot of times they’ll just write the bill off,” she said. “I don’t know if that’s because they know that we know our way to the media, but we don’t necessarily threaten that. But they see us on the news a lot.”

Constrained by the Law

Before she ran for Shelby County General Sessions Court judge in 1998, Moore was a public defender trying capital cases. She was starting to get burned out, but she didn’t want to leave public service.

She won that election and the two since.

Moore has an easy rapport with attorneys Settle and Pritchard. And she tries to maintain a firm, but friendly demeanor with defendants.

In late May, she told a courtroom packed with defendants that she’d been where they are: Sued by creditors and having her wages garnished.

It was back in the 1980s, Moore said during an interview in her chambers, when she was a new attorney with the public defender’s office.

“I had a husband who walked off, left me with the kids, stopped paying child support and kept it moving. And I struggled,” she said.

She filed for bankruptcy in 1995.

Her empathy surfaces on her Facebook page, where she has posted articles about a subprime auto lender and an essay about the insecurity of a life in poverty.

Years ago, she took a stand when she heard cases involving car lenders who charged what she saw as exorbitant interest rates.

“I would strike it out and say: ’32%? That is unconscionable.’ That’s the legal word you can use to say, ‘I ain’t doing it,’” she said.

In response, the creditors’ lawyers sent letters reminding her that the law allowed them to charge the contractual interest rate.

“I just stopped striking it out because there was really no gray area with that. The law said this is what it is.”

Moore said she can’t be — and isn’t — swayed by the relative power of the parties involved, even when the plaintiff is a massive, profitable health care system and the defendants are often poor and without counsel. “If you start factoring that in, then you become biased.”

In April, Moore heard the case of a mother of three who owed more than $3,000. In her slow pay motion, the defendant proposed paying $30 per month.

Moore turned to Settle. “What do y’all need on that?” she asked.

At least $200 a month, Settle replied.

“I can’t do $200,” said the defendant, who works at a warehouse.

Moore then turned to the defendant’s sworn affidavit of income and property. The mother’s $2,000 monthly income left her $1,300 in the red.

Moore zeroed in on the ages of her sons (11, 17 and 19) and the defendant’s sizable clothing allowance and food budget. They were old enough, Moore reasoned, to sacrifice a little so their mother could pay more.

The 11-year-old is autistic, nonverbal, wears diapers and can only eat pureed foods, the mother told the judge. Moore shared that an elderly relative was on a similar diet, but she didn’t cut the defendant a break.

“Even with what you told me, I think you can do $100,” she said, before signing a court order directing the defendant to pay $130 per month.

On the same morning Barrett and Nelson were in court, a Shelby County Schools kindergarten teacher came to confront a $6,800 debt.

Settle asked for $140 per month. The teacher countered with $50 a month, but the judge seemed offended.

“I won’t even consider it,” Moore said. The teacher’s husband, who’d accompanied his wife to court, spoke up, but Moore cut him off.

“You married a grown-ass woman,” Moore snapped.

“Please don’t curse,” the teacher said.

“I apologize,” Moore said quickly. “It’s just frustrating.”

Taped to a door in the judge’s chambers is a prayer that says in part: “Help me to treat others today as I desire to be treated.”

She said she reads it every time she heads to the bench.

“I want to do and say what is right and pleasing to God because sometimes these folk, honey, they’ll make you want to cuss,” she said.

Debt That Will Follow Her to the Grave

After Moore heard the rest of the cases on the docket that January day, she called Barrett’s name again.

Barrett stood, and Settle asked the judge to set her payments at $100 a month.

The judge agreed, denying Barrett’s motion to pay $40 per month.

“This is going to be my last time setting this up,” Moore said sternly. “You gone be paying on this for many, many months to come.”

Months later, Barrett was still bothered by the outcome.

“If you know I can’t pay $40, why you think I can pay $100?” Barrett said.

If she’d had a chance, she would have told the judge she was perpetually late on her utility bill and sometimes, she’s had to let her car insurance lapse because she can’t afford it. “She don’t take but a few seconds to make that sentence. It was just moving them in and moving them out. They don’t have no kind of empathy for people.”

Between February and May, Barrett managed to make her payments on time, by shorting other bills and relying on payday loans. But this month, she missed her payment due date.

If Methodist doesn’t add any interest to Barrett’s debt and she pays as ordered, she will pay it off in 330 months.

She will be 90 years old.

Not long after her day in court, Barrett filed her 2018 taxes.

She made $13,800.

“It’s in the hands of God now,” she said. “There’s only so much I can do.”