Advancing Health Podcast: "A New Solution to Medical Debt"

Date: April 8, 2026
Host: Molly Smith, American Hospital Association
Guests: Allison Sesso (CEO/President, Undue Medical Debt), Eva Sal (Policy Lead, Undue Medical Debt)

Overview

In this engaging episode of Advancing Health, host Molly Smith sits down with Allison Sesso and Eva Sal from Undue Medical Debt to discuss the persistent and growing problem of medical debt in the United States. With one in four Americans burdened by some form of medical debt, the conversation covers both practical relief efforts and systemic policy challenges. The episode dives into how Undue Medical Debt works with hospitals to abolish debt, the limitations of current safety nets, and bold ideas for real, upstream solutions.

Key Discussion Points & Insights

The Scope and Impact of U.S. Medical Debt

• Alarming Statistics:
  • "Seven in 10 U.S. adults say they receive medical bills they can't afford." (A, 00:00)
  • Over 15 million people have had $27 billion in medical debt relieved by Undue Medical Debt. (C, 01:32)
  • The national medical debt problem is estimated at at least $220 billion. (C, 04:27)
• Wide-Reaching Harm:
  • Beyond financial strain, medical debt burdens mental health and prevents many from seeking further necessary care. (C, 01:25; D, 02:54)
  • "Most people really want to pay their bills, but the gap between what they're expected to pay and what they actually have in resources is just way too wide and wider." (C, 04:27)

How Undue Medical Debt Works

• Mission & Model:
  • A non-profit operating like a for-profit debt buyer—except instead of collecting, they abolish debt for people under 400% of the federal poverty level, or whose debt is ≥5% of their income. (C, 01:38)
  • Works with over 70 health systems and 300+ hospitals nationwide. (C, 01:17)
  • “We never ever collect a single penny from a patient. We would never do that.” (C, 01:48)
• Impact on Patients:
  • Eliminating debt provides relief, enabling patients to seek needed care again without fear. (C, 09:54)
  • Debt relief is targeted, often by ZIP code or community, aligning with donor intent. (C, 11:06)
• Process:
  • Works with hospitals after collections have failed, typically reviewing up to seven years of “bad debt” files.
  • Patients meeting criteria are identified through presumptive eligibility models and debt is purchased for pennies on the dollar—generating significant impact per donated dollar. (C, 08:57)
  • “$1 of a donation to us releases $100 on average of medical debt.” (C, 09:44)
  • Donors include churches, local governments, and others; nearly 30 government contracts completed or underway. (C, 11:20)

Policy and System Challenges

• Coverage Gaps and Underinsurance:
  • Coverage is the best protection, yet even those with insurance are not safe due to high deductibles and cost-sharing.
  • “Underinsurance… means that people are spending more than 10% of their income on healthcare expenses.” (D, 06:48)
  • High-deductible and “bronze” plans in the ACA Marketplace increasingly fail to protect families—especially those on low and middle incomes. (B, 07:58)
• Upstream Solutions & Policy Recommendations:
  • Relief programs are essential, but “fundamentally what we're doing is not solving the problem of medical debt and its creation in the first place.” (C, 01:57)
  • “Financial assistance is not health coverage. And so we need to stop treating it like that…” (D, 14:02)
  • Increasing calls for robust policy change: access to affordable, comprehensive coverage for all. (D, 14:02)
• Policy Activity:
  • State-level reforms target aggressive debt collections (e.g., lawsuits, wage garnishments) and seek to better regulate financial assistance policies. (D, 12:00)
  • Concerns expressed over policies eroding coverage and the over-emphasis on price transparency as a "silver bullet" (which they argue, it is not). (D, 12:49)
  • Notably, bipartisan agreement exists around limiting extraordinary debt collection tactics.

Notable Quotes & Memorable Moments

• On Underinsurance:

  "When people walk through the door of a hospital or emergency room rather, and they have a $5,000 deductible, but their earnings would in no way allow them to pay or meet that deductible... they're underinsured because their insurance is actually not serving them."
  — Eva Sal, (06:48)

• On Removing Medical Debt:

  “We focus on people that are 400% of poverty or below, or if the debt is 5% or more of their income... We never ever collect a single penny from a patient. We would never do that.”
  — Allison Sesso, (01:38)

• On Why Debt Relief Matters:

  “This removes that barrier to care that they want to see removed.”
  — Allison Sesso, (10:54)

• On Financial Assistance vs. True Coverage:

  “Financial assistance is not health coverage. And so we need to stop treating it like that.”
  — Eva Sal, (14:02)

Solutions for Hospitals: Presumptive Eligibility

• What Is It:
  • Screening patients early—at the point of service—to determine likely eligibility for financial aid, streamlining access and reducing administrative burden. (D, 15:06)
  • Tools for presumptive eligibility reduce paperwork and ensure eligible patients get timely assistance before receiving large bills.
• Benefits:
  • “Offering a contactless and paperless option for patients.” (D, 15:44)
  • Helps hospitals efficiently allocate financial assistance, reduces friction for patients under stress, and improves outcomes.
• Resources:
  • The AHA and Undue Medical Debt offer additional case studies and guidance for hospitals looking to implement such programs. (B, 16:15)

Important Timestamps

• Introduction to Guests + Mission of Undue Medical Debt: 00:13–02:54
• Scope of Medical Debt & Policy Issues: 04:04–07:58
• How the Relief Model Works in Practice: 08:57–10:58
• Policy Conversations and State Action: 11:44–13:26
• The Limits of Financial Assistance & Need for Coverage Reform: 14:02–14:45
• Presumptive Eligibility Solution for Hospitals: 15:06–16:15

Conclusion

This episode of Advancing Health offers a compelling overview of America's medical debt crisis and insights into both immediate relief and long-term solutions. Through the experiences and passion of Allison Sesso and Eva Sal, listeners gain an understanding of the practicalities of debt relief, the day-to-day impact of underinsurance, and the urgent need for systemic reform. Hospitals and policy innovators alike are called to use data, empathy, and bold thinking to create a future where medical debt is no longer a barrier to care.