Stock photo of words on wall saying, "Debt will tear us apart."

Lizzie Presser was looking for the intersection of two wide-ranging and little-known facets of American life: the broad power of contempt laws, and the criminalization of medical debt. The ProPublica reporter  found it in Coffeyville, Kansas, and came back with a startling story. “When Medical Debt Collectors Decide Who Gets Arrested,” published October 2019, exposes a system that gives financial bounty hunters the power of cop, judge and jury — leaving patients in a deepening pit of debt.

Coffeyville’s aggressive stance toward those in medical debt often meant jail time for debtors. One man was jailed after he couldn’t pay a $818 medical bill after an accident; another was arrested over a $230 bill while she was four months pregnant. Presser found 11 arrests and more than 30 warrants related to medical debt in the previous year.

Such situations aren’t unique to Coffeyville. As Presser explains, debtors have been jailed under contempt powers for money owed to payday lenders, or landlords, or day-care services. But Coffeyville is where Presser felt she was able to best shine a light on the story — and does so with a memorable group of sources including a cattle rancher who’d been appointed magistrate judge; a debtor who fended for himself in court while shuttling his son back and forth to chemotherapy treatments; and a lawyer quoted as saying, “The two growth industries in Coffeyville are health care and funerals.”

Lizzie Presser

Lizzie Presser

Presser covers health and healthcare policy for ProPublica. She’s a two-time finalist for the National Magazine Award and the Livingston Award. She spent three months reporting this story, including three trips to Coffeyville. We asked how she found the story, verified the depth of the situation, and gained the trust of sources on all sides of a power imbalance. An annotation follows our Q and A, which has been edited for length and clarity.

How did this story develop … and how did you find Coffeyville, Kansas, as an illustration of it?
I’d studied the law of contempt for a separate article I wrote earlier this year, and at one point this summer, I grew curious about how these powers intersected with medical debt. When I dug around, I saw that the ACLU had written an extremely thorough, and quite disturbing, report on the criminalization of private debt, including medical debt. They chronicled how judges, at the request of debt collectors, use their contempt authority against debtors. I spoke with the lead author, Jennifer Turner, and she passed along the names of lawyers around the country who had seen this play out in the context of medical debt. I reached out to them and eventually settled on Kansas, where I focused on Coffeyville. There was a litigious hospital, aggressive debt collectors, and a judge willing to issue bench warrants.

How much time did you spend on the story?
In all, I spent about three months. I took three trips to Coffeyville, Kansas — and spent a total of three weeks there. And when I wasn’t in Kansas, I was requesting and analyzing records, conducting interviews over the phone, and eventually piecing the reported story together.

Several people share details that at first blush may seem unflattering/embarrassing. How did you earn their trust?
I generally abide by the hang-out-for-awhile theory of journalism. For this story, I spent a lot of time in the courthouse. Some defendants were quick to open up to me; most, though, grew more at ease after they saw me interacting with others in the foyer of the courthouse. The judge and the debt collectors also got used to me sticking around. I had a lot to ask about the process and I wanted to know what they thought about their respective roles. They were generous enough to entertain my questions.

I also spent a lot of time pulling names and addresses from court documents, and I knocked on dozens of stranger’ doors for this story. If they didn’t answer, I left hand-written notes about who I was and why I was appearing at their doorstep. That helped, too.

I think people generally feel more comfortable if they see that I’m investing time. I’m lucky enough to have the resources to do that.

Did the story change much during editing? If so, how?
I’ve never woven a story around so much live scene and dialogue before. My editor, Alexandra Zayas, cut the fat between scenes and helped finesse the transitions. The story is complicated and has a lot of explanatory elements, so we also had to figure out how much we could explain up top without bogging a reader down, and how we could sprinkle technical details in elsewhere. That was tricky, and luckily, Alex has a knack for streamlining.

How closely did you work with other contributors on the story, such as the photographer (Edmund D. Fountain), researcher (Doris Burke) or the team that designed/produced it (Jillian Kumagai and Agnes Chang)?
Edmund Fountain flew down while I was in town, so we traveled around Coffeyville together for a few days. I would talk to him about different people I’d interviewed before he shot, but he had his own vision around how to photograph — and he did a gorgeous job. Doris Burke had worked on other medical debt stories this year, so she volunteered to pull information for me. She’s an incredible researcher, and she pulled background information on some of the people in the story, which was helpful, and also pretty fascinating to peruse. There’s a lot you can learn about people on the internet. Jillian Kumagai is super collaborative, which I love, and she always lets me see the photos that come in. She asks me my favorites, and she ultimately chooses. We went back and forth on a few different layouts for the header image (or in this case, triptych), and the rest was her design with Agnes.

Is there anything you learned while working on this story that will be helpful in the future, either to you or to other journalists?
I’ve had a tendency to focus on the experiences of people harmed by policy or law. In Coffeyville, I tried something different — to report the story as relational, and to try to understand not only the patients’ perspectives, but the debt collectors’ and the judge’s. I want to report more stories like this — examining process — in the future.

What has the response been, particularly from folks in Coffeyville?
The response was quite overwhelming — from readers, from medical debtors, from local journalists interested in covering similar issues in their communities. I think that generally speaks to how pervasive medical debt is in this country; about one in six people have health care bills in collections.

I haven’t been back to Coffeyville since the story came out, so I can’t say for certain, but the buzz online has been interesting to follow. A lot of hospital patients have been posting about their issues with billing and their experiences in court. The patients I wrote about, too, have been surprised by the support they’ve received following publication.

The annotation: Storyboard’s questions are in red; responses from Presser in blue. To read the story without annotations, click the ‘Hide all annotations’ button, which you’ll find just below the social media buttons in the top right-hand menu, or at the top of your mobile screen.

When Medical Debt Collectors Decide Who Gets Arrested

ON THE LAST TUESDAY of July, Tres Biggs stepped into the courthouse in Coffeyville, Kansas, for medical debt collection day, a monthly ritual in this quiet city of 9,000, just over the Oklahoma border. He was one of 90 people who had been summoned, sued by the local hospital, or doctors, or an ambulance service over unpaid bills. Some wore eye patches and bandages; others limped to their seats by the wood-paneled walls. Biggs, who is 41, had to take a day off from work to be there. He knew from experience that if he didn’t show up, he could be put in jail. How did you find Tres Biggs? And did it take much convincing for him to allow you to write about him so intimately? I met Tres in the courthouse on my first day in Coffeyville. He was shy and closed-lipped at first. He also wasn’t sure if his wife wanted to share such personal family details, so I decided to reach out to her directly. I ended up driving to their farmhouse to introduce myself to her and explain the story I was trying to write. She and Tres talked about it afterward, and they agreed to be interviewed. Since I was in Coffeyville for so long scouring court records, I made it very clear to both Heather and Tres that I could work around their schedules. I went over to their house a few different times for interviews and to spend time with the family.

Before the morning’s hearing, he listened as defendants traded stories. One woman recalled how, at four months pregnant, she had reported a money order scam to her local sheriff’s office only to discover that she had a warrant; she was arrested on the spot. A radiologist had sued her over a $230 bill, and she’d missed one hearing too many. Another woman said she watched, a decade ago, as a deputy came to the door for her diabetic aunt and took her to jail in her final years of life. Now here she was, dealing with her own debt, trying to head off the same fate.

Biggs, who is tall and broad-shouldered, with sun-scorched skin and bright hazel eyes, looked up as defendants talked, but he was embarrassed to say much. You’re able put the reader inside Biggs’ head. Did you ask him later what he had been feeling during the hearing? In this case, I could tell he was embarrassed. He started talking about when he was jailed, in a quiet voice, and then very quickly clammed up. After a few other defendants spoke about their experiences with jail, he shared a couple more details, but his eyes were darting around. I asked him later if he was embarrassed, and he confirmed that he was. His court dates had begun after his son developed leukemia, and they’d picked up when his wife started having seizures. He, too, had been arrested because of medical debt. It had happened more than once.

Judge David Casement entered the courtroom, a black robe swaying over his cowboy boots and silversmithed belt buckle. A nice piece of description. How deliberately do you look for small details that describe or reveal character, such as Judge Casement’s belt buckle or the “sun-scorched skin” from the previous graf? I usually find physical description difficult, but with Judge Casement, I didn’t have to search very far. I was charmed by his outfit when I met him in his office after court. I figured that if I noticed the belt buckle and the cowboy boots and found them evocative, a reader would too. When I first started writing magazine stories, my editors would jokingly scold me for barely trying my hand at physical description. I’ve always found it uncomfortable to paint someone’s image with just a few words. But, I now have those editors’ voices in my head, and I make a point to look for details like the sun-scorched skin. He is a cattle rancher who was appointed a magistrate judge, though he’d never taken a course in law. Judges don’t need a law degree in Kansas, or many other states, to preside over cases like these. Casement asked the defendants to take an oath and confirmed that the newcomers confessed to their debt. A key purpose of the hearing, though, was for patients to face debt collectors. “They want to talk to you about trying to set up a payment plan, and after you talk with them, you are free to go,” he told the debtors. Then, he left the room.

The first collector of the day was also the most notorious: Michael Hassenplug, a private attorney representing doctors and ambulance services. What made Hassenplug “notorious”? Almost all the patients I spoke to had a story about Hassenplug. One patient, Crystal Dyke, was put in jail for missing hearings related to a bill owed to a radiologist, whom Hassenplug represented, and when I watched her tell her grandmother about the imprisonment, her grandmother replied that Hassenplug nearly requested a warrant for her arrest, twenty years earlier. Coffeyville is a small place, and Hassenplug is the most prominent local debt collector.  Every three months, Hassenplug called the same nonpaying defendants to court to list what they earned and what they owned — to testify, quite often, to their poverty. It gave him a sense of his options: to set up a payment plan, to garnish wages or bank accounts, to put a lien on a property. It was called a “debtor’s exam.”

If a debtor missed an exam, the judge typically issued a citation of contempt, a charge for disobeying an order of the court, which in this case was to appear. If the debtor missed a hearing on contempt, Hassenplug would ask the judge for a bench warrant. As long as the defendant had been properly served, the judge’s answer was always yes. In practice, this system has made Hassenplug and other collectors the real arbiters of who gets arrested and who is shown mercy. If debtors can post bail, the judge almost always applies the money to the debt. Hassenplug, like any collector working on commission, gets a cut of the cash he brings in.

Across the country, thousands of people are jailed each year for failing to appear in court for unpaid bills, in arrangements set up much like this one. The practice spread in the wake of the recession as collectors found judges willing to use their broad powers of contempt to wield the threat of arrest. Judges have issued warrants for people who owe money to landlords and payday lenders, who never paid off furniture, or day care fees, or federal student loans. Some debtors who have been arrested owed as little as $28.

More than half of the debt in collections stems from medical care, which, unlike most other debt, is often taken on without a choice or an understanding of the costs. Since the Affordable Care Act of 2010, prices for medical services have ballooned; insurers have nearly tripled deductibles — the amount a person pays before their coverage kicks in — and raised premiums and copays, as well. As a result, tens of millions of people without adequate coverage are expected to pay larger portions of their rising bills.

The sickest patients are often the most indebted, and they’re not exempt from arrest. In Indiana, a cancer patient was hauled away from home in her pajamas in front of her three children; too weak to climb the stairs to the women’s area of the jail, she spent the night in a men’s mental health unit where an inmate smeared feces on the wall. In Utah, a man who had ignored orders to appear over an unpaid ambulance bill told friends he would rather die than go to jail; the day he was arrested, he snuck poison into the cell and ended his life.

In jurisdictions with lax laws and willing judges, jail is the logical endpoint of a system that has automated the steps from high bills to debt to court, and that has given collectors power that is often unchecked. I spent several weeks this summer in Coffeyville, reviewing court files, talking to dozens of patients and interviewing those who had sued them. How long were you in Coffeyville? What kind of reception did you receive there? I was in Coffeyville for about three weeks in total. I stuck out, and people certainly looked at me as if I were a foreigner. People had different reactions. Patients were bemused and pleased. The court staff were welcoming and amenable to my sometimes overwhelming requests. The judge was curious to know what I was hearing from defendants about their experiences, and also how other judges acted differently.  Hassenplug and the other collectors and lawyers seemed more wary  of me. Everyone asked me the same question: Why Coffeyville?  Though the district does not track how many of these cases end in arrest, I found more than 30 warrants issued against medical debt defendants. At least 11 people were jailed in the past year alone.

With hardly any oversight, even by the presiding judge, collection attorneys have turned this courtroom into a government-sanctioned shakedown of the uninsured and underinsured, where the leverage is the debtors’ liberty.

How much research went into these paragraphs, which expand the scope of the story to reveal that Coffeyville isn’t an outlier in how medical debt is pursued? Are there any research resources that were especially helpful? The ACLU’s report on the criminalization of private debt, which we linked to in the story, was the most helpful resource. I spoke with many lawyers around the country who had experiences in cases like these, and also medical debt experts, debt collection scholars, and judicial authority scholars. I spent time compiling local news stories on arrests of medical debtors and particularly aggressive debt collectors, too. The trickiest part for me was compiling a database of my own. Local courts tend not to group cases by the type of debt, for example, or the outcome, like arrest. I requested every docket from the last Tuesday of the month — which is considered medical debt collection day — from the past year in Coffeyville, and then I manually searched the case records for each defendant who had been found in contempt and built a spreadsheet to track down those who had warrants issued against them.

SEATED AT THE FRONT of the courtroom, Hassenplug zipped open his leather binder and uncapped his fountain pen. He is stout, with a pinkish nose and a helmet of salt and pepper hair. His opening case this Tuesday involved 28-year-old Kenneth Maggard, who owed more than $2,000, including interest and court fees, for a 40-mile ambulance ride last year. Maggard had downed most of a bottle of Purple Power Industrial Strength Cleaner, along with some 3M Super Duty Rubbing Compound, “to end it all.” His sister had called 911.

Maggard took his seat. He had cropped red hair, pouchy cheeks and mud-caked sneakers. “The welfare patients are the most demanding, difficult patients on God’s earth,” Hassenplug told me, with Maggard listening, before launching into his interrogation: Are you working? No. Are you on disability? He was diagnosed with schizoaffective disorder, bipolar type, and anxiety. Do you have a car? No. Anyone owe you money you can collect? I wish.

They had been here before, and they both knew Maggard’s disability checks were protected from collections. Hassenplug set down his pen. “Between you and me,” he asked, “you’re never going to pay this bill, are you?”

“No, never,” Maggard said. “If I had the money, I’d pay it.”

Hassenplug replied, “Well, this will end when one of us dies.” Do you look for opportunities to get dialogue — rather than quotes — into your stories when appropriate? I generally try to establish intimacy in a story either through close-focused reconstruction of events or live, unfolding scene and dialogue. In Coffeyville, I was struck by some of the vivid scenes in the courthouse that I was witnessing, and I wanted readers to feel like they were there with me.

Though debt collection filings are soaring in parts of America, Hassenplug speaks with pride about how he discovered their full potential in Coffeyville long before. A transplant from Kansas City, he was a self-dubbed “four-star fuck-up” who worked his way through law school. He moved to Coffeyville to practice in 1980 and soon earned a reputation as a hard-ass. I can’t pass up the opportunity to ask: Was there a discussion about whether “hard ass” should be one word or two? I left this critical decision to the standards editor, Diego Sorbara. When I told him you had asked this question — which he loved — he went back to the dictionary. He has since concluded that it deserves to be hyphenated. He thanks you for your eye.  He saw that his firm, Becker, Hildreth, Eastman & Gossard, hadn’t capitalized on its collections cases. The lawyers didn’t demand sufficient payments, and they rarely followed up on litigation, he said. Where other attorneys saw petty work, Hassenplug saw opportunity.

One striking aspect of this story is that it doesn’t just confine itself to those on the wrong end of the debt-collection system; it explores those who benefit from it, such as Hassenplug. Was that your intent when you began reporting in Coffeyville, or did the scope expand with the reporting? It was definitely my hope when I started reporting, but I knew I’d have to earn my way there. Any time I write about people harmed by some practice, I am curious to know how and where and why that practice originated. I think tracing the history can be quite telling. Because this story was local, in a sense, once Hassenplug suggested the critical role that he had played in ramping up debt collection practices in Coffeyville, I wanted to know how he worked, and how he thought. He believes in the fairness of his practices, and I wanted readers to understand his perspective. The last thing I wanted was for him to be some flat caricature. I observed him in court several times, and I spoke to him on the phone as well, but it wasn’t until my final day in Coffeyville that he gave me a long sit-down interview.

Hassenplug started collecting for doctors, dentists and veterinarians, but also banks and lumber yards and cities. He recognized that medical providers weren’t being compensated for their services, and he was maddened by a “welfare mentality,” as he called it, that allowed patients to dodge bills. “Their attitude a lot of times is, ‘I’m a single mom and … I’m disabled and…’ And the ‘and’ means ‘the rules don’t apply to me.’ I think the rules apply to everybody,” he told me.

He logged his cases in a computer to track them. First with the firm and later in his own practice, he took debtors to court, and he won nearly every time; in about 90% of cases nationally, collectors automatically win when defendants don’t appear or contest the case. Hassenplug didn’t need to accept $10 monthly payments; he could ask for more, or, in some cases, even garnish a quarter of a debtor’s wages. His fee was, and often still is, one-third of what he collects. He asked the court to summon defendants, over and over again. It was the judge’s contempt authority that backed him, he said. “It’s the only way you can get them into court.”

The power of contempt was originally the power of kings. Under early English rule, monarchs were considered vicars of God, and disobeying them was equivalent to committing a sin. Over time, that contempt authority spread to English courts, and ultimately to American courts, which use it to encourage compliance with the judicial system. There is no law requiring that a court use civil contempt when an order isn’t followed, but judges in the U.S. can choose to, whether it’s to force a defendant to pay child support, for example, or show up at a hearing. A person jailed for defying a court order is generally released when they comply. Why did you choose to trace the history of contempt law for the reader here? I find it fascinating. I initially thought I’d write an entire section on contempt law but then thought better of it. I wrote this because I wanted the reader to understand the remarkable transformation — that a power that originated from authoritarian rulers’ believed proximate to God is now wielded by non-lawyer, low-level judges in courts across America.

When Casement took the bench in 1987, after passing a self-study exam, he didn’t know much legalese — he had never been in a courtroom. But attorneys taught him early on that the power of contempt was available to him to punish people who ignored his orders. At first, Casement could see himself in the defendants. “I was a much more pro-debtor aligned judge, much more sympathetic, much less inclined to do anything that I thought would burden them,” he told me. “And over the years, I’ve gradually moved to the other side of the fulcrum. I still consider myself very much in the middle, and I don’t know if I am or not.”

Once a bustling industrial hub, Coffeyville has a poverty rate that is double the national average, and its county ranks among the least healthy in Kansas. Its red-bricked downtown is lined with empty storefronts — former department stores, restaurants and shops. Its signature hotel is now used for low-income housing. “The two growth industries in Coffeyville,” Hassenplug likes to say, “are health care and funerals.”

Coffeyville Regional Medical Center is the only hospital within a 40-mile radius, and it reported $1.5 million in uncollectible patient debt in 2017. A nonprofit run in a city-owned building, the hospital accounts for the vast majority of medical debt lawsuits in the county — about 2,000 in the past five years. It also accounts for the majority of related warrants. Account Recovery Specialists Inc. handles its collections, and it does so for hospitals in most Kansas counties. Though the hospitals can direct ARSI and its contracted attorneys to tell judges not to issue warrants, hardly any have. The Coffeyville hospital’s attorney, Doug Bell, said that its only motivation is to continue to serve the area, and that Kansas’ decision to not expand Medicaid under the Affordable Care Act has had a “dramatic effect on the economic liability of small rural hospitals.”

Three nearby hospitals in this rural region have closed in the past several years, meaning ambulances make more trips. A half-hour from Coffeyville, Independence runs its ambulance service at about a $300,000 annual loss. Its bills were at the root of four arrests this year alone. Derek Dustman, who is 36 and works odd jobs, had been driving a four-wheeler when he was hit by a car and rushed to the hospital. Though he was sued for not paying his $818 ambulance bill, he didn’t have a license to drive to the courthouse. This spring, he spent two nights in jail. “I never in a million years thought that this would end with jail time,” he told me.

For years, Hassenplug has requested that the judge issue warrants on the ambulance service’s behalf. When I asked Lacey Lies, the city’s director of finance, if she ever considered telling him not to resort to bench warrants, she was puzzled. “You’re saying an attorney with no teeth?”

HE FIRST TIME Tres Biggs was arrested, in 2008, he was dove hunting in a grove outside Coffeyville. It had been just a year since his 6-year-old son Lane was diagnosed with leukemia, and Biggs watched him breathe in the fresh air, seated on a haybale under an orange sky. When a game warden came through to check hunting permits, Biggs’ friends scattered and hid. He wasn’t the running type, and he took Lane by the hand. The warden ran Biggs’ license. There was a warrant out for his arrest. Biggs asked a friend to take Lane home and crouched into the warden’s truck, scouring his memory for some misstep.

The last few years had been a blur. His wife, Heather, had quit her job as a babysitter to care for their son. Then, she got sick. Some days, she passed out or felt so dizzy she couldn’t leave her bed. Her doctors didn’t know if the attacks were linked to her heart condition, in which blood flowed backward through a valve. To provide for his wife, son and two other kids, Biggs worked two jobs, at a lumber yard and on construction sites. He didn’t know when he would have had time to commit a crime. He’d never been to jail. As he stared out the window at the rolling hills, his face began to sweat. He felt his skin tighten around him and wondered if he would be sick.

There’s a lot of vivid description in these grafs. Why did you decide to focus so much on this incident? And how much reporting did it to take to elicit the details, like the “tightening skin”? I realized early on in reporting this story that one of the most disturbing elements was that a lot of people who were ultimately jailed had no idea that a warrant was out for their arrest. They were pulled over at traffic lights, or questioned as witnesses to crimes, or stopped at court when they came to pay bills, and an officer cuffed and booked them. It’s disorienting and terrifying. I wanted the reader to feel that through Tres’s experience.
When I’m reconstructing a scene, I don’t stop asking questions until I can close my eyes and imagine it. I want to be able to hear it, see it, smell it, and feel it. I interviewed Tres, Heather and their son Lane about this night until I felt like I was getting close. With emotions, I find that our vocabulary is pretty limited. Tres kept telling me that he was scared, for instance. But fear feels different to different people. I wanted to understand how it manifested for Tres — so I asked him over and over again until I could imagine the sensations he was describing, like tightening skin.

The warrant, he learned at the jailhouse, was for failure to appear in court for an unpaid hospital bill. Coffeyville Regional Medical Center had sued him in 2006 for $2,146, after one of Heather’s emergency visits; neither of his jobs offered health insurance. In the shuffle of 70-hour workweeks and Lane’s chemotherapy, he had missed two consecutive court dates. He was fingerprinted, photographed, made to strip and told to brace himself for a tub of delousing liquid. His bail was set at $500 cash; he had about $50 to his name.

His friend bailed him out the next morning, but at the bond hearing, the judge granted the $500, minus court fees, to the hospital. Biggs compensated his friend with a motorboat that a client had given him in exchange for a hunting dog. But it wasn’t long before the family received a new summons. In 2009, a radiologist represented by Hassenplug sued them for $380.

Some court hearings fell on days when Lane had treatment, at a hospital in Tulsa, an hour south. Heather refused to postpone his care. Lane’s condition was improving — in a year, he would be cancer-free — and his dirty blond hair was sprouting again. Her health, though, had taken a turn. She began having weekly seizures, waking up on the floor, confused about where their Christmas tree had gone or why a red Catahoula puppy was skidding around their ranch house. Her doctors concluded she had Lyme disease, which was affecting her nervous system and wiping her short-term memory. Each time she woke up, she repeated: “Don’t take me to the hospital.”

Biggs was still on the hook for the bill that had landed him in jail; bail had covered only part of it, and the rest was growing with 12% annual interest. The hospital had garnished his wages, and the radiologist had garnished his bank account, seizing contributions that his family had raised for Lane’s care. Living on $25,000 a year, Biggs couldn’t afford to buy insurance. His family was on food stamps but didn’t qualify for Medicaid, a federal insurance program for people in poverty. Other states were about to expand it to cover the working poor, but not Kansas, which limited it, for families of his size, to those who earned under $12,000. Like millions of others across America, he and Heather fell into a coverage gap.

By 2012, the Biggs family had accrued more than $70,000 in medical debt, which it owed to Coffeyville Regional Medical Center and other hospitals, pediatricians and neurologists. Some forgave it; others set up lenient payment plans. Coffeyville’s was the only hospital that sued. The doctors who took them to court were represented by Hassenplug.

Biggs began to panic around police, haunted by the fear that at any moment, he might be locked up. That spring, outside the Woodshed gas station, he spotted a sheriff’s deputy who was also an old friend. To shake off his dread, he asked the friend to run his license. The deputy found another warrant, signed by Casement, involving the $380 radiologist’s bill. “You’re not really going to take me in, right?” Biggs remembers asking. The deputy said he had no choice. Bail, as usual, was set at $500.

The family filed for bankruptcy, a short-term fix that erased their debt but burdened them with legal fees. They lost their home and started renting. Biggs ultimately got a job that offered insurance, as a rancher, covered by Blue Cross Blue Shield. But it required Biggs to pay the first $5,000 before it covered medical expenses. When chest pain hit him as he worked cattle in the heat, and he began vomiting, the only nearby hospital was Coffeyville’s. In 2017, the hospital sued again. It was the family’s sixth lawsuit for medical debt.

Sitting in Casement’s courtroom this July, Biggs calculated that he was losing about $120 by taking time off from work to attend this hearing. “I haven’t received a bill,” he told me, slouched over his turquoise shorts. “The only thing I received was this summons.” Around noon, he finally sat down with an ARSI representative, who explained that the underlying bill had been garnished from his wages, but he still owed $328 in interest and court fees. He had another couple thousand dollars in collections for separate bills he hadn’t paid, for which he hadn’t yet been sued. He said the most he could afford to pay, every two weeks, was $12.50.

BEFORE THE END of the Tuesday docket, Casement returned to the courtroom to read off the names of the hospital’s defendants. Five had failed to show up for contempt citations, to give their reasons for missing their debtor’s exams. Casement saw that two of the no-shows hadn’t been properly notified of the hearing, so attorneys would need to try to reach them again. The judge read the names of the other three defendants and told the hospital’s collections lawyer, “That would be a bench warrant if you want it.”

The following morning, I was reading court files in the clerks’ office when Christa Strickland arrived at 10:20 in flip-flops and black leggings, her caramel hair wrapped in a bun atop her head. She ran her finger down a docket on the bulletin board and asked why her case wasn’t listed. When the clerk pulled up her file, she told Strickland that her contempt hearing had been on Tuesday and she was one day late. “You need to call the law office of Amber Brehm,” the clerk insisted, referring to ARSI’s contracted lawyer, who represents the hospital. She handed over the phone number.

Strickland sat on a hard bench and took out her cellphone. She had saved the hearing in the wrong day on her calendar, but she had taken the day off from work and wanted to clear up the misunderstanding. “I had a court date,” she said when a man answered at the law office. “I thought it was today but apparently it was yesterday. I’m just needing to see if I can set something up?”

“By not appearing at that, the court would be in the process of issuing a bench warrant,” he said.

“What does that mean?” Strickland asked, shaking her head.

“You don’t know what a bench warrant means?” he asked. “That means you will be arrested and taken to jail and ordered to post bond.”

“Oh my God.” Strickland squeezed her eyes shut, wetness smudging her mascara. She poked at her cheek with her index finger. Her father was a preacher. She’d never been in trouble with the law. She had made a mistake, she tried to explain. She wanted to make an arrangement to pay.

The man on the phone told her that it might take a couple weeks before the court processed her warrant paperwork, which the law office had not yet submitted. Once the judge issued the warrant, she could turn herself in. Strickland wanted to scream, Ill pay the bill, dont make me go to jail! but she didn’t have the money. Instead, she looked at the ceiling and asked: “Turn myself into the court? The police station?”

“The Sheriff’s Department,” he responded.

“They’re here in the same building,” she said. “I won’t leave here until I get this figured out. Thank you!”

How did you record this scene? Did you ask Christa Strickland later what was said on the other end of the phone call? I was already reading through court records when Christa came in to ask a clerk for help. She said her name, and I remembered it from the hearing the day before, when she hadn’t showed up. I followed Christa out of the clerk’s office and introduced myself, explaining the article that I was writing. She said she had to make a phone call, and I asked if I could shadow her. She was definitely confused about who I was and how I knew about her case, but once I explained a bit more about what I was trying to do, she said okay. This call was made on speakerphone in the courthouse. I shadowed her around court the rest of the morning (and later, to her home — which didn’t make it into the story).

She hung up. Prick, she muttered to herself. Youre going to talk to me like Im a freaking idiot? Thats not okay. Educate me. The court has to process it? Her mind kept moving in circles. She herself worked in debt collection, for an auto title lending company. She understood that everyone was doing their job. Still, she couldn’t grasp how this bill had gotten this far.

Before she had taken this position, during her second pregnancy, her right breast had developed a chronic infection. In 2008, she was uninsured, needed surgery to remove the swollen abscess and ran up a $2,514 bill. More than a decade later, she was still chipping away at a balance that, because of interest and court fees, had more than doubled to $5,736. She had fallen behind on her monthly payment plan and now worried that her booking photo would be on Mugshot Monday, a Facebook album run by the Police Department. She imagined what she would tell her boss: I went to jail … because I missed a court date … for medical bills. It sounded absurd.

She spotted a sheriff’s deputy in a bulletproof vest with a name tag that said Bishop and a pistol on his hip. “Hey!” she called out, explaining her phone call and how the man said something about a warrant and turning herself in. Bishop radioed into dispatch and smiled with an update: “There’s no warrant in the system yet,” he told her.

Yet!” Strickland replied, deflating his look of reassurance. “That’s what I’m worrying about.”

“You better give Amber a call back,” Bishop said.

When I asked ARSI about how attorneys decide to request warrants, Joshua Shea, who is general counsel, told me that they don’t. The judge can choose to issue one if court orders are not followed, he said. But Casement said the opposite, telling me that he gave the choice to the attorneys. “I’m not ordering a bench warrant. My decision is to give them that option,” Casement told me. “Whether they exercise it is up to them, but they have my blessing if that’s what they want to do.”

Shea sent me an eight-page email to make clear, in large part, that ARSI, as a collection agency, has no involvement in the courts, and that Brehm is a lawyer whom the agency contractually employs and who represents the hospital directly. Her email address, though, has an ARSI domain, and her resume lists her as ARSI’s director of legal. Brehm said that court hearings aren’t the only option for debtors, who can call her instead and answer questions under oath. Shea said nobody — not the hospital, ARSI, Brehm or the court — uses the threat of jail to “extract payment.”

Strickland reached Brehm after several days, and the attorney agreed to a new hearing. On Aug. 13, when they met in court, Brehm sat at the front of the room.

“We’re giving you a second chance on that citation; just to try to take care of this without there having to be any sort of bench warrant,” the lawyer said. “I want to make sure that we’re all on the same page about the consequences of not coming into court when the order has been issued.”

Strickland nodded.

“Again, if you set a payment plan and keep it,” Brehm said, “we won’t have to worry about that.”

IN SOME COURTHOUSES, like Coffeyville’s, collection attorneys are not only invited to decide when warrants are issued, but they can also shape how law is applied. Recently, Hassenplug came to believe that debtors were only attending every other hearing in a scheme to avoid jail, and he raised his concern with the judge. He suggested that the judge could fix this by charging extra legal fees; Casement wrote a new policy explaining that anyone who missed two debtor’s exam hearings without a good reason would be ordered to pay an extra $50 to cover the plaintiff’s attorney fees. If they didn’t pay, they would be given a two-day jail sentence; for each additional hearing that they missed, they would be charged a higher attorney fee and get a longer sentence.

Most states don’t allow contempt charges to be used for nonpayment, and some, like Indiana and Florida, have concluded that it is unconstitutional. Michael Crowell, a retired law professor at the University of North Carolina and an expert in judicial authority, reviewed Casement’s policy. “You can’t lock people up for contempt for failing to pay unless you have gone to the trouble to determine that they really have the ability to pay,” he said. Casement told me he hadn’t made findings on ability to pay before ordering defendants to foot attorney’s fees, “but I know that’s something the court should consider,” he said. He also made plain why he wrote the policy: “Mr. Hassenplug and Brehm’s outfit have asked me to.” (Brehm denied she requested this.)

Casement has not done everything the debt collection lawyers have suggested. At first, he agreed to their requests to set bail at the amount of the debt, but he eventually settled on $500. “Most people can come up with $500,” he said. “It may not be their money, but they know someone who will pay.” He made sure no one was arrested unless they’d been reached by personal service or certified mail.

Kansas law allows courts to order debtors in “from time to time,” leaving discretion to judges. Casement limited the frequency of Hassenplug’s debtor’s exams to once every three months. He came to the decision by his own logic around what seemed like a reasonable burden for defendants, and it remains his personal policy today. The law also states that anyone found to be disabled and unable to pay can only be ordered to appear once a year. Without an attorney, debtors like Kenneth Maggard don’t know to assert this right.

Allowing bail money to count toward collections raises some of the most critical legal questions. Hassenplug told me that he thinks it’s great that cash bail is applied to the debt. “A lot of times, that’s the only time we get paid, is if they go to jail,” he said.

Peter Holland, the former director of the Consumer Protection Clinic at the University of Maryland Law School, explained that this practice reveals that the jailing is not about contempt, but about collection. “Most judges will tell you, ‘I’m working for the rule of law, and if you don’t show up and you were summoned, there have to be consequences,’” he explained. “But the proof is in the pudding: If the judge is upholding the rule of law, he would give the bail money back to you when you appear in court. Instead, he is using his power to take money from you and hand it to the debt collector. It raises constitutional questions.”

Congress has not acted on advocates’ calls to amend the Fair Debt Collection Practices Act to prohibit collectors from requesting warrants. There are also no current efforts to bar nonprofit hospitals or medical providers that receive funds through Medicare or Medicaid from seeking warrants. Some states have reformed their laws, to make sure defendants are properly served or to prohibit wage garnishments for debt. But legal experts on collections say that more remains to be done, like taking jail out of the equation and instead requiring debtors to sign a financial affidavit or a promise to appear.

Shea, from ARSI, said that using the legal process is time-consuming and costly — a last resort; arrests are “the least desirable stage for any case to reach for all involved.” Even after lawsuits are filed, they try to connect eligible debtors with the Coffeyville hospital to apply for financial assistance, he said. Last year, the hospital wrote off $1.7 million in charity care, said Bell, the hospital lawyer. “That is evidence of a hospital that cares.”

Casement said he did not consider the legality of his policies a problem. He placed some blame on the health care system. “What we have isn’t working,” he said. “As a lifelong Republican, I would probably be hung, but I think we need health care for everybody with some limits on what it’s going to cost us.”

The way he saw it, he had wide latitude to enforce compliance with a court order, though he acknowledged that creditors used bail money to their advantage. “I don’t know whether the Legislature intended it to be used that way or not,” he told me. “I have not had enough pushback from the defendants’ side to give me the impression that I’m really abusing this badly.”

BEFORE I LEFT Coffeyville, I sat down with Hassenplug in the low-ceilinged courtroom. I asked him whether he thought that the system in Coffeyville was effectively imprisonment for debt, in a country that has outlawed debtors’ prisons. “The only thing they’re in jail for is not appearing,” he replied. “I do my job, I follow the law. You just have to show up in court.”

Debt collection is an $11 billion industry, involving nearly 8,000 firms across the country. Medical debt makes up almost half of what’s collected each year. Today, millions of debt collection suits are overwhelming state courts. The practice is considered a “race of the diligent,” where every creditor is rushing to the courthouse, hustling to get the first judgment, in order to be the first to collect on a debtor’s assets.  In Hassenplug’s view, though, this work is not the rich taking from the poor. He laughed at how locals spread rumors, saying that he seized wheelchairs or Christmas trees. Once, he confessed, he took a man’s Rolex, only to find out it was a fake. Some months, he said, even his law office could not make ends meet.

After a couple of hours, a clerk poked her head into the courtroom and told us it was time to leave. Hassenplug and I began to walk out, and on the terrazzo steps, he asked if I wanted to see his buildings. He owned five of them on a shuttered stretch of town. He wondered out loud if he was making a mistake by inviting me, but he was pleased when I accepted. “There ain’t any place on earth quieter than downtown Coffeyville,” he said, leading me into the silent streets.

He walked me through the alleys under a cloudless sky, and when he arrived at one of his buildings, he tapped a code to his garage. The door lifted, and inside, five perfectly maintained motorcycles, Yamahas and Suzukis, were propped in a line. To their left, nine pristine, candy-colored cars were arranged — a Camaro SS with orange stripes, a Pontiac Trans Am, a vintage Silverado pickup with velvet seats. He toured me around the show cars, peering into their windows, and mused about what his hard work had gotten him. Why did you choose to end the story with this anecdote? How could I not choose to end the story with this anecdote?

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