This article was produced in partnership with nonprofit news organization MLK50, which is a member of the ProPublica Local Reporting Network.

This year, a hospital housekeeper left her job just three hours into her shift and caught a bus to Shelby County General Sessions Court in Memphis, Tenn.

Wearing her black and gray uniform, she had a different kind of appointment with her employer, Methodist Le Bonheur Healthcare: The hospital was suing her for unpaid medical bills.

In 2017, the nonprofit hospital system based in Memphis sued the woman for the cost of hospital stays to treat chronic abdominal pain she experienced before the hospital hired her.

She now owes Methodist more than $23,000, including around $5,800 in attorney’s fees.

It’s surreal, she says, to be sued by the organization that pays her $12.25 an hour. “You know how much you pay me. And the money you’re paying, I can’t live on,” says the housekeeper, who asked that her name not be used for fear that the hospital would fire her for talking to a reporter.

From 2014 through 2018, the hospital system, which is affiliated with the United Methodist Church, has filed more than 8,300 lawsuits against patients, including some of its own workers. After winning judgments, it has sought to garnish the wages of more than 160 Methodist workers and has actually done so in more than 70 instances over that time, according to an MLK50-ProPublica analysis of Shelby County General Sessions Court records, online docket reports and case files.

Some of the debts were accrued while the employees worked at Methodist; others predated their time there. The figures do not include debts incurred by onetime Methodist employees who have since moved on.

It’s not uncommon for hospitals to sue patients over unpaid debts. In fact, as NPR reported Tuesday, recent research shows that more than a third of hospitals in Virginia do so. And earlier reporting from NPR and ProPublica found the practice in several other states.

But what is striking at Methodist, the largest hospital system in the Memphis region, is how many of the patients being sued are the hospital’s own employees. Hardly a week goes by in which Methodist workers aren’t on the court docket fighting debt lawsuits filed by their employer.

Between January and mid-June, a reporter observed more than a dozen Methodist employees in court to defend themselves in suits brought by the hospital over hospital bills.

That includes a Methodist Le Bonheur employee who owes more than $1,200. In January, she proposed paying $100 a month, even though her sworn affidavit listed monthly expenses that exceeded her $1,650 monthly income. After conferring with an attorney for Methodist, Judge Betty Thomas Moore agreed to the worker’s proposal, but she has already missed a payment.

A few weeks later, a Methodist employee appeared for an initial hearing wearing hospital scrubs. The hospital had sued her for more than $4,000. When she left the courtroom, she was annoyed. Her employer knew where she worked, she said, and should have contacted her before suing her.

“I don’t know why they can’t come upstairs,” she said outside the courtroom.

And in May, an employee who has worked for Methodist for more than four years carried a large envelope full of bills with her into the courtroom. She owed more than $5,400, which included a 2017 hospital charge from the newborn unit. That is the same year that her daughter was born, according to her sworn affidavit, which also listed a checking account balance of less than $4.

The woman offered to pay $10 biweekly, or $20 most months, but Methodist’s attorney wanted $200 per month. The judge ordered her to pay $100 per month.

What makes matters worse, employees say, is that Methodist’s health insurance benefits only allow employees to seek medical care at Methodist facilities, even though the financial assistance policies at its competitors are more generous.

A specialist in hospital billing practices says that if the hospital is suing a fair number of its own employees, it’s time to examine both the insurance provided to workers and the pay scale.

Given that the hospital is suing some of its own employees, “one would hope … the hospital would look at the insurance they provide workers,” says Mark Rukavina, a former nonprofit hospital consultant and currently a manager at Community Catalyst, a health care advocacy organization.

Methodist declined requests for an interview. It did not respond to specific written questions about the lawsuits it files against its workers or about how its policies reflect the values of the United Methodist Church. Instead, in a written statement, it said it is committed to working with patients who are having trouble paying their medical bills.

“As the second largest private employer in Shelby County, we recognize the responsibility we have as an organization to contribute to the success of the diverse communities we serve and are purposeful about creating jobs in our community — intentionally choosing to keep services like printing, laundry and others in-house that are typically outsourced by the health care industry,” the hospital said.

Methodist also declined to answer a question about whether it has any policy that prohibits employees being sued by Methodist from talking to a reporter about the lawsuits filed against them by the hospital.

Employer and legal adversary

On a single January day, there were 10 defendants on the docket whose place of employment was listed in court records as Methodist.

Employees in scrubs sat just feet away from the attorneys in dress suits — attorneys their employer had hired to sue them. The hospital’s role as a tax-exempt organization that both employs the defendants and is suing them went unremarked upon by judges, attorneys and the defendants themselves.

Methodist’s financial assistance policy stands out from peers in Memphis and across the country, MLK50 and ProPublica found. The policy offers no assistance for patients with any form of health insurance, no matter their out-of-pocket costs. Under Methodist’s insurance plan, employees are responsible for a $750 individual deductible and then 20% of inpatient and outpatient costs, up to a maximum out-of-pocket cost of $4,100 per year.

The housekeeper’s story is documented in Shelby County General Sessions Court records, including online docket reports and online payment history. A reporter interviewed the housekeeper multiple times in person and on the phone. The employee gave the reporter six years of itemized Methodist hospital bills, her credit report and other past-due medical bills. Most of her debts were incurred before she started working at Methodist.

Five times between 2012 and 2014, she visited the hospital for stomach problems, according to the itemized bills. (Years later, she had surgery to treat diverticulitis.) At those times, she had insurance through her job at a hotel, where she cleaned rooms for $10.66 an hour. After insurance paid its share, she owed just over $17,500.

In 2015, the housekeeper left the hotel job and lost her insurance. Three times that year she went to Methodist’s ER, but since she was uninsured and had little income, she qualified for financial assistance. Methodist wrote off more than $45,000 in hospital bills.

In a statement, Methodist said it gives an automatic 70% discount to uninsured patients and free care to uninsured patients at or below 125% of the federal poverty guidelines. For a single adult with two dependents, that would be just over $26,600. Uninsured patients who earn more than that, but less than twice the poverty limit, are also eligible for discounts, it said.

In 2016, unable to find work, the housekeeper left Memphis. For more than a year, she says, she and her son were homeless, bouncing between relatives in Chicago, where she was born, and Texas.

But she missed her daughter and grandchildren in Memphis. So in 2017, she returned. In August 2017, Methodist sued her for the bills she accumulated when she was insured years earlier. Later that month, she was hired at a Methodist hospital, starting at $11.95 an hour.

The hospital’s collections agency, which it owns, didn’t have her correct address and was unable to serve notice that she had been sued, but last year, Methodist tried again. This time, it had the right address.

In November, a process server handed her the civil warrant at her South Memphis apartment.

At the process server’s recommendation, she called the hospital’s collection agency and offered to pay $50 every two weeks. “But they said it wasn’t enough,” she recalls. “I would just have to go to court. They said I’d be owing them all my life.”

In a sworn affidavit filed with the court this year, the housekeeper listed her dependents as a grandson and her 27-year-old son, who she says has bipolar disorder and schizophrenia. She told the court she earned $16,000 in 2017, which puts her more than $4,000 below that year’s federal poverty level for a family of three. (Because she had insurance, though, she was ineligible for assistance under the hospital’s policy.)

Fred Morton, a retired Methodist minister in Memphis, says he was surprised to learn that Methodist is suing its own employees.

“The employees should be paid an adequate minimum wage at the very least,” he says. “Certainly they should not be predatory to their own employees on medical bills. That’s very much contrary to Scripture.”

He said that Methodist bishops who serve on its board bear responsibility for reminding it of the denomination’s values.

“It’s a matter of the church pushing on its own,” Morton says.

Three United Methodist Church bishops serve on the hospital’s board. Bishop Gary Mueller’s office referred a reporter to Methodist Le Bonheur Healthcare’s communications office. Bishop Bill McAilly declined to comment. Bishop James E. Swanson did not respond to multiple requests for comment.

When the housekeeper appeared before a General Sessions Court judge this year, she’d filed a motion offering to pay $50 biweekly, or $100 in most months. When the hospital’s attorney asked for a $200 per month, she was stunned.

“This is my only job, this is my only income, so how am I supposed to live?” she remembered thinking.

Nervous that the judge would side with the hospital, the housekeeper made another offer.

“I could do $75 every two weeks,” she said quickly.

The attorney agreed and the judge signed the order.

Being an employee and defendant is “really kind of sad,” the housekeeper says. Asked how she manages to make ends meet, she says she doesn’t: “It’s killing me — killing me softly.”

She says she didn’t reach out to the hospital’s payroll department or a manager about the hospital bills she’s being sued for. “They don’t care about that. … That I do know.”

‘I don’t want to be homeless again’

Part of what makes paying medical bills so hard for some Methodist employees is that their wages are low, lagging behind several other large employers in the Memphis market. In December, St. Jude Children’s Research Hospital announced it was raising its minimum pay for full and part-time workers to $15 an hour. St. Jude’s decision followed a similar commitment by the Shelby County government, Shelby County Schools and Blue Cross Blue Shield of Tennessee.

At Methodist, which operates five hospitals in Shelby County, the lowest-paid employees make $10 an hour and about 18% of workers make less than $15 an hour, the hospital reported in response to MLK50’s 2018 Living Wage Survey.

As recently as 2017, the Greater Memphis Chamber advertised on its website that the city offered a workforce at “wage rates that are lower than most other parts of the country.”

The United Methodist Church’s Social Principles, which state the denomination’s position on everything from climate change to the death penalty, speak directly to what employees should earn. “Every person has the right to a job at a living wage,” it states. The Living Wage Model statement on the church’s website says, “Exploitation or underpayment of workers is incompatible with Christ’s commandment to love our neighbor.”

Methodist, which made Forbes’ 2019 list of Best Employers by State, did not answer specific questions about pay for employees. On its website, it says, “It is the policy of Methodist Le Bonheur Healthcare to pay its employees competitive, market-based wages.”

Neither Methodist, nonprofit Baptist Memorial Healthcare nor Regional One, the public hospital, pay all their employees at least $15 an hour. Even that figure would make it impossible to make ends meet for an employee trying alone to support a household with dependents, according to MIT’s Living Wage Calculator and another created by the Economic Policy Institute, both of which take into account local living expenses.

The housekeeper’s $12.25 an hour pay falls well short of that. Without overtime, she says, her take-home pay would be around $1,600 per month. Her rent is $610.

Even with as much overtime as she gets, she’s turned to payday loans. Since December, she’s renewed a $425 payday loan every two weeks, paying $71 each time. “You have to rob from Paul to pay Peter,” she says. “It doesn’t never seem like you can get ahead.”

The housekeeper applied for a job at Walmart but was told the store nearest her is not accepting applications. She doubts the pay will be any better, but she hopes it will be less stressful.

“Times be hard, because sometimes my body feels like I can’t make it,” she says. “But I get up anyway, because I don’t want to be homeless again.”

Wendi C. Thomas is the editor of MLK50: Justice Through Journalism. Email her at wendicthomas@mlk50.com and find her on Twitter at @wendi_c_thomas.

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There’s a green van parked on the edge of downtown Miami on a corner shadowed by overpasses. The van is a mobile health clinic and syringe exchange where people who inject drugs like heroin and fentanyl can swap dirty needles for fresh ones.

One of the clinic’s regular visitors, a man with heavy black arrows tattooed on his arms, waits on the sidewalk to get clean needles.

“I’m Arrow,” he says, introducing himself. “Pleasure.”

This mobile unit in Miami-Dade County is part of the only legal needle exchange program operating in the state. But a new law in Florida — a needle exchange law that won the support of Florida’s conservative legislature, and was signed by Gov. Ron DeSantis Wednesday — aims to change that.

Needle exchanges have been legal in many other states for decades, but southern, Republican-led states like Florida have only recently started to adopt this public health intervention.

The timing of the statewide legalization of needle exchanges comes as Florida grapples with a huge heroin and fentanyl problem. When people share dirty needles to inject those drugs, it puts them at high risk for spreading bloodborne infections like HIV and hepatitis C. For years, Florida has had America’s highest rates of HIV.

Even so, Arrow says he and every user he knew always put the drugs first. Clean needles were an afterthought.

“Every once in a while, I did use someone else’s and that was a thrill ride — wondering whether or not I was going to catch anything. But I’m blessed; I’m 57 and I don’t have anything,” says Arrow, whose full name NPR has agreed not to use because of his use of illegal drugs.

“Now I can shoot with a clean needle every time,” he says.

The Miami experiment

According to the Centers for Disease Control and Prevention, needle exchanges prevent the spread of viruses among users of injection drugs.

But the advocates who want to offer needle exchanges face challenges. For example, carrying around loads of needles to hand out without prescriptions can violate drug paraphernalia laws. Many states mapped out legal frameworks decades ago to handle this particular public health intervention. But it was illegal to operate exchanges in Florida until 2016. That’s when the state legislature gave Miami-Dade County temporary permission to pilot a needle exchange program for five years.

“This is more than just a needle exchange,” says Democratic state senator Oscar Braynon. “This has become a roving triage and health center.”

Braynon has been sponsoring needle exchange bills — including the bill for the pilot project — since 2013. This year he introduced Senate Bill 366 to allow the rest of Florida’s counties to authorize similar programs.

In three years of operation, Miami’s pilot program has pulled more than a quarter million used needles out of circulation, according to reports the program filed with the Florida Department of Health. By handing out Narcan — the drug that reverses opioid overdoses — the exchange has prevented more than a thousand overdoses. The program also offers clients testing for HIV and hepatitis C, which is how Arrow knew he was negative. Finally, the program connects people to medical care and drug rehab.

“We have made it so easy for people to get into HIV care now, and we have so many people who we never would have known were infected — and would have infected countless other people — who are on their medications,” says Dr. Hansel Tookes, head of Miami’s needle exchange pilot program He has been pushing legislators to legalize needle exchanges since he was a medical student six years ago.

Tookes was in Tallahassee, the state capital, this May when the expansion bill passed its final vote. He said he spent the return flight home to Miami staring out the window.

“I looked down at Florida the entire ride,” he says, “and I just had this overwhelming feeling like, ‘Oh my God, we just did the impossible and we’re going to save so many people in this state.’ “

Why harm reduction trumped politics

When Republican state senator Rob Bradley first deliberated over needle exchanges in Florida six years ago, he was critical.

“You’re trying to make sure the person has a clean needle, which is outweighing the idea of the person breaking the law,” he declared back in 2013, before casting his vote against the idea.

This is the primary objection of conservative lawmakers — the concern that these programs promote illegal drug abuse.

Responding to this skepticism with data has been central to changing lawmakers’ minds. Decades of research show needle exchanges do not encourage drug abuse, and that they lower other health risks to people who are vulnerable and often hard to reach. It’s part of a public health approach known as “harm reduction.”

At a recent meeting ahead of the vote on statewide legalization, Ron Book — a powerful Florida lobbyist who chairs the Miami-Dade County Homeless Trust — voiced a question that comes up a lot about the needle exchange and heroin use.

“Doesn’t that help encourage it?” he asked Tookes.

“Nobody who used our program — and we collect a lot of data — was a first-time user of opioids when they came there,” Tookes told him. “Not one person.”

In Miami, the needle exchange pilot project has also earned the support of law enforcement. Officers say it’s a relief to know more injection drug users are keeping their syringes in special sharps containers, provided by the exchange, to safely dispose of dirty needles.

“Now, for our officers, when they’re doing a pat down … that sharps container is really protecting you from a loose needle 100 percent of the time,” says Eldys Diaz, executive officer to the Miami Chief of Police. “That’s an extraordinary source of comfort for us.”

This year, when state senator Bradley heard discussion of the needle exchange bill again, he had a different response.

“I just want to say, when I started my career in the Senate, I voted against the pilot project — and I was wrong,” he said as he voted for the bill this time. “And the results speak for themselves. It’s very good public policy.”

The state’s new needle exchange law passed unanimously in the Florida Senate and 111 to 3 in the Florida House, and goes into effect July 1.

Arrow gets a future

If it weren’t for the tattoos running down his arms, it would be hard to recognize Arrow as the man who once slept under highway overpasses. His skin is now clear, and he has some meat on his bones — he looks healthier.

“How have you been?” Tookes asks, greeting Arrow at a clinic where needle exchange clients can get follow-up care.

“Wonderful,” Arrow says. “I feel good.”

He looks and feels better, but it’s been a rough year.

Last May, Arrow’s girlfriend died from a heart infection — a serious condition that can happen to people who inject drugs. After that, Arrow says, he overdosed on purpose. Narcan from the needle exchange brought him back.

But he kept using.

Arrow says he doesn’t remember a lot from this period, but does remember using so much heroin that he ran out of fresh needles between visits to the exchange. So he grabbed other people’s used needles.

And then he tested positive for HIV and hepatitis C.

Tookes and his colleagues threw Arrow another life raft: They got him an inpatient drug treatment bed.

At Arrow’s checkup with Tookes, a string of keychains from Narcotics Anonymous clicked at his waist.

“My chain of sobriety,” he says of the links. “I got 30-days, 60-days, and 90-days chips,” he says.

Arrow’s HIV is under control. And he’s connected to health services for people living with HIV, including getting medication that cured his hepatitis C.

Now, he’s focused on staying sober, one day at a time. And he’s starting to want new things. “Thanks to this man right here,” he says, nodding to his doctor — Tookes.

As more Florida counties elect to begin needle exchanges, there’s no guarantee that every person who turns to them will get as far as Arrow. But Tookes, Braynon and other supporters hope such services will at least give more people the chance to recover from addiction — and protect themselves from needle-borne illnesses.

This story is part of NPR’s reporting partnership with WLRN and Kaiser Health News, a nonprofit news service of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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Today, antiretroviral medicines allow people with HIV, the virus that causes AIDS, to live long, productive lives. But at the onset of the AIDS epidemic in the early 1980s, the disease was considered a death sentence. No one was sure what caused it or how it was spread. Some doctors and nurses refused to treat patients with the disease; others protected themselves by wearing full body suits.

Cliff Morrison, a nurse at San Francisco General Hospital at the time, remembers being appalled by what he was seeing: “I would go in patients’ rooms and you could tell that they hadn’t had a bath,” he says. “They weren’t being taken care of.”

In 1983, Morrison organized a team of healthcare providers to open Ward 5B, an in-patient AIDS special care unit at San Francisco General Hospital. The medical team on the unit encouraged patients to make their rooms like home, and allowed families and partners to visit whenever they could. They comforted patients by touching them, and would even sneak in pets.

5B was the first unit of its kind in the nation — and it became a model for AIDS treatment, both in the U. S. and overseas. Now, a new documentary, called 5B, tells the story of the doctors and nurses who cared for patients on the ward.

Dr. Paul Volberding was a doctor on Ward 5B and went on to co-create an AIDS clinic at the hospital, which was one of the first in the country. He emphasizes how critically ill the patients on the unit were.

“These were people that were really, sometimes literally, dying when they came into the hospital, so whatever we could do to make them more comfortable was really important,” he says.

The work on 5B was emotionally draining, and death was a constant reality. Still, Volberding describes his time there as a “blessing.”

“The care that patients were getting was really special and very different than the rest of the hospital,” he says. “It was always a complete privilege to do this work.”

Morrison adds, “I had some really wonderful experiences with people in their passing, and they taught me a great deal. It really put in perspective the fact that life is on a continuum, and death is just part of that continuum. I saw people have beautiful deaths, and that was wonderful.”

Interview highlights

On how everyone who came into the hospital with the virus in the early 1980s died

Volberding: I don’t think most people can understand today how devastating a disease AIDS was back in those days. … It’s just impossible to appreciate that HIV, if it’s untreated, kills essentially 100 percent of the people. It’s much worse than Ebola, much worse than smallpox. So, everyone died. Every patient that was sick enough to come to us to look for medical care would die from this disease. And people knew that there was a lot of education to be done, but they knew that this was a really bad situation.

On how they didn’t know if what they were seeing was infectious when the first patients came in with the rare cancer, Kaposi’s sarcoma, which ended up being one of the symptoms of the as-yet-unknown AIDS virus

Volberding: I wasn’t worried about catching anything from the patients because that’s not what I expected in taking care of cancer patients. I didn’t expect to be worried about anything, and wasn’t really. But the care that the patients were getting was pretty spotty in the hospital. I think that was one of the things that led Cliff and the others to really put together the nursing unit.

Morrison: In my experience, in already what had been seen and what I was hearing from the specialists around us with the information that was coming out, was that I wasn’t at risk providing care to people by touching people. And everybody around us was saying, “Oh you’re just being cavalier. This is really not what you should be doing, and you’re giving the wrong message.” And our response always was, “We’re giving the right message.” So we were dealing with a lot of hysteria and misinformation and just outright discrimination, I think, very early on.

On expanding the hospital’s family and visitors’ policy for Ward 5B

Morrison: We also noticed right away … that we needed to really look at issues around family and visitation, because healthcare was very rigid and was really stuck on this whole idea [regarding] visiting hours that it could only be immediate family. Most of our patients didn’t have family around. … We almost immediately began talking about, in all of these regular meetings and sessions that we had, that maybe we needed to start letting our patients tell us who their family was, and that we needed to kind of move away from this whole idea of traditional family and biological family.

Volberding: I think that the patients were so sick — and they were so in need of support — that the idea of visiting hours and keeping people away didn’t make sense.

Morrison: There were times when they were alone in their rooms and they always needed something. They were very anxious. It not only made them more comfortable, it made our lives a lot easier having people that were there in the rooms most of the time.

On the bond that existed among 5B staff members

Volberding: It was a family. The physicians, the staff and the clinic and in the inpatient unit — we all worked so closely together because those were our patients. As physicians, those were our patients. And we were on the unit every day seeing our patients, and it was, again, a very special group of people.

On how the homophobia of the time influenced patient care

Morrison: That was, I think, probably the most glaring reality of the situation. Even in San Francisco — which, even at that time was considered the gay mecca — gay people had very established careers and homes and families, and yet all of that started coming apart. And it really was centered around homophobia. There were people in the hospital that should have known better. … There was a group of nurses that basically said that what we were doing was crazy and that we were putting all of them at risk. It went before the labor board — but that was all homophobia.

On the evolution of AIDS treatment

Volberding: In 1987 we began to have some drugs that were doing something. … And then, by 1996, the so-called triple therapy was developed and that was really a turning point in the epidemic. We could suddenly start seeing some of our patients actually get better — not just die more slowly, but actually get better.

And some of those people are still alive today. The effort since ’96 has been to take those potent drugs and make them less toxic and more convenient. Today, we treat this very typically with what we call single tab regimens — one pill taken once a day that contains two, three or even four drugs — all in the same pill. Many of my patients don’t have any side effects at all from the medicines they’re taking. The change from the early days, and seeing the drugs being developed, and now seeing that this is truly a chronic condition is, I think, one of the most amazing stories we’ll ever hear from in medicine.

Amy Salit and Mooj Zadie produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for the Web.

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