“I just don’t pay them.”

I was with a group of acquaintances, and we had been engaged in a spirited conversation about the costs of medical care. While I was the only one present who worked in health care, the group itself was fairly homogenous, with individuals in similar stages of life and financial security. Access to health insurance was of no concern in this group, and neither would have been out-of-pocket expenses. When the conversation inevitably drifted to complaints about the rising costs of that care, one person described a new practice that they had recently adopted. A “life hack,” they called it. It was the “life hack” of not paying any of their medical bills.

There is a whole culture now built upon using “life hacks” to get ahead. TikTok videos and savvy podcast hosts describe countless practices from “credit card churning” and soliciting service retention offers all the way to “manufactured spending” and “skiplagging.” Some of these practices are shrewd and socially accepted, while others reside in the gray zones in the terms of service. Regardless of where each of these practices lies on an ethical spectrum, they seem to be increasing in popularity among my age peers, frustrated by rising costs and an uncertain economic outlook.

But their admission, almost a boast, of nonpayment, struck me immediately. It was said without guilt or remorse, even in the presence of me, a physician! And no one else in the conversation pushed back on the practice. I wondered, “Why would a group of typically ethically forward individuals generally agree that a calculated failure to pay medical bills was acceptable?” Especially when they all had the financial capacity to easily do so.

As surprised as I had been when I first learned of this practice, I have now been present on two separate occasions, and with separate groups, where this “life hack” was given as a tutorial. Some described the practice of paying medical bills only after they have gone to collections and then paying the collection agency a fraction of the original bill. For others, the mechanism is to simply not worry even after they are sent to collections since medical debt is treated differently on credit reports and therefore any unresolved judgments are less likely to cause financial consequences. The common theme was less about the decision itself than the framing. By labeling the practice as a “life hack,” there was no consideration about the ethical implications. While premeditated failure to pay for non-health care goods and services would likely receive strong societal condemnation, why do ethics seem to be suspended when this is done for medical care?

Economists have observed similar behaviors before. During the late 2000s financial crisis, the strongest predictor of who would walk away from an underwater mortgage they could afford wasn’t the size of the loss, but moral conviction and recognition of the practice. People who thought strategic default was ethically wrong were 77 percent less likely to say they’d do it. And knowing someone who’d strategically defaulted made people 82 percent more likely to say they would do it too. While not identical scenarios, this information is instructive for our consideration of strategic failure to pay medical debt. Like strategic defaulting, it likely spreads through conversations, one table and one Reddit thread at a time. I have now been at three of those tables.

Now, I want to be clear as there is a real crisis of medical debt in the United States. Approximately one in five Americans carries medical debt, and the vast majority is involuntary and the byproduct of some emergency or life-changing diagnosis. Furthermore, the cost of medical care continues to rise, and does so at a time when many are losing access to affordable health insurance. They are left with few options in times of crisis. As the popularity of high-deductible Health Savings Account (HSA)-eligible health plans continues to increase, more individuals are responsible for a greater portion of their care out-of-pocket.

Consumer advocacy groups and legislative bodies recognize the harm medical debt causes in our society and various policies have been implemented to address the issue. In 2022, the three major credit bureaus (Equifax, Experian, and TransUnion) announced they would remove medical debts less than $500, delay reporting for a grace period of one year after the debt became delinquent, and remove paid debt from credit reports. Seventeen states have passed legislation protecting residents from medical debt, with many restricting medical debts from consumer credit reports. In January 2025, the Consumer Financial Protection Bureau (CFPB) finalized a nationwide rule that would have banned medical debt from credit reports or being used in credit decisions. However, this rule was vacated by a federal court later that year when CFPB declined to defend the new rule when it was challenged in court.

Those patchwork protections rest on an empirical claim, but a valid one. When the CFPB examined five million credit records, it found that people carrying medical collections defaulted less often than their credit scores would have predicted. Medical debt seems to be more of a record that something happened to an individual, and not a reliable indicator of whether a person will pay their mortgage or car loan. Every piece of legitimate advocacy guidance carries the premise that it is intended to benefit those who cannot afford to pay. Charity care is means-tested by design. But while advice travels, the premise does not necessarily travel with it.

That is what makes this “life hack” a gaming of the system rather than a loophole. While it might seem to be a victimless practice, there are consequences. And there is a fundamental difference between medical debt due to inability to pay versus medical debt due to deliberate failure to do so. This is a conscious, voluntary action. And the concern is that every solvent defector, including each of my acquaintances, is a small argument against these credit protections. And groups looking to put medical debt back on credit reports are looking for exactly that argument.

We now have some idea of how often patients pay what they owe, and the answer is unsettling. Health economists found that repayment of owed cost sharing (the cost attributed to patients that includes deductibles and co-pays, and is the cost my acquaintances were declining to pay) was roughly 54 percent before the pandemic and has fallen since then. This proportion is somewhat misleading, however, since they also showed that in over 90 percent of cases, patients paid either all or none of the liability. While this is not a causal relationship, the pattern seems to be less consistent with financial hardship, which would likely include more partial payments or negotiated installments, than a conscious decision to decline payment of bills. Furthermore, the proportional decline they saw was driven not by patients paying smaller portions of their bills, but by a larger share of patients paying nothing at all. More dinner table conversations. More Reddit posts.

Unpaid liability is a cost to hospitals and physicians, and hospitals are not helpless. While it is becoming more common to require prepayment for elective medical care, it would never be an appropriate practice to enact prepayments of emergent care. And what barriers would systemic prepayment requirements produce when enacted in nonelective primary and specialty care?

Truthfully, unpaid patient liability represents less than 10 percent of expected payments for both inpatient and outpatient care among privately insured patients. And even if every solvent professional in America ceased paying their portion of medical care tomorrow, the system could potentially absorb the shock. But this was never about the money itself. The answer here is not to put medical debt back on credit reports. What is being spent down is not hospital revenue, but the small, very recent, hard-won agreement that getting sick is not a moral failure and that the bill which follows should not be read like one. It took decades of advocacy to win that agreement; we cannot let it be compromised by a “life hack.”

Dan Pierce is a physiatrist.