The New York Times just put a Kansas Republican senator back in the exam room he left for Congress.

According to a New York Times investigation , Sen. Roger Marshall’s obstetric practice sued more than 700 patients for unpaid bills before he entered politics. Dozens faced arrest warrants after missing court dates. The coverage is raw. It should be. It is also incomplete if it stops at outrage and never asks what happens when a physician-owned practice cannot collect for work already done.

Independent physician practices operate in a familiar milieu: care is delivered first, invoices follow later, and collection depends on third-party payers and the patient’s remaining share eventually clearing.

What Actually Happened In Kansas?

Dr Marshall practiced for more than two decades as an obstetrician-gynecologist in western Kansas, including rural Barton County. He served his community by delivering babies and taking care of women. He also founded a surgery center that morphed into a hospital.

Court records reviewed by the Times illustrated collection actions under his name or through Heartland Regional OBGYN, the practice he owned or co-owned. He eventually left clinical practice around 2016 when he won a House seat and later moved to the Senate.

The reporting describes lawsuits, wage and bank garnishments, and contracts carrying an 18 percent annual interest rate. About 81 people were arrested after failing to appear in court. Marshall’s spokesperson has argued that judges—not doctors—issue those warrants, that patients were treated regardless of ability to pay, and that affiliated hospital billing used the same outside collection procedures common across Kansas businesses. Private practice lives with the balance: the patient owes what insurance did not pay, and if they do not pay, the practice either writes it off against the doctor’s own margin or sends it to collections and, when necessary, litigation. That is the factual frame—private practice, patient balances, collection litigation—not a hospital monopoly quietly writing every unpaid invoice off as charity theater. Large non-profit hospitals fold those same write-offs into Form 990 “community benefit,” often at chargemaster list prices rather than cost, so an uncollected bill becomes a tax-exempt talking point instead of a loss the physician has to eat.

The Patient Side Is Brutal—And The Numbers Are Real

Here is the contradictory truth: medical debt wrecks families, and pretending otherwise is dishonest.

Researchers with the Consumer Bankruptcy Project estimated that medical bills or illness-related income loss contributed to about two-thirds of personal bankruptcies —roughly half a million families a year in that accounting. Kaiser Family Foundation surveys have found that about four in ten U.S. adults report some form of medical or dental debt. Urban Institute analysis still counted nearly 10 million consumers with medical debt in collections on credit records in 2024.

Aggressive collection on small balances can feel like punishment for being sick. Patients deserve transparency, real insurance protection, and payment plans before the courthouse. Arrest over a missed medical-debt hearing is a policy failure dressed as process. Indeed, the Times article features real people affected by that process put in action.

Businesses Collect. Medicine Can’t Pretend It Is Different

Here is the other half. A physician practice is still a business with payroll, malpractice premiums, nurses, staff, insurance and rent. Unpaid invoices are not “community benefit.” They are uncompensated labor and capital unless someone absorbs them.

If a contractor renovates a kitchen and the homeowner ghosts the final invoice, nobody calls the contractor a villain for filing a lien. If a law firm bills hourly and the client stiffs the fee, collection is ordinary. Restaurants do not treat walking out on the check as a social justice movement. Medicine alone is told that performing the service creates a moral duty to pretend money is optional.

Marshall’s clinic did not invent American collections law. It used it. One may argue the tactics were harsh—especially the interest rate and the path to warrants—without arguing that physicians must work for free.

Why Independent Practices Feel Cornered

After inflation, Medicare physician payment has fallen by roughly 33 percent since 2001, according to the American Medical Association , while hospital-side payment trajectories have moved in the opposite direction—a divergence documented in prior Forbes reporting, including when another conversion-factor cut took effect without an inflation adjustment. High-deductible plans then shift more of the remaining bill onto patients who cannot pay the physician who has already delivered the care.

Clinics face an ugly choice: absorb the loss, sell to a system that can cross-subsidize or sue at scale and collect. Outrage at one senator’s old docket is easy, especially across a partisan divide. Repairing the payment design that manufactures uncollectible balances is harder—and more useful to the patient, the next physician, and the American health-care system.