This article is part of “Unaffordable America,” a series examining rising economic inequality in the U.S. and the policies that drive it.

Stricken with severe abdominal pain, Randy Slaughter spent three days at a nonprofit hospital in College Station, Texas, in April 2024. But doctors couldn't determine the cause and sent him home, Slaughter said, advising him to change his diet.

His stomach issue gradually went away, but the financial pain from his visit to Baylor Scott & White Medical Center lingered.

Although he has health insurance through his architectural firm employer, Slaughter, 36, said his policy carries a high deductible of $10,000 requiring sizable out-of-pocket payments. His hospital bill totaled $33,393, his records show, generating an out-of-pocket obligation of $9,309 that he arranged to pay down every month on an interest-free plan.

“That $150 a month is a real kick in the shins,” Slaughter said.

Hospital costs are among the major forces driving Americans deeper into debt and widening the inequality gap. Over the past two decades, those costs have risen far faster than any other sector of the U.S. economy, said Zack Cooper, associate professor of public health at Yale University.

Paying for hospital care is “the leading driver of health spending growth,” Cooper said. “And the genesis of a lot of the affordability pressure folks are feeling has to do with health care.”

For many Americans, experts say, it will only get worse.

President Donald Trump’s signature piece of legislation, dubbed the One Big Beautiful Bill Act, will cause at least 10 million Americans to lose their health care coverage by 2034, according to the Congressional Budget Office. The bill will usher in cuts to Medicaid, largely through strict work requirements, and reduce the number of people eligible for reduced cost coverage through the Affordable Care Act, also known as Obamacare.

Like many others saddled with steep hospital bills, Slaughter struggled to keep up with his monthly payments. But when he asked the hospital if he could pay a lower amount, the billing department threatened to send his account to collections, according to a recording of the phone conversation reviewed by NBC News.

“When you talk to billing, you can’t speak to anyone that’s making these decisions, and you can’t go into the hospital to see someone face to face,” he said.

After NBC News asked the hospital about Slaughter’s experience with its billing, it erased his remaining balance of $4,431, his account shows.

Julie Smith, a spokeswoman for Baylor Scott & White, said she could not go into specifics on Slaughter’s case because he did not sign a legal document freeing her to do so. (Slaughter said he was concerned the hospital could share his private information with third parties.)

But Smith acknowledged that the billing process is “one of the most complex and confusing parts of the healthcare journey,” especially for patients receiving emergency care.

“One of our top priorities is improving this experience for those we serve,” she added.

Flagging medical bills

How much does a particular procedure cost at your nearest hospital? It’s supposed to be easy to find out.

Federal rules went into effect in 2021 requiring hospitals to provide such information in a “consumer-friendly format.” But pricing information on hospital websites can be hard to grasp owing to huge data files and the complex way it’s presented.

An analysis of pricing at half the nation’s hospitals — a total of 3,236 facilities — shows that the costs of the same procedures are literally all over the map. And it’s the people without health insurance, whose ranks are expected to grow by the millions in the next 10 years, who are charged the highest amounts.

OrbDoc, a health care technology company that uses artificial intelligence to create tools for clinicians, performed an analysis for NBC News that examined what hospitals charge uninsured patients for particular procedures compared with what Medicare pays. Insurance companies negotiate different rates for procedures, so using those figures would not have allowed for an apples-to-apples comparison.

The OrbDoc analysis found that hospitals on average charge the uninsured almost five times what Medicare pays for the same procedure. The analysis echoes conclusions from other academic research.

Hospitals in Nevada charge the highest premium to Medicare payments, at almost 12 times, while Maryland facilities charged the lowest premium nationwide — 1.2 times. Maryland is unusual: Since 1971, it has regulated hospital pricing through its Health Services Cost Review Commission. Hospitals in Texas, where Slaughter lives, charge nearly eight times Medicare’s pricing for the same procedures.

For-profit hospitals charge on average 8.7 times what Medicare pays for the procedures, while federal government-owned hospitals charge 4 times, OrbDoc found. State and local hospitals charge 4.5 times, on average, and private nonprofit hospitals charge 5.4 times what Medicare pays.

Insured patients, whose insurers negotiate with facilities for reduced rates, also pay up for outsized hospital charges through higher out-of-pocket costs. Slaughter’s hospital records, for example, show Baylor Scott & White billed him $1,486 for his emergency department visit. Medicare pays $166.53 for such a visit, government data shows.

After his insurance paid its share of the bill, Slaughter’s out-of-pocket cost was $456 for the emergency department visit, almost three times what Medicare pays, according to OrbDoc’s analysis. The company has a free tool that flags medical bills for problems such as duplicate charges and high markups

“If an insured patient needs forensic accounting to understand the bill, the system is broken,” said Abdus Muwwakkil, CEO of OrbDoc.

Smith, the Baylor Scott & White spokeswoman, said in an email that the $1,486 billed to Slaughter is a “standard charge for a physician providing level 5 care in an emergency department.

“This charge is consistent for everyone, regardless of their insurance type,” Smith added. “Reimbursements for this charge, however, do vary by insurance type.”

Experts say a major driver of hospital costs is industry consolidation—hospital systems acquiring other facilities. A 2024 research paper co-authored by Yale's Cooper found that from 2010 to 2015, anticompetitive mergers of hospitals raised prices by more than 5%.

Another problem: Hospitals don’t make it easy for patients to access or understand their financial assistance programs.

Slaughter said he experienced this during his three-day stay at Baylor Scott & White. On the second day, he said, a hospital billing official came to his room to provide him with an estimate of what his costs would be and asked for his credit card for partial payment. Slaughter said he was on painkillers and groggy, but he recalls asking about the hospital’s financial assistance program, which the official said he did not qualify for.