Heather Waldron and John Hawley are losing their four-bedroom house in the hills above Blacksburg, Va. A teenage daughter, one of their five children, sold her clothes for spending money. They worried about paying the electric bill. Financial disaster, they say, contributed to their divorce, finalized in April.

Their money problems began when the University of Virginia Health System pursued the couple with a lawsuit and a lien on their home to recoup $164,000 in charges for Waldron’s emergency surgery in 2017.

The family has lots of company: Over six years ending in June 2018, the health system and its doctors sued former patients more than 36,000 times for more than $106 million, seizing wages and bank accounts, putting liens on property and homes, and forcing families into bankruptcy, a Kaiser Health News analysis has found.

A day after this article first appeared online on Sept. 9, Virginia Gov. Ralph Northam and UVA president James Ryan committed to changing UVA Health System’s collections practices.

Both Northam and Ryan expressed ignorance about UVA practices that were an open secret in Charlottesville, with hundreds of medical lawsuits often filed in a week.

Northam “was only just made aware of these practices,” said spokeswoman Alena Yarmosky, adding that he “is not involved” in day-to-day university operations.

UVA executives said Friday it would increase financial assistance, give bigger discounts to the uninsured and “reduce our reliance on the legal system.”

“This will have a huge impact on patients to the good,” Doug Lischke, the health system’s chief financial officer, said in an interview. The changes will “positively, drastically reduce the legal process” of lawsuits, garnishments and property liens. “We believe this is much more generous than what we’re doing now.”

Lischke called the new policy “a first step” that could later include financial assistance beyond what was announced Friday. UVA also plans to ask the Virginia General Assembly to change a state law requiring state agencies, including health systems, to “aggressively collect” unpaid bills and charge 6% interest on the balance, he said.

But independent experts said the new UVA policy still leaves numerous patients exposed to lawsuits and crippling bills. By leaving family assets vulnerable and not fully discounting sticker-price charges, the new UVA guidelines remain “very tough on the poor and near-poor who have managed to amass anything of value that will help them with the daily costs of life,” said Sara Rosenbaum, a health policy professor at George Washington University.

Unpaid medical bills are a leading cause of personal debt and bankruptcy, with hospitals from Memphis to Baltimore criticized for their role in pushing families over the financial edge.

But UVA Health System stood out for the scope of its collection efforts and how persistently it goes after payment, pursuing poor as well as middle-class patients for almost all they’re worth, according to court records, hospital documents, and interviews with hospital officials and dozens of patients.

UVA sued patients for as little as $13.91 and as much as $1 million during most of that period, until July 2017, when it restricted lawsuits to those owing more than $1,000, the analysis shows.

Every year, the health system sued about 100 of its own employees who also happened to be patients. It garnisheed thousands of paychecks, largely from workers at lower-pay employers such as Walmart, where UVA took wages more than 800 times.

Under a Virginia program designed to help state and local governments collect debt, it also seized $22 million in state tax refunds to patients with outstanding medical bills in the last six fiscal years — most of it without court judgments, said health system spokesman Eric Swensen.

Over many years, it filed thousands of property liens from Albemarle County all the way to Georgia.

Beyond its recovery of debts, UVA hit some former patients with an additional 15% for legal costs, plus 6% interest on their unpaid bills, which over the course of years can add up to more than the original bill.

The health system also has the most restrictive eligibility guidelines for financial assistance to patients of any major hospital system in Virginia, interviews and written policies show. Savings of only $4,000 in a retirement account can disqualify a family from aid, even if the family’s income is barely above poverty level.

The hospital, ranked No. 1 in Virginia by U.S. News & World Report, is taxpayer supported and state funded, not a company with profit motives and shareholder demands. Like other nonprofit hospitals, it pays no federal, state, or local taxes on the presumption it offers charity care and other community benefits valued at least as much as those breaks.

Though there are no national data on hospital debt collection, UVA’s pursuit of patients went beyond that of a number of other institutions.

Johns Hopkins Hospital in Baltimore has sued roughly 240 patients a year, on average, since 2009, according to a May report in the Baltimore Sun. UVA, by comparison, often sues that many former patients in a week and averages more than 6,000 cases a year, court data show.

Private, nonprofit Yale New Haven Health System files liens only if a bill is more than $10,000, and then only if the property is worth at least $300,000, a spokesman said. Falls Church, Va.-based Inova Health says it does not file liens on patient homes or garnishee wages.

Tenet Healthcare, a national, for-profit chain whose stock trades on Wall Street, says it does not sue uninsured patients who are unemployed or who lack significant assets other than their house.

Industry standards are few and vague. The American Hospital Association says its members follow Internal Revenue Service guidelines, which merely require hospitals to have a financial assistance policy and to make “reasonable efforts” to determine whether a patient qualifies for help before initiating collections.

Patients find themselves unable to pay UVA bills for many reasons: They are uninsured or sometimes have short-term coverage that does not pay for treatment of preexisting illnesses. Or they are out of network, or have a “high-deductible” plan — increasingly common coverage nationwide that can require patients to pay more than $6,000 before insurance kicks in. Virginia’s Medicaid expansion, which took effect this year, covers families with low incomes, but is still projected to leave hundreds of thousands uninsured.

Patients also have trouble because like many U.S. hospitals, UVA bills people lacking coverage at rates far higher than what insurance companies pay on behalf of their members. Such bills often have little connection to the cost of care, experts say. Insurers obtain huge discounts off hospital sticker prices — 70% on average in UVA’s case, according to documents it files with Medicare.

The $164,000 billed to Waldron for intestinal surgery was more than twice what a commercial insurer would have paid for her care, according to benefits firm WellRithms, which analyzed bills for Kaiser Health News. Charges on her bill included $2,000 for a $20 feeding tube.

Waldron, 38, an insurance agent and former nurse, appreciates the treatment she received for an intestinal malformation that almost killed her. But, she says, “UVA has ruined us.”

Hancock is a senior correspondent and Lucas is data editor for Kaiser Health News (KHN), a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.