WASHINGTON - At President Donald Trump's speeches and rallies, Stephen Miller often can be found backstage, watching the teleprompter operator. As other White House staffers chat or look at their phones, Miller's attention remains glued to the controls.
The energy and crowd-thrilling parts of Trump's speeches usually happen during his impromptu diversions from the planned address. When Trump veers, colleagues say, Miller sometimes directs the operator to scroll higher or lower through the speech, so when the president is ready to pick it up again, he will hit those passages and make those points.
Miller knows where he wants the president to go.
At defining moments in his career, Trump has benefited from clever writers and brand-makers who helped craft his public image. A co-author made him a best-selling business guru with "The Art of the Deal." The producers of "The Apprentice" cast him as a reality television star.
Now it is Miller, Trump's 33-year-old senior adviser, who is writing the central plot of his presidency.
Two and a half years into Trump's term, Miller's power in the White House is at its peak, according to top administration officials. As one of Trump's longest-tenured and most trusted aides, his influence in the West Wing is rivaled only by Jared Kushner, Trump's son-in-law, they say.
Miller, a former press aide to then-Sen. Jeff Sessions, was among the first staffers on Trump's presidential campaign. He has since provided Trump with unswerving loyalty and fierce devotion, translating the president's frustrations and grievances into exalted language and policy prescriptions.
In Trump, Miller has found a champion for his ideological goals. He is the singular force behind the Trump administration's immigration agenda - making him a crucial White House figure on an issue central to the president's reelection campaign.
In an interview Friday with The Washington Post, Miller aggressively minimized his role in the administration and would accept no credit for its direction. He said he sees himself as a conservative populist, someone who pushed his liberal high school in California to have the Pledge of Allegiance recited on a daily basis, who says he sees U.S. citizenship "as something sacred" and who regards immigration as a defining element of the nation's future.
Effusive in praising his boss, Miller said he experienced a "jolt of electricity to my soul" when he saw Trump announce his presidential run, "as though everything that I felt at the deepest levels of my heart were for now being expressed by a candidate for our nation's highest office before a watching world."
With sections of the West Wing under summer renovation, Miller has been working out of the Eisenhower Executive Office Building next door, setting up in the Secretary of War suite, a spacious, elegant command post appointed with oil paintings, fine leather furniture and a small forest's worth of hardwood.
Barely a decade removed from college, Miller is at the seat of power. His authority has grown in recent months as he engineered a leadership purge at the Department of Homeland Security, removing or reassigning the head of every immigration-related agency in seven weeks.
And his long-sought policy goals are reaching fruition. On Monday, Miller secured tighter immigration rules that can disqualify green-card applicants if they are poor or deemed likely to use public assistance, cutting off a pathway to U.S. citizenship for those immigrants who could become a burden on taxpayers, or "public charges."
Miller's horizon extends beyond one or even two presidential terms. He views the public charge rule as vital to his goal of reducing immigration, and he has told colleagues it will have "socially transformative effects" on American society.
"Immigration is an issue that affects all others," Miller said, speaking in structured paragraphs. "Immigration affects our health-care system. Immigration affects our education system. Immigration affects our public safety, it affects our national security, it affects our economy and our financial system. It touches upon everything, but the goal is to create an immigration system that enhances the vibrancy, the unity, the togetherness and the strength of our society."
This account of Miller's role in the White House and his relationship to Trump is based on interviews with Miller and 22 current and former administration officials, nearly all of whom have worked directly with him. His colleagues speak of him with a mix of admiration, fear and derision, impressed by his single-minded determination and loyalty to the president, despite an awkward and sometimes off-putting style. Some of the same co-workers who deplore his political machinations say he can be charming and likable when he's not angling toward an outcome.
Miller often launches into pedantic arguments with others in the White House, citing lengthy, arcane statistics that he mentally stores like munitions. He reads "every economic analysis, every think tank paper, every Wall Street Journal editorial on immigration," said another colleague.
Obsessed with terminology, Miller tells others in the West Wing that how issues are talked about - and what terms the media and legislators use - is often as important or more important than anything else.
He is dismissive of Kushner's more moderate immigration views and efforts to forge compromise, other senior officials say, and Miller has questioned how much the president's son-in-law knows about the topic.
After the publication of this article online, Miller called those claims "utterly malicious fabrications."
"Jared and I are close friends, with deep mutual trust, and we work hand-in-hand together to support the president's agenda, including on immigration," he affirmed.
Several of the officials who shared their candid views were unusually concerned with how they would be quoted, worried that specific words or phrases could be traced back to them. They said Miller would read quotes about himself with forensic interest to identify his critics, and to retaliate.
Some officials have developed nicknames for Miller to avoid being overheard saying his name aloud. Staffers at one DHS agency call him "our little friend," or simply "SM."
While Miller's ardent views on immigration are well known, the nature of his relationship to the president is less understood. Miller has survived longer in the White House than nearly every other senior administration figure who is not a member of Trump's family.
Though he frequently spoke at rallies during Trump's presidential campaign to warm up crowds, and later made numerous television appearances to defend administration policies, Miller has largely receded from public view in recent months. He has grown more influential even as his visibility fades.
Miller's restrictionist immigration agenda has lent a degree of intellectual and ideological coherence to the gut-level animus that fuels Trump, furnishing a policy framework for the president's "Make America Great Again" message.
The public charge rule is a case in point. "Does the president believe that poor immigrants who can't support themselves should live off the public dole? No," one senior official said. "Did he have any idea what the public charge rule was before Miller? No."
"You can't overstate how excited Stephen was for the public charge rule to be out there," said a senior administration official who, like some others who agreed to talk about Miller, spoke on the condition of anonymity because they fear angering him.
Steve Bannon, Trump's former chief strategist, said it was a "perfect example" of Miller's role in the administration.
"He's burrowed down into the apparatus to make fundamental change," Bannon said in an interview. "People don't even see a lot of the stuff he's working on."
As an argumentative young congressional staffer, and before that as a conservative student columnist at Duke University, Miller developed a reputation for showmanship and superciliousness, viewed by peers as a hunger for recognition. In the West Wing, he has learned to sublimate those impulses to advance his broader goals and make sure the credit goes to his boss.
Colleagues describe him as a unique influence over the president, but some caution that his powerful reputation is overstated because Trump typically seeks input from multiple advisers. Miller does not have anything like a hold on the president, they say, but he works relentlessly to outmaneuver and wear down rivals to steer Trump where he wants to go.
Stephanie Grisham, the White House press secretary, disputed this characterization. "Stephen works tirelessly on behalf of this country and the president, not to outmaneuver or wear down anyone," Grisham said in an interview.
Miller and the president have a relationship of "mutual trust," she said, calling Miller "very intellectual."
Miller rarely, if ever, disagrees with the president in meetings, and instead seeks to convince him behind the scenes, with afternoon meetings or visits to the residence or Oval Office.
Miller's allies in the immigration restrictionist movement - those who are seeking to curb the number of foreigners coming to the United States - say he has done more than anyone to advance their cause.
"I think he's changed the terms of the debate," said Steven Camarota, senior policy adviser at the Center for Immigration Studies, a Washington think tank that Miller aligned with as a congressional aide. "He's played a huge role in making the immigration debate less about the plight of illegal immigrants and more about what's in the best interests of the United States."
"He is intensely loyal and a good foot soldier," Camarota added. "And if you're president, you value that incredibly."
Miller said he took an interest in immigration in high school because it was a simmering topic in Southern California at the time. He was a contrarian in a family of Democrats.
"All of my immediate, near immediate and distant relatives were all liberal Democrats," he said. "I don't think I ever met a conservative to whom I was related."
Miller said he challenged the teachers and administrators at his Santa Monica high school because he believed the history and government courses discouraged patriotism and failed to promote a shared American identity - the values he credits for successfully assimilating previous waves of immigrants, including his own family.
"I had the sense that the education system focused more on emphasizing the things that distinguish us rather than the things that unite us," Miller said. For immigration to function there has to be an emphasis on e pluribus unum, and creating a national cohesion."
Right-wing populism armed him to wage a culture war against what he viewed as an empty multiculturalism. The career he has built since then is one, long, breathless polemic.
Others who have left the administration say Miller should be judged as a failure even by the standards of his own immigration goals, noting that illegal border crossings have soared, many of Trump's initiatives have been blocked in court and the routine functions of the agencies responsible for U.S. immigration enforcement - including Immigration and Customs Enforcement and the Border Patrol - have become politicized.
Among Miller's co-workers are a few who believe he harbors racist views. "I don't know what other principle could animate such a laserlike focus," said one former career official at the DHS.
Miller bristled at the claim, calling anyone who labels him a racist "an ignorant fool, a liar and a reprobate who has no place in civilized society."
"It is a scurrilous and scandalous lie born of a complete and total lack of understanding of the harms done by uncontrolled migration to people of all backgrounds, and born of a contempt for this nation, for our law enforcement officers and for the citizens who live here - and oftentimes, I might add, born of a personal grudge against this administration," Miller said, without pause.
Those close to Miller say he views his work as "saving American society," that more "immigration control" can change the volume and profile of those coming to the United States.
Short of a legislative path to achieve that goal, he views changes to the public charge rule as the next-best option, with the potential to weed out hundreds of thousands of applicants per year.
The Republican Party, and especially its pro-business elements, have conventionally supported robust levels of legal immigration. Miller has been at the forefront of efforts to shred that consensus, which he views as "a broken establishment" and a "decayed system."
While many of Trump's advisers favored the president's rhetoric on the threat of illegal immigration, they urged him to retain a more welcoming message for those seeking to come to the United States legally. But Miller insisted that slashing those visas should be central to the president's agenda, because it is central to the electoral map that runs through the Rust Belt and Upper Midwest.
Miller spoke of recently visiting Johnstown, Pennsylvania, for his grandfather's funeral, describing it as a once-vibrant community that collapsed after local steel mills shuttered. Miller slammed "globalism" and "the owners of capital" for moving jobs overseas in search of cheaper labor.
"When you see the idled steel mills and you think about and you look at the empty town squares and you think about how much was lost along with the steel mill in the sense that it's a whole community and a community memory that's gone," Miller said.
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Miller drafts most of the president's public remarks, sometimes chatting with him beforehand to hear his thoughts and then crafting them into a speech. Trump often does not look at a speech until the plane ride before he gives it, current and former aides said, making Miller's tone more influential.
"The thing about Stephen is he can bully anybody he wants because he and the president share similar views, and he is channeling the president's beliefs," said a senior official.
Because Trump has strong feelings about immigration but just superficial knowledge of how the immigration system works, the president relies heavily on Miller to explain and interpret it for him, the official said.
"Miller speaks with 100 percent confidence in whatever he does, and with a tone of absolute authority," another former official said.
Several senior figures said Miller has been determined to ensure that he remains the dominant voice in the West Wing on immigration matters. In the presence of alpha male figures including former chief of staff and DHS secretary John Kelly, or current acting DHS secretary Kevin McAleenan, Miller tends to be more deferential, longtime observers say.
Miller was determined to pass the hard-line Raise Act in 2017 - which sought to slash legal immigration levels in half - even though it was met with widespread opposition and skepticism in the West Wing, according to former senior administration officials. "He just methodically pounded away, got senators to say they'd support it and then found his way in front of the president," one former senior administration official said.
There was soon a public messaging push for the legislation that others opposed. Miller decided to go to the podium in the West Wing and defend it himself because efforts to convince and explain the policy to others on the White House communications staff did not go well.
Last summer, when Republicans still controlled Congress, Miller soured the president on the slightly more moderate immigration bill known as "Goodlatte II" that some administration officials regarded as the best shot at hammering out a deal with Democrats. Miller urged the president to demand more, including an end to the U.S. family-based immigration model, which the White House calls "chain migration." The efforts have failed so far.
"All of that stuff bogged down the effort and turned it into something no Democrat would ever vote for," another former official said. The administration has turned instead to executive actions. "Ever since then it's been a nonstop push to 'put points on the board' to show the president is fulfilling his immigration promises."
A senior Capitol Hill official who regularly interacted with the White House said most policy discussions were with Miller's policy office or Jared Kushner, in an effort to gauge what moderate Republicans would support, what Democrats might accept and whether a compromise was possible.
During those meetings, Miller did not regularly push his colleagues on the Hill as he does DHS or other officials. "But the lingering question was always, 'Where is Stephen on this?' "
Most interactions, this person said, were Miller trying to scuttle a deal he did not like or interjecting himself at the last minute. Most everyone in immigration policy circles knew he had the most sway with Trump.
The legislative official said Miller was far less interested in cutting deals and more interested in brimstone rhetoric and keeping immigration as a fiery hot issue.
"He is not looking to get something done in a bipartisan way," the person said. A number of GOP senators and aides - including Sens. Charles Grassley, R-Iowa, and Lindsey Graham, R-S.C. - have criticized Miller to Trump and have argued against Miller's effectiveness.
Miller has pushed the president to embrace wedge issues, such as late-term abortion, a transgender military ban and immigration, seeing them as cultural wars the president can win.
One of his favorite tactics is to call "deep in the building" at the DHS and other agencies, giving orders to employees several layers beneath the Cabinet secretaries. As DHS secretary, Kelly told Miller to stop doing that and instructed his own employees to alert him when Miller did. Kelly declined to be interviewed for this article.
But Miller continued under DHS Secretary Kirstjen Nielsen and began convening meetings on Fridays of lower-level employees, where he would alternately scream, demand and encourage, according to attendees. Cabinet heads would sometimes see their own staffs leaving the West Wing and ask why they had been there. Nielsen would often find that her subordinates had talked to Miller about a policy without her being involved, current and former officials said.
She and her staff instructed subordinates to alert the front office if Miller called them out of the blue to request statistics or discuss a policy proposal, insisting that the secretary's office would handle the response. They saw Miller attempting to marshal statistics to win arguments by blindsiding his rivals with their own agencies' data, making them look uninformed and incompetent when they appeared unfamiliar with the numbers he already had.
In spring 2018, with the number of border crossings rising, Miller helped devise the "zero tolerance" prosecution effort with then-Attorney General Jeff Sessions and Sessions adviser Gene Hamilton. Homeland Security officials and Health and Human Services scrambled to come up with a plan to implement the crackdown. During a span of six weeks, border agents took children away from migrant parents and sent the adults to court for prosecution. At least 2,600 families were separated until public outrage forced the president to back down.
Miller defended the separations and had encouraged the president to enact them - telling others in the West Wing that they would prove to be a migration deterrent. Trump soon realized it was a "PR nightmare," in the words of one senior administration official, and blamed Miller. The president also grew frustrated with Miller over the botched implementation of the travel ban in the first weeks of the administration.
Miller is among the few administration officials who continue to defend zero-tolerance separations today, insisting the approach would have worked if the policy had continued.
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Miller is obsessed, current and former administration officials said, with boosting deportations. Early in his tenure, he tried to persuade Kelly, as DHS chief, to deport anyone who was here illegally. Kelly wanted to focus on criminal felons, frustrating Miller, people familiar with the disagreement said.
"He is singularly focused on how to get people out of the country," a former senior administration official said.
At times when others have hesitated to implement Miller's directives, he has questioned their loyalty and encouraged the president to cut them loose. In April, when Ronald Vitiello was close to Senate confirmation as ICE director, the White House abruptly pulled his nomination, ending his 30-year career in federal law enforcement.
Vitiello, along with Nielsen, had challenged plans to launch a "family operation" targeting thousands of migrant parents and children in long-planned raids - a move that was likely to inflame Democrats ahead of the confirmation vote. Asked why Vitiello was ousted, Trump told reporters he wanted to go in "a tougher direction."
While some in the administration fret over images of squalid and inhumane detention conditions at the border, Miller has argued that they, too, are a deterrent - and that publicizing them is not a bad strategy.
One longtime Trump adviser said Miller is frequently focused on how many people are coming over the border. "He would say, look at these statistics, you're going to have a new city the size of Brooklyn or the Bronx every year? How long can the country sustain that?"
DHS senior officials say they sometimes feel torn between two bosses: the one who is close to the president and the other who actually runs their agency.
Miller has installed handpicked political appointees across the DHS, including several who were staffers at restrictionist groups such as the Federation for Immigration Reform (FAIR). He will surprise lower-level staffers with phone calls urging them to implement his ideas, telling them "this is the most important thing you will do at your agency."
Miller rarely puts anything in writing, eschewing email in favor of phone calls. Written communications sent by others who closely ally with him are often viewed as the expression of Miller's wishes.
"He's always micromanaging everything we do, or trying to, without really knowing or appreciating the operational challenges," said a DHS official who has been on the receiving end of Miller's ire.
Miller was so eager for the administration to finalize the public charge rule this spring that he accused former U.S. Citizenship and Immigration Services director Francis Cissna of moving too slowly, firing him in May and installing former Virginia attorney general Ken Cuccinelli in his place. Miller has told others he prefers political appointees who are not career agency officials, because he thinks the latter lack urgency and are too accustomed to what he calls "bureaucratic inertia."
One senior official who works with Miller said he's rightly skeptical of the traditional policymaking process, because he expects every administration initiative on immigration to be blocked in federal court.
"Stephen's argument, in a nutshell, is that you can go through the whole process, dot every i, cross every t, get thousands of comments, come up with the regulation - and we'll still get sued and an activist judge will enjoin it," a senior official said.
"His argument is that judges are not making decisions based on facts, so there's no point to trying to win a political fight with a legal fight," the official said. "Just do the reg and try to get to the Supreme Court as fast as possible."
Some grass-roots activists whom Miller cultivated during Trump's campaign also have soured on him, including Sara Blackwell, the founder of a group called Protect American Workers.
Blackwell, a Florida attorney, represented Disney employees in a lawsuit against the company; they sued, claiming they were directed to train foreign workers hired to replace them. Seeing ideological kinship with her on the same economic arguments against outsourcing and guest worker programs, Miller invited Blackwell to campaign rallies in 2015, and she said she spoke at several events.
"Stephen Miller taught me a lot," she said. "I thought he was brilliant. He blew my mind with how much he knew."
After Trump's victory, Miller invited Blackwell to visit the White House, a visit she believed was meant to help convey the message that the president would deliver on his pledges to "protect American workers." Blackwell published an op-ed on the Breitbart news site after her White House visit saying as much.
An aide to Miller called Blackwell soon after, chastising her for writing about the meeting without Miller's permission.
"He hasn't spoken to me since then," Blackwell said in an interview. She said she and others feel discarded by Miller and Trump.
Miller, who turns 34 in the coming week, said he has no plans beyond his current job and no personal ambitions. There is only Trump.
"Every day of my life I thank God for having the privilege to come and work here for this president and this mission," he said. "And you cannot understand me, you cannot understand anything that I say, do or think if you do not understand that my sole motivation is to serve this president and this country, and there is no other."
Miller finished speaking and ended the interview, apologizing. He was late for a meeting elsewhere in the building. He rushed out of his office and started down the hallway. He was running.
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The Washington Post's Emily Davies contributed to this report.
POPLAR BLUFF, Mo. - The people being sued arrived at the courthouse carrying their hospital bills, and they followed signs upstairs to a small courtroom labeled "Debt and Collections." A 68-year-old wheeled her portable oxygen tank toward the first row. A nurse's aide came in wearing scrubs after working a night shift. A teenager with an injured leg stood near the back wall and leaned against crutches.
By 9 a.m., more than two-dozen people were crowded into the room for what has become the busiest legal docket in rural Butler County.
"Lots of medical cases again today," the judge said, and then he called court into session for another weekly fight between a hospital and its patients, which neither side appears to be winning.
This year, Poplar Bluff Regional Medical Center has filed more than 1,100 lawsuits for unpaid bills in a rural corner of Southeast Missouri, where emergency medical care has become a standoff between hospitals and patients; both going broke. Unpaid medical bills are the leading cause of personal debt and bankruptcy in the United States, according to credit reports, and what's happening in rural areas such as Butler County is a main reason why. Patients who visit rural emergency rooms in record numbers are defaulting on their bills at higher rates than ever before. Meanwhile, many of the nation's 2,000 rural hospitals have begun to buckle under bad debt, with more than 100 closing in the past decade and hundreds more on the brink of insolvency as they fight to squeeze whatever money they're owed from patients who don't have it.
The result each week in Poplar Bluff, a town of 17,000, has become so routine that some people here derisively refer to it as the "follow-up appointment" - 19 lawsuits for unpaid hospital bills scheduled on this particular Wednesday, 34 more the following week, 22 the week after that. Case after case, a hospital that helps sustain its rural community is now also collecting payments that are bankrupting hundreds of its residents.
"Think of me as the referee," the judge explained, as he called the first case. "It's my job to be fair. I'm not going to be chugging for either side."
On one side of the courtroom was a young lawyer representing the hospital, and he carried 19 case files that totaled more than $55,000 in money owed to Poplar Bluff Regional. Three nearby hospitals in Southeast Missouri had already closed for financial reasons in the past few years, leaving Poplar Bluff Regional as the last full-service hospital left to care for five rural counties, treating more than 50,000 patients each year. It never turned away patients who needed emergency care, regardless of their ability to pay, and some people without insurance were offered free or discounted treatment. In the past few years, the hospitals' total cost of uncompensated care had risen from about $60 million to $84 million. Its ownership company, Community Health Systems, a struggling conglomerate of more than 100 rural and suburban hospitals, had begun selling off facilities as its stock price tanked from $50 per share in 2015 to less than $3 as the lawyer approached the judge to discuss the first case.
"We're seeking fair payment for services we've provided. Nothing else," he said.
Behind him in the courtroom were some of Poplar Bluff Regional's patients - a population that was on average sicker, older, poorer and underinsured compared with the rest of the United States. More than 35 percent of people in Butler County have unpaid medical debt on their credit report, about double the national rate. Most of the 19 people on the morning docket had been treated in the emergency room and then didn't pay their bill for more than 60 days before receiving a summons to court. Many of them had insurance but still owed their co-pay or deductibles, which have tripled on average in the past decade across the United States. One patient owed more than $12,000 after being treated for a heart attack. Another was being sued for $286. If the hospital won a judgment, it had the right to garnish money from a patient's paycheck or bank account, or it could put a lien against a house.
"I'm hoping to negotiate a payment plan, but I can only afford $20 a month," one patient told the court.
"I'm late for work, so if there's someplace I can sign, I guess I'll just sign," said another patient, who owed more than $3,000 after spending six hours in the emergency room for chest pain.
"How am I supposed to pay $4,000 to see a doctor if I'm barely making $2,000 a month?" asked another.
One by one, the patients came up to plead their cases until the judge called Gail Dudley, 31, who was sitting with her mother in the third row. She had gone to the emergency room at Poplar Bluff Regional in 2017 after passing out because of complications from Type 1 diabetes. The hospital had given her medication to stabilize her blood sugar, kept her overnight for observation, and then sent her home with a bill for $8,342, of which she was still responsible for about $3,000 after insurance. She'd tried to appease the hospital's billing department by sending in an occasional check for $50, but with accumulating interest and penalty fees, the balance on her account had remained essentially the same for two years.
"I'm grateful for what they did for me, and I know I owe it, but I don't have that kind of money," she said.
The judge gestured in the direction of the hospital's attorney and then looked at Dudley. "Would you like a chance to talk to this gentleman for a moment and see if you two can work something out?"
"OK," she said. "We might as well try."
Matthew McCormick, 27, led Dudley into the hallway to begin the same negotiation he'd been having with dozens of hospital patients each week. On Thursdays, he was listed as a hospital attorney for the court docket in Doniphan, population 1,997. On Mondays, it was Kirksville; Tuesdays were Bloomfield, and Wednesdays often brought him here, to a 95-year-old courthouse in Butler County, where he'd represented Poplar Bluff Regional on more than 450 billing cases in 2019.
"We'd like to find a way to work with you on this," he told Dudley as they sat down together in the courtroom lobby. He reached out to shake her hand. He smiled and offered his business card. For the past year, he'd been working on behalf of the hospital as the newest attorney for a law firm called Faber and Brand, which promised to "use the judicial system to recover money owed." McCormick's cases hardly ever went to trial. More than 90 percent of the people being sued weren't represented by an attorney, and at least half didn't show up in court, resulting in default judgments in the hospital's favor. The rest of the patients McCormick met came into court with little to offer in their own defense except for apologies and stories of poverty, poor health, unemployment and bad luck.
"I'm real sorry about this," Dudley said. "If I'd been thinking straight, I would never have let them take me to the emergency room. I know I can't afford that. I wish I could pay you all of it right now."
"Let's make this as easy as we can," he told her. "Is there something you can pay? A little each month?"
"I don't have anything extra," she said, thinking about the paycheck she earned for a full-time job as a clerk at Goodwill, which totaled $736 every two weeks. After paying for rent and utilities on a subsidized three-bedroom apartment, groceries, and child care for her 6-year-old son and 3-year-old daughter, she sometimes ran out of money by the end of the month.
"How about $15 out of every paycheck?" she offered, even though she doubted she could afford it. When McCormick didn't immediately respond, she revised her offer. "Thirty? How's that?"
"Let's say thirty," McCormick said.
He had more patients waiting to negotiate, so he thanked Dudley and led her back into the courtroom to sign her judgment. It said she had agreed to a total claim of $3,021, plus $115 in court costs and 9 percent annual interest. She would send the hospital $60 each month until the balance was paid in full, and if she didn't make a payment, the hospital could pursue garnishment of her wages.
"I'm glad you worked something out," the judge said as he signed off on the agreement.
The court clerk handed Dudley a copy of the judgment, and once she was back outside the courtroom she took out her phone to run the math. If everything went right, and she somehow managed to save and pay $60 each month, she'd be sending checks to Poplar Bluff Regional for the next 5
In order to make 66 monthly payments, she had to somehow come up with the first, but her bank account was almost empty and payday was still a week away. Dudley left the courthouse, got into the car with her mother, then changed into a polo shirt for work. They drove away from the cobblestone streets of downtown and headed toward Goodwill.
"Could've been worse," said her mother, Norma Garcia, 48. "Sixty isn't so terrible."
"It is if you don't have it," Dudley said. "Who do you know that's sitting on an extra 60 each month?"
They drove past a dollar store, a payday lender and a fast-food restaurant advertising "full-time career opportunities" starting at $7.80 an hour.
"Maybe you can borrow it?" Garcia suggested.
"I don't do credit cards or lenders," Dudley said. "That'd just be another debt I couldn't pay."
"I meant from somebody."
"Who?" Dudley asked. "Everyone we know is paying the hospital already."
Their family had lived for three generations in Poplar Bluff's predominantly black neighborhood just north of downtown, where according to credit records more than half of adults had debt in collections for unpaid auto loans, credit cards or medical bills. Dudley's aunt had been sued twice by Poplar Bluff Regional and was forfeiting 15 percent of her paycheck to a court-ordered hospital garnishment. Her cousin was being sued for $1,200. Her sister owed $280.
But none of them had cycled through the emergency room as often as Dudley during the past several years. Her two pregnancies had complicated her diabetes, and she'd tried to save money by skimping on insulin. Instead of paying $50 every few months for a preventive medication, she had collapsed at work and been rushed to the emergency room, where she was sent home with thousands of dollars in now-unpaid bills. Poplar Bluff Regional was an ambitious rural hospital - a $173 million facility with a cancer center, a cardiac center, dozens of specialists and state-of-the-art surgical suites - and Dudley believed she was alive because of it. But during the past five years, the average amount that rural patients owed for hospital visits nationwide had doubled, and Dudley was earning $11 an hour at Goodwill as new hospital bills kept arriving in her mailbox.
She owed a $100 co-pay from another hospital visit in November 2018 that had already been sent to collections.
She owed $485 from another trip to the ER in April.
She owed $159 for lab tests, $85 for a doctor's visit and now $60 for her first court-mandated payment, which was due at the end of the month.
"I'm trying to make peace with the fact that this debt could sit on me forever," she said.
"Maybe I can help," Garcia offered, even though she was on disability and avoiding her own billing notices from the hospital, seeking $365 in unpaid deductibles.
"It's my bill to pay," Dudley said. She'd been saving a little money for back-to-school supplies, and she said it was enough for her first month's payment. "I'll handle it," she said. "There's no other choice."
There was one person in town who did believe patients had another choice, and over the past several years Daniel Moore had begun encouraging his clients to make it.
"Don't pay one cent," the lawyer had advised dozens of clients. "I don't care how much the hospital says you owe. Fight them over it."
Moore had been working for almost five decades as a self-described "old hillbilly lawyer" out of a converted house downtown. He specialized in criminal defense, with more than 400 cases pending all over the state, and he liked to align himself with the underdog. He'd been unable to afford a doctor himself while growing up on a farm with no running water, so when clients began coming to his office with bills from Poplar Bluff Regional that they could neither pay nor understand, he had agreed to take a look.
What Moore found in some of those itemized receipts didn't make sense to him either: $75 for a surgical mask; $11.10 for each cleaning wipe; $23.62 for two standard ibuprofen pills; $592 for a strep throat culture; $838 for a pregnancy test. He searched through court records and discovered that the hospital was collecting hundreds of monthly garnishments from hourly employees at places like Quickstop, Earl's Diner, Wendy's, Instant Pawn and Alan's Muffler.
He decided to represent several hospital patients free, and went to court against the hospital for a jury trial for the first time late in 2015. Moore's client was a Poplar Bluff police officer with decent insurance, an Army veteran who went to the emergency room one afternoon because of chronic stomach problems. He'd been given a battery of tests in the ER, then treated with three IV medications before being discharged after three hours with a bill for $6,373. His insurance had paid some, but the hospital was suing him for co-pays totaling about $1,650, plus interest.
"The facts show that he came to the hospital and received treatment that alleviated his symptoms," the hospital's lawyer at the time told the jury. "He received three separate bills. He just didn't pay the balance."
"These charges are outrageous," Moore told the jury. "He doesn't owe the hospital anything."
A billing manager from the hospital took the stand and said Poplar Bluff's prices were in line with other hospitals in rural Missouri. She mentioned the high cost of providing care at rural hospitals, which must pay higher salaries in order to recruit doctors, nurses and specialists while also suffering more from federal cuts to Medicaid and Medicare compared with urban hospitals.
Moore began to question her about each charge on his client's itemized receipt. Why, he asked, did it cost $800 to spend approximately 40 seconds with a doctor? Why was the hospital charging $211 for an oxygen sensor that was on sale for $16 at Walmart? Then Moore asked about three identical charges on the bill labeled "IV Push," which each cost $365.
"An IV push, if I understand it, that's the act of sticking the needle in that little port and then squeezing it," Moore said. "Is that right?"
"Yes," the billing manager said.
"So that takes maybe five seconds, right?"
"So you, the hospital, think that act alone, not counting the drugs inside the IV, which cost thousands of dollars more - that act alone is worth $365.38?"
"Yes," she said again.
"It makes me so mad," Moore told the jury, in his closing argument. "If you're content to let the hospital just crush people, then go on and give them their measly $1,650. But what you can do today is say, 'Hey, we're tired of this.' How many times are we going to let working people take the shaft?"
"In reality, this is a simple bill," the hospital's lawyer countered. "All we're asking for is his co-pay and his deductible. The hospital provided treatment. He still owes."
The jury deliberated for less than an hour and then found in favor of Moore's client, wiping away his hospital debts. But whatever sense of victory Moore felt was mitigated over the next months as Poplar Bluff Regional's lawsuits continued to spread across the civil courts of Southeast Missouri, and he agreed to take on more free cases. "The hospital circuit," Moore called it, which meant Mondays in Caruthersville, Tuesdays in West Plains and Wednesdays in Poplar Bluff.
On Thursdays, it was Doniphan, a town of fewer than 2,000 people, where Poplar Bluff Regional had filed more than 300 lawsuits over the past several years. Moore drove past horse farms and timber plants, parking near an abandoned hospital. Ripley County Memorial had closed six months earlier, and there were locks on the doors and a sign taped above the ambulance bay.
"For Nearest Emergency Services, go 29 miles to Poplar Bluff Regional," it said, and now several of those Poplar Bluff patients had been summoned right back to downtown Doniphan, to a red brick courthouse at the center of the town square.
They crowded next to one another on a wooden bench in the lobby, waving their hospital bills as fans against the late July heat while they waited for the courtroom to open and then entered one by one: a husband and wife who went for cancer treatments at Poplar Bluff Regional each week but couldn't afford the co-pays. A community college student who owed more than $7,000 for treatment of a chronic heart condition. And then the judge, who had presided over hundreds of hospital cases during his career and also recused himself from one case a few years earlier, when the patient being sued was his wife.
"How are we all doing today?" he asked, as he looked down at a docket with 14 more cases between a hospital ownership company that couldn't afford to keep losing money and patients who couldn't afford to pay. Both sides were drowning in debt, fighting to stay above water, and pulling each other back down.
"It's another full docket," the judge said. "We might as well get started."