Johns Hopkins Hospital sicced collections attorneys on thousands of patients over the past decade, often taking extraordinary measures to extract payment from patients who probably owed no money at all under the state laws governing the non-profit medical provider.

According to a new report from union researchers with National Nurses United (NNU), the hospital’s outside counsel sued 2,438 separate former patients between January 2009 and December 2018, typically over sums so modest that they pose no threat to the balance-sheet health of either JHH or the broader Johns Hopkins Medicine network of facilities and providers.

The median amount JHH deemed worth taking to court was $1,438. A hospital that has taken in $16.5 billion in operating revenue over the past decade has used the courts to go after a total of just $4.4 million in unpaid bills.

That works out to about a third of a penny for every dollar the hospital generated from in the 10 years of lawsuit activity detailed in the NNU report. But while inconsequential to the JHH bottom line, the money at issue is potentially ruinous for the people the hospital sues.

Forty-three Hopkins patients have ended up filing for bankruptcy after being sued by the hospital. One such desperate victim of the Hopkins collections practices documented the way in which she was forced to teeter on the edge of a knife, financially speaking, when the hospital sought $10,745 from her. She relied on food stamps to feed herself and two minors on a take-home income of $2,201.33 at the time the hospital sued.

Many of the approximately 2,000 patients sued by JHH who have not yet turned to bankruptcy for relief are likely not far from that life-changing cliff. More than 300 defendants live in zip codes where the median household income is below $45,000. More than 1,000 of them live in zip codes where the child poverty rate is 19 percent or higher.

These topline indicators are imprecise, but strongly indicate that those targeted by the hospital’s legal attack dogs probably should have been offered free or heavily subsidized care when they turned to the largest high-quality hospital in Baltimore, the report suggests.

As a not-for-profit medical provider, Johns Hopkins has received hundreds of millions of public dollars in tax exemptions. Maryland law is crystal clear about what all that subsidization from taxpayers is supposed to ensure for the neediest people in the state. Anyone surviving on an income less than 200 percent of the federal poverty line may not be charged for health care that’s deemed necessary. Families getting by on between two and five times the federal poverty income must be billed on a sliding scale that reduces their prices by between 20 and 80 cents on the dollar.

Some of those sued by Hopkins in the past decade almost certainly qualified for such financial assistance from the taxpayer-supported medical center. JHH did not respond to ThinkProgress’s repeated attempts to clarify how it delineates between patients it should sue and those it should work with according to financial assistance laws that govern its operations.

One unnamed Baltimore resident the hospital sued reported earning $13.95 an hour from a job at another non-profit employer in the area. That wage should have translated to at least a 60 percent writeoff on his bills from a 2014 visit to the hospital, the NNU researchers note, but he “was billed $2,100.86 and received no adjustment on the amount.”

JHH’s lawyers spent the next two years chasing the man’s meager earnings in court, repeatedly asking a judge to order his wages garnished to repay a debt he likely should not have owed under state law.

Another unnamed defendant in a Hopkins debt suit was working for McDonald’s when he ended up in the JHH emergency room. Despite his slack earning power, he was issued an unadjusted $1,990 bill for the visit and eventually subjected to a garnishment order to collect $2,081.98 – the original, dubious billing amount plus about a hundred bucks in interest and court fees.

Many of the Hopkins suits target even smaller amounts of money than these questionable examples. The hospital sued a man named Eric Simmons over the $524 remainder of its billings not covered by his insurance following an ankle injury. An unnamed 55-year-old woman got sued for $280.13 that hadn’t been covered by her insurance, eventually informing a judge that she had just $92.18 in the bank – which led Hopkins’ lawyers to ask the court’s help extracting all $92.18 through a bank levy.

The hospital’s media team repeatedly declined to answer detailed questions from ThinkProgress about the report’s findings, including specific queries about how JHH goes about determining which working-class patients are rich enough to sue and which should be given free or reduced-price care. The communications staff provided only a brief and vague statement portraying the debt litigation as just another part of taking care of the infamously hard-hit community it serves.

“Our mission is to improve the health of our community, and everything we do is to advance that goal,” Johns Hopkins Medicine’s senior public relations director Kim Hoppe wrote in an email. “Our first priority is providing care. Those who have the ability to pay for their health services should do so. For those who cannot pay, we consider it our mission to make sure they receive the care they need.”

The legally dubious and ethically grim practices detailed by the nursing union are not entirely new for Hopkins. A Baltimore Sun investigation published in 2008 documented similar abusive collections practices by the charitable hospital over the first decade of the millennium.

Though a hospital spokesperson initially responded to the Sun reporters by claiming the hospital only goes after “deadbeats,” JHH appeared to back down from the practices after the stories had put a spotlight on them. It filed less than 500 total debt suits from 2009 to 2013, after the Sun found 14,000 such cases in the prior half-decade.

That dramatic downturn in collections suits proved short-lived, however, as filings began to spike anew in 2014. JHH’s lawyers have sued more than 300 people each year since, bringing the total to almost 2,000 lawsuits over the past five years – a far cry from the rate exposed by the Sun’s journalism but still a widespread assailing of financially vulnerable people who rarely received the financial assistance the hospital is required to extend.

Hopkins is far from alone in imposing such alarming billing and collection practices on an underprivileged community that turns frequently to a major urban medical provider operated under the kinds of charitable mandates that Maryland law contains.

San Francisco’s only level-one trauma center, recently renamed in honor of Facebook founder Mark Zuckerberg’s $75 million donation to the facility, habitually threatened emergency room patients with collections efforts until a Vox investigation shamed administrators into changing policy. A cluster of emergency rooms housed within not-for-profit hospitals in the St. Louis area have been outsourced to a for-profit provider that sidesteps the type of financial assistance requirements Hopkins appears to be flouting, resulting in a spate of aggressive collections suits that caught local news attention in 2016. And the same general flavor of practices was exposed at a western Missouri hospital back in 2014.

The debts many medical providers pursue in brazen and sharp-elbowed fashion are not only ethically dubious and legally suspect in the context of tax-exemptions, charitable-care funding allotments, and not-for-profit law. The prestidigitations of the debt collection industry often reveal that these debts are essentially bogus within the context of raw market forces.

Some health care providers don’t even bother hiring lawyers to go after unpaid billings. They simply sell their “bad paper” to third-party collectors, at pennies on the dollar.

The bird-in-the-hand logic these debt-buyers use to strike deals with doctors and hospitals has created an opportunity for consumer advocates and economic inequality activists: If the people doing the billing will take less than what the bill says to walk away, then the debts aren’t actually worth what hospitals say they are. Occupy Wall Street activists wiped out medical debts ostensibly worth $15 million in 2013, at a cost of just $400,000.

Despite the success that both journalists and radical activists have had in exposing the abusive practices and accounting fictions that help enforce the gaping class inequities of the world’s largest economy – and despite the legal constraints that are supposed to come with tax-exempt status – it remains possible for major institutions like Hopkins to operate the same old way. And as the official JHH response to the damning findings of the NNU report illustrate, such institutions remain willing to bet that they can sweep aside criticism through public-relations banalities and radio silence.