Editor's note: This is the Washington analysis in Patients Rising's Medical Bankruptcy in America series — a six-state review of approximately 900 federal bankruptcy filings and the role of 340B-participating hospitals as creditors. State-level analyses for Virginia, Wisconsin, Washington, Louisiana, Colorado, and Maine are publishing on a rolling cadence. Methodology available on request.

Across 146 individual Chapter 7 and Chapter 13 bankruptcy filings from the District of Washington — January through August 2024, with a small number of earlier filings — the data shows the largest verified 340B-hospital debt total in our six-state series and the most concentrated single-system pattern we have documented in any state.

The headline numbers

• 146 cases in the dataset (118 Chapter 7, 23 Chapter 13, 5 failed/OCR-pending)
• 81 percent of cases include medical debt
• 35 percent include verified medical debt owed to a 340B-participating hospital
• Total verified 340B hospital debt: $1,044,903 — the largest in our series
• The Providence health system, including its Swedish and Kadlec affiliates, appears on 41 of 47 verified 340B creditor lines — the most concentrated single-system pattern we have observed in any state
• Providence-system balances account for over $360,000 — more than one-third of the total verified 340B debt in the dataset

For context: Washington's 35 percent 340B-exposure rate is lower than Wisconsin's (65 percent) or Virginia's (53 percent). But its total dollar volume is higher than any state except Virginia. The pattern is driven by a small number of very large balances concentrated in a single corporate family.

The Washington hospital landscape

Washington's hospital landscape is more fragmented than Maine's duopoly or Virginia's regional split, but it is dominated by a small set of large nonprofit systems that all participate in 340B at their major facilities.

Providence St. Joseph Health is the largest hospital network in Washington and the largest in the Pacific Northwest. Fourteen Washington hospitals, including Providence Sacred Heart Medical Center in Spokane (the flagship eastern Washington hospital), Providence Regional Medical Center Everett, Providence St. Peter Hospital in Olympia, and Providence facilities in Centralia, Walla Walla, Colville, and Chewelah — plus the entire Swedish Medical Center family in the Seattle metro (Swedish First Hill, Cherry Hill, Ballard, Edmonds, Issaquah, Mill Creek) and Kadlec Regional Medical Center in Richland. All major Providence-system facilities are 340B disproportionate-share hospitals.

Other significant 340B participants on Washington bankruptcy schedules include MultiCare Health System (Tacoma General/Allenmore, Mary Bridge Children's, Good Samaritan in Puyallup, MultiCare Auburn, MultiCare Deaconess in Spokane), Virginia Mason Franciscan Health (the merged Virginia Mason / CHI Franciscan operation, part of CommonSpirit Health nationally), UW Medicine (Harborview, UW Medical Center, Northwest Hospital, Valley Medical Center — Harborview is among the largest 340B disproportionate-share hospitals in the country), PeaceHealth, and Confluence Health in the Wenatchee Valley.

A network of municipally-owned critical-access hospitals serves rural Washington counties — all participating in 340B by virtue of their critical-access designation. Samaritan Healthcare in Moses Lake, North Valley Hospital in Tonasket, Arbor Health in Morton, and roughly two dozen others. They appear on the bankruptcy schedules at lower individual balances than the major systems but cumulatively as a significant share of rural-Washington cases.

The Washington hospitals that do not participate in 340B — Overlake Medical Center in Bellevue, EvergreenHealth Medical Center in Kirkland's main campus, and Kaiser Permanente Washington's closed-network facilities — barely appear on bankruptcy schedules in this dataset. The 340B hospitals dominate.

The Providence ecosystem

The dominant pattern in this dataset is the Providence ecosystem's presence on bankruptcy schedules.

That single corporate family of hospitals accounts for roughly 35 percent of total verified 340B debt across the entire dataset. In raw case counts, the Providence ecosystem appears on more bankruptcy schedules than the next two largest systems (Confluence Health and MultiCare) combined.

Providence St. Joseph Health, headquartered in Renton, Washington, is the second-largest Catholic health system in the United States — behind CommonSpirit Health, which through Virginia Mason Franciscan Health is Providence's principal competitor in the state. Its 2023 federal Form 990 reports total revenues exceeding $27 billion across its full Pacific footprint. It received approximately $1.3 billion in COVID-era federal relief. The Washington-specific 340B benefits captured by Providence are not separately itemized in any public filing.

The bankruptcy schedules show the patient-side ledger of those numbers — what households actually owe Providence-system hospitals at the moment they file for federal bankruptcy protection.

The single largest balances

Six cases — six of 146 — account for approximately $620,000 of the total verified 340B debt in the dataset:

• About $179,000 to Kadlec Regional Medical Center (Providence-affiliated) — an eastern Washington joint Chapter 7 with household income around $120,000 a year. The middle-class catastrophe case: a household whose annual margin would take twenty-six months of full application to cover a single hospital balance.
  
• About $115,000 to PeaceHealth System (likely 340B) plus $32,000 to Providence on the same schedule — a southwest Washington joint Chapter 7 with 95 percent of unsecured debt medical. A two-Catholic-system case.
• About $87,000 to Virginia Mason Franciscan Health St. Joseph Medical Center Tacoma — a south Puget Sound single Chapter 7, household monthly income roughly $4,900 against negative $2,782/month margin. Single hospital, single filer, with sixteen months of monthly margin shortfall already on the schedule before filing.
• About $70,000 to a local critical-access hospital in central Washington — joint Chapter 7, household income roughly $4,300/month. The local 340B hospital appearing as the entire medical-debt picture.
• About $53,000 total — a north-central Washington joint Chapter 7 split between Confluence Health (roughly $33,000) and a smaller critical-access facility (roughly $20,000). Ranch laborer at $2,000/month combined household income.
• About $46,000 to UW Medicine plus $39,000 to a separate air-ambulance provider — a central-Washington joint Chapter 7 where an air transfer from Yakima Valley to Seattle, plus the destination hospital's inpatient charges, account for nearly all the medical debt.

These six balances together account for approximately $620,000. The remaining forty-five 340B-exposed cases divide approximately $570,000 among them.

Geographic distribution

Washington's ten congressional districts distribute cases roughly proportional to population, with concentrations in the more populous Puget Sound metros (Pierce, King, Snohomish) and substantial representation in central and eastern Washington's rural districts.

What the Washington data implicates instead is the dominance of the Providence health system across the state's hospital landscape, regardless of congressional district.

On the air-ambulance pattern

The central-Washington case noted above — an air-ambulance transfer to UW Medicine plus the destination hospital's charges — is the second air-ambulance medical-bankruptcy case in our series. The first appears in the Colorado dataset (a Meeker, Colorado case with roughly $65,000 to a regional air-medical provider). Both follow the same pattern: a medical event in a rural area, ground stabilization at a local hospital, an air transfer of $35,000 to $65,000 to an academic destination hospital, then significant additional inpatient charges at the destination.

Air ambulance services are not themselves 340B participants — they are billed separately as out-of-network providers. The federal No Surprises Act, effective January 2022, was specifically designed to protect privately-insured patients from balance-billing exposure on air-ambulance transports. Whether No Surprises Act protections were properly applied to this case is not visible on the bankruptcy schedule. What is visible is the result.

What patients in this dataset were not told

Washington's hospital systems on these schedules all participate in 340B. All certify their eligibility annually to the federal Health Resources and Services Administration. All capture the program's outpatient drug-pricing discounts. None of them is required, by federal law, to tell patients at the point of care that the hospital is a 340B participant — or what charity-care policy applies, or how to apply.

There is no federal statutory definition of a "340B patient." The 340B statute, written in 1992, never defined the term. HRSA's 1996 attempt at a guidance-level definition was struck down in Genesis Healthcare v. Becerra in November 2023 as unenforceable. In current practice, Washington's 340B-participating hospitals — like 340B hospitals nationally — can classify a patient as 340B-eligible after the fact, by reviewing the patient's records days or weeks after a prescription is filled. The patient is never informed of the classification.

There is no federal statutory definition of "charity care." Providence's published charity-care policy, MultiCare's, Virginia Mason Franciscan's, and UW Medicine's are each different documents with different eligibility thresholds and different application requirements. Two patients with identical financial circumstances can be charity-care eligible at one Washington hospital and not at another, and neither hospital is doing anything wrong under federal law.

There is no federal requirement that any Washington hospital tell a patient at the point of care what charity-care policy applies to them. There is no federal requirement that the patient be told the eligibility threshold, the application process, or the documents required.

The patients on the schedules in this dataset may have been eligible for charity-care write-offs at the Washington hospitals that subsequently became their creditors. They were not told. The bill came. Then the collections letters. Then the bankruptcy filing.

What "community benefit" includes

Providence and the other Washington nonprofit systems on these schedules report annual "community benefit" expenditures on IRS Form 990 Schedule H. The American Hospital Association aggregates those reports into the figure it cites every time the 340B program is questioned: nearly $100 billion in 340B-hospital community benefits in 2023.

That figure is assembled by the trade association of the same hospitals being scrutinized, from data those hospitals self-report under federal definitions that do not exist. The category includes financial assistance to patients, unreimbursed Medicaid, research and education, the Medicare shortfall, "community-building activities," and bad debt — the last of which includes patient bankruptcy write-offs.

When a Chapter 7 discharge enters for a Washington patient who owes Providence Sacred Heart Medical Center or Kadlec Regional Medical Center or any of the other systems on these schedules, the balance becomes uncollectable as a matter of federal law. The hospital writes the balance off. Under federal hospital-reporting conventions, the hospital may aggregate that write-off into its annual "community benefit" disclosure.

The same bankruptcies the hospitals helped create become part of the hospitals' reported community contribution.

What 146 Washington filings show

• One hundred and eighteen Washington households filed for bankruptcy protection in 2024 with medical debt on their schedules.
• Fifty-one of those households owed money to 340B-participating hospitals.
• The total balance owed to 340B hospitals exceeded $1,044,000 — the largest in our six-state series.
• More than one-third of that million-dollar total was owed to a single corporate family: the Providence health system, its Swedish affiliate in Seattle, and its Kadlec affiliate in Richland.
• The largest single-hospital balance — roughly $179,000 to Kadlec — was on the schedule of a household earning about $120,000 a year, a household substantially above any common definition of low-income.
• The lowest-income household with a 340B-hospital creditor — a ranch-labor family at $24,000 a year — owed two 340B hospitals a combined $53,000.

The 340B program was created in 1992 to support hospitals serving disproportionate shares of low-income patients. The Washington hospitals on these schedules participate in that program, certify their eligibility annually, and receive the federal drug-pricing discounts.

The patients whose existence justifies that participation appeared, in 2024, in federal bankruptcy court. They were not told they were 340B patients. They were not told what charity-care policy might have applied to them. They were not told there was an alternative to bankruptcy.

The hospitals will write the balances off.

The patients had to file bankruptcy to get there.

The schedules are in the federal court file.

The file is public.

We have read it.

Methodology and aggregate data tables available on request.