Bridget Narsh's son, Mason, needed urgent help in January 2020, so she was offered the chance to send him to Central Regional Hospital, a state-run mental health facility in Butner, North Carolina.

The teen, who deals with autism and post-traumatic stress and attention-deficit/hyperactivity disorders, had started destroying furniture and running away from home. His mother worried for the safety of Mason and the rest of the family.

But children in crisis in North Carolina can wait weeks or months for a psychiatric bed because the state lacks the services to meet demand. And when spots do become available, they are expensive.

The standard rate at Central Regional was $1,338 a day, which Narsh could not afford. So, when a patient relations representative offered a discounted rate of less than $60 a day, her husband, Nathan, signed an agreement.

Mason, now 17, was hospitalized for more than 100 days in Central Regional over two separate stays that year, documents show.

But when requests for payment arrived the following year, Narsh said she was shocked. The letters — which were marked "final notice" and requested immediate payment — were signed by a paralegal in the office of Josh Stein, North Carolina's attorney general. The total bill, $101,546.49, was significantly more than the roughly $6,700 the Narshes expected to pay under their agreement with the hospital.

"I had to tell myself to keep my cool," says Bridget Narsh, 44, who lives with her husband and three children in Chapel Hill. "There is no way I could pay for this."

Medical bills have upended the lives of millions of Americans, with hospitals putting liens on homes and pushing many people into bankruptcy. In recent years, lawmakers have railed against privately operated hospitals, and states have passed laws intended to make medical billing more transparent and limit aggressive debt collection tactics.

Some state attorneys general — as their states' top law enforcement officials — have pursued efforts to shield residents from harmful billing and debt collection practices. But in the name of protecting taxpayer resources, their offices are also often responsible for collecting unpaid debts for state-run facilities, which can put them in a contradictive position.

Stein, a Democrat running for governor in 2024, has made hospital consolidation and health care price transparency a key issue during his time in office.

"I have real concerns about this trend," Stein said in 2021 about the state's wave of hospital consolidations. "Hospital system pricing is closely related to this issue, as consolidations drive up already inordinate health care costs."

Stein refused an interview request about Mason's bills, which arrived at the end of 2021 because the North Carolina government suspended debt collection in March 2020 as the nation felt the economic fallout of the COVID-19 pandemic.

Across the nation, states seize money or assets, file lawsuits, or take other steps to collect debts from people who stay at state-run hospitals and other institutions, and their efforts can disproportionately affect racial and ethnic minorities and the poor, according to health care consumer advocates. In North Carolina, officials looking to collect unpaid debt are permitted to garnish residents' income tax refunds.

Attorneys general must balance their traditional role of protecting consumers from harmful debt collection practices and the state's obligation to serve taxpayers' interests and fund services, said Vikas Saini, a cardiologist and the president of the Lown Institute, a Massachusetts-based nonpartisan think tank that advocates for health care reform.

The Narsh case is "the perfect storm of every problem in our health care system," says Saini, who at the request of KFF Health News reviewed the payment demand letters the family received. Far too often health care is unaffordable, billing is not transparent, and patients end up facing enormous financial burdens because they or a loved one is sick, Saini said.

The Narsh family had Blue Cross and Blue Shield health insurance at the time of Mason's hospitalizations. Bridget Narsh has records showing insurance paid about $7,200 for one of his stays. (Mason is now covered by Medicaid, the state and federal health insurance that covers some people with disabilities and low income people.)

In a written statement, Nazneen Ahmed, a spokesperson for Stein's office, said state law requires most agencies to send their unpaid debts to the state Department of Justice, which is charged with contacting people who may owe money.

Ahmed directed KFF Health News to the North Carolina Department of Health and Human Services, which oversees Central Regional Hospital.

Bailey Pennington Allison, an agency spokesperson, said in a written statement that officials researched the Narsh case and determined the state had properly followed procedures in billing the family.

The state bases its rates for services on the costs of the treatment, nursing, professional consultation, hospital room, meals, and laundry, Pennington Allison said. Hospital staffers then work with patients and families to learn about their income and assets to determine what they can afford and what they will be charged, she said.

The spokesperson did not address why Mason's parents were offered, but did not ultimately receive, a discounted rate both times he was admitted in 2020.

Narsh contacted an attorney, who negotiated the bill with the state. In April, her family reached an agreement with North Carolina officials to pay $100 a month in exchange for the state reducing the charges by roughly 96% to about $4,300. If Narsh defaults, however, the deal stipulates she must come up with the original total.

States can take a variety of approaches to debt collection. North Carolina is one of about a dozen that can garnish residents' income tax refunds, says Richard Gundling, a senior vice president for the Healthcare Financial Management Association, a membership organization for finance professionals.

Gundling says state officials have a responsibility to protect taxpayer money and collect what is owed but that seizing income tax returns can have more severe consequences for people with lower incomes. "There is a balance that needs to be struck to be reasonable," he says.

With health care a leading cause of personal debt, unpaid medical bills have become a major political issue in North Carolina.

State lawmakers are considering a bill called the Medical Debt De-Weaponization Act, which would curb the ability of debt collectors to engage in "extraordinary collection" such as foreclosing on a patient's home or garnishing wages. But the current version of the bill would not apply to state-operated health care facilities like the one Mason Narsh went to, according to Pennington Allison.

In a written statement, Stein said he supports legislative efforts to strengthen consumer protections.

"Every North Carolinian should be able to get the health care they need without being overwhelmed by debt," Stein said. He called the bill under consideration "a step in the right direction."

Narsh said the unexpectedly high amount of the bill was frustrating, at least in part because for years she struggled to get Mason more affordable, preventive care in North Carolina. Narsh says she had difficulty finding services for people with behavioral issues, a shortage acknowledged in a state report released last year.

Multiple times, she says, she has been left with no option but to take him to a hospital to be evaluated and admitted to an inpatient mental health facility not suitable for people with complex needs.

Community-based services that allow people to receive treatment at home can help them avoid the need for psychiatric hospitals in the first place, Narsh said. Mason's condition improved after he received a service dog trained to help people with autism, among other community services, Narsh says.

Corye Dunn is the public policy director at Disability Rights North Carolina, a Raleigh-based nonprofit mandated by the federal government to monitor public facilities and services to protect people with disabilities from abuse. The irony, she says, is that the same system that's ill-equipped to prevent people from falling into crisis can then pursue them with big bills.

"This is bad public policy. This is bad health care," Dunn says.

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.