By the time Astra Augustus left Virtua Memorial Hospital in New Jersey after the last of four surgeries, she'd run up about $255,000 in bills.
At first she thought she was lucky. Virtua gave her a charity discount, to $30,530. Then she got statements from the doctors who treated her in the hospital, adding $18,000. "I didn't know who to pay first," said Ms. Augustus, who has a monthly income of $2,200.
Virtua sued last month after she fell behind in her $400-a-month installment plan.
Hospitals' fast-rising sticker prices are adding to the financial burdens of the 49 million Americans without insurance, more than 20 million of whom won't be covered under President Barack Obama's Affordable Care Act.
So-called full charges at hospitals grew an average 10 percent a year between 2000 and 2010, according to Gerard Anderson, a Johns Hopkins University professor who analyzed hospital financial reports.
While the charges appear on hospital invoices across the U.S., the amounts people actually pay vary widely, depending on their health coverage. The system is so irrational that those without any insurance can get stuck owing the most money, said David Himmelstein, a professor at City University School of Public Health at Hunter College in New York.
"It's unconscionable," said Mr. Himmelstein, who co-authored a 2009 study that found illness and medical debt was a factor in more than 60 percent of personal bankruptcies. "It adds to the already grave suffering of the uninsured."
Rich Umbdenstock, president of the American Hospital Association, doesn't defend the pricing structure. He said it's part of a "broken system" that has evolved over decades and that hospitals can't change on their own.
Full charges keep rising because hospitals have to try to make up for charity care, debts they can't collect and inadequate reimbursements from the government Medicare and Medicaid programs, Mr. Umbdenstock said.
"If we could have fixed this, we would've," he said. "Why would we want to perpetuate this?" Stories about people facing insurmountable bills are "one of the toughest PR issues we have" and damage the industry's credibility, he said.
While "hospitals are not victims," he said, "we are caught up in a larger system." He said that unfortunately for some uninsured Americans, it's a "crazy system."
The nation's 5,000 community hospitals provided $41 billion in uncompensated care in 2011, or 5.9 percent of total expenses, according to the Washington-based trade group. That number was calculated from the costs of the care, not the full charges, and included charity and bad debt, or what's owed after attempts to collect, according to the AHA.
The "vast majority" of patients pay less than the full charges billed, Mr. Umbdenstock said. Medicare and Medicaid rates for the most part don't cover costs, while private insurers strike deals that average 34 percent above costs, AHA data show.
Between 2000 and 2010, payments to hospitals went up at the same average annual rate as hospitals' costs, according to Mr. Anderson, director of the Center for Hospital Finance and Management at the Bloomberg School of Public Health at Johns Hopkins in Baltimore.
The average full-charge bill was 2.5 times costs in 2000 and 3.6 times costs 10 years later, Mr. Anderson said. He analyzed data contained in reports hospitals file annually with U.S. regulators outlining what they spend, what they charge and what they're paid.
Markups over costs varied widely, even geographically, according to Mr. Anderson. They were highest in 2010 in Nevada, where the average full-charges bill was 5.91 times costs. Pennsylvania was second at 5.58 times. In Maryland -- which has a hospital price control law -- the average was 1.37 times costs, the lowest in the U.S.
That range is evidence that full charges "have no relationship to reality," said David Knowlton, president of the New Jersey Health Care Quality Institute, a Pennington-based nonprofit. They're like automobile sticker prices, starting points for bargaining, he said. "You're going to highball me, then discount from that. That's just what hospitals do."
He said it was difficult to predict whether the 2010 health care law would have any limiting effect on full-charge growth.
The health care law will by 2017 expand coverage so that 27 million more Americans will have insurance, according to Congressional Budget Office estimates.
Most people without coverage are in working families, according to the Kaiser Commission on Medicaid and the Uninsured. About 63 percent were in households with incomes under $50,000 in 2011, according to a September report by the U.S. Department of Health and Human Services. Such households took a bigger financial hit between 2000 and 2010 than the rest of the population.
Proposed regulations from the Internal Revenue Service say nonprofits, about 58 percent of community hospitals, can demand "not more than the amounts generally billed to individuals who have insurance." For-profit institutions won't be subject to the rules.