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Twins Thomas and James Cavatore were only about a month old in winter 2016, still in the neonatal intensive care unit at a Houston, Texas, hospital, when the bills started rolling in. Just as steadily as Thomas improved, James deteriorated, undergoing nearly a dozen operations and as many emergency room visits during his short life.

James was just seven months old when he died in hospice. But the Cavatore family would be haunted by an avalanche of bills for years to come, despite having medical insurance.

“I got one bill, and it was $1.1m,” said Federico Cavatore, the boys’ father. “I joked to myself, I said, I’m going to frame this and put it in Thomas’ room and say, ‘This is why you’re getting a scholarship to college.’”

The Cavatores were hit with “surprise bills”, expenses for medical supplies, co-payments and deductibles, and calls from bill collectors. James’ birth and treatment probably cost the family close to $38,000 out-of-pocket, though they were served with bills charging them many times that amount, forcing them to spend hours challenging the claims and bringing their financial costs down, even as their emotional costs spiraled upwards.