Last month, theConsumer Financial Protection Bureau proposed a rule toframe what debt collectors are allowed to do when pursuing manytypes of overdue bills, including medical debt.

Elham Mirshafiei was at the library cramming for final examsduring her senior year at California State University-Long Beachwhen she grew nauseated and started vomiting. After the 10thepisode in an hour, a friend took her to the nearest emergency room. Diagnosis: an intestinal bugand severe dehydration. In a few hours, she was home again, withinstructions to eat a bland diet and drink plenty of fluids.

That was in 2010. But the $4,000 bill for the brief emergencydepartment visit at an out-of-network hospital has trailed her eversince. Mirshafiei, 31, has a good job now as a licensed insuranceadviser in Palo Alto, Calif. But money is still tight and herpriority is paying off her $67,000 student loan debt rather thanthat old hospital bill.

Once or twice a year she gets a letter from a collection agency.She ignores them, and, so far, the consequences have beenmanageable. “It's not like electricity that gets cut off if youdon't pay it,” she said.

Related: Medical debt tops list of collectioncalls

Mirshafiei has plenty of company. At least 43 million other Americans have overdue medical bills on theircredit reports, a federal Consumer Financial Protection Bureaureport on medical debt found in 2014. And 59 percent ofpeople contacted by a debt collector say the exchange was overmedical bills, the most common type of contact stemming from anoverdue bill, according to the CFPB.

Last month, the CFPB proposed a rule to frame what debt collectors are allowed to dowhen pursuing many types of overdue bills, including medicaldebt.

Federal law already prohibits debt collectors from harassing consumersor contacting them before 8 a.m. or after 9 p.m., among otherthings. But the law, which was passed in 1977, didn't anticipateemails and text messages. The CFPB's proposal clarifies how debtcollectors can use these communication tools. And it would allowconsumers to opt out of being contacted this way.

The rule also specifies that debt collectors can make no morethan seven telephone calls weekly over a specific debt.

But some consumer advocates panned the effort. “This really doesn't go far enough toprotect consumers and make sure that consumers are not abused orharassed or subject to unfair collection practices in debtcollection,” said April Kuehnhoff, an attorney at the NationalConsumer Law Center who specializes in debt collection.

For instance, the center wants a limit of just three telephoneattempts each week on a debt. The seven-call limit could beparticularly tough on people with medical debt, Kuehnhoff said.They may accumulate bills from several providers for a singlemedical event — hospital, doctors, a lab and a nursing home, forexample — and all could be in collections separately, potentiallyresulting in dozens of calls each week.

Debt collectors aren't necessarily in favor of the seven-callcap either, but for different reasons. They say that limiting thenumber of calls could lead to more litigation or adverse creditreporting rather than working out a payment plan. Overall, theproposed rule seemed to strike a good balance between collectionindustry and consumer concerns, said Leah Dempsey, vice presidentand senior counsel for federal affairs at ACA International, a tradegroup representing 2,500 debt collectors, asset buyers and relatedprofessions.

The general consensus is that people should pay their debts. Buttaking responsibility for medical debt isn't always asstraightforward as paying off a large-screen TV that someone put ona credit card. Did health insurance pay the correct amount? Was theperson screened for eligibility for Medicaid, charity care orfinancial assistance?

“The actual debt collector problem is often about the lack ofaccountability that providers have for the people that they passtheir debt along to,” said Leonardo Cuello, director of healthpolicy at the National Health Law Program.

When a debt collector calls, consumers who are confused aboutthe bill should ask, in writing and generally within 30 days, thatthe debt be validated. Debts are often bundled and sold multipletimes to different collectors, which means errors may be introducedalong the way. “There are no magic words; you don't need to citethe statute,” said Justin J. Lowe, legal director at Health LawAdvocates, a nonprofit law firm in Boston that helps people withlow incomes who are having trouble accessing or paying for medicalcare.

At that point, the collection agency has to stop activitiesuntil it proves what the consumer owes. The proposed CFPB rulewould spell out verification information that must be providedalong with instructions for consumers about how to dispute thedebt.

The proposal would also address other practices, including thecollection of so-called zombie debt. That refers to a bill that haspassed a time limit — or statute of limitations — for bringinglegal action, often between three and six years, depending on thestate. In many states, if a collector sues someone for such atime-barred debt, consumers can raise the issue in court in theirdefense. If a judge agrees, the case could be dismissed.

Consumer advocates have long wanted debt collectors to beprohibited from trying to collect zombie debt. After several years,it can be difficult for patients to remember whether a bill hasbeen paid or to locate records, they argue.

The proposed CFPB rule would prohibit debt collectors from suingor threatening to sue consumers for zombie debt, but only if thecollectors knew or should have known that the statute oflimitations had expired. That puts the onus on the consumer toprove what was in the debt collector's mind rather than merelyshowing that too much time had passed to collect.

While a college student in 2010, Elham Mirshafiei went to ahospital that wasn't in her insurance network for treatment of anintestinal bug and severe dehydration. She still carries the $4,000debt from that visit.

It's unclear how the proposed changes announced by the CFPBmight affect Mirshafiei's situation. The statute of limitations inCalifornia on written contracts is four years.

One thing someone in Mirshafiei's situation should be aware ofis that making a payment could reset the statute of limitations,Lowe said. The debt collector could argue that by making a paymentthe person is affirming that he or she owes the debt.

Because of her damaged credit, Mirshafiei needed a relative toco-sign for student loans for graduate school. She worries that ifshe tries to buy a house, she'll have trouble getting approved.

“I just hope that in the next chapter of my life I don't have tobe denied things because of this stain on my record,” she said.

As the federal government moves ahead with the rule to addressvarious types of debt collection activities, legislators in a fewstates have introduced bills that specifically target medical debt.Their efforts often focus on improving access to financialassistance for medical care and limiting predatory debt collectiontactics.

Last month, Washington Gov. Jay Inslee signed a law that reduces the maximum interest rate on medical debt prior to acourt judgment from 12 percent to 9 percent. It also prohibitssending a medical debt to collections until 120 days after thepatient is sent the initial bill and requires collection agenciesto provide itemized statements to patients for medical and hospitaldebts and to notify them of their possible eligibility for charitycare.

In Oregon, a bill sponsored by Rep. Andrea Salinas would requirenonprofit hospitals and affiliated clinics to provide care free ofcharge to families with incomes up to 200 percent of the federalpoverty level (about $43,000 for a family of three) and charge asliding scale for families earning up to 400 percent of the povertylevel (about $85,000 for a three-person family).

Like the Washington law, the Oregon billplaces limits on the interest charged for medical debt. It alsorequires health care facilities to screen patients for eligibilityfor financial assistance and insurance.

The bill passed the House last month.

Some hospitals already have strong financial assistancepolicies, but the playing field needs leveling, said Salinas. “Wereally need hospitals to be a part of the solution to preventconsumers from going into bankruptcy over medical debt.”

Kaiser Health News isa nonprofit news service covering health issues. It is aneditorially independent program of the Kaiser Family Foundation,which is not affiliated with Kaiser Permanente.

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• Health care providers frustrated with the 'awkwarddance' of debt collection
• Consumers more likely to pay hospital bills ifcosts are clear