Medical debt and illness have destroyed their lives.
Doug Dworshak can't bring himself to discuss what life was like before his heart attack last year, before he and his wife, Carol, started drowning in debt, before they both were forced to quit their jobs.
Before the stress, worry, frustration and disbelief came to a climax with the loss of their home in August.
"I don't want to talk about it," he says as tears fill his eyes after an unsuccessful attempt to tamp down his emotions.
It hurts too much.
"I thought we'd be happy by now," Carol adds.
Doug, 61, was diagnosed with heart disease last year and forced to quit his longtime job as a meat cutter at Butcher Block. A few months later, Carol, 60, suffered a back injury in a car accident and was no longer able to work at Panera Bread. The medical debt from ambulance calls, emergency room visits and hospital stays added up to a seemingly insurmountable $300,000. There was no more money to pay bills, buy household necessities and keep up the mortgage, The Bismarck Tribune reported.
The Dworshaks aren't alone -- statistics show countless others across the country also face crippling medical debt. But the Mandan couple had imagined the years leading up to retirement as being less stressful, happier.
"Whoever said your 60s are the golden age, I'd like to knock the snot out of that guy," Doug says.
In the past year, the weight of their financial crisis and his serious chronic medical condition landed Doug at the hospital multiple times. The debt and the lack of identity of a job have led the prideful man down a road of depression and hopelessness to thoughts of suicide.
"I've worked since I was 15 years old," he says. "You have no idea how much I hate not working. I can't support my family. It downright sucks."
From his living room couch, Doug blankly stares at the TV screen on a December afternoon.
"I feel whipped. I damned near hate my life," he says. "I can't do a damned thing about it. I've never been this poor before."
Carol, who is still recuperating from her back injury, stays close to Doug in case he faints or has an anxiety attack, or shows signs of a stroke.
She found a part-time job over the winter last school year as a school bus aide in Mandan. It paid $13 an hour -- but only for about four hours a day.
After impatiently waiting about six months for the paperwork to process, Doug is receiving $1,260 monthly in Social Security Disability payments. With Carol still looking for a new part-time job, the couple is living nearly $800 below the poverty rate for a family of two. They get $300 monthly through the Supplemental Nutrition Assistance Program for groceries and make visits to local food pantries.
Before their plight, the Dworshaks, married since 1988, were considered middle class. They were happy and relaxed.
"We never fought like we do now," Doug says. "Everything is on the edge."
He is angry, frustrated and disillusioned.
"I don't know if we can ever get (our life) back," he says
Carol tries to maintain a small amount of cautious optimism as unwanted circumstances keep popping up like gopher colonies on the North Dakota prairie.
"We always lived paycheck to paycheck, but we always made it," she says. "We never lived beyond our means. We will make it. I don't know how, but we will."
A national issue
The Dworshaks aren't alone. People across the country face the same dilemma -- crippling medical debt.
More than one-fourth of Americans have a difficult time paying medical expenses, according to a 2016 study by the Kaiser Family Foundation and the New York Times. Many are faced with the quandary -- pay for medical bills and prescription drugs, or for food, rent, transportation and utilities?
The Commonwealth Fund, a nonprofit private foundation supporting independent research on health policy reform, conducted a survey in 2018 in which more than half of the respondents -- over 21 million people -- "experienced one or more dire financial consequences related to medical care," despite having health insurance.
In the same survey, one-third of respondents said they used up most of their savings, and nearly one-fourth stated they were unable to pay for basic necessities. Nearly one-third were contacted by a collection agency for unpaid bills.
"It's the worst," said Alicia Kellebrew, a counselor with the Village Family Service Center in Fargo. "People can't control" health-related issues.
The nonprofit provides behavioral health services in 15 communities across North Dakota and Minnesota. Kellebrew counsels clients on banking and financial issues. Most hospitals and clinics have internal hardship programs to which patients can apply to reduce or eliminate medical debt, and patients also can arrange for a no-interest monthly payment plan.
"You have to catch it before it goes to collections," Kellebrew said.
Many people with medical debt get into trouble by maxing out credit cards or borrowing against 401(k) retirement accounts, she said. It creates a snowball effect when there are unanticipated "dark-horse expenses" such as car or house repairs, or medical emergencies.
Bankruptcy is an option, but Kellebrew cautions against filing too soon -- if a medical condition is ongoing, new bills that rack up will not fall under the final bankruptcy agreement.
Kellebrew said people need to stop digging a financial hole and start asking questions. She works with clients to create an operational budget so they can meet monthly needs.
"Take care of you first," she said. "You are more important than debt."
It's June, and the foreclosure of the Dworshaks' home is inevitable. They're busy in their garage, packing camping gear and other belongings into an old recreational vehicle.
Their German shepherd, Chase, not quite a year old and still acting like an overgrown puppy, roams the backyard, though the dog still always seems to be near Doug's side. Having Chase around the house has given Doug a diversion from the couple's troubles. Even if Chase is just fetching chew toys or leaping onto the couch to give Doug a lick on the cheek, it's less time that Doug is thinking about their desperate situation.
That's why the decision to send Chase to live at their daughter's home miles away was gut-wrenching for Doug. It was a fear he knew would probably come true.
"That's one of the saddest things," Doug says, fighting back the tears. "I've got to give my buddy away."
Other decisions have to be made, as well — what to keep, what to throw away, what to give away and what to leave behind if they run out of time before the foreclosure deadline.
"Hey, Carol," Doug shouts from inside the garage. "What do you say we take everything to the dump and hit the road?"
Later, Doug brushes by Carol inside the garage, gently touching her shoulder as he walks by.
"It would kill her if I threw it all away," he whispers.
It's July 15, and the North Dakota Housing Finance Agency, which aims to make housing affordable for state residents, is set to foreclose on the Dworshaks' home of seven years.
Carol frantically makes last-minute calls to the state agency and to the state office of the U.S. Department of Housing and Urban Development in Fargo, surrounded at her kitchen table by letters, other paperwork, and loose papers with scribbles and calculations.
Doug, angry and disillusioned by the drawn-out, roller-coaster bureaucratic process, slumps on the edge of the couch smoking a cigarette and staring at the floor.
For months the Dworshaks' mortgage has been placed in deferred status. But it's time to make a payment or face foreclosure.
"Carol, it's time to wake up," Doug yells. "The government isn't going to do anything for us. Let's take a few things and let them have the rest. I don't even want the house anymore."
"I do," Carol answers in a quiet voice.
A short time passes and the cellphone rings. It's a representative from HUD. Carol retreats to the back of the house to take the call. A short time later, she walks out.
"Well, we're screwed," she says. "I did what I could. It's over."
As the shock wears off, Carol's eyes begin to well up with tears as she sits beside Doug on the couch.
"I never thought life would turn out like this," Doug says. "That's what I get for being sick."
Before a "sheriff's sale" is held to auction a foreclosed property, multiple attempts are made to reconcile the mortgage debt with the homeowner, a process that takes months.
"We want to keep people in their homes," said Dave Flohr, director of the North Dakota Housing Finance Agency's Home Ownership Division. "No one makes money on a foreclosure."
He cited court costs, upkeep, utilities and taxes as examples of expenditures the agency takes on after a foreclosure.
Once the homeowner becomes a month late on a mortgage payment, the state agency is required to send notices and make phone calls for up to three months of delinquency. Arrangement options can result in deferred payments or temporary reduced payments.
Flohr said the most important thing for people to do when behind on their mortgage payments is to communicate with their loan provider.
"Don't ignore the phone calls and letters," he said. "If we don't know what's occurred, we can't help you."
The agency also offers grant programs such as the Rehab Accessibility Program and a rental assistance program, and it contributes to local nonprofit organizations like Community Action and Helping Hands.
Down and out
It's Aug. 19, just days after Doug has had another nearly weeklong stay at a local hospital. Earlier in the day, the couple attended a court hearing finalizing the foreclosure of their home. Now, four Mandan police officers are at the front door, and the Dworshaks must vacate their home immediately.
They thought they had one more day. Confused and overwrought, they're forced to leave behind several large appliances, furniture, dry goods and a freezer full of food. They spend the night in their RV, parked in the street.
"I feel overwhelmed; sometimes I feel hollow," Carol says five weeks later. "Where are we going to go? I don't know."
The Dworshaks are now homeless and living in their cold, overstuffed RV with a leaky roof, parked on Carol's sister's property near Lincoln.
"It was OK for about a week," Doug says. "Now we are moody and arguing all the time. Everything is so cramped."
Carol wishes she had more privacy and room to move without bumping into Doug.
"I try to look at the bright side, and I can't find one," she says, tears welling in her eyes. "We try to keep on going and we just can't."
As the days and weeks go on, the Dworshaks are hoping to find someplace to rent with the help of programs through Community Options and Burleigh County Housing Authority. The couple visits food pantries like Ministry on the Margins for help, as well.
As a last resort, the Dworshaks' daughter and son-in-law have property near rural Litchville, southwest of Valley City. The house, although in disrepair, is better than their current living conditions — but it's far from job opportunities and medical care. Doug and Carol Dworshak are now living with family near Litchville, and a GoFundMe account has been set up in the couple's name.
As he ponders what their future might be, Doug can't help but also look to the past.
"Life was good before I got sick," he says.