Within months, the state enacted a that required hospitals to proactively screen patients and give financial aid to those who qualify for it. Oregon’s new rules, which took effect in July 2024, required hospitals to skip applications for nearly all patients — a rarity among hospitals nationwide.

“They will be told up front, Hey, we got you,” said Democratic Oregon state Sen. Lisa Reynolds, who introduced the legislation. “You are here at a very scary time in your life because of illness or injury, and we got your back.”

The law worked.

Oregon Health & Science University’s hospital, one of the largest in the state, saw 64% of its patients automatically qualify for financial assistance in the early months of the new law, up from 12% previously.

In their first full fiscal year under the law, spending by Oregon hospitals on financial assistance more than doubled, on average, according to federal financial reports from about two-thirds of the state’s hospitals. That’s compared with their last full year before the change.

For patients, the switch meant direct relief from high healthcare costs, advocates said.

“They don’t have to have the late nights being like, how am I going to afford my mortgage? How am I going to afford these medical bills?” said Adam Zarrin, a director of state government affairs for the advocacy group Blood Cancer United.

Hospitals in the state have pushed back on the requirements, saying they , and they face added financial strain from the Trump administration’s domestic policy agenda. Millions of people are health insurance in coming years under cuts to Medicaid pushed through by Republicans in Congress.

Oregon’s early success is the first big test of a new approach that more states are turning to, known as . Hospitals skip the applications and screen patients automatically to determine if they qualify for aid.

North Carolina this year to include patients with income up to triple the poverty line. and are requiring hospitals to automatically grant financial aid by July 2027.

A Promising Tool To Prevent Medical Debt

As many as 100 million adults in the U.S. have healthcare debt, according to a ³Ô¹Ï²»´òìÈ analysis. That financial burden can alter people’s lives, forcing them to skip prescriptions and follow-up care to avoid further bills.

Hospitals are a of that debt, and they have faced growing scrutiny over and billing practices.

Policymakers have focused specifically on nonprofit hospitals, which account for the sector. Nonprofit hospitals , in exchange for providing benefits to their communities — a vaguely defined standard under federal law. Many hospitals meet this requirement by providing free or discounted care to low-income patients.

That financial assistance, however, can be difficult to get. Applications can be onerous and confusing. Congress and state officials have spent years testing policies to and , with mixed results.

Research finds , as does the degree to which hospitals property, sales, or income taxes.

“Hospitals have been on the winning side of this deal for a long time,” said Reynolds, the Oregon lawmaker. “They enjoy millions and millions and millions of dollars in tax breaks, and that money is supposed to be then spent on poor people who can’t afford their care or even their copayments. It has not penciled out.”

Reynolds pressed for Oregon’s screening requirement, she said, to hold hospitals “accountable for what they should have been doing all along.”

Early evidence suggests the law is doing what Reynolds hoped. Oregon hospitals’ spending on free and discounted care increased to 2.7% of all operating expenses, on average, from 1.4%, among the roughly two-thirds of hospitals with available federal data.

That brings hospitals in Oregon closer to the national average for nonprofit hospitals, which from 2021 to 2024 was about 2.4%, according to an analysis by Johns Hopkins University researcher Hossein Zare, who studies the industry.

More Help for the Insured

Among those in Oregon who started to get more help: patients with health insurance.

OHSU’s spending on help for insured patients reached about $39 million in the first year under the law, federal data shows, about five times as much as in previous years.

Lawrence Furnstahl, then OHSU’s chief financial officer, said in a public meeting in January 2025 that, before the law, insured patients often didn’t apply for help and instead paid their share of the bills. The new automatic screening often wiped out or reduced what they owed — including for large deductibles that patients have to meet out-of-pocket before insurance will kick in.

Patients who pay hospital bills often still carry medical debt, surveys show, because many use from family, friends, or banks to afford their care.

A from the Commonwealth Fund found that 1 in 3 adults with private insurance have medical debt.

“It defies the purpose of health insurance coverage, which is to enable people to get healthcare when they need it and protect them from serious costs,” said Sara Collins, an economist and senior scholar with the Commonwealth Fund.

‘A Very Different World’

For hospitals, the new requirements come as healthcare costs are climbing and federal support for the safety net is shrinking. Nationally, an estimated will be uninsured in 2034 as a result of President Donald Trump’s signature tax-and-domestic-spending law and the expiration of enhanced Obamacare subsidies that Republican lawmakers allowed to lapse at the end of last year.

Hospitals supported Oregon’s new presumptive eligibility law, said Sean Kolmer, an executive vice president for the Hospital Association of Oregon. But they’re feeling more financial pressure, with the organization expecting the state’s uninsured rate to 10% or higher in coming years, he said, up from about 3% .

“That’s a very different world,” he said.

OHSU saw costs rise rapidly. “It is a good thing, but it is an expensive thing,” Furnstahl said in a public meeting as he gave an update on the first months under the law.

In the first year under the new law, OHSU spent about $64 million on free and discounted care — of what it spent on operations that year.

The true cost of more up-front screening is hard to quantify, medical debt experts said. It must also take into account how many people would have never paid their bills anyway and how much hospitals save by not chasing payments.

Lawmakers said hospitals pressed them for relief, and in April, Oregon to ease the state’s screening requirement.

The original law required hospitals to screen everyone on Medicaid or who was uninsured and anyone who owed $500 or more. Lawmakers raised the monetary screening threshold for a single visit . The Medicaid or uninsured requirement remains.

Reynolds, who spearheaded the original law, was unsympathetic to hospitals’ cost concerns. But she agreed to the rollback because she wanted hospitals to have some relief as they fine-tuned their screening process. Oregon hospitals reported that their screening data was less accurate for patients with higher incomes, leading some people who didn’t qualify for help to receive financial assistance.

OHSU studied economic data for Oregon’s residents and reported that about 57% likely had incomes that qualified them for its financial assistance, slightly under the 64% of patients who were receiving help.

Hospitals’ warning of increasing financial stress was a motivator for Democratic Rep. Rob Nosse, who chairs the healthcare committee in the Oregon House of Representatives.

“I don’t want any suburban or rural hospitals to close on my watch,” Nosse said.

People who are no longer automatically eligible can still apply for help with bills less than $1,500, he said.

“I’ve got to make it more expensive for someone to get healthcare so that the hospitals can stay in business,” he added. “What a country.”

This article is part of “,” an investigative series from and ³Ô¹Ï²»´òìÈ about how hospitals can protect their patients from the life-altering harms of medical debt.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Hospitals have the ability to proactively screen patients to see if they’re eligible for aid and, if so, automatically wipe out or reduce their bills —

A growing number of and researchers believe requiring hospitals to use presumptive eligibility would protect low-income Americans from falling into medical debt, especially with federal funding cuts expected to increase the number of people without health insurance.

Texas has among the highest , and policymakers in Texas are considering legislation that would require to use presumptive eligibility before sending patients a bill.

In a first-of-its-kind analysis, Tradeoffs examined the presumptive eligibility policies of 166 nonprofit general and children’s hospitals in Texas. The goal was to shed light on how easy or difficult hospitals make it for low-income people to get financial aid without an application.

Scroll to the bottom of the page to explore a searchable table with all 166 hospitals’ policies.

Here’s what we found:

1. Nearly half of nonprofit hospitals in Texas (44%) say they will bill patients before screening them for free or discounted care.

Some hospitals screen patients after sending a single bill. Others may send multiple bills and hire collection agencies to chase after debts before they check whether a patient is eligible for help.

The most common approach is for hospitals to say they will screen patients before taking “,” which include garnishing their wages, selling the debt to a debt collector, or denying further care until outstanding bills are paid.

Anna Stelter, vice president of policy for the Texas Hospital Association, said hospitals want to investigate other options for payment — like Medicaid or county safety net programs — before they offer financial assistance.

“We do want to make sure that whoever is financially responsible for that care is identified and pays,” Stelter said. “Charity care is the relief of last resort.”

Just one nonprofit in Texas, Memorial Hermann Health System, has a written policy that requires its hospitals to check and proactively reduce or wipe out what patients owe before sending bills.

Research shows that when patients receive financial aid makes a difference.

A 2022 study found that patients who received hospital financial aid within weeks of care were to return to the doctor and get treatment for conditions like diabetes and depression. Conversely, published in 2024 found that wiping out people’s medical debt years later on their mental and physical health, healthcare use, or financial situation.

2. Most hospitals say they do not reimburse patients who qualify for financial aid for money they have already paid.

Hospitals often put patients on payment plans to chip away at bills they can’t afford. But only 10 of 166 nonprofit hospitals in Texas guarantee a full refund to patients found to be eligible for financial aid. Most others say they won’t return money that patients paid before being screened.

Surveys show patients and to cover what they owe. , one-third of Americans without health insurance said they had borrowed money for medical care in the previous year.

“It is very frustrating,” said Aimee Carlock, who was required to pay $5,500 to Texas Health Resources to schedule uterus surgery. She later qualified for free care, and the hospital wiped out her remaining $16,000 bill. But the $5,500 was gone. “That’s a lot of money to me,” said Carlock, a self-employed housecleaner who was recently approved for food stamps.

offers refunds only in the amount a patient has paid in excess of what the hospital typically charges someone with insurance. All hospitals must offer refunds to patients who qualify for financial aid in these situations to avoid federal penalties.

Texas Health didn’t respond to an interview request after Carlock agreed to grant the system permission to speak about her experience.

In some cases, patients must fill out extensive applications to recoup their money. The application for Abilene-based instructs patients to “completely and precisely” fill in financial and personal details, describing their savings and listing Social Security numbers for family members they live with who might help with the bills. Patients must submit two current pay stubs, a tax return, two months of bank statements, and a justification of why they need help.

“Explain circumstances in which paying this hospital bill would create a hardship,” the .

Hendrick Health didn’t respond to questions about its policy.

3. Many hospitals never tell patients that their debt has been forgiven.

Some of the largest nonprofit hospital systems in Texas don’t notify patients when their bill has automatically been wiped out. That includes , Texas Health Resources, and Texas hospitals owned by , one of the nation’s largest .

Research shows patients who don’t know their debt has been forgiven may skip needed care. A 2026 study found that people with medical debt were as likely to delay future physical and mental healthcare as people without medical debt.

“If the patient doesn’t get some sort of notice,” said Erin Fuse Brown, a health policy researcher at Brown University, the possibility that they could be billed “hangs like a sword over their neck.”

Stelter, with the Texas Hospital Association, said many hospitals have limited staff in their billing departments. “Notifying patients whose bill was completely forgiven that they were presumptively eligible is probably lower on the totem pole than helping somebody who’s trying to complete an application,” she said.

If hospitals offer someone less than the maximum discount available, the hospital to notify the patient, in case they want to appeal for a full write-off.

Texas Health and Christus Health didn’t respond to interview requests about their policies. A CommonSpirit spokesperson declined an interview.

4. Some hospitals say their financial assistance policies don’t reflect how they actually operate. These discrepancies can work to patients’ advantage — or detriment.

AdventHealth says some of its Texas patients get screened for financial assistance before getting bills, a consumer-friendly practice. The system’s however, has no requirement for when hospitals must screen patients.

“We want patients to understand and have access to available financial assistance before receiving a bill whenever possible,” said Tim Reiner, senior vice president for revenue cycle for the system, which owns and operates four hospitals in Texas.

also screens patients for help before sending bills, if they are uninsured, a spokesperson said. There is no requirement for its eight hospitals to do so under the system’s policy.

According to , Covenant Health, a five-hospital system based in Lubbock, must screen patients before sending bills to collection agencies and lists detailed criteria for who is eligible to have bills proactively wiped out.

But in 2019, the system decided not to use presumptive eligibility “due to the regulatory requirements and administrative complexities,” said spokesperson Ainsley Nelson. “Our focus continues to be ensuring compassionate access to care and helping patients navigate the financial assistance options available to them.”

Covenant is owned by Providence, a multistate Catholic health system based in Renton, Washington, which agreed to refund or erase in patient bills after charged that the system of charity care.

Providence said the system fixed the problem identified by investigators, refunded patients, and now coaches its employees to communicate “with compassion and respect.”

5. Who qualifies for presumptive eligibility varies significantly from one hospital to another.

Hospitals in Texas get to decide who is eligible to be automatically screened for and enrolled in financial assistance.

Presumptive eligibility policies often apply to people who are homeless, deceased, or already enrolled in state or federal programs to help low-income households with medical care, housing, food, or prescriptions. Some hospitals have additional criteria, including writing off bills for anyone in a religious order who took a vow of poverty.

Some hospitals share little to no public information about who they will proactively screen. Thirteen hospitals owned by , one of the nation’s largest Catholic health systems, say only that it may screen patients “with a sufficient unpaid balance.”

Ascension didn’t respond to questions about its eligibility criteria.

This variation means that a patient’s ability to access free care depends greatly on where they go.

6. Some hospitals provide less generous charity care to patients who receive it automatically instead of submitting an application.

At CommonSpirit’s hospitals across southeastern Texas, patients who are auto-enrolled get help with debt from the prior 12 months. Patients who submit an application get the same help with prior bills, plus free or discounted treatment for the next six months.

limits financial assistance for auto-enrolled patients to individual visits. Applicants may be eligible going back 12 months before approval.

North Texas Medical Center didn’t respond to additional questions about its policy.

7. Policies that are supposed to be easily accessible to patients are often difficult to find.

Hospital financial assistance policies are intended to be transparent to patients and the public. For more than a decade, has required nonprofit hospitals to .

In practice, finding these policies and deciphering them is often hard.

To find the policies of all nonprofit hospitals in Texas, Tradeoffs started with a list of hospital financial assistance policy websites maintained by the nonprofit Dollar For. To verify websites were up to date and fill in missing policies, Tradeoffs scoured hospital websites, often clicking through multiple links to locate policies.

In cases in which hospitals did not publish full policies online, Tradeoffs requested copies from hospitals and filed a public records request with the state of Texas, which requires hospitals to submit charity policies annually.

“You would have to know what you’re looking for before you went looking for it, or you’re never going to find it,” said Ray Kluender, an associate professor at Harvard University, who has had to hunt for hospital policies as part of his research on medical debt.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Aimee Carlock needed surgery in August 2025 to treat severe pain and bleeding from her uterus. But first, she needed to come up with $5,500.

Texas Health Resources, one of the state’s largest nonprofit hospital systems, told her it wouldn’t schedule the procedure unless she paid up front, Carlock said. The self-employed house cleaner didn’t have the money.

“I panicked because I live paycheck to paycheck,” she said. “I have no extra money whatsoever.”

Carlock borrowed cash from her best friend and parents. Her father offered money he inherited when Carlock’s grandfather died a few years ago.

Only after the surgery did Carlock, 35, learn she qualified for hospital financial aid. Her care should have been free, but the system doesn’t give full refunds. The $5,500 was gone.

Carlock’s poor health has kept her out of work most of this year. She took out loans for groceries and utilities and applied for food stamps. It will take years, she said, to chip away at what she owes.

“I’m just trying to pick myself back up,” Carlock said. “But it’s really hard.”

Hospitals have a tool to automatically screen people like Carlock for financial aid and grant them relief — a process known as . But if, when, and how hospitals deploy this tool is largely up to them; there are few state or federal requirements.

A found that in Texas nearly half of nonprofit hospitals say they will bill patients before screening them for financial aid. And most hospitals will not offer refunds to patients who pay and are eventually found to qualify for free care.

Many patients are unaware that hospitals offer financial help, often known as charity care. Others are stymied by onerous applications that require people to turn over financial information, such as bank statements, car notes, pay stubs, retirement accounts, and even divorce records.

“It’s like going through a tax audit,” said Stanford University health economist Neale Mahoney, who studies medical debt. “The current system is broken.”

An estimated 100 million adults in the U.S. have healthcare debt, according to a ³Ô¹Ï²»´òìÈ analysis. That includes amounts people owe to hospitals and doctors, as well as loved ones, credit card companies, and banks. This debt can be life-altering, forcing people to take on additional jobs, push off retirement, or cut back on essentials like groceries and medical care.

Tradeoffs analyzed the financial assistance policies of all 166 nonprofit general hospitals and children’s hospitals in Texas, which has than .

The analysis is believed to be the first detailed look at presumptive eligibility policies of nonprofit hospitals, which . They get these tax breaks in exchange for , such as financial assistance. and in have questioned whether nonprofits do enough to earn those tax breaks.

Since 2020, a , including Texas, have debated or adopted requirements for hospitals to use presumptive eligibility in financial assistance to protect patients from avoidable debt.

“This is clearly an industry that is not policing itself very well,” said Tom Oliverson, a physician and Texas lawmaker who has proposed legislation to require hospitals to screen patients before sending a bill.

Automatic screening is a good option to help some patients, said Anna Stelter, vice president of policy at the Texas Hospital Association. But often, she said, there are other payment options, such as insurance, which hospitals need to pursue first. “Charity care is the relief of last resort,” she said.

Most Texas Hospitals Can Automatically Give Help

To identify nonprofit hospitals in Texas, Tradeoffs consulted state and federal records and a list of hospital policies maintained by , a group that helps patients apply for financial assistance. To verify policies were up to date, Tradeoffs scoured websites, often clicking through multiple links to find policies. When policies were missing, Tradeoffs reached out directly to hospitals and filed public records requests with the state, which requires hospitals to submit policies annually.

Tradeoffs’ analysis found that nearly every Texas nonprofit hospital can screen and proactively reduce bills when patients are found eligible for help.

Nationally, around 90% of nonprofit hospitals reported the same in 2022, according to an analysis of federal data for Tradeoffs by the independent research institute RTI International. That’s up from 72% six years earlier.

Hospitals’ use of automatic financial aid , in part, to the Affordable Care Act, which added protections for patients. The law created for hospitals that aggressively go after payment without trying to identify whether patients need help. Presumptive eligibility is .

Covenant Health, a five-hospital system based in Lubbock, was the only system in Texas to say it does not automatically grant financial aid, though its policy allows it.

Covenant doesn’t use the option “due to the regulatory requirements and administrative complexities,” said Ainsley Nelson, the system’s spokesperson. “Our focus continues to be ensuring compassionate access to care and helping patients navigate the financial assistance options available to them.”

Bill First or Screen First?

About 8% of hospitals in Tradeoffs’ analysis have policies that require screening patients for charity care before sending a bill.

Far more, 41%, say they screen patients before turning unpaid bills over to debt collectors or taking , such as garnishing wages, placing a lien on property, or denying further care without payment.

Southeastern Texas hospitals owned by , for example, will automatically wipe out bills only “after all other eligibility and payment sources have been exhausted,” according to its Texas financial assistance policy.

CommonSpirit declined an interview request.

Research shows the sooner patients get financial aid, the better it is for their health.

found that people were more likely to be diagnosed and treated for conditions like depression and diabetes and make follow-up appointments when they received financial aid within weeks of receiving care. of people who had medical debts wiped out after months or years found no health benefit from the relief.

The signal is clear, said Ray Kluender, an associate professor at Harvard University, who worked on both studies. “The timing of when financial assistance is provided by a hospital is just extraordinarily important.”

Some hospitals told Tradeoffs that what they do isn’t always written in policy. For example, spokespeople for and say their systems screen some patients before sending bills — though their policies include no requirement to do so.

When hospitals do wipe out patient costs after sending bills, about 40% say they will not inform patients their balance has been cleared. Just 8% require notification, and the rest say nothing about it in their policies.

“Patients will not be notified to inform them of this decision,” reads CommonSpirit’s policy.

Stelter, with the Texas Hospital Association, said many hospitals have limited staff in their billing departments and would likely prioritize helping patients apply over notifying those who already got help.

“It’s cruel to not notify someone,” said Erin Fuse Brown, a Brown University professor who studies medical debt. “Not to give them the closure to say you can spend that money elsewhere. You can buy your groceries this month. You can fill your prescription because you don’t have to budget for this.”

People with medical debt are three to four times as likely to delay future physical and mental healthcare as people without medical debt, a .

Hospitals Want To Help Patients — And Get Paid

Texas has for decades required nonprofit hospitals to meet one of a few they give patients — one of which is spending at least 4% of their annual patient revenue on charity care.

Research has found such spending targets have had mixed results. Some hospitals helped more patients, and others spending or , including training doctors and subsidizing money-losing but essential services.

The Texas Hospital Association in the state offers presumptive eligibility, but Stelter said screening tools can be unreliable.

Before they grant aid, hospitals want to know if a patient might be among the narrow population of adults who or if a grant might cover their bills — a determination that can require additional time and information.

Stelter also said that providing aid before sending bills could let insurers off the hook. Patients with insurance typically must spend some money before insurers pitch in, known as a deductible. Insurers can hold down consumers’ monthly premiums by raising deductibles, which have climbed to an average of for job-based coverage and for people on marketplace plans.

If they know hospitals will pick up the tab, “what incentive does an insurer have to lower a deductible?” Stelter said.

Hospitals nationwide are expected to come under since Congress reduced subsidies for many people buying health insurance through the Affordable Care Act, and are expected to push millions of low-income Americans .

That policy shift leaves hospitals to pick up more of the safety net, which they can’t afford, said Jill Horwitz, a Northwestern University health policy professor.

“It would be wonderful if nonprofit hospitals could solve the problem of Americans being uninsured or underinsured by paying for the free care,” Horwitz said. “But nonprofit hospitals do not have the money to solve what is ultimately a major federal problem.”

‘You Had To Pay It’

Becca Wahl said she knew nothing about financial assistance when she landed in Memorial Hermann Katy Hospital last October with a concussion after fainting in a Walmart.

“I just thought you had a bill and you had to pay it,” said the 33-year-old uninsured yoga instructor.

So when Wahl saw the $38,000 tab for her emergency room visit, she panicked. The bill was more than she makes in a year.

“I thought, ‘I’m doomed,’” Wahl said. “I just went out to get a birthday card and fell over. And now I have $38,000 of debt.”

Shortly afterward, the hospital called and revised her bill, offering its price for patients who pay cash, she said. That left Wahl with $11,000 in debt and a $1,000-a-month payment plan — better than $38,000, but still out of reach.

Desperate, Wahl went online and found Dollar For, which helps patients apply for financial aid. One week after Dollar For submitted Wahl’s application, Memorial Hermann wiped out her bill.

Memorial Hermann’s policy says its hospitals should screen patients for financial assistance before sending a bill.

Wahl agreed to waive her patient privacy rights so Memorial Hermann could talk about her case. But the hospital declined an interview request. A spokesperson told Tradeoffs that Memorial Hermann is “dedicated to ensuring that every patient has access to clear information about the expected costs of services, and available coverage options and our financial assistance program.”

Wahl is just glad that she doesn’t have to put her life on hold while she pays off that debt.

“The amount of stress that was lifted off of my shoulders by finding out that this medical debt was forgiven was huge,” she said.

Few Hospitals Give Refunds

Some patients who pay down their bills before hospitals wipe them out never get their money back, Tradeoffs found.

Roughly 2 in 3 nonprofit hospitals in Texas have policies that say patients won’t receive full refunds.

CommonSpirit’s policy has no requirement to refund patients who get automatic financial aid. Felicity Simmons, a system spokesperson, said in an email clarifying its policy that “refunds are case specific.”

A few hospitals say they will return amounts that exceed what the — a federal requirement for all facilities. That is the case at Texas Health, where Carlock paid $5,500 up front for her uterine surgery, before the hospital wrote off the rest of her bill.

Carlock’s $5,500 stayed with the hospital.

Carlock agreed to give Texas Health permission to speak with Tradeoffs about her bill. Texas Health didn’t respond.

Stelter with the Texas Hospital Association said hospitals follow for refunding patients. Those regulations require hospitals to fully refund some patients who submit an application. The rules don’t apply to those who got help through presumptive eligibility, experts on the regulation told Tradeoffs.

States Seek Standards

By July 2027, six states will require hospitals to use presumptive eligibility for certain patients: , , , , , and

Oregon has arguably one of the most aggressive approaches. Starting in July 2024, hospitals had to screen anyone who owes more than $500 and every patient who is on Medicaid or uninsured — . Lawmakers in 2026 amid and the law’s impact on hospital finances.

Hospitals in Oregon more than doubled the amount of charity care they provided, on average, during their first full year under the law, Tradeoffs found. That’s based on an analysis of available Medicare data from roughly two-thirds of hospitals. At OHSU Hospital in Portland, one of the state’s largest, the percentage of patients receiving financial aid jumped from 12% before the law .

In Texas, state representative Oliverson, a Republican, hopes his state will go even further than Oregon. He proposed legislation in 2025 that would require nonprofit hospitals to screen patients and provide aid before sending bills. Those that don’t would face penalties.

The legislation failed, but Oliverson said he plans to reintroduce it in 2027. The lawmaker said nonprofits are falling short of their obligations.

“If you’re sending bills to people that you know when you finally get around to screening them for charity they’re not going to be obligated to pay,” he said, “that should be grounds for losing your tax-exempt status.”

Oliverson said hospitals that already care for a higher share of low-income patients would be exempt from his proposed requirements. But he’s adamant that most nonprofit hospitals should be doing more to protect patients from unnecessary debt.

“If you’re advertising that you’re willing to accept uninsured patients and that you have a charity program,” Oliverson said, “you got to deliver on that.”

This story is part of , an investigative series from and ³Ô¹Ï²»´òìÈ about how hospitals can protect their patients from the life-altering harms of medical debt. Read our full .

Melanie Evans is a reporter for Tradeoffs, a nonprofit newsroom reporting on healthcare’s toughest choices. to get the latest stories every Thursday morning.

Tradeoffs’ reporting for this series was supported, in part, by the California Health Care Foundation, the National Institute for Health Care Management Foundation, and the Solutions Journalism Network.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

One way patients can avoid medical debt is through hospital financial assistance, also known as charity care. Most of the nation’s hospitals offer free or discounted medical care to patients with very high medical debt or low incomes.

Getting financial assistance, however, can be challenging. Many that hospitals offer financial help, surveys show, and leave others stymied.

Hospitals often demand that applicants turn over bank statements, pay stubs, tax returns, divorce filings, or other materials, and submit their applications in person, by mail, or by fax.

“They don’t make it easy,” said Neale Mahoney, a Stanford University economist who studies medical debt.

Such hurdles leave many patients with unpaid bills they should never have had to pay in the first place. In a single year, hospitals and health systems billed patients for at least , one analysis found.

As healthcare costs climb and more people lose their coverage, states and hospitals are testing an emerging approach to fix this problem: automatically screening patients to see if they qualify for assistance and proactively wiping out debt when they do. This is known as “presumptive eligibility.”

Under this approach, patients may have the cost of their care wiped out before they see any bills — but not always. Hospitals differ on when, how, and for whom they use auto-enrollment, potentially impinging on patients’ finances.

Here’s what you need to know about how auto-enrollment works.

What is hospital financial assistance?

In many states, hospitals for whom they provide financial aid. Eligibility is typically based on income for the patient’s entire household. The closer patients are to poverty, the less they have to pay. Patients with middle incomes and insurance are sometimes eligible for discounts, especially if their bills would gobble up a big chunk of what they earn.

require hospitals to wipe out bills for low-income patients, though income cutoffs vary. Georgia, for example, mandates free care for anyone with income slightly above the federal threshold for poverty. In several states — including Oregon, North Carolina, and Maryland — patients can earn double that amount and still get free care.

But in most states, many patients must complete applications to receive assistance.

Several states in recent years have and designed to make it easier for people to get help. , however, suggests gaps persist.

How many hospitals use auto-enrollment?

Nearly all nonprofit hospitals say they screen and automatically reduce bills for certain patients.

Under the Affordable Care Act, nonprofit hospitals must make reasonable efforts to find people who are eligible for help before they take patients to court, sell their debt to collection agencies, or ding their credit over bills. Presumptive eligibility is one way hospitals can comply with the regulation, which took effect in 2016.

In the first year under the new rules, about 70% of tax-exempt hospitals nationwide said they screened patients and proactively reduced bills, according to an analysis of federal data for Tradeoffs by the independent research institute RTI International. As of 2022, that figure was nearly 90%.

The federal law doesn’t apply to for-profit and public hospitals, which don’t have to report the actions they take before going after patients for unpaid bills.

In six states, policymakers require hospitals to use presumptive eligibility and skip applications for certain patients. Those states are California, Delaware, Illinois, Maryland, North Carolina, and Oregon.

Who is eligible to be automatically enrolled in financial assistance?

In most states, hospitals decide which patients can skip the application.

Common groups automatically screened include people who are homeless, deceased, or already enrolled in state or federal programs to help low-income households with housing, food, or prescriptions. Other hospitals have more unique criteria, like , which will write off bills for anyone in a religious order who took a vow of poverty.

Eligibility criteria are often buried in official policies and hard to find or decipher. Some hospitals share little to no public information about whom they will proactively screen. Thirteen hospitals owned by Ascension, one of the nation’s largest Catholic health systems, state only that they may screen patients “with a sufficient unpaid balance.”

Across the half-dozen states with presumptive eligibility mandates, eligibility rules vary. Maryland, for example, requires hospitals to proactively wipe out bills only for patients who already get government help for food or utilities but are ineligible for Medicaid. In Illinois, lawmakers created less-stringent requirements for rural hospitals compared with urban facilities.

In Oregon, starting in 2024, hospitals had to screen anyone who owed more than $500 and every patient on Medicaid or who is uninsured. In 2025, roughly 80% of Oregon patients who got financial help with bills never filled out an application, based on data shared publicly by the first 26 hospitals to do so. The state’s legislature this year raised the screening threshold to include patients who owe at least $1,500 for a single visit.

Without an application, how do hospitals figure out who gets help?

Hospitals have several ways to find patients eligible for financial assistance.

Typically, hospitals turn to public records, any information patients have previously volunteered, or tools from consumer credit companies to estimate whether patients qualify to have bills reduced.

For example, if a hospital sees that a patient lives in a high-poverty ZIP code or has no address listed, that could be enough to deem them eligible. Many pay companies to run employment and credit checks on patients to determine whether they qualify for free care.

Hospitals may also consider how likely patients are to pay bills, regardless of how much they earn. This is called “propensity to pay.” California and Oregon prohibit its use, concerned that hospitals may try to collect more often from people who dutifully pay their bills even though their incomes qualify them for financial assistance.

When do hospitals screen patients for financial aid?

It depends.

Illinois, North Carolina, and Oregon require hospitals to screen certain patients before they send any bills. California hospitals will have to do the same starting in 2027.

Some hospitals voluntarily screen patients before sending bills; others try to collect money from patients first. As long as they screen patients before suing them for very overdue bills, hospitals can stay within the letter of the federal law that pushed many of them to embrace presumptive eligibility.

For example, the is to screen patients only “after all other eligibility and payment sources have been exhausted.”

Anna Stelter, vice president of policy for the Texas Hospital Association, said hospitals want to investigate other options for payment — like Medicaid or county safety net programs — before they give out financial assistance.

“We do want to make sure that whoever is financially responsible for that care is identified and pays,” Stelter said. “Charity care is the relief of last resort.”

Hospitals’ publicly posted policies may also be fuzzy about when they will screen for patients likely eligible for help. For example, in Fort Worth, Texas, says its goal is to determine a patient’s eligibility “as soon as sufficient information is available.”

Who pays the bills when patients get free care?

In one sense, we all do. Taxpayers cover some or all of the cost of financial assistance, though the amount varies by hospital.

About half the nation’s hospitals are nonprofit and legally get a pass on paying most taxes. KFF estimates that nonprofit hospitals in 2020 that they would otherwise have paid as income, sales, or property taxes.

Government-owned and for-profit hospitals have their own sets of tax benefits to help offset costs for low-income patients. Government hospitals often , and for-profit hospitals generally receive smaller government subsidies, like for caring for high numbers of uninsured and Medicaid patients.

Whether taxpayer dollars fully cover hospitals’ costs for financial assistance depends on the amount of government support they receive — information often not publicly available. It also hinges on how many patients need help, how many meet hospitals’ criteria for assistance, and how many get through an application. Research shows hospitals spend on financial assistance, from less than 1% of yearly expenses to more than 7%.

Philanthropy and hospitals’ income cover costs not absorbed by tax dollars.

This article is part of “,” an investigative series from and ³Ô¹Ï²»´òìÈ about how hospitals can protect their patients from the life-altering harms of medical debt.

Melanie Evans is a reporter for Tradeoffs, a nonprofit newsroom reporting on healthcare’s toughest choices. to get the latest stories every Thursday morning.

Tradeoffs’ reporting for this series was supported, in part, by the California Health Care Foundation, the National Institute for Health Care Management Foundation, and the Solutions Journalism Network.

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .