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 .

Next, she drove to meet an 85-year-old and her daughter, who had come in from out of town. The older woman had “pretty advanced dementia” and was scheduled to move into the secure memory care unit of a senior living facility that day, said Martinelli, who works as an aging life care manager with Mir Care Consultants in Central Texas. The three of them had a 9 a.m. meeting with the primary care doctor who would complete the paperwork for the move.

At the meeting, Martinelli explained the situation, and the doctor said he’d fill in the patient’s forms that afternoon. But later in the day, she got a call from a colleague saying that the doctor wouldn’t be able to complete the forms that day after all. That created a scramble because the woman wasn’t safe alone in her house. Martinelli ended up calling a home care agency she trusted. “I begged them to provide me with a caregiver in the next four hours,” she said.

If a combination of appointments, bureaucracy, vigilance, and worry about a vulnerable older person — often interspersed with medical emergencies — sounds familiar, it might help to know about a service its providers ruefully call the best-kept secret in eldercare.

Independent certified professionals like Martinelli used to be known as geriatric care managers. That’s what I called the people who make the 125-mile move from his apartment to a continuing care community near me, and later helped my disabled sister transition from her home to an assisted living facility.

I also used words like “godsend” and “indispensable.” After the moves, the care managers kept tabs on both my father and sister monthly and eased my fears that something urgent might strike the moment I left on a vacation or a work trip.

About a decade ago, these experts rebranded themselves as aging life care managers. It usually takes a couple of years to become one. Most enter the profession as nurses or social workers; some are physical or occupational therapists or gerontologists. They must attain a required combination of before they can take the certification exam.

The Aging Life Care Association, the nonprofit that represents these professionals, was founded in the 1980s and has grown to more than 2,000 members, but care managers still have a persistent public awareness problem.

“When we talk to someone, they say, ‘I wish I could have called you six months ago, but I didn’t know you existed,’” said Susy Elder Murphy, who owns Aging Well Eldercare, a large practice serving Washington, D.C., and its Maryland suburbs.

The caller is typically an adult child, the Aging Life Care Association has reported. Martinelli described a common scenario: “Mom is in the hospital, or the children went to visit and hadn’t realized she was so sick. They’re in a crisis.”

Enter the aging life care manager. What distinguishes her (it is usually a woman) from people with confusingly similar names — senior care advisers, patient advocates, care navigators — is her independence.

Aging life care managers work for the client and the family paying them, not for hospitals or insurance companies. Moreover, the association’s specifically prohibits “accepting or giving referral fees, fee splitting, kickbacks or other similar arrangements in exchange for client referrals.”

Contrast that with companies that promise free advice on senior living, like A Place for Mom. Care facilities pay A Place for Mom fees for steering new residents their way, as the organization . Advisers for companies that receive fees may be unlikely to recommend places that don’t pay, or to recommend home care, unless the company also contracts with local agencies.

“They’re really marketers, salespeople,” Julie Wagner, chief executive of the Aging Life Care Association, said about the referral companies. Some companies are about these financial incentives.

“If you want to buy a car and you go to the Ford dealer, they will not say, ‘I really see you in a Subaru,’” Murphy said. “You should be talking to someone who’s objective, neutral, and experienced.”

Care managers don’t come cheap. Wagner said association members’ hourly rates range from $150 to $350, with big geographic variations. In Texas, Mir’s standard rate is $185 an hour, billed in 15-minute increments. In Washington, Murphy’s practice charges $210 an hour. Sometimes families share the cost, as my sister and I did. And in some cities, social service agencies provide these specialists on a sliding scale.

Aging life care managers serve as coordinators, not hands-on caregivers, and the range of services they provide is quite broad.

They can, for example: Arrange and oversee a move to or within a senior living facility. Deal with insurers, including Medicare and Medicaid. Drive a client to the dentist. Recommend not only local residential communities and home care agencies but elder law lawyers, medical specialists, therapists, , and hospice organizations. Visit weekly or monthly to see that everything is going smoothly. Alert family members if it isn’t.

“A part of our job is mediating between family members, acting as a sounding board,” Martinelli said.

In fact, care managers like Murphy find their clients often seem more willing to listen to them than to their adult children — even if the advice is the same. “Your mom didn’t change our diapers or teach us to talk,” she said. “It’s a different relationship.”

In a of clients and families commissioned by the Aging Life Care Association, “the responses were overwhelmingly positive,” said Jullie Gray, a co-author of the study who teaches at the University of Washington School of Social Work.

The nearly 200 respondents did not constitute a representative national sample, Gray said. But 93% said the benefits of hiring an aging life care manager outweighed the costs, and 99% said they would recommend such a manager to someone else. The survey’s findings were presented at the 2025 meeting of the Gerontological Society of America.

Jeffrey Bernstein, an engineer in Middleton, Massachusetts, has for years relied on Aging Well Eldercare for help with his parents, two older siblings, and an aunt, all in Maryland. Like many people who eventually learn about care managers, “I had no idea such a person existed,” he said, until his wife read about them in a magazine.

Bernstein, 65, was unable to relocate to care for his family directly. But with care managers, “when something came up, they were there, they stepped up,” he said. “More importantly, they knew what to do when I wouldn’t have. It was tremendously helpful for my peace of mind.”

The same was true with Martinelli’s 85-year-old client in Austin. She spent the night with temporary caregivers and moved into her new home in the memory care unit that Tuesday, after her doctor finally produced the necessary documentation. “She went in just before noon,” Martinelli reported. “She had lunch.”

How was the new resident adjusting? “It’s been OK,” Martinelli said, sounding relieved. “So far, so good.”

The New Old Age is produced through a partnership with .

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

According to a , nearly 60% of Americans favor a system of Medicare for All, while 85% of Democrats support it. For years, Democrats in Congress symbolic that have had no chance of passage but have been supported by dozens of members.

Democratic Sen. Chris Van Hollen of Maryland added his support in December. “I was listening to my constituents,” he said. “It’s just reached the complete breaking point. Our system is unaffordable and unsustainable with premiums going up, copays going up and up.”

At a time when more than 100 million Americans carry medical debt, it’s easy to get behind a promise of free, or free-ish, no-hassle health care. But turning an inspirational slogan into law gets gnarly. Those three words, Medicare for All — a pledge to bring universal healthcare to every American — mean not one thing to supporters but many. And all versions of such a system face considerable obstacles to enactment.

“Medicare for All is a slogan, not a concrete proposal, so it’s hard to have an opinion on,” said Amy Finkelstein, a Massachusetts Institute of Technology economist who, with Stanford’s Liran Einav, wrote , which laid out what the pair considered a realistic and fiscally responsible plan for providing basic insurance to every American.

“What we can afford is a basic plan — what we call a shack, not a chateau,” Finkelstein said. Its bedrock would be a government-funded skinny plan less generous than Medicare, with potential constraints such as a limited number of physical therapy visits or stricter criteria for getting a knee replacement, but guaranteed robust basic coverage for catastrophic medical conditions. She estimated that most Americans would opt for supplemental coverage.

The most high-profile political proponent of Medicare for All this election season is Abdul El-Sayed, the Democratic senatorial candidate in Michigan, who has made a more sweeping proposal central to his platform — far more chateau than shack. It would create one plan that covers a suite of medical needs with no cost to patients, including dental and vision care, which traditional Medicare doesn’t cover.

(Traditional Medicare has increasingly come to resemble private insurance with premiums and coinsurance, and, unlike standard commercial plans, it has no annual out-of-pocket maximum. To fill such gaps, patients buy separate Medigap and drug plans.)

“The most important thing is just to make Medicare whole — meaning no charge for medical care — rolling back the complexity and costs of the last 10 years,” El-Sayed told ³Ô¹Ï²»´òìÈ.

His program would start off covering children and adults five years younger than the current eligibility age for Medicare and close the gap over a period, he has estimated, of eight years. To ease the transition for the healthcare system, he would initially set the Medicare payment rates to mirror the totals doctors and hospitals receive now to avoid a “price shock” to their operations. Future increases would be limited to the rate of inflation.

One big question is how to make the financing work in a highly profitable industry. National health spending was projected to hit in 2025, or nearly 20% of the U.S. gross domestic product.

The United States as much on healthcare per person than many peer countries. And health insurance is often a company’s second-largest expense after payroll.

But how will the government divert financial outlays of employers and households into a new Medicare for All system without new taxes or massive government spending?

When polls ask voters whether they would support Medicare for All if it meant losing their insurance or paying new taxes, support often drops.

“You could decide to raise taxes and cover more,” Finkelstein said. “If you don’t want to cut current Medicare benefits, you could decide to bust the budget, which seems to be a common practice.”

Joe Biden said that, as president, he any Medicare for All bill, given the cost, which was estimated at up to . The bills in Congress don’t include very detailed financing plans.

Economists who have mapped out the possibilities are divided on a realistic path.

A group of that converting to a Medicare for All program could save $450 billion annually. That’s in part because a government plan could negotiate — or simply set — far better prices for hospitals, doctors, drugs, and devices than private insurers. It would reduce the overhead created by private insurance with its army of negotiators, coders, and claim deniers — and reduce profits.

Strong forces are pushing back against such “rightsizing” of exorbitant prices, most notably: insurers, hospitals, and drug and device manufacturers. In 2022, they spent on lobbying and have been a powerful force for job creation. But a grand Medicare for All proposal may simply be a strategy to open the debate to lesser possibilities. President Barack Obama’s initial Affordable Care Act proposal contained ambitious ideas — such as drug price negotiation — that fell by the wayside to get the votes for passage.

Texas Democratic Senate candidate James Talarico supports what he calls “Medicare for Y’all” — allowing people under 65 to buy into Medicare.

“There are versions of Medicare for All that could potentially include our proposal, and versions that could look extremely different,” Finkelstein said.

Support in some parts of the industry is growing.

According to one survey, more than have said they’d prefer some sort of single-payer system. Though the American Medical Association is opposed, its student and resident sections are the opposition. The , the nation’s second-largest physician group, also supports Medicare for All. Obama called the ACA a “starter house.” It was “an improvement, but it has not met the need,” Van Hollen said.

Now the growing number of Medicare for All proponents will have to define exactly what kind of new house they can accept and afford.

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 .

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Paul Nestadt is about as steeped in suicide prevention as a person can be.

He treats suicidal patients as a psychiatrist, has co-authored scores of research papers on how and why people kill themselves, and teaches graduate courses on the subject.

But he’ll be the first to admit: “I can’t tell you which of my patients is likely to die by suicide in the next six months.”

Almost nobody can.

predictions of who will be suicidal are only slightly better than a coin toss. And they haven’t improved over 50 years.

But that doesn’t make Nestadt hopeless. Instead, it pushes him to pursue interventions that don’t require pinpointing people at risk.

Chief among them: making it harder for people to carry out the act of killing themselves.

“Instead of asking every doctor to figure out which patient will die by suicide and locking that patient up, it might be that we need to make sure there aren’t loaded guns available,” Nestadt said.

In an ongoing series, ³Ô¹Ï²»´òìÈ is examining approaches to suicide prevention that expand beyond providing people at risk with medication and therapy. Although those are lifesaving measures, many clinicians, researchers, and people who have lost loved ones to suicide agree that more is needed. The challenge is that when it comes to firearms, broad policy approaches quickly become constitutionally complicated and politically polarizing.

Research shows that limiting access to lethal means is one of to save lives. It can involve on buildings to prevent people from jumping, as well as someone can buy or be prescribed at once.

And .

“That’s the one that will save the most lives,” said Nestadt, medical director at the Johns Hopkins Center for Suicide Prevention.

It may also be the most difficult to achieve.

killed themselves with a gun last year, representing more than half of all suicide deaths in the U.S., according to preliminary federal data. Even as overall suicide rates have dipped recently, gun suicides have hit record highs for five years in a row.

Many of the deaths are among , two groups that have had high suicide rates for years. But more recently, gun suicides have risen among and among some and men. Researchers say a during the covid pandemic underscores the need for prevention efforts that can be applied widely.

Some people assume it’s futile to restrict access to bridges, pills, or guns. The thinking goes: Those who want to kill themselves will simply find another way.

But . Creating barriers for one method doesn’t typically push people to another.

Suicide risk can surge quickly, with people spending or even five minutes between deciding to die and acting on it. Anything that delays such action — for example, having to unlock a safe to access a gun — gives them time to reconsider or for someone to intervene.

However, in the U.S., discussion around guns — even in the context of a traditionally bipartisan topic such as suicide prevention — is a political lightning rod. Mentions of background checks, waiting periods, or red flag laws often send people running to their respective corners. Gun owners and the firearm industry say many of the policies suicide prevention advocates seek threaten their Second Amendment rights, and many policymakers see the topic as a nonstarter.

President Donald Trump has been a of gun owners. His administration has dozens of firearms regulations and rescinded a previous that called gun violence a public health crisis. It has also revoked grants focused on and working on the issue.

The White House did not respond to specific questions about how these actions may affect the nation’s high rate of gun suicides or what it’s doing to prevent such deaths. But spokesperson Lauren Bis said in a statement that “President Trump is committed to Making America Healthy Again and that includes mental health.” She pointed to the administration’s for mental illness and an announcement of for veteran suicide prevention.

The Limits of Red Flag Laws

One gun policy that has gained some traction, , is the , more commonly known as a red flag law.

Adopted in some form in , these laws allow judges to temporarily remove a person’s guns when evidence suggests they pose a danger to themself or others.

Although such laws are often passed in the wake of , they’re more effective at preventing suicide.

Still, they require identifying someone at risk.

Someone like Dorothy Paugh’s dad.

In 1965, when Paugh was a young girl, her dad lost his job. He was distressed, not knowing how he’d support his wife and five children, Paugh said. He reviewed his life insurance policy, told his wife where he kept important documents, and bought a handgun.

“If my mom had been able to get an extreme risk protection order or if Dad’s best friend had asked to hold his gun for a while, maybe my dad would not have shot himself. He might have lived,” Paugh said.

Decades later, Paugh in Maryland and sat in the legislative gallery when the measure was passed.

She believes the law is saving lives.

across show that for every 10 to 20 guns removed under red flag laws, one suicide is averted, .

But Paugh also recognizes the law’s limitations.

“It wouldn’t have saved my son,” she said.

Her 25-year-old son, Peter, . He’d recently bought a house with his girlfriend and hosted a birthday celebration for his brother. He’d purchased a gift ahead of Mother’s Day — five novels by Charles Dickens, Paugh’s favorite author — that Paugh received after .

Unlike in her father’s case, Paugh said, no one saw warning signs for Peter. “I did not know that my son was suicidal. I didn’t have a clue,” she said. Even if a red flag law existed then, she wouldn’t have thought to use it.

The people most vulnerable to firearm suicide usually aren’t identified as such by family members or clinicians, said , a clinical psychologist and the executive director of the New Jersey Gun Violence Research Center.

Studies have shown that among people who die by suicide, those who used guns were less likely to have in the past. And most veterans and service members who die by gun suicide about their suicidal thoughts in the months leading to their death.

That’s why red flag laws are just a first step in suicide prevention, Anestis said. They target specific individuals at high risk — the aspect that makes such laws more politically palatable — but they do not apply to the many other people who are quietly suicidal.

Lessons From Road Safety

Nestadt, the Johns Hopkins psychiatrist, said the nation needs to approach suicide prevention the way it approaches car accidents.

“You’re not trying to figure out who’s at risk of an accident” by testing people’s reaction time or cataloging who gets into fender benders, Nestadt said.

Instead, speed limits, passed seat belt laws, and required auto manufacturers to install air bags and shatter-resistant windshields. The significantly.

Applying a similar strategy to suicide might involve requiring permits and background checks to buy a gun, as well as instituting before completing the purchase.

found that enacting a permit-to-purchase law in Connecticut was associated with a roughly 15% decrease in gun suicide rates, while repealing such a law in Missouri was linked to a 16% increase in firearm suicide rates.

About have enacted laws requiring owners to lock up their guns in homes where children live, a practice shown to . That’s an issue of particular importance, with 245% among Black youths and 98% among Latino youths since 2014.

Anestis said laws requiring permits and safe storage can also reduce homicides and other gun injuries.

Those types of violence not only hurt people directly but also increase their risk of suicide. people who are exposed to gun violence in their community experience trauma and become habituated to the idea of injury or death. That “double whammy” makes them more likely to kill themselves, Anestis said.

Responsibility, Rights, and Saving Lives

Gun owners and firearm trade associations generally oppose universal measures, such as requiring permits and waiting periods. They prefer education campaigns that teach people how to recognize warning signs, talk about mental health, and safely store guns — initiatives that place .

The National Shooting Sports Foundation, which represents the firearms industry, has partnered with the American Foundation for Suicide Prevention to create to be posted in gun shops.

“Our purpose is to provide educational materials to the firearm-owning community on how to help prevent suicide and save lives,” Bill Brassard, the NSSF’s senior director of suicide prevention initiatives, said in a statement.

The National Rifle Association said policies focused on guns miss deeper concerns that make someone suicidal, such as mental illness.

“Suicide is a serious issue that deserves serious solutions focused on the underlying causes, not on political efforts to restrict the rights of law-abiding Americans,” NRA spokesperson Justin Davis said in a statement. “A truly dangerous individual needs to be incapacitated, not just deprived of one particular means of harm.”

Some initiatives have managed to bring together unlikely bedfellows — gun store owners, public health experts, and even libraries — to to secure firearms at home, identify locations that will while they’re in crisis, and educate people on how to .

Those efforts give Paugh hope and fuel her passion to continue advocating for better mental health care, open conversations about suicide, and policies that decrease access to guns.

“It’s not a cure-all,” Paugh said of those policies. But “it does save lives.”

Having lost a parent and a child, she knows how valuable that can be.

“If you’re that one person or that person’s family, it’s all the difference in the world,” she said.

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

Court papers indicate a settlement in the case against the Department of Labor , although the parameters of any such deal are unknown.

It would come amid premium surges on Affordable Care Act marketplaces that have led millions to drop coverage this year. The Trump administration has also been sharply focused on expanding access to alternative coverage, such that avoid ACA rules on preexisting conditions and benefit requirements.

“Depending on what happens with the settlement, this could be an even bigger expansion,” said , director of the Center for Health Policy and the Law at the Georgetown University Law Center. “People are worried that it is the opening salvo into promoting junk plans that don’t meet the ACA requirements.”

The plaintiff, Data Marketing Partnership, against the Department of Labor in 2019, during the first Trump administration. It wants official recognition as an employer so it can continue to allow its limited partners to buy into a type of job-based health insurance that doesn’t have to comply with state insurance rules or offer coverage as robust as required under the ACA.

But to grasp the claim, one also has to understand how the coverage works.

A consumer shopping for health insurance may come across information online or from a marketer about this concept, sometimes called “limited partnership” coverage. The pitch? Buy insurance offered through Data Marketing Partnership and handled by LP Management Services. To qualify, the consumer must download an app that tracks their internet searches. The company could then sell that data.

Some potential consumers may be turned off by the thought of their internet searches being tracked, but others may find it appealing because it allows them to become a limited partner eligible to buy into the company’s employee health insurance plans. But can these partners be considered employees?

The court’s answer has potential implications for regulators and consumers. Some health policy and market experts warn that a green light could lead to a proliferation of aggressively marketed and potentially questionable insurance with limited recourse for consumers because the plans would be exempt from state oversight.

“If this took off, you logically could see the rise of a whole bunch of what, functionally, would be unregulated insurance companies,” said , who was the principal deputy assistant secretary of the Department of Labor’s Employee Benefits Security Administration during Joe Biden’s presidency and now runs his own consulting outfit.

No one knows if the department is going to change its long-running stance defending the case. But any settlement could add more uncertainty to insurance markets.

Already insurers are requesting double-digit increases in ACA premiums again next year, partly because declining enrollment often means that the healthiest policyholders are leaving. That trend could accelerate in coming years as more people are drawn into alternatives such as limited-partnership policies.

States Act as Federal Case Plays Out

The Department of Labor defended the case throughout the first Trump administration and the Biden era, issuing a sharply worded in early 2020 stating that people who simply download software to “capture data as they browse the Internet” are not “employees or bona fide partners.”

A district court judge in Texas, the ACA unconstitutional in a decision ultimately rejected by the Supreme Court, called the advisory opinion “” in a 2020 ruling in favor of the data marketer. The U.S. Court of Appeals for the largely upheld the lower court’s decision but ordered it whether someone who downloads software is either a “working owner” or a “bona fide partner.”

The employer-employee relationship is at the heart of the case because of a designed to help large, self-insured employers offer retirement and health benefits to workers without having to meet varying rules from multiple states.

That law — the Employee Retirement Income Security Act — allows such plans to avoid most rules set by the states, which generally regulate most other types of insurance and assist consumers who report problems with their policies. As self-insured employer plans, the policies also don’t have to comply with some ACA rules, such as the 10 broad categories of “essential health benefits.”

“If the case goes the wrong way, it could impact consumers or hamstring the states,” said Marie Grant, Maryland’s insurance commissioner.

Arguments over what constitutes an employer plan are not new, and other organizations have tried offering such coverage. Some states have taken action against purveyors of limited-partner policies.

Maryland in 2024 , The Vitamin Patch, for offering limited-partnership insurance after investigating complaints and determining it was not licensed to sell coverage in the state.

Washington in 2021 to stop offering its plans in the state and fined it $25,000.

and in 2024 warned consumers about this type of coverage.

“These plans do not provide comprehensive medical coverage and can leave consumers with large, unpaid medical bills,” according to Connecticut’s notice.

Maine’s announcement noted that entities offering these types of health insurance included The Vitamin Patch as well as Affiliated Workers Alliance, Consumer Data Partners, Employers Business Alliance, Socios Buenos, and Strategic Limited Partners.

State insurance commissioners in the Department of Labor case citing their concerns about losing the ability to enforce consumer protections.

“This is not a Republican-Democrat thing,” Khawar said. “It’s really a story about state authority, the way such authority would be significantly undermined in insurance markets.”

What’s the Risk?

Still, these limited-partnership plans are viewed by proponents as a needed additional choice for consumers, at potentially lower cost than ACA plans.

When the case was filed, attorneys general , for example, urged the Department of Labor to back Data Marketing’s request to designate its limited partners as employees. That would provide an option for people who “earn too much to qualify” for ACA subsidies and be an interim solution until the ACA could be repealed and replaced, they wrote. They argued that states would retain some regulatory authority and added that the Department of Labor, which oversees self-insured employer plans, could set requirements to “encourage” stable companies to enter the market.

Critics, the attorneys general wrote, might fear that ACA alternatives will draw away younger or healthier people, thus affecting those who remain, but they argued that had already happened.

Data Marketing’s attorneys emailed ³Ô¹Ï²»´òìÈ that they could not provide a comment for this article because the case is in active litigation. Neither the White House nor the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, responded to questions from ³Ô¹Ï²»´òìÈ about whether the Department of Labor has changed its stance and how the administration views limited-partnership health plans.

In court filings, however, Data Marketing said that without an employer designation, it would have to end the insurance coverage, affecting about 50,000 policyholders. That would also hurt its ability to generate revenue, it argued, because offering insurance is “a significant attractor” to get people to join its partnership and let it access their electronic data.

, who helped oversee ACA implementation in the Biden administration and is now a managing director at consultancy Manatt Health, had a different take. “The only reason why these sorts of products exist is because they aren’t beholden to consumer protection rules of the ACA and can essentially make money by attracting good risk, people who are healthy,” she said.

Maryland’s Grant echoed this warning, saying that proliferation of such plans could lead to even higher premiums in the ACA markets, if those who remain are older or sicker than those who leave.

Nineteen patient advocacy groups to the Department of Labor Aug. 11 urging it to continue its defense in the case, warning that a settlement that says such arrangements create an employer-employee relationship could “significantly” undermine “both state regulatory authority and decades of bipartisan efforts to promote stable, well-functioning health insurance markets.” Some of those groups in support of the department in 2021.

Days after the August letter, U.S. Rep. Bobby Scott (D-Va.), the ranking member of the House education and workforce committee, warned the department against increasing the availability of “questionable employment relationships” and the insurance they offer.

He cited reports of call centers’ misleading consumers “who think they are enrolling in comprehensive health insurance but instead sign up for junk coverage under the guise of creating an employment relationship with what the consumer believed to be a traditional health insurer.”

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

When making the appointment, Zordani said, he’d been told the clinic was in his insurer’s network. Upon arrival, Zordani was summoned to the clinic’s financial office and told he had to make a $5,000 preservice deposit, because Mayo had since determined it did not accept his insurance. He was automatically designated “self-pay,” even though his plan had out-of-network benefits.

Not having that kind of cash on hand — and angry on principle — he refused. His appointment was canceled.

“I was so livid,” Zordani said, recalling that day in early April 2024. He later learned that Mayo had sent a message to him in his insurance carrier’s patient portal shortly before his visit with an estimate of the cost: $565, not the larger amount it later demanded.

Traditionally, patients usually receive bills for their share only after getting treatment. But what Zordani faced is becoming increasingly common — hospitals or other medical providers seeking prepayments.

“We regret that this individual’s experience did not meet the high standard of communication we strive to provide when helping our patients understand their insurance coverage and financial responsibility,” Andrea Kalmanovitz, Mayo’s communications director, said in an emailed statement. “When prospective patients don’t have clarity that Mayo Clinic is not in-network with their health plan, unexpected pre-service deposit requests may result.”

says it requires prepayments in a variety of cases, including for “noncontracted” — also known as out-of-network — insurance plans.

The trend of hospitals asking for money up front represents a double whammy for patients.

Medical providers are collecting larger shares of what patients might owe at a time when rising deductibles mean patients are owing more for care. The preservice charge could be all or part of a remaining deductible, for example, or a sizable percentage of what the visit or treatment might cost. Those deductibles go up when hospital prices, drug costs, and labor expenses increase, as insurers try to slow premium growth by shifting more costs to patients.

People are “basically being asked to self-insure,” said Richard Gundling, a senior vice president at the Healthcare Financial Management Association, an organization for finance professionals.

As that happens, hospitals figure more patients will have trouble meeting those deductibles, so they want to get as much up front as possible.

“Things like preservice deposits and those kinds of moves are probably going to become more and more likely,” said Chip Kahn, a visiting senior fellow at KFF and the American Enterprise Institute and former president and CEO of the Federation of American Hospitals. “That will make it harder on the provider, the clinician, and harder on the patients.”

The deposits can’t be viewed in isolation, Gundling said: It’s a bigger issue than just hospitals asking for money up front. The challenge, he said, is: “How do we maintain access to care when more patients can’t absorb the level of out-of-pocket costs?”

Already, consumers are increasingly worried about paying for healthcare. A recent found that lower out-of-pocket costs ranked as the top change insured adults would like to see from their coverage plans. KFF is a health information nonprofit that includes ³Ô¹Ï²»´òìÈ.

The average deductible in family coverage offered by employers is $3,762 per person, , while the average deductible in Affordable Care Act plans to a similar amount, $3,786.

A Consumer Concern

, a health insurance consumer assistance program in New York state, hears from people who are concerned about prepayments, said Diane Spicer, a supervising attorney.

“We see this mostly with insured folks who are seeking out-of-network care but who have out-of-network coverage,” Spicer said, “and also sometimes for care that is not covered.”

Just how many hospitals collect what are often called point-of-service payments is not known, according to Kodiak Solutions, a technology company that provides services to health systems to help manage their revenue.

“But it is becoming more and more the center of many of our conversations with health systems,” said , a vice president leading Kodiak’s revenue cycle intelligence team.

In addition to Mayo, Baltimore-based says that “it is our policy to collect all amounts owed before services are rendered” for non-emergency care. University of Texas-affiliated in Houston, one of the nation’s premier cancer treatment centers, says patients who pay for their own care “will be asked to pay an initial deposit determined by the care center, based on the type of cancer.”

On average, hospitals collect about a quarter of what they expect the patient will owe, Szaflarski said, based on what they estimate the insurer will pay — a percentage that has grown in recent years.

For example, if a person is coming in for imaging and the insurer will reimburse $1,000 for that scan, the hospital will seek $250 from the patient up front, he said. “That used to be closer to $150.”

It also varies by hospital, and sometimes by state.

“The state of Indiana has some of the lowest cash collections in the country. They are Midwest nice,” Szaflarski said. He added that California and Texas are among those that collect more.

Even as hospitals increasingly collect more upfront payments, however, their uncollected debt is also rising, according to data Kodiak collected from more than 2,300 hospitals nationwide.

said that’s because of a “fundamental shift” in coverage as plans “increasingly feature higher deductibles, greater coinsurance, and more complex cost-sharing structures: all elements that increase the nominal patient responsibility without improving—and often reducing—the probability of collection.”

While many hospitals are doing fine, some, especially in rural areas, have thin margins — and things could soon tighten further as cuts to ACA and Medicaid funding lead to more people being uninsured.

As a result, hospitals “have to be concerned” about every cost-sharing dollar, Kahn said.

After Zordani returned to Denver, he said, it took a while to find another specialist. He eventually had a procedure in late June 2024, at a Denver hospital not affiliated with Mayo, to fix a .

The following fall, he filed a in Arizona civil court. He was awarded $47,500 in economic damages and attorney fees after an arbitrator in September 2025 determined Mayo violated a state consumer fraud law because it failed to reach him to say that his plan was not in-network before he traveled. Mayo’s statement to ³Ô¹Ï²»´òìÈ did not include any reference to the settlement.

“Had they notified me in timely fashion as required, I would not have flown there,” Zordani said. He’s still angry that the clinic didn’t ask his permission before designating his care as self-pay, which meant he wasn’t going to use his insurance, and he’s still unclear on how they calculated the $5,000 preservice amount.

When Do Consumers Have to Make Preservice Payments?

There is one clear rule: In emergency situations, hospitals that accept federal Medicare financing cannot, , demand upfront payment before stabilizing a patient who arrives at an ER, said , a senior fellow and health policy researcher at the Brookings Institution.

Other consumer protections are less clear.

Patients who get in-network care may have some recourse in their contracts with their insurers, so they should check the fine print, experts told ³Ô¹Ï²»´òìÈ.

“In out-of-network settings, I’m not aware of any barriers that would prevent a provider from doing this,” Fiedler said of preservice deposits.

How those amounts are calculated also appears widely up to the provider and can be opaque.

“They could just say $1,500 and you’d be like, ‘Oh, is that 10%, or is that how much is left on my deductible?’” said , senior director of healthcare campaigns at PIRG, a national federation of independent consumer advocacy groups.

Yet, she added, the patient might be scheduling three months in advance, so the provider wouldn’t know how much was left on the deductible. She recommends consumers ask for an itemized bill and call their insurer to find out whether it has rules regarding the charges.

Also unclear are how and when patients get their money back if they overpay.

Overpayments can happen if patients don’t require the services originally estimated or when insurers pay other bills first, such as the anesthesiology cost or a surgeon’s fees. If those payments are counted toward a patient’s deductible, yet the patient had already made a prepayment to the hospital for the expected deductible, to the hospital.

How soon they get their money back can vary and can depend on state laws, though a small number of states directly address the issue. As of this year, medical providers to reimburse patients within 30 days of a determination of an overpayment. Some states, including Maryland, prohibit certain hospitals from requiring prepayment simply to avoid offering financial assistance.

After alleging that some patients had to wait more than a year to get reimbursed, Arizona Attorney General Kris Mayes recently under state consumer protection laws against SimonMed Imaging, which has 170 locations in 10 states.

, SimonMed agreed to issue refunds within an average of 60 days.

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

Last year, Baltimore had three in the span of three months in its Penn North neighborhood.

In one incident, more than two dozen people were hospitalized after many were , lying in the streets or on sidewalks. No one died, but some came close.

Follow-up that the street drugs of N-methylclonazepam, a benzodiazepine that operates similarly to Xanax or Valium. Like opioids, benzodiazepines suppress breathing. When they’re combined, the goes up. And benzodiazepines don’t respond to opioid overdose reversal drugs.

Afterward, the created test strips specifically for benzodiazepines. The group distributed them — along with test strips that identify other harmful adulterants, such as fentanyl, , and medetomidine — at clinics and neighborhood events. The strips, available at no cost, can also be found in bars and spread out on street corners. People testing drugs mix a small amount with water and then dip a test strip into the liquid. The strip will change color if it identifies an adulterant.

“Nobody really knows what they’re getting whenever they’re getting stuff off of the street,” said Candy Kerr, a spokesperson for the coalition. “Having the test strips available for the general public gives them the option to move slower if they’re going to use whatever they’re going to use.”

But a new federal policy could make it harder for organizations such as Kerr’s to give out the test strips, and they’re worried that overdoses could increase. In late April, the Substance Abuse and Mental Health Services Administration banned the use of federal grants for distributing strips to the public and for some other harm reduction practices that have been credited with saving lives. Test strips have been used for to identify adulterants.

sent to local health departments and nonprofits that provide addiction services explained that the Trump administration believes those harm reduction practices “facilitate illicit drug use and are incompatible with Federal laws.”

According to the letter, grants from the Department of Health and Human Services also cannot be used for programs that support the use of clean needles or drug paraphernalia such as pipes, or to fund a type of that people can , so someone is aware and can call for help if they overdose. 

The Trump administration wants to focus more on other techniques, such as giving out naloxone, an overdose reversal drug available as a nasal spray, according to Emily Hilliard, an HHS spokesperson.

“It is critical that federal funding provided by the American taxpayer goes to effective, common-sense solutions that have been proven to save lives and keep people out of an endless cycle of addiction and moves them into a life of recovery,” she said.

The new policy does not prohibit federal funds from being used to purchase test strips for use by law enforcement officers, public health officials, EMTs, or other medical professionals.

That creates an important exception for government agencies that test drugs and send out on what adulterants are saturating the drug supply in certain locations.

Still, , who oversaw SAMHSA’s in the Biden and Trump administrations, says there is a substantial body of evidence giving test strips to people who use drugs can change behavior.

“There’s some people deciding not to use the substances, some people deciding to reduce, to use less, or take other types of precautions, including naloxone, and making sure that there are people around that can actually then help in the case of an overdose,” Olsen said.

Kerr said the best approach would be to continue to promote the use of test strips while also continuing to give out lifesaving medications like naloxone. She believes that working on all fronts has helped lead to Baltimore’s decline in overdose deaths, which more than 40% since 2023.

Under the new policy, nonprofits will still be able to hand out test strips, but they will have to find other funding for that work, which Kerr finds worrisome.

“We’ve been making these strides forward because we’ve had these things, because we’ve been funded,” she said. “We’re going to have to pull money from other places.”

To pay for the test strips, Kerr said, the Baltimore Harm Reduction Coalition will have to cut back on services such as giving out hygiene and wound care kits. But she said that option is better than risking another mass overdose in Baltimore — or allowing even just one preventable fatality.

This article is from a partnership that includes , , and ³Ô¹Ï²»´òìÈ.

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

BALTIMORE — In March in a McDonald’s parking lot off a busy street, mental health clinician Michala Williams met a 38-year-old woman in a car.

“So, you called the police for help?” Williams asked the woman, who was sobbing uncontrollably and said she sometimes thinks about harming herself.

She told Williams she has children ranging from age 2 to 22, she was dealing with health issues, and that her fiancé had recently been jailed. She felt so overwhelmed she couldn’t eat.

The woman, who asked not to be named so that she could freely discuss her mental health, explained she’d tried to get help the previous month by driving to the hospital but got pulled over on the way because her car registration had expired.

“I don’t care if I get pulled over,” she said. “But I was saying, ‘I don’t know what to do. I just want to go to the hospital.’”

The officer arrested her for acting erratically, so instead of going to the hospital she went to jail.

“I had to sit inside of a cold cell. I couldn’t use the bathroom or anything,” the woman said.

On the day she met Williams, she’d decided to call 911. The dispatcher recognized the woman didn’t need a police response but instead needed one of Baltimore’s mobile crisis teams, which send a clinician and a peer counselor to meet people in mental health distress.

By the end of an hourlong conversation, Williams set the woman up with referrals to a psychiatrist, a therapist, legal help, and a case manager to determine if her child with autism was eligible for government services.

“She’s been through a lot of trauma, and no one is going to deny that,” Williams said. “But I now have to take all of that and decide, ‘OK, here’s steps 1, 2, and 3,’ because we got to find a little bit of sliver of something to give her some hope that there’s help out here.”

For years, the mobile crisis teams, which are overseen by , a nonprofit that acts as the city’s mental health department, have diverted calls from police to mental health professionals. However, the units have a limited scope, focused on people in mental health crises.

Now Baltimore is tapping into some of the roughly $400 million from opioid-related legal settlements to build out a broader service to operate around the clock and respond to other kinds of crises when police aren’t needed.

Baltimore logged to 911 in 2024, but tens of thousands of them didn’t require traditional emergency services, like police, firefighters, or EMTs, according to , an expert in community safety at Georgetown Law.

Instead, the calls were about, for example, a homeless person who fell asleep in a store, a person who seemed confused in a public park, and someone who was yelling at passersby on the street.

Such calls “don’t require a badge, a gun, and handcuffs to resolve,” Duckett said.

Often those people end up in jail instead of getting the help they need, he said. A study that when a non-law enforcement team responded to 911 calls in Durham, North Carolina, it resulted in fewer arrests than when police responded — especially for callers who were Black, men, or ages 25-39. Police responses can also lead to trauma for that person or a less satisfactory outcome than another community service response would produce, Duckett said. The idea behind the Baltimore mobile crisis teams — and the new service — is to find out what people in crisis may need and how to connect them to those resources instead of arresting them.

From 2021 to 2025, Baltimore’s homicide rate decreased by 60%, setting records for the drop in violence. But at the same time, drug overdoses made national records, as about 1,000 people here each year from 2020 to 2023.

In 2018, Baltimore opted out of a global settlement that other jurisdictions made with opioid makers and distributors and instead sued them independently. As the opioid-related lawsuits were settled, city officials decided that the settlement awards it receives must be spent on drug-related harms — or on services that help prevent addiction, such as housing support, healthcare, and education.

One seeks to directly address overdoses by placing boxes of the overdose reversal drug naloxone at every subway stop. Expanding 911 services is part of a larger strategy to beef up city services, with $15 million in settlement funds allocated so far, according to Sara Whaley, Baltimore’s director of overdose response. Whaley hopes the expansion will help the city think differently about how it responds to residents in crisis — regardless of why they’re calling 911.

She views the calls as an opportunity to help solve a problem rather than be punitive. “What are the wraparound services and support that can help prevent them from being involved in this, in that emergency system?” she said.

For example, the person falling asleep in a store may need connection to community housing. The goal is to reduce violence, get people proper resources, and avoid the cycle of incarcerating people dealing with poverty, addiction, and mental health.

, executive director of the Health Lab at the University of Chicago, of services like these. She said they offer peace of mind for callers that “they’re going to be met with the right response at the right time.”

“We also see responders themselves feeling like they have a better toolbox in their ability to pursue actual resolution to these calls,” she said.

To expand its system, Baltimore looked to cities — including Durham — that have adopted similar models to reroute callers who don’t need emergency responders.

Durham’s diversion program is called the , or HEART. The program estimates it has diverted more than 12,000 calls in four years. It said police backup was needed for only 0.02% of those calls and that response times have improved for all types of 911 calls.

Durham has of the HEART calls, showing that nonpolice responders in Durham have helped with everything from finding housing for a woman fleeing domestic violence to setting up medical appointments for a homeless veteran.

In one case, a hotel manager called 911 asking for help finding a blind man housing for the night, since the hotel didn’t have accessible rooms available. The HEART responders booked him a room and the next day provided a ride to meet with an organization that could help secure housing.

This article is from a partnership that includes , , and ³Ô¹Ï²»´òìÈ.

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

Now, the same pain had returned — on the left.

This time, Rangel was in the U.S. and lacked health insurance. In 2019, he moved to Portland, Maine, where one of his daughters lives.

As a green-card holder, he qualified to purchase health insurance through the Affordable Care Act marketplace. But he quickly realized that the premiums for someone his age were beyond his budget. He decided to go without insurance, even though it had been a priority for him.

Instead, Rangel signed up for a plan at a concierge practice where patients pay as little as $70 a month for services, including unlimited office visits and minor procedures such as stitches and biopsies.

But when Rangel was diagnosed with a hernia, surgery became unavoidable. Ben Hagopian, his primary care physician, helped him compile a list of hospitals and surgical centers to consider. Rangel has a PhD in management, a field he pursued while serving in the navy in Venezuela. Armed with that knowledge and a naturally inquisitive mind, he began researching prices.

His efforts paid off when the bill came.

The Medical Service

Rangel had what is called an , which occurs when the contents of the abdomen bulge through a weak spot in the lower abdominal wall. The condition is relatively common, particularly among older adults.

In most cases, surgery is required to fix the muscle wall and can be performed . There are three main surgical approaches to repair an inguinal hernia: open, laparoscopic, and robot-assisted. Studies have shown that the three approaches have similarly low rates of hernia recurrence and are .

Rangel underwent an open repair, an approach often preferred by physicians for recurrent hernias. He said his operation lasted less than two hours, and he walked out of the surgical center shortly afterward.

The Bill

$2,900: The flat rate Rangel ultimately paid for his hernia repair at an outpatient surgery center in Maryland, including the surgeon’s fee and anesthesia. He said he also paid around $1,800 to travel to the surgery center from his home in Maine, including airfare, meals, and lodging for him and his wife.

The Billing Problem: No Insurance — But Time To Shop

Because Rangel did not have insurance, he had no protections from high costs — except time and his ability to shop for an acceptable price for his procedure.

Rangel’s first stop was a nonprofit hospital close to home. He scheduled a consultation with a surgeon with MaineHealth, the state’s largest health system, and received an estimate showing it would cost approximately $23,000 to repair his hernia laparoscopically.

Laparoscopic procedures generally cost more because surgeons use more advanced tools. Still, the average laparoscopic inguinal hernia repair costs nearly twice as much at a hospital as it does at an ambulatory surgery center for a patient , which pays $5,280 for the hospital-based option.

“I wasn’t going to mortgage my life just to have surgery and spend the next 30 years paying off the debt,” said Rangel, now 64.

So, he kept shopping. He considered a surgical center in Oklahoma that was far cheaper, but he ultimately ruled it out because it was so far away. He also explored traveling to Universidad de los Andes in Santiago, Chile, where another of his daughters lives. There, his hernia repair would have cost about $7,000, but once he added thousands of dollars in travel expenses, that option no longer made financial sense.

Gerard Anderson, a professor who analyzes healthcare spending at the Johns Hopkins Bloomberg School of Public Health, said patients without health insurance are often the ones hit hardest by wide price variations.

A closer look at any hospital bill helps explain why. “Every hospital is different,” he said, “but generally about half of the total charge is the facility fee,” a charge added to hospital care to help cover overhead costs.

Anderson said hospitals often mark up prices far more than smaller facilities do.

Medical billing researchers say the price gap between hospitals and ambulatory surgery centers partially reflects the higher overhead costs of operating a hospital.

Hagopian, Rangel’s physician, acknowledged that hospitals have higher administrative expenses. “But that doesn’t explain the high costs.”

MaineHealth declined to comment to ³Ô¹Ï²»´òìÈ, directing questions about the hospital-based procedure’s cost to Jeffrey Austin, president of the Maine Hospital Association.

Austin said that, unlike surgery centers, hospitals must absorb the costs of providing “money-losing” services, such as behavioral healthcare and care for Medicaid patients. He added that revenue generated by large hospitals in a health system supports other facilities, improving access to care.

Hospital prices, which can vary widely, are also driven by negotiations with insurers and market concentration. For uninsured patients, those list prices can become the starting point for negotiations — or the full amount owed.

Anderson noted that standardized payment rates exist for Medicare and Medicaid but not for most privately priced medical services. “In the private sector, providers can charge whatever they want.”

The Resolution

Rangel has another daughter in Argentina, a son in Venezuela, and other family in Spain. But he decided to stop looking around the globe for a good price, because he finally found what he was looking for in Maryland.

In April, he traveled to the Affordable Hernia Surgery center in Rockville, where he said “an efficient, well-coordinated system” guided him through the entire process.

“I received professional and very human care,” Rangel said. He was fully recovered within two weeks, as his surgeon predicted, he said.

The surgery center charged Rangel a flat fee for his hernia repair. The added travel expenses for the two-day trip with his wife went toward airline tickets, transportation, meals, and one night in a hotel.

Rangel said he paid about $4,700 total.

Alan Kravitz, the surgeon who performed Rangel’s operation, said the price difference uninsured patients face compared with insured patients is far from fair. “In the predatory and strategic world of U.S. healthcare pricing, uninsured patients generally get charged more than providers would accept from Medicare or commercial insurance.”

Kravitz then pulled out an estimate another patient had received for an inguinal hernia repair from a different large health system. The price: $37,000.

The Takeaway

Without insurance, many patients are on their own to negotiate.

“With the help of their primary physicians, patients can dig into prices and compare their options to avoid falling into medical debt,” Rangel said.

That approach, however, is most feasible for elective procedures with several surgical options offering comparable outcomes.

Patients facing medical emergencies do not have the luxury of comparing prices before seeking care, though many hospitals offer cash-pay discounts or charity care for those paying without insurance.

Billing analysts say patients who do have time to shop should look beyond cost alone. They recommend checking the quality of hospitals and surgical centers by reviewing publicly available ratings and patient reviews. that higher prices do not necessarily translate into a better quality of care, but it’s also important to select a reputable care provider.

Comparison shopping for medical care can be time-consuming. But for patients facing elective procedures, the effort can pay off — sometimes saving thousands of dollars.

“This was a learning experience for me,” Rangel said, “and I hope it will be for other people, too.”

Bill of the Month is a crowdsourced investigation by ³Ô¹Ï²»´òìÈ and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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