Far too often, consumers feel powerless when they receive any medical bill and especially when the size of the bill is particularly shocking. Many feel paralyzed and unsure of how they will pay off their medical debt. Too few people understand that non–profit hospitals are legally obligated to provide financial assistance or charity care, as well as other investments that benefit the community. Hospitals have been scrutinized over whether the benefit provided is a fair exchange for tax exemptions. Recent attention on non-profit hospitals for aggressively pursuing individuals to collect on their medical debt has been frustrating for patients and policymakers. However, advocates have been finding ways to promote transparency and accountability, and to implement systemic policy solutions.  

Get Involved in the Community Health Needs Assessment 

The Affordable Care Act included provisions to increase hospital transparency of community benefit activities and charity care policies. It requires nonprofit hospitals to conduct a Community Health Needs Assessment (CHNA) every three years and develop an implementation strategy (IS) to address the identified needs. The intention of the CHNA is for hospitals to engage with their communities to identify how they can better serve the health needs of residents and focus community benefit activities based on what is learned through the assessment. Hospitals vary in their approach and some may not practice an inclusive model of engagement. At a minimum, hospitals are required to seek input from public health experts and members of medically underserved communities, including low-income and minority populations. They must also take into consideration any written comments provided on their previous CHNA and IS. These requirements present an opportunity for advocates. 

Advocates could take the following steps to partner with hospitals in their communities: 

  • Examine the hospital’s community benefit spending. Community Benefit Insight provides data based on reports (IRS Form 990 Schedule H) that hospitals submit annually to the IRS. It includes information on charity care, community health improvement programs and more. Use the data to start a conversation with hospital leadership and identify areas for partnership. 

  • Identify hospital staff overseeing community benefit and needs assessment work. Build rapport with them to demonstrate that you are a trusted partner. 

  • Provide information on community needs, and leverage the strengths and assets community organizations and residents can bring to the table. There may be opportunities for hospitals to fund community-based organizations to help with CHNA efforts or address particular needs. 

  • Encourage community members to review and submit written comments on the most recent CHNA and IS. 

Review the Hospital Financial Assistance, Billing and Collections Policies 

Financial assistance or charity care often constitutes the largest portion of community benefit spending. Despite this, many patients know little about these policies. Kaiser Health News reported that nearly half of nonprofit hospitals routinely bill patients who would be eligible for charity care. Countless people have received bills even though they may have been eligible for free or reduced care. In 2018, Methodist Healthcare in Tennessee reported that $21 million of the $43 million dollars reported as bad debt was attributed to patients eligible for financial assistance. Half of the patients who were pursued for medical debt at Methodist should have had their bills forgiven or reduced. 

While it is not clear why so many individuals did not get financial assistance, a possibility may include a burdensome application process that deters individuals from applying. Unfortunately, the lack of a uniform application process allows hospitals to require different documents to determine eligibility. Additionally, individuals may be deterred from seeking help due to language barriers or immigration status, which may leave patients unaware of how to get support.  

Know Your Rights  

Financial assistance documents must be publicized widely and available without charge. They must also be translated into any languages spoken by 5 percent of the overall community served by the hospital, or by 1,000 individuals in the community. This includes the following documents: 

  • Financial assistance policy and a plain–language summary outlining eligibility criteria 

  • Financial assistance application 

  • Billing and Collection policy outlining actions that may be taken for non–payment 

  • Listing of providers covered and not covered by the hospital’s financial assistance policies 

Voice Your Story and Advocate for Change 

Many states have taken action to strengthen community benefit requirements. The National Academy for State Health Policy (NASHP) highlights states that have implemented policies that bolster accountability for their hospital community benefit expenditures. For example, Illinois and Utah require that hospitals spend the equivalent of their property tax amount on community benefit; Pennsylvania outlines community benefit standards for hospitals, such as providing at least 20 percent of patients free or discounted care; Oregon set a minimum level of community benefit spending and a sliding scale reduction for those earning up to 400 percent of the federal poverty line (FPL).  

Advocates are also currently leading the way in multiple states to ensure strong consumer protections regarding medical bills. For example, End Medical Debt Maryland is a coalition of 55 unions, churches, and social justice organizations working to pass The Medical Debt Protection Act. Some of the provisions include extending the timeline to apply for financial assistance and prohibiting extraordinary collective measures such as placing liens on homes. In New Mexico, NM Together for Healthcare was a community effort that led to the passage of Health Benefits for Certain Non-Citizens to ensure immigrants access to health care regardless of status and The Patient’s Debt Collection Act, which requires hospitals help patients identify coverage options and prevent hospitals from sending patients below 200 percent of FPL to collections. These community efforts allowed consumers to voice their stories of legal battles with medical debt and stress the damaging impact it has on families. 

Whether sharing a personal narrative on the harms of medical debt or voicing your concerns on health issues in the community, individual advocacy efforts can make an impact to keeping hospitals accountable and ensuring everyone has equitable access to affordable health care.