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.<\/p>\n
Texas Health Resources, one of the state\u2019s largest nonprofit hospital systems, told her it wouldn\u2019t schedule the procedure unless she paid up front, Carlock said. The self-employed house cleaner didn\u2019t have the money.<\/p>\n
\u201cI panicked because I live paycheck to paycheck,\u201d she said. \u201cI have no extra money whatsoever.\u201d<\/p>\n
Carlock borrowed cash from her best friend and parents. Her father offered money he inherited when Carlock\u2019s grandfather died a few years ago.<\/p>\n
Only after the surgery did Carlock, 35, learn she qualified for hospital financial aid. Her care should have been free, but the system doesn\u2019t give full refunds. The $5,500 was gone.<\/p>\n
Carlock\u2019s 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.<\/p>\n
\u201cI\u2019m just trying to pick myself back up,\u201d Carlock said. \u201cBut it\u2019s really hard.\u201d<\/p>\n
Hospitals have a tool to automatically screen people like Carlock for financial aid and grant them relief \u2014 a process known as presumptive eligibility<\/a>. But if, when, and how hospitals deploy this tool is largely up to them; there are few state or federal requirements.<\/p>\n A Tradeoffs investigation<\/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.<\/p>\n 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.<\/p>\n \u201cIt\u2019s like going through a tax audit,\u201d said Stanford University health economist Neale Mahoney, who studies medical debt. \u201cThe current system is broken.\u201d<\/p>\n An estimated 100 million adults<\/a> in the U.S. have healthcare debt, according to a KFF Health News 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.<\/p>\n Tradeoffs analyzed the financial assistance policies of all 166 nonprofit general hospitals and children\u2019s hospitals in Texas, which has higher rates of people in medical debt<\/a> than most states<\/a>.<\/p>\n The analysis is believed to be the first detailed look at presumptive eligibility policies of nonprofit hospitals, which typically don\u2019t pay income, sales, and property taxes<\/a>. They get these tax breaks in exchange for providing community benefits<\/a>, such as financial assistance. Lawmakers<\/a> and regulators<\/a> in recent<\/a> decades<\/a> have questioned whether nonprofits do enough to earn those tax breaks.<\/p>\n Since 2020, a wave of states<\/a>, including Texas, have debated or adopted requirements for hospitals to use presumptive eligibility in financial assistance to protect patients from avoidable debt.<\/p>\n \u201cThis is clearly an industry that is not policing itself very well,\u201d said Tom Oliverson, a physician and Texas lawmaker who has proposed legislation to require hospitals to screen patients before sending a bill.<\/p>\n 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. \u201cCharity care is the relief of last resort,\u201d she said.<\/p>\n \u201cI\u2019m just trying to pick myself back up, but it\u2019s really hard,\u201d says Aimee Carlock, who had to borrow money to prepay $5,500 for uterine surgery \u2014 money the hospital system, Texas Health Resources, held on to even after wiping out the rest of her bill under its financial aid policy. (Laura Buckman for KFF Health News and Tradeoffs)<\/p>\n Most Texas Hospitals Can Automatically Give Help<\/strong><\/p>\n To identify nonprofit hospitals in Texas, Tradeoffs consulted state and federal records and a list of hospital policies maintained by Dollar For<\/a>, 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.<\/p>\n Tradeoffs\u2019 analysis found that nearly every Texas nonprofit hospital can screen and proactively reduce bills when patients are found eligible for help.<\/p>\n 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\u2019s up from 72% six years earlier.<\/p>\n Hospitals\u2019 use of automatic financial aid can be traced<\/a>, in part, to the Affordable Care Act, which added protections for patients. The law created stiff penalties<\/a> for hospitals that aggressively go after payment<\/a> without trying to identify whether patients need help. Presumptive eligibility is one way to comply with the law<\/a>.<\/p>\n 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.<\/p>\n Covenant doesn\u2019t use the option \u201cdue to the regulatory requirements and administrative complexities,\u201d said Ainsley Nelson, the system\u2019s spokesperson. \u201cOur focus continues to be ensuring compassionate access to care and helping patients navigate the financial assistance options available to them.\u201d<\/p>\n Tom Oliverson, a physician and Texas state representative, is pushing legislation that would require nonprofit hospitals in the state to screen low-income patients for financial aid and automatically discount or write off patient costs before sending bills. (Danielle Villasana for KFF Health News and Tradeoffs)<\/p>\n Bill First or Screen First?<\/strong><\/p>\n About 8% of hospitals in Tradeoffs\u2019 analysis have policies that require screening patients for charity care before sending a bill.<\/p>\n Far more, 41%, say they screen patients before turning unpaid bills over to debt collectors or taking more aggressive actions<\/a>, such as garnishing wages, placing a lien on property, or denying further care without payment.<\/p>\n Southeastern Texas hospitals owned by CommonSpirit Health<\/a>, for example, will automatically wipe out bills only \u201cafter all other eligibility and payment sources have been exhausted,\u201d according to its Texas financial assistance policy.<\/p>\n CommonSpirit declined an interview request.<\/p>\n Research shows the sooner patients get financial aid, the better it is for their health.<\/p>\n One study<\/a> 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. A separate study<\/a> of people who had medical debts wiped out after months or years found no health benefit from the relief.<\/p>\n The signal is clear, said Ray Kluender, an associate professor at Harvard University, who worked on both studies. \u201cThe timing of when financial assistance is provided by a hospital is just extraordinarily important.\u201d<\/p>\n Some hospitals told Tradeoffs that what they do isn\u2019t always written in policy. For example, spokespeople for AdventHealth<\/a> and Houston Methodist<\/a> say their systems screen some patients before sending bills \u2014 though their policies include no requirement to do so.<\/p>\n 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.<\/p>\n \u201cPatients will not be notified to inform them of this decision,\u201d reads CommonSpirit\u2019s policy.<\/p>\n 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.<\/p>\n \u201cIt\u2019s cruel to not notify someone,\u201d said Erin Fuse Brown, a Brown University professor who studies medical debt. \u201cNot 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\u2019t have to budget for this.\u201d<\/p>\n People with medical debt are three to four times as likely to delay future physical and mental healthcare as people without medical debt, a recent study found<\/a>.<\/p>\n Hospitals Want To Help Patients \u2014 And Get Paid<\/strong><\/p>\n Texas has for decades required nonprofit hospitals to meet one of a few targets for how much help<\/a> they give patients \u2014 one of which is spending at least 4% of their annual patient revenue on charity care.<\/p>\n Research has found such spending targets have had mixed results. Some hospitals helped more patients, and others scaled back charity care<\/a> spending or spent less on other community benefits<\/a>, including training doctors and subsidizing money-losing but essential services.<\/p>\n The Texas Hospital Association touts that almost every hospital<\/a> in the state offers presumptive eligibility, but Stelter said screening tools can be unreliable.<\/p>\n Before they grant aid, hospitals want to know if a patient might be among the narrow population of adults who qualify for Medicaid in Texas<\/a> or if a grant might cover their bills \u2014 a determination that can require additional time and information.<\/p>\n 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\u2019 monthly premiums by raising deductibles, which have climbed to an average of about $2,100 per person<\/a> for job-based coverage and $3,700 per person<\/a> for people on marketplace plans.<\/p>\n If they know hospitals will pick up the tab, \u201cwhat incentive does an insurer have to lower a deductible?\u201d Stelter said.<\/p>\n Hospitals nationwide are expected to come under increasing financial strain<\/a> since Congress reduced subsidies for many people buying health insurance through the Affordable Care Act, and new federal Medicaid cuts<\/a> are expected to push millions of low-income Americans off the rolls<\/a>.<\/p>\n That policy shift leaves hospitals to pick up more of the safety net, which they can\u2019t afford, said Jill Horwitz, a Northwestern University health policy professor.<\/p>\n \u201cIt would be wonderful if nonprofit hospitals could solve the problem of Americans being uninsured or underinsured by paying for the free care,\u201d Horwitz said. \u201cBut nonprofit hospitals do not have the money to solve what is ultimately a major federal problem.\u201d<\/p>\n \u2018You Had To Pay It\u2019<\/strong><\/p>\n 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.<\/p>\n \u201cI just thought you had a bill and you had to pay it,\u201d said the 33-year-old uninsured yoga instructor.<\/p>\n 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.<\/p>\n \u201cI thought, \u2018I\u2019m doomed,\u2019\u201d Wahl said. \u201cI just went out to get a birthday card and fell over. And now I have $38,000 of debt.\u201d<\/p>\n Becca Wahl received a $38,000 emergency room bill from Memorial Hermann Katy Hospital after getting a concussion from fainting. According to the hospital\u2019s own policy, Wahl qualified for financial aid and should have never received a bill. (Danielle Villasana for KFF Health News and Tradeoffs)<\/p>\n 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 \u2014 better than $38,000, but still out of reach.<\/p>\n Desperate, Wahl went online and found Dollar For, which helps patients apply for financial aid. One week after Dollar For submitted Wahl\u2019s application, Memorial Hermann wiped out her bill.<\/p>\n Memorial Hermann\u2019s policy says its hospitals should screen patients for financial assistance before sending a bill.<\/p>\n 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 \u201cdedicated 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.\u201d<\/p>\n Wahl is just glad that she doesn\u2019t have to put her life on hold while she pays off that debt.<\/p>\n \u201cThe amount of stress that was lifted off of my shoulders by finding out that this medical debt was forgiven was huge,\u201d she said.<\/p>\n Becca Wahl had no idea she qualified for hospital financial assistance when she received a $38,000 emergency room bill for treating a concussion. \u201cI thought, \u2018I\u2019m doomed,\u2019\u201d recalls Wahl, an uninsured yoga instructor. \u201cI just thought you had a bill and you had to pay it.\u201d (Danielle Villasana for KFF Health News and Tradeoffs)<\/p>\n Few Hospitals Give Refunds<\/strong><\/p>\n Some patients who pay down their bills before hospitals wipe them out never get their money back, Tradeoffs found.<\/p>\n Roughly 2 in 3 nonprofit hospitals in Texas have policies that say patients won\u2019t receive full refunds.<\/p>\n CommonSpirit\u2019s 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 \u201crefunds are case specific.\u201d<\/p>\n A few hospitals say they will return amounts that exceed what the hospital would typically charge someone with insurance<\/a> \u2014 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.<\/p>\n Carlock\u2019s $5,500 stayed with the hospital.<\/p>\n Carlock agreed to give Texas Health permission to speak with Tradeoffs about her bill. Texas Health didn\u2019t respond.<\/p>\n Stelter with the Texas Hospital Association said hospitals follow federal regulations<\/a> for refunding patients. Those regulations require hospitals to fully refund some patients who submit an application. The rules don\u2019t apply to those who got help through presumptive eligibility, experts on the regulation told Tradeoffs.<\/p>\n States Seek Standards<\/strong><\/p>\n By July 2027, six states will require hospitals to use presumptive eligibility for certain patients: California<\/a>, Delaware<\/a>, Illinois<\/a>, Maryland<\/a>, North Carolina<\/a>, and Oregon.<\/a><\/p>\n 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 \u2014 before they send a bill<\/a>. Lawmakers raised the threshold to $1,500<\/a> in 2026 amid concerns over imperfect screening tools<\/a> and the law\u2019s impact on hospital finances.<\/p>\n 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\u2019s based on an analysis of available Medicare data from roughly two-thirds of hospitals. At OHSU Hospital in Portland, one of the state\u2019s largest, the percentage of patients receiving financial aid jumped from 12% before the law to 64%<\/a>.<\/p>\n 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\u2019t would face penalties.<\/p>\n The legislation failed, but Oliverson said he plans to reintroduce it in 2027. The lawmaker said nonprofits are falling short of their obligations.<\/p>\n \u201cIf you\u2019re sending bills to people that you know when you finally get around to screening them for charity they\u2019re not going to be obligated to pay,\u201d he said, \u201cthat should be grounds for losing your tax-exempt status.\u201d<\/p>\n Oliverson said hospitals that already care for a higher share of low-income patients would be exempt from his proposed requirements. But he\u2019s adamant that most nonprofit hospitals should be doing more to protect patients from unnecessary debt.<\/p>\n \u201cIf you\u2019re advertising that you\u2019re willing to accept uninsured patients and that you have a charity program,\u201d Oliverson said, \u201cyou got to deliver on that.\u201d<\/p>\n This story is part of Hidden Help<\/a>, an investigative series from Tradeoffs<\/a> and KFF Health News<\/a> about how hospitals can protect their patients from the life-altering harms of medical debt. Read our full data analysis methodology<\/a>.<\/em><\/p>\n Melanie Evans is a reporter for Tradeoffs, a nonprofit newsroom reporting on healthcare\u2019s toughest choices. Sign up for the weekly newsletter<\/a> to get the latest stories every Thursday morning.<\/em><\/p>\n Tradeoffs\u2019 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.<\/em><\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/em><\/p>\n This article<\/a> first appeared on KFF Health News<\/a> and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License<\/a>.<\/p>","protected":false},"excerpt":{"rendered":" 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\u2019s largest nonprofit hospital systems, told her it wouldn\u2019t schedule the procedure unless she paid up front, Carlock said. The self-employed house cleaner didn\u2019t…<\/p>\n","protected":false},"author":0,"featured_media":16128,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-16127","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/16127"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=16127"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/16127\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/media\/16128"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=16127"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=16127"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=16127"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}