Dan Weissmann
Federal regulation requires that every one nonprofit hospitals have monetary help insurance policies — often known as “charity care” — to scale back or expunge folks’s medical payments. New analysis from Dollar For, a corporation devoted to serving to folks get entry to charity care, means that fewer than one-third of people that qualify for charity care truly obtain it.
“An Arm and a Leg” host Dan Weissmann talks with Dollar For founder Jared Walker about its latest work, and the way new state applications focusing on medical debt in locations like North Carolina could change the best way hospitals method charity care.
Plus, a listener from New York shares a useful useful resource for navigating charity care appeals.
Dan Weissmann
Host and producer of “An Arm and a Leg.” Previously, Dan was a workers reporter for Marketplace and Chicago’s WBEZ. His work additionally seems on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.
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Transcript: New Lessons within the Fight for Charity Care
Note: “An Arm and a Leg” makes use of speech-recognition software program to generate transcripts, which can comprise errors. Please use the transcript as a instrument however test the corresponding audio earlier than quoting the podcast.
Dan: Hey there–
Clara lives in New York City together with her husband Remy and their household. And, not too long ago, over the course of a yr, that they had some … medical encounters. At hospitals.
Nothing super-dramatic: Remy broke his ankle in August of final yr. Hello, emergency room. Hello, ER invoice.
They had a second child in November 2023 — a boy! — who ended up needing to spend a day in neonatal intensive care. He’s effective. They named him Isaac.
And one evening early this yr, Isaac simply… wasn’t trying good. Lethargic. Had a fever.
Clara: We determined to provide him Tylenol. Um, and he spit all of it again out.
Dan: They took his temp once more. 100 and three level 5.
Clara: We began Googling, um, what’s like dangerously excessive fever for a child
Dan: And yep. For a child that little, 100 three level 5 is beginning to get iffy. Like attainable threat of seizure. But it was late at evening. No pediatrician, no pressing care. Hello new, unwelcome questions.
Clara: The final thing you need to be interested by is, Oh shit, that is going to be actually costly. You need to be interested by, let’s go to the ER proper now, be certain he doesn’t have a seizure.
Dan: So they went. And the oldsters on the ER gave Isaac extra tylenol, he didn’t spit it out, his fever went down. They went house, relieved about Isaac and a little bit anxious concerning the payments.
After insurance coverage, they had been greater than eight thousand {dollars}. Clara didn’t suppose her household might afford something like that.
And the billing workplace didn’t provide super-encouraging recommendation.
Clara: principally each time I’ve known as, they mentioned, why don’t you begin making small funds now so it doesn’t go into collections.
Dan: However. Clara listens to An Arm and a Leg. Where we’ve been speaking about one thing known as charity take care of years. This summer time, we requested listeners to ship us their payments – and inform us about their expertise with charity care. Clara was one of many people who responded.
Just to recap: Federal regulation requires all nonprofit hospitals to have charity care insurance policies, additionally known as monetary help.
To cut back folks’s payments, and even forgive them totally, if their earnings falls under a stage the hospital units.
We’ve been super-interested in charity care right here for nearly 4 years, ever since a man named Jared Walker blew up on TikTookay spreading the phrase and providing to assist folks apply, by means of the nonprofit he runs, Dollar For.
Since then, we’ve discovered a LOT about charity care. Dollar For has grown from an infinitesimally tiny group — principally Jared, not getting paid a lot -to a small one, with 15 folks on workers.
Jared says they’ve helped folks with hundreds of purposes and helped to clear tens of millions of {dollars} in hospital payments.
And prior to now yr, they’ve been as much as a LOT and so they’ve been studying alot. Before we decide up Clara’s story — which ends together with her providing a brand new useful resource we will share — let’s get an enormous obtain from Jared.
This is An Arm and a Leg, a present about why well being care prices so freaking a lot, and what we will possibly do about it. I’m Dan Weissmann. I’m a reporter, and I like a problem. So the job we’ve chosen on this present is to take some of the enraging, terrifying, miserable components of American life- and convey you a present that’s entertaining, empowering and helpful.
In early 2024, Dollar For put out a few massive analysis studies documenting how a lot charity care doesn’t get awarded. And why folks don’t obtain it.
Jared: I really feel like for a very long time we’ve got been trying round on the consultants, proper? Who are the consultants? And the place can we discover them and what can we ask them?
Dan: Finally, they undertook a serious analysis venture of their very own. They analyzed hundreds of IRS filings from nonprofit hospitals, and in contrast what they discovered to a examine from the state of Maryland based mostly on much more exact knowledge.
And they employed a agency to survey a pattern of greater than 11 hundred folks. Then ran focus teams to dig in for extra element.
Jared: I believe that what these studies have simply revealed is like, we’re the consultants like greenback for truly is aware of greater than everybody else about this.
Dan: The quantity of charity care that hospitals don’t give to individuals who qualify for it?
The knowledge evaluation produced a quantity: 14 billion {dollars}. Which Jared and his colleagues say is a conservative estimate.
The survey confirmed that greater than half of people that qualify for charity care don’t get it. About two thirds of these people have no idea that it exists. Some individuals who learn about it simply don’t apply. And some who do get rejected, though they qualify.
Their conclusion: “We found that only 29% of patients with hospital bills they cannot afford are able to learn about, apply for, and receive charity care.” None of which shocked Jared.
Jared: It’s like, Oh, like our assumptions have been appropriate on this. Like folks don’t learn about charity care. The course of sucks. Um, lots of people that ought to get it, don’t get it. Um, and hospitals have put all of the ache and the entire duty on the affected person
Dan: Those topline findings put Dollar For’s accomplishments in context.
Jared: Like we’ve got submitted over 20, 000 of those monetary help purposes.
Dan: 20, 000 folks. That’s spectacular. That’s I do know you’re counting the cash. How a lot cash is it that you just’re speaking about to this point?
Jared: I believe we’re closing in on 70 million, 70 million in medical debt aid. So
Dan: Right. It’s a begin.
Jared: there you go.
Dan: It’s a begin.
Jared: It sounds nice, and you then see the 14 billion quantity and also you’re like, oh, shoot. What are we doing? What are we doing?
Dan: giggle crying emoji.
Jared: Yeah, yeah, yeah.
Dan: And so, for a lot of the yr, Jared and his staff have been testing a method to tackle a 14 billion greenback drawback.
Jared: We have spent the yr making an attempt to work with hospitals. We got here at this – how will we put a dent within the 14 billion? If it’s not going to be by means of TikTookay, and it’s not going to be by means of particular person affected person advocacy, then what if we moved additional upstream, and as a substitute of sufferers discovering out about us one to a few months after they get a invoice, what in the event that they heard about us on the hospital?
Dan: Jared envisioned sufferers getting evaluated for charity care, and getting referred to Dollar For for assist making use of, earlier than they take a look at. He thought
Jared: Maybe we might make a much bigger dent into that 14 billion. And, I believe that that was wishful considering.
Dan: Wishful considering. That’s how Jared now describes his hopes that hospitals would see that they might do higher by sufferers, along with his assist, and signal proper as much as work with him.
Jared: Um, effectively they haven’t, Dan. So, we don’t have, uh, you already know, we’ve received one hospital.
We’ve received one hospital. I don’t know if there’s a smaller hospital within the United States. It is Catalina Island Health. It is a small hospital on an island off the coast of California
And when sufferers go in there, they inform them about Dollar For, and so they ship them over. Um, that was what we had been hoping to do with these bigger programs.
Dan: Jared talked to a number of hospitals. He went to conferences for hospital revenue-department directors. He didn’t get a number of traction
Jared: You know, that is one factor the place I’m like, I don’t need to be completely unfair to the hospitals.
They’re big entities which you could’t simply transfer shortly like that.
it’ll take much more on their finish than it might on our finish, we might spin up one in every of these partnerships in per week.
And. They’re going to want a number of time and it’s going to, you already know, how will we implement this? Um, you already know, with a small Catalina Island hospital it was straightforward, however in the event you’re speaking to Ascension
Dan: Ascension Healthcare– an enormous Catholic hospital system. 100 thirty-six hospitals. More than 100 thirty thousand staff. Across 18 states, plus DC. Jared says they may get hundreds of charity care purposes a month. A deal to steer people to Jared isn’t a easy handshake association.
Jared: How do you, how do you do this? You know, how do you implement that? I imply, it’s a ache within the ass. And these hospitals, and extra so, hospitals usually are not motivated to determine this out.
Dan: Yeah. Right.
Jared: Unless you’re in North Carolina,
Dan: North Carolina. In 2023, North Carolina expanded Medicaid. In July 2024, Governor Roy Cooper introduced a program that might use Medicaid cash to reward hospitals for forgiving Medical debt.
Gov. Roy Cooper: below this program. Hospitals can earn extra by forgiving medical debt than making an attempt to gather it. This is a win win win.
Dan: Under this system, hospitals can get extra Medicaid {dollars} in the event that they meet sure situations. One, forgive a bunch of current medical money owed. Another: Make positive their charity care insurance policies shield sufferers who meet earnings threhholds set by the state.
A 3rd: they need to pro-actively determine sufferers who’re eligible for charity care — and notify these sufferers earlier than sending a invoice, possibly even earlier than they go away the hospital.
Jared: I’m very excited to see how that appears sooner or later. Because in the event you bear in mind, the large 4, like our shit listing, is Texas, Florida, Georgia, North Carolina.
Dan: Jared’s shit listing. The states the place, over time, he has heard from the best quantity of people that have problem getting hospital charity care. Where he typically has to combat hardest to assist them get it.
Jared’s shit listing, the large 4, had been the 4 largest states (by inhabitants) that had rejected the growth of Medicaid below the Affordable Care Act.
Because of how the ACA was written, no Medicaid growth means much more individuals who don’t have some huge cash and simply don’t have ANY insurance coverage in any respect.
It’s an enormous drawback. And North Carolina was a type of states the place it was hardest.
Jared: And in, you already know, the span of a yr, North Carolina has expanded Medicaid, and created the most effective medical debt charity care insurance policies within the nation.
This regulation basically says that they need to determine them early. So that’s like – on paper, you already know, it sounds wonderful.
Dan: Onpaper it sounds wonderful. We’ll come again to that. But first, let’s clarify: This wasn’t a sudden transformation. The governor, Roy Cooper, who we heard in that clip? He spent like seven years pushing the state to develop Medicaid.
The legislature lastly agreed in 2023. And then Cooper and his staff spent months this yr determining bake medical-debt aid into the plan. It took a ton of maneuvering.
Our friends at KFF Health News coated the method. Here’s Ames Alexander, who reported that story with Noam Levy, describing the method on a public radio present known as “Due South.”
Cooper’s staff began out by making an attempt to quietly bounce their concepts off a number of hospitals..
Ames Alexander KFF Health News: But then phrase received again to the hospital trade’s highly effective lobbying group. That’s the North Carolina Healthcare Association. And the Association was by no means completely satisfied about it. .
Dan: They raised a stink. And claimed the entire thing could be unlawful, the feds shouldn’t approve it.
Cooper and his well being secretary Cody Kinsley received saved going– and so they did get the feds to log out on the plan. So it was authorized.
But it wasn’t obligatory. They had been providing hospitals cash, however these hospitals wanted to say sure. And that didn’t occur immediately.
Ames Alexander KFF Health News: When Cooper and Kinsley unveiled this plan on July 1st, there wasn’t a single hospital official who would be part of them there for the press convention. Ultimately, although, all 99 of the state’s hospitals signed on. And it’s not, it’s probably not laborious to grasp why they stood to lose a number of federal cash.
Dan: Lose OUT on a ton of NEW federal cash. A ton. According to KFF’s reporting, a single hospital system stands to achieve like 800 million {dollars} a yr for taking part.
And you already know, interested by that — how a lot cash hospitals had been contemplating turning down — sort of places into perspective Jared’s expertise making an attempt to get them to work with him. He wasn’t providing anyone 800 million {dollars} a yr.I mentioned to Jared: Seems like this might be laborious to duplicate elsewhere. Other states aren’t going to have the ability to put that sort of new federal cash on the desk. And Jared mentioned:
Jared: I believe earlier than like, Oh, can we replicate it? I’m identical to, how will we make it? How will we make it work in North Carolina?
Dan: That is: How to ensure when it will get carried out, that it actually works? Remember, Jared mentioned earlier than: This all sounds wonderful ON PAPER. We’ll have a few of his caveats after the break. Plus the remainder of Clara’s story.
An Arm and a Leg is a co-production of Public Road Productions and KFF Health News — that’s a nonprofit newsroom protecting well being points in America. KFF’s reporters do wonderful work — you simply heard one in every of them breaking down how North Carolina put that deal collectively. I’m honored to work with them.
Jared loves the concept behind North Carolina’s initiative on charity care: Hospitals need to display screen folks whereas they’re on web site, and allow them to know earlier than they go away the hospital what sort of assist they could be eligible for.
Jared: Making positive {that a} affected person is aware of what is out there to them earlier than they go away could be very highly effective. , like, that’s the place the duty needs to be. Um, however how do you do it? And what occurs in the event you don’t? Right?
Dan: In different phrases, Jared says, the satan is in implementation, and in programs of accountability. He’s seen what occurs when these programs are pourous.
Jared: In Oregon, that they had that regulation that was like, Oh, you may’t sue sufferers with out first checking to see in the event that they’re eligible for charity care. . And you then discover all these folks which might be being sued that had been by no means screened.
Dan: Yeah, Oregon handed a regulation in 2019 that required hospitals to guage sufferers for charity care earlier than they might be sued over a invoice. Jared’s colleague Eli Rushbanks analyzed a pattern of hospital-bill lawsuits in a single county. He might solely see affected person’s earnings in a number of of them– however in virtually half of these, that earnings was undoubtedly low sufficient that the debt ought to’ve been forgiven.
He additionally took a big-picture look: In the years after the regulation took impact, two thirds of hospitals gave out LESS charity care than that they had given earlier than. Probably not what lawmakers had hoped for.
Hospitals in North Carolina may have two years to totally implement the screening requirement, known as “presumptive eligibility.”
Some hospitals across the nation already use automated programs for this: They test your credit score, pull different knowledge. Some of them use AI.
Jared says he’s seen some hospitals over-rely on the tech.
Jared: Some hospitals which might be utilizing presumptive eligibility instruments will use that as a option to say, Oh, we already screened you. You can’t apply, however the affected person is sitting there going, effectively, I’m eligible.
Your instrument will need to have received it improper. Cause this stuff usually are not 100% correct, or consider one thing like this, you lose your job, or possibly you’re on the hospital since you simply gave start to a different human. So now you’re a family of 4. It’s a 4 as a substitute of three.
And clearly the presumptive eligibility instrument isn’t going to have the ability to know that and calculate that. So in the event you go to the hospital and say, now I need to apply and so they say, effectively, you don’t get to use as a result of we already screened you and also you’re not eligible. That’s bullshit.
Dan: So, as North Carolina hospitals carry their programs on-line, Jared needs to push for a course of the place sufferers can attraction a machine-made determination. Jared: I’d love to have the ability to take a look at that
how does that affect how many individuals are getting charity care and that 14 billion?
Dan: What do you suppose is your greatest shot for the subsequent yr of sort of shifting in the direction of 14 billion?
Jared: We are attempting to determine that out. Um, clearly the election will play into that, however I believe that if I needed to guess the place we might land, um, I believe that we are going to double down on our affected person advocacy work.
Dan: Jared says they’ll undoubtedly additionally proceed to work with advocates and officers on coverage proposals. But…
Jared: The solely motive anybody cares about what we’ve got to say about coverage is as a result of we all know what the affected person experiences. So I believe that if the, the extra folks we assist, the extra alternative we should push insurance policies ahead that we need to see occur
Dan: So, this can be a good place to notice: If you or anyone you already know has a hospital invoice that’s scaring you, Dollar For is a superb first cease. We’ll have a hyperlink to their web site wherever you’re listening to this. They’ve received a instrument that may enable you shortly determine in the event you would possibly qualify for charity care out of your hospital. Plus tons of how-tos. And they’ve received devoted workers that can assist you in the event you get caught.
And we simply heard Jared say they’re not backing away from that work, at the same time as they goal to affect coverage.
About coverage — Jared does have one different considered their work in that space
Jared: We suppose that we’re going to get a little bit bit extra feisty, uh, shifting ahead. So I’m, I’m enthusiastic about that.
Dan: I talked with Jared lower than per week after the election. We didn’t know but which get together would take the House of Representatives, and naturally there’s nonetheless a LOT we don’t learn about what issues seem like from right here. Jared had only one prediction.
Jared: I believe we’re going to be wanted, you already know, that rather more.
Dan: I believe we’re all gonna want one another greater than ever. Which is why I’m happy to carry us again to Clara’s story from New York.
You would possibly bear in mind: Her household had three hospital adventures within the area of a yr.
The first one, the place her husband broke his ankle, received her began. The invoice was eighteen hundred {dollars}, after insurance coverage. A LOT for his or her household. But she had a number of issues going for her.
One, she knew charity care existed. Not as a result of the hospital talked about it.
Clara: No, I learn about it from an arm and a leg,
Dan: And two, she had the talents. Because by coaching, she’s a librarian. And —you might already know this however — folks come to libraries trying for lots extra than simply books.
Clara: People on a regular basis, will are available and usher in a kind or need assistance navigating completely different programs and, and even simply trying and making an attempt to see the place to begin.
Dan: So, she went and located her hospital’s monetary help coverage on-line. Saw that her household met their earnings necessities. Found the shape. Submitted it. Got provided a reduction… that also left her household on the hook for greater than they might comfortably pay.
And determined to see if she might ask for extra. Was there an appeals course of? There was.
But she didn’t discover the entire info she wanted on-line. The course of wasn’t fast.
Clara: Numerous cellphone tag. And I don’t know if the invoice pay cellphone traces are staffed higher than the monetary assist cellphone traces. But, you already know, you get an answering machine rather a lot. You need to name again. The particular person doesn’t bear in mind you. They’re not in a position to hyperlink your account.
All the issues that I simply really feel like they’re actually greasing the wheels of the paying for the invoice choice, however truly not making it particularly accessible to do the monetary assist and attraction course of.
Dan: Clara hung in there. Here’s what she advised my colleague Claire Davenport.
Clara: Being a listener of the podcast, I really feel like I’m a part of a group of people who find themselves form of maneuvering by means of the loopy healthcare system. And I do sort of have Dan’s voice in my head, like, that is nuts. This will not be your fault. This is loopy and never proper.
Dan: Also, when she was angling for extra assistance on her husband’s ER invoice, she knew something she discovered might turn out to be useful: She was as a result of give start on the identical hospital fairly quickly.
Her persistence paid off. In the top, the hospital lowered that 1800 greenback invoice to simply 500 {dollars}.
Two weeks later, Isaac was born. And spent an additional day within the NICU. That, plus the late-night fever that despatched them to the ER left Clara’s household on the hook for about 6500 {dollars}.
Clara used what she’d discovered the primary time by means of as a playbook. Apply, then attraction to ask for extra assist. She says that made it a little bit easier. But not easy, and never fast.
Isaac was born in November 2023. His ER go to was in April 2024. When Clara talked with our producer in early August 2024, she was nonetheless ready to listen to the hospital’s determination about her attraction. Was it gonna be accredited?
Clara: In the occasion that it’s not, I believe we simply put it on just like the longest fee plan we will. Maybe we might ask household for assist.
Dan: Update: Just a few days after that dialog, the hospital mentioned sure to Clara’s attraction. Her new whole, 650 {dollars}. About a tenth of that preliminary quantity.
Which, sure, is a pleasant story for Clara and her household. But the explanation I’m so happy to share her story is that this:
Clara: Actually, I made a template which you could let your listeners use for making an attraction letter. I’ll share it with you.
Dan: Clara thought it could be helpful as a result of a part of the appliance and attraction course of — not all of it was simply details and figures and pay stubs. There was additionally a possibility to put in writing a letter. Which opened up questions.
Clara: I really feel like It’s not completely clear what you’re supposed to place within the letter and who you’re interesting to and the way emotional you’re purported to make it versus how technical
Dan: Here’s how she approached it.
Clara: I used to be making an attempt to consider if I used to be studying the letter, what would assist paint the image of this invoice in context of all the pieces else. making an attempt to place myself of their footwear, studying it, what could be helpful to sort of add extra depth to our story than simply the invoice. And then additionally I simply tried to be actually grateful and categorical genuine gratitude for the good care we obtained.
Dan: She additionally included a practical estimate of what her household might truly pay. Which the hospital ended up agreeing with.
And sure, Clara shared that template with us. We’ll put up a hyperlink to it wherever you’re listening to this. Please copy and paste, and fill within the blanks, and please-tell us if it really works for you.
A giant lesson right here is, don’t take no for a remaining reply. Don’t take “We’ll help you this much” for a remaining reply. Clara found one different factor: Don’t surrender if it appears to be like like you might have missed a deadline. She missed one.
Clara: So I known as them and mentioned, I’m actually nervous. ” I didn’t ship it in time. It could be off by a pair days. Is this going to be an enormous drawback? And they mentioned, No, don’t fear about it.
It’s completely effective. Just ship it. So I’m considering, Okay, wait. There are so many people who find themselves going to get lower off or get their invoice and notice, Oh, effectively, I completely missed the window. So let’s go for the fee plan choice. When truly,
Dan: If you’ve received the chutzpah, and the time, and the persistence to make the subsequent name and ask… you might get a unique reply.
It sucks that it’s this difficult. But I recognize each clue that it’s not not possible. And I recognize Clara sharing her story — and her template with us.
I advised Jared about it.
Jared: Yeah, that’s wonderful. I imply, I like, uh, it’s so humorous. it’s simply the concept of you’ve this affected person that’s going by means of all of these items and is so busy making an attempt to deal with their very own well being, do their very own factor, and so they’re out right here making templates in order that different folks can , you already know, leap by means of the identical hoops as a result of we all know We’re all going to have to leap by means of the hoops, uh, is simply, man, how irritating is that?
But how wonderful is it that you’ve got, you’ve constructed a group of individuals which might be, you already know, prepared to, uh, take these sort of crappy, not sort of, very horrible experiences and, um, and switch it into one thing that’s useful for different folks. I believe that’s wonderful.
Dan: Me too! So that is the place I ask you to assist maintain an excellent factor going. We’ve received a lot to do in 2025, and your donations have all the time been our largest supply of help. After the credit of this episode, you’ll hear the names of some people who’ve pitched in simply in the previous few weeks.
And that is The Time to assist us construct. The place to go is arm and a leg present dot com, slash, help.
That’s arm and a leg present dot com, slash, help .
We’ll have a hyperlink wherever you’re listening.
Thank you a lot for pitching in in the event you can.
We’ll be again with a model new episode in a number of weeks.
Till then, care for your self.
This episode of An Arm and a Leg was produced by Claire Davenport and me, Dan Weissmann, with assist from Emily Pisacreta — and edited by Ellen Weiss.
Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for viewers. Bea Bosco is our consulting director of operations.
Lynne Johnson is our operations supervisor.
An Arm and a Leg is produced in partnership with KFF Health News. That’s a nationwide newsroom producing in-depth journalism about well being points in America and a core program at KFF, an unbiased supply of well being coverage analysis, polling, and journalism.
Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this present.
And due to the Institute for Nonprofit News for serving as our fiscal sponsor. They permit us to simply accept tax-exempt donations. You can be taught extra about INN at INN.org.
Finally, thanks to all people who helps this present financially.
“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.
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