ST. CLOUD, Minn. — Cori Roberts was dwelling in a rented basement 4 years in the past when she was recognized with early-stage cervical most cancers.
Recently divorced, the previous stay-at-home mom had began working once more in her mid-40s, taking a human sources job that paid $41,000 a 12 months. Then, regardless of having insurance coverage, she was hit with greater than $8,000 in medical payments.
“I had my car and a basket of clothes,” Roberts recalled. “Medical bills were not something I could have afforded.”
Roberts sought monetary help from CentraCare, the St. Cloud-based well being system that handled her. It’s a nonprofit charity that receives thousands and thousands of {dollars} in federal, state, and native tax breaks. In trade, it’s obliged to supply charity care to sufferers who can’t afford their medical payments. But Roberts mentioned CentraCare advised her she made an excessive amount of to qualify.
Roberts as a substitute scrimped on groceries and Christmas presents for her children and paid off greater than $6,000 over two years. Then CentraCare sued her final 12 months as a result of she hadn’t paid off all of the debt.
“They’re supposed to be a nonprofit,” Roberts mentioned. “It’s like, ‘Come on!’”
CentraCare earmarks a tiny fraction of its funds for serving to sufferers with medical payments they’ll’t pay, but it surely’s not alone, a Minnesota Star Tribune-KFF Health News investigation discovered.
Minnesota’s hospitals and well being programs are among the many least charitable within the nation, the investigation discovered, offering much less monetary assist as a proportion of their working budgets on common than hospitals in nearly each different state, together with Illinois, Iowa, Nevada, and Texas.
The investigation drew on an in depth evaluation of each hospital charity care program within the state, an evaluation of 5 years of hospital monetary information, and dozens of interviews with sufferers, hospital executives, and state officers.
Nationally, hospitals spend a mean of about 2.4% of their working budgets on charity care, in response to federal hospital information compiled by Hossein Zare, a researcher at Johns Hopkins University. Minnesota hospitals spend a couple of third of that, on common.
Some spend significantly much less. Of Minnesota’s 123 basic hospitals, 62 devoted lower than 0.5% of their working budgets to charity care from 2020 by means of 2024, the Star Tribune-KFF Health News investigation discovered.
“The system is not working,” mentioned Erin Hartung, director of authorized providers at Cancer Legal Care, a Minnesota nonprofit that helps sufferers with medical debt and different monetary challenges. “And the burden is falling hardest on the people who are least able to bear it.”
CentraCare’s flagship St. Cloud Hospital spent lower than 0.25%, in response to the evaluation. That works out to $25 in affected person assist for each $10,000 spent on hospital operations.
Charity care will change into much more important in coming years as Minnesotans lose well being protection or can’t afford rising copays and deductibles. The state’s uninsured price rose sharply final 12 months, hitting its highest level since 2017, and it’s anticipated to extend additional as funds cuts pushed by President Donald Trump pressure states to pare Medicaid and different security internet packages. Charity care can also be crucial to many individuals with medical insurance who can’t afford their payments.
Hospital officers say it’s unfair to count on them to resolve this affordability drawback when lots of their amenities are financially strained. “No amount of charity care from hospitals will ever fully meet the needs of uninsured or underinsured Minnesotans. The need is simply too great,” Minnesota Hospital Association spokesperson Tim Nelson mentioned in an announcement.
But state Attorney General Keith Ellison mentioned hospitals have an obligation to spice up charitable assist for all needy sufferers in trade for the tax breaks they obtain.
“There is a benefit you get from being a nonprofit hospital in the state of Minnesota,” he mentioned. “But do the people get the benefit?”
Several small Minnesota hospitals give monetary assist to fewer than two dozen sufferers a 12 months. Mahnomen Health Center, which not too long ago transformed to a rural emergency heart, didn’t present any charity care in eight years, regardless of serving one among Minnesota’s most impoverished regions. Other hospitals serving massive low-income populations have been amongst these offering the least charity care, the evaluation discovered.
Several components assist clarify why Minnesota hospitals present so little monetary assist. For one, job-based insurance coverage and an expanded Medicaid program supply broad protection. Hospitals in states with much less authorities help and extra uninsured individuals usually spend extra on charity care.
But Minnesota sufferers additionally face vital boundaries accessing monetary assist at many hospitals, together with inconsistent eligibility requirements and intensive functions, the Star Tribune-KFF Health News investigation discovered.
To qualify at many hospitals, sufferers should submit detailed private data, together with financial institution statements, retirement accounts, mortgage paperwork, and estimates of different belongings akin to automobiles, properties, or livestock.
And as a result of Minnesota has not standardized the standards for charity care, sufferers would possibly obtain assist at one hospital however not one other. The investigation discovered that some hospitals give free care to sufferers with an annual family earnings of $47,000, whereas others cap it at about $15,000.
Had Roberts pushed 30 miles east to Princeton or 35 miles north to Little Falls, she would have discovered medical suppliers with extra beneficiant monetary assist insurance policies than CentraCare. But she didn’t know to look.
Roberts, now 49, has remarried and lives in a split-level dwelling in St. Cloud adorned with inspirational plaques akin to “Faith, Family, Friends.” CentraCare not too long ago dropped the lawsuit towards her, however solely after she took out a mortgage towards her retirement plan to repay the medical debt. “It just feels very unfair,” she mentioned.
Roberts thumbs by means of copies of her cost data at dwelling. (Anthony Soufflé/The Minnesota Star Tribune)
CentraCare’s flagship hospital in St. Cloud earmarks solely a fraction of its funds for serving to sufferers who can’t pay their medical payments. (Anthony Soufflé/The Minnesota Star Tribune)
‘We Have To Defend Being Paid’
CentraCare spokesperson Karna Fronden mentioned medical privateness legal guidelines prevented her from discussing Roberts’ case. She additionally declined interview requests in regards to the well being system’s charity care spending.
In an announcement, Fronden mentioned CentraCare gives help along with charity care, akin to serving to enroll sufferers in insurance coverage. “This helps provide broader, longer-term protection for patients,” she mentioned.
Other hospital leaders mentioned they serve their communities in methods moreover forgiving medical payments, together with coaching medical doctors and nurses and preserving money-losing providers akin to obstetrics and psychological well being care.
“Rural hospitals like ours are often portrayed as though we are sitting on piles of cash and simply choosing not to spend it on charity care. That is far from the reality,” mentioned Robert Pastor, chief govt of Rainy Lake Medical Center in International Falls.
“We are the second- or third-largest employer in town, running on razor-thin margins while navigating escalating labor and supply costs and routine underpayment by public programs,” Pastor mentioned. “Meanwhile, many health insurers post billions in profits.”
Hospitals usually are paid much less for care supplied to Medicare and Medicaid sufferers. More than 80% of Rainy Lake’s sufferers are on a type of authorities packages.
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Minnesota hospitals collectively write off about $200 million of what’s deemed unhealthy debt yearly after making an attempt unsuccessfully to gather unpaid payments from sufferers by means of calls, letters, and even lawsuits. By comparability, they commit about $163 million yearly to charity care, state figures present. In 2024, hospitals collectively posted $2.4 billion in internet earnings.
“I feel like I’m put in the position, being the hospital, where we have to defend being paid,” mentioned Patti Banks, the pinnacle of Ely-Bloomenson Community Hospital and a senior Minnesota Hospital Association board member.
Some hospitals face intense monetary pressures. Thirty-one have misplaced cash on operations in 4 of the previous eight years. HCMC in Minneapolis — the state’s largest security internet hospital, which gives probably the most charity care — is dropping a lot cash that, with out extra taxpayer help, it could close.
But bigger well being programs akin to Mayo Clinic, Essentia Health, and Sanford Health have remained financially sound. And the working margins at most CentraCare hospitals exceeded 10% in 2024, state information reveals.
Medical Debt’s High Toll
Abby Kelley-Hands is a particular training coordinator in St. Paul with a uncommon immune situation that causes frequent, extreme allergic reactions. She says that after she misplaced well being protection for a month due to an insurance coverage snafu a couple of years in the past, she was hit with greater than $20,000 in payments from Mayo Clinic and denied monetary assist. (Jeff Wheeler/The Minnesota Star Tribune)
Nationwide, well being care debt — a lot of it from hospitals — burdens an estimated 100 million people, rising their stress and even resulting in untimely deaths, studies show.
Abby Kelley-Hands, a particular training coordinator in St. Paul, has a uncommon immune situation that causes frequent, extreme allergic reactions. Her sickness may be managed solely with a pricey drug, which a Mayo Clinic physician prescribed.
When Kelley-Hands briefly misplaced well being protection in 2021 in an insurance coverage mix-up, she was hit with greater than $20,000 in payments. And though she and her husband earned lower than $100,000 a 12 months, Kelley-Hands mentioned Mayo denied her monetary help as a result of she earned an excessive amount of.
“I was in tears,” Kelley-Hands mentioned. “It was so scary and so hard. And it causes all of this additional stress, which then makes you sicker and less able to even figure things out.”
Kelley-Hands and her husband offered a automotive and agreed to a cost plan earlier than Mayo would resume her therapy, she mentioned. Her husband now bikes 5 miles to work. They haven’t any dishwasher. And she and her husband took a honeymoon solely final fall, seven years after their wedding ceremony. “We live very simply,” she mentioned.
Mayo spokesperson Kristyn Jacobson declined to debate Kelley-Hands’ case.
In 2024, state lawmakers banned hospitals from denying care to sufferers with excellent debt. And in 2025, Attorney General Ellison reached an settlement with Mayo to overtake its charity care program after an investigation discovered the multibillion-dollar establishment was systematically discouraging sufferers from making use of.
After the state started investigating Mayo, the system’s charity care spending nearly doubled, topping 1.5% of working bills in 2024.
‘Optimized To Get Payment’
Complying with a 2023 state law, Minnesota hospitals now publish their monetary assist insurance policies on-line, though a number of, together with CCM Health in Montevideo and Northfield Hospital, did so solely after being contacted by the Star Tribune or KFF Health News.
But many hospitals make monetary assist harder to seek out than details about paying payments, mentioned Jared Walker, founding father of Dollar For, a nonprofit that helps sufferers nationally apply for charity care.
“Hospitals have optimized to get payment,” he mentioned. “If you want to get on a payment plan, if you want to get on a credit card, it’s so easy.”
Glacial Ridge Health System in Glenwood posts a “Bill Pay” tab on the top of its homepage. But it takes a number of clicks to seek out the hospital’s monetary help plan. The data couldn’t be discovered on the positioning trying to find “charity care” or “financial assistance.” The public hospital 130 miles northwest of Minneapolis devoted lower than 0.7% of its working funds to charity care from 2019 to 2024.
Patients in interviews steadily mentioned they weren’t advised about charity care.
Joe Robling, 29, was handled at St. Francis Regional Medical Center in Shakopee for a damaged pelvis and fractured backbone after a 2024 motorbike accident. His mom, Janet, who helped him navigate the payments, mentioned the hospital by no means knowledgeable him about monetary assist.
“They didn’t offer any of that,” she mentioned.
Robling, a development employee in Henderson, was between jobs and uninsured. “He had zippo,” Janet Robling mentioned. “What he had in reserves were all depleted.”
The Allina Health-affiliated hospital billed him greater than $19,000, the Roblings mentioned.
An web advert linked the household to Dollar For, which helped Robling qualify for charity care 5 months after his accident.
Allina spokesperson Jennifer Steingas declined to touch upon the case, citing medical privateness restrictions, however mentioned the well being system has since reached out to the household.
In one other case, M Health Fairview’s University of Minnesota Medical Center didn’t supply monetary assist to an unemployed and uninsured man from Idaho whereas he was hospitalized for 2 months for psychiatric care and amassed $150,000 in payments.
Attorney Margaret Henehan, who represented the person, mentioned the hospital as a substitute provided him a two-year cost plan at $6,500 a month. “He had no income, which he told Fairview,” Henehan mentioned.
The man, who isn’t recognized due to his psychological well being situation, finally acquired charity care after his sister, a health care provider, reached out to Henehan for assist.
Aimee Jordan, a Fairview spokesperson, mentioned she couldn’t touch upon the case due to affected person privateness legal guidelines, however she mentioned sufferers who’re provided cost plans can all the time apply for charity care, even after a hospitalization.
M Health Fairview University of Minnesota Medical Center in Minneapolis, pictured in March 2013. (Joel Koyama/The Minnesota Star Tribune)
A Maze of Standards
State legislation prohibits hospitals from making “unreasonable” calls for of sufferers after they apply for charity care. But the legislation units few particular requirements.
The result’s a dizzying array of insurance policies, together with 11 earnings thresholds utilized by Minnesota hospitals to find out whether or not sufferers qualify without spending a dime care, the Minnesota Star-Tribune-KFF Health News evaluation discovered.
HCMC dad or mum firm Hennepin Healthcare in Minneapolis and Olmsted Medical Center in Rochester supply the best threshold without spending a dime care, at 300% of the federal poverty level — nearly $48,000 a 12 months for a person.
Sometimes requirements fluctuate even between neighboring hospitals. Madelia Health in south-central Minnesota limits financial assistance to sufferers who make lower than twice the federal poverty stage. About 13 miles away at Mayo’s hospital in St. James, patients earning twice as much can qualify for assist.
To decide eligibility, some Minnesota hospitals take into account solely earnings, however most demand details about sufferers’ financial institution accounts as nicely. More than two-thirds require much more data, together with the worth of retirement accounts, life insurance coverage insurance policies, property, and automobiles. Madelia’s policy states patients “may be required to sell recreational vehicles.”
Stringent necessities be certain that restricted sources go to sufferers who want them, mentioned Travis Olsen, chief govt of Hendricks Community Hospital, close to the South Dakota border. “We don’t feel it’s fair for someone with lower annual income but yet owns numerous acres of land, debt-free, to be able to qualify for charity care.”
In addition to copies of tax returns, W-2 types, pay stubs, and financial institution statements, Hendricks asks aid applicants 53 questions on their funds. These embrace questions in regards to the make, mannequin, and worth of automobiles; the present market worth of farm tools, livestock, and land; and the acquisition worth and sq. footage of properties.
Other hospital functions ask sufferers to element their month-to-month spending on meals, utilities, and different medical payments.
Olsen mentioned neighborhood stress is extra of a deterrent to making use of for assist than the appliance: “People are too proud to pick up an application. We all know each other.”
But Walker at Dollar For mentioned the most important barrier is complexity. “The drop-off rates are much higher the more questions you ask and the more documentation you have to provide,” he mentioned.
Arleen Mullenax had a cancerous tumor faraway from her neck at Mayo in Rochester. Assembling her assist software and following up with the hospital billing division amid her “cancer fog” was nearly greater than she might take, she mentioned.
“I knew as a former office manager I had to stay on top of it,” she mentioned. “But it was the most daunting thing I had to do as a patient.”
The Mayo Clinic campus in Rochester, Minnesota. Last 12 months, the multibillion-dollar establishment overhauled its charity care program after an investigation discovered it was systematically discouraging sufferers from making use of. (Aaron Lavinsky/The Minnesota Star Tribune)
Fixing the System
Ellison and several other state lawmakers say Minnesota’s hospitals ought to make it easier for sufferers to entry charity care.
They’ve known as for, amongst different issues, frequent eligibility requirements and a typical software throughout hospitals. New York and Maryland have already got each.
“Eliminating as many barriers as possible for people is really important,” mentioned state Sen. Liz Boldon, who additionally mentioned she hopes lawmakers can enact these requirements subsequent session.
The Minnesota Hospital Association has opposed standardizing monetary help, saying hospital boards are in the perfect place to evaluate the necessity for charity care of their communities. “Adding mandates for providers across the state will not close that gap, and will only increase bureaucratic and procedural barriers to patient care,” spokesperson Nelson mentioned.
Ellison additionally has pushed to require hospitals to make use of a course of that mechanically screens and qualifies low-income sufferers for monetary assist with out requiring an software.
Minnesota Attorney General Keith Ellison says Minnesota hospitals ought to present extra monetary help to sufferers to justify their tax-exempt standing. (Alex Kormann/The Minnesota Star Tribune)
Some hospital programs, together with South Dakota-based Sanford Health, already use software program that checks sufferers’ eligibility primarily based on data akin to their credit score historical past, mentioned Nick Olson, the system’s chief monetary officer. At Sanford Health’s 10 hospitals in Minnesota, a couple of quarter of the sufferers who obtain monetary assist get it this fashion, he mentioned.
Nearly all Sanford hospitals commit greater than 1% of their working expenditures to charity care — larger than most hospitals within the state.
Screening software program may be pricey. Several executives at small Minnesota hospitals mentioned they’ll’t afford it. But there are different choices. In California, Los Angeles County is creating a public system to permit hospitals to rapidly assess sufferers’ eligibility so that they don’t have to purchase a system themselves.
Other states — together with Texas and Nevada — have legal guidelines requiring hospitals to offer minimal quantities of charity care.
Back in St. Cloud, Roberts mentioned that when she drives previous CentraCare’s $200 million growth at its Plaza campus in St. Cloud, she wonders why Minnesota hospitals don’t dwell as much as larger requirements themselves.
“They have all the money,” she mentioned. “But they can’t grant a good person some grace?”
Minnesota Star Tribune employees writers Bill Lukitsch and Victor Stefanescu contributed to this report.
Roberts incurred greater than $8,000 in medical payments after she was recognized at CentraCare with early-stage cervical most cancers. She says the well being system advised her she made an excessive amount of — about $41,000 a 12 months — to qualify for monetary assist. (Anthony Soufflé/The Minnesota Star Tribune)