Federal legislation requires that every one nonprofit hospitals have monetary help insurance policies — also referred to as “charity care” — to cut back or expunge folks’s medical payments. New analysis from Greenback 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 Greenback For founder Jared Walker about its latest work, and the way new state applications focusing on medical debt in locations like North Carolina might change the way in which hospitals strategy charity care.
Plus, a listener from New York shares a useful useful resource for navigating charity care appeals.
Dan Weissmann
@danweissmann
Host and producer of “An Arm and a Leg.” Beforehand, Dan was a employees reporter for Market and Chicago’s WBEZ. His work additionally seems on All Issues Thought-about, Market, the BBC, 99 P.c Invisible, and Reveal, from the Middle for Investigative Reporting.
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Emily Pisacreta
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Claire Davenport
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Transcript: New Classes within the Combat for Charity Care
Notice: “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 device however examine the corresponding audio earlier than quoting the podcast.
Dan: Hey there–
Clara lives in New York Metropolis along with her husband Remy and their household. And, lately, over the course of a 12 months, that they had some … medical encounters. At hospitals.
Nothing super-dramatic: Remy broke his ankle in August of final 12 months. Hiya, emergency room. Hiya, ER invoice.
They’d a second child in November 2023 — a boy! — who ended up needing to spend a day in neonatal intensive care. He’s nice. They named him Isaac.
And one evening early this 12 months, Isaac simply… wasn’t wanting good. Torpid. 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. However it was late at evening. No pediatrician, no pressing care. Hiya new, unwelcome questions.
Clara: The very last thing you wish to be desirous about is, Oh shit, that is going to be actually costly. You wish to be desirous about, let’s go to the ER proper now, be certain he doesn’t have a seizure.
Dan: In order that 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 bit of anxious concerning the payments.
After insurance coverage, they had been greater than eight thousand {dollars}. Clara didn’t assume 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: Nevertheless. Clara listens to An Arm and a Leg. The place we’ve been speaking about one thing known as charity look after years. This summer season, 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.
Simply to recap: Federal legislation 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 fully, if their revenue falls beneath 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 TikTok spreading the phrase and providing to assist folks apply, by means of the nonprofit he runs, Greenback For.
Since then, we’ve realized a LOT about charity care. Greenback For has grown from an infinitesimally tiny group — principally Jared, not getting paid a lot -to a small one, with 15 folks on employees.
Jared says they’ve helped folks with 1000’s of functions and helped to clear thousands and thousands of {dollars} in hospital payments.
And prior to now 12 months, they’ve been as much as a LOT and so they’ve been studying alot. Earlier than we decide up Clara’s story — which ends along with her providing a brand new useful resource we are able to share — let’s get a giant obtain from Jared.
That is An Arm and a Leg, a present about why well being care prices so freaking a lot, and what we are able to 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 one of the vital enraging, terrifying, miserable elements of American life- and convey you a present that’s entertaining, empowering and helpful.
In early 2024, Greenback For put out a few large 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 wanting round on the consultants, proper? Who’re the consultants? And the place can we discover them and what can we ask them?
Dan: Lastly, they undertook a significant analysis mission of their very own. They analyzed 1000’s of IRS filings from nonprofit hospitals, and in contrast what they discovered to a research from the state of Maryland based mostly on much more exact information.
They usually 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 information 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 a few who do get rejected, regardless that they qualify.
Their conclusion: “We discovered that solely 29% of sufferers with hospital payments they can not afford are in a position to study, apply for, and obtain charity care.” None of which stunned Jared.
Jared: It’s like, Oh, like our assumptions have been right on this. Like folks don’t learn about charity care. The method 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 accountability on the affected person
Dan: These topline findings put Greenback For’s accomplishments in context.
Jared: Like we’ve got submitted over 20, 000 of those monetary help functions.
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 simply’re speaking about to this point?
Jared: I believe we’re closing in on 70 million, 70 million in medical debt aid. So
Dan: Proper. 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: snort crying emoji.
Jared: Yeah, yeah, yeah.
Dan: And so, for many of the 12 months, Jared and his group have been testing a technique to tackle a 14 billion greenback downside.
Jared: Now we have spent the 12 months making an attempt to work with hospitals. We got here at this – how can we put a dent within the 14 billion? If it’s not going to be by means of TikTok, and it’s not going to be by means of particular person affected person advocacy, then what if we moved additional upstream, and as an alternative 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 Greenback For for assist making use of, earlier than they try. He thought
Jared: Perhaps 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 may do higher by sufferers, along with his assist, and signal proper as much as work with him.
Jared: Um, properly they haven’t, Dan. So, we don’t have, uh, , we’ve acquired one hospital.
We’ve acquired one hospital. I don’t know if there’s a smaller hospital in america. It’s Catalina Island Well being. It’s a small hospital on an island off the coast of California
And when sufferers go in there, they inform them about Greenback For, and so they ship them over. Um, that was what we had been hoping to do with these bigger techniques.
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 already know, that is one factor the place I’m like, I don’t wish to be completely unfair to the hospitals.
They’re enormous entities which you could’t simply transfer shortly like that.
it will take much more on their finish than it might on our finish, we might spin up one among these partnerships in per week.
And. They’re going to wish a number of time and it’s going to, , how can we implement this? Um, , with a small Catalina Island hospital it was simple, however should you’re speaking to Ascension
Dan: Ascension Healthcare– a giant Catholic hospital system. 100 thirty-six hospitals. Greater than 100 thirty thousand workers. Throughout 18 states, plus DC. Jared says they could get 1000’s of charity care functions 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 already know, how do you implement that? I imply, it’s a ache within the ass. And these hospitals, and extra so, hospitals will not be motivated to determine this out.
Dan: Yeah. Proper.
Jared: Until 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: underneath this program. Hospitals can earn extra by forgiving medical debt than making an attempt to gather it. This can be a win win win.
Dan: Below this system, hospitals can get extra Medicaid {dollars} in the event that they meet sure situations. One, forgive a bunch of present medical money owed. One other: Be certain that their charity care insurance policies shield sufferers who meet revenue threhholds set by the state.
A 3rd: they should pro-actively determine sufferers who’re eligible for charity care — and notify these sufferers earlier than sending a invoice, possibly even earlier than they depart the hospital.
Jared: I’m very excited to see how that appears sooner or later. As a result of should you keep in mind, the massive 4, like our shit checklist, is Texas, Florida, Georgia, North Carolina.
Dan: Jared’s shit checklist. The states the place, through the years, he has heard from the best quantity of people that have problem getting hospital charity care. The place he typically has to battle hardest to assist them get it.
Jared’s shit checklist, the massive 4, had been the 4 greatest states (by inhabitants) that had rejected the growth of Medicaid underneath the Inexpensive Care Act.
Due to 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 downside. And North Carolina was a type of states the place it was hardest.
Jared: And in, , the span of a 12 months, North Carolina has expanded Medicaid, and created top-of-the-line medical debt charity care insurance policies within the nation.
This legislation basically says that they should determine them early. In order that’s like – on paper, , it sounds wonderful.
Dan: Onpaper it sounds wonderful. We’ll come again to that. However 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 increase Medicaid.
The legislature lastly agreed in 2023. After which Cooper and his group spent months this 12 months determining tips on how to bake medical-debt aid into the plan. It took a ton of maneuvering.
Our friends at KFF Well being Information coated the method. Right 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 group began out by making an attempt to quietly bounce their concepts off just a few hospitals..
Ames Alexander KFF Well being Information: However then phrase acquired again to the hospital trade’s highly effective lobbying group. That’s the North Carolina Healthcare Affiliation. And the Affiliation was by no means blissful about it. .
Dan: They raised a stink. And claimed the entire thing can be unlawful, the feds shouldn’t approve it.
Cooper and his well being secretary Cody Kinsley acquired stored going– and so they did get the feds to log out on the plan. So it was authorized.
However it wasn’t obligatory. They had been providing hospitals cash, however these hospitals wanted to say sure. And that didn’t occur instantly.
Ames Alexander KFF Well being Information: When Cooper and Kinsley unveiled this plan on July 1st, there wasn’t a single hospital official who would be a part of them there for the press convention. In the end, although, all 99 of the state’s hospitals signed on. And it’s not, it’s probably not onerous to know why they stood to lose a number of federal cash.
Dan: Lose OUT on a ton of NEW federal cash. A ton. Based on KFF’s reporting, a single hospital system stands to achieve like 800 million {dollars} a 12 months for collaborating.
And , desirous about that — how a lot cash hospitals had been contemplating turning down — form 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 12 months.I mentioned to Jared: Looks like this could be onerous to duplicate elsewhere. Different states aren’t going to have the ability to put that form 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 can we make it? How can we make it work in North Carolina?
Dan: That’s: How to verify when it will get applied, that it actually works? Bear in mind, 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 Highway Productions and KFF Well being Information — that’s a nonprofit newsroom protecting well being points in America. KFF’s reporters do wonderful work — you simply heard one among 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 should display folks whereas they’re on web site, and allow them to know earlier than they depart the hospital what sort of assist they might be eligible for.
Jared: Ensuring {that a} affected person is aware of what is offered to them earlier than they depart may be very highly effective. , like, that’s the place the accountability must be. Um, however how do you do it? And what occurs should you don’t? Proper?
Dan: In different phrases, Jared says, the satan is in implementation, and in techniques of accountability. He’s seen what occurs when these techniques are pourous.
Jared: In Oregon, that they had that legislation that was like, Oh, you’ll be able to’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 legislation 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 revenue in just a few of them– however in nearly half of these, that revenue was undoubtedly low sufficient that the debt ought to’ve been forgiven.
He additionally took a big-picture look: Within the years after the legislation took impact, two thirds of hospitals gave out LESS charity care than that they had given earlier than. In all probability not what lawmakers had hoped for.
Hospitals in North Carolina could have two years to totally implement the screening requirement, known as “presumptive eligibility.”
Some hospitals across the nation already use automated techniques for this: They examine your credit score, pull different information. A few 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 solution to say, Oh, we already screened you. You possibly can’t apply, however the affected person is sitting there going, properly, I’m eligible.
Your device should have acquired it flawed. Trigger this stuff will not be 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 an alternative of three.
And clearly the presumptive eligibility device isn’t going to have the ability to know that and calculate that. So should you go to the hospital and say, now I wish to apply and so they say, properly, 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 deliver their techniques on-line, Jared desires to push for a course of the place sufferers can attraction a machine-made resolution. Jared: I’d love to have the ability to check that
how does that influence how many individuals are getting charity care and that 14 billion?
Dan: What do you assume is your finest shot for the subsequent 12 months of form of shifting in 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’d land, um, I believe that we’ll 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. However…
Jared: The one purpose 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 must push insurance policies ahead that we wish to see occur
Dan: So, this can be a good place to notice: If you happen to or anyone has a hospital invoice that’s scaring you, Greenback For is a good first cease. We’ll have a hyperlink to their web site wherever you’re listening to this. They’ve acquired a device that may assist you shortly determine should you may qualify for charity care out of your hospital. Plus tons of how-tos. They usually’ve acquired devoted employees that will help you should you get caught.
And we simply heard Jared say they’re not backing away from that work, whilst they intention to affect coverage.
About coverage — Jared does have one different thought of their work in that space
Jared: We expect that we’re going to get a bit of 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 Home of Representatives, and naturally there’s nonetheless a LOT we don’t learn about what issues appear to be from right here. Jared had only one prediction.
Jared: I believe we’re going to be wanted, , that rather more.
Dan: I believe we’re all gonna want one another greater than ever. Which is why I’m happy to deliver us again to Clara’s story from New York.
You may keep in mind: Her household had three hospital adventures within the house of a 12 months.
The primary one, the place her husband broke his ankle, acquired her began. The invoice was eighteen hundred {dollars}, after insurance coverage. A LOT for his or her household. However she had just a few 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. As a result of by coaching, she’s a librarian. And —chances are you’ll already know this however — folks come to libraries wanting for lots extra than simply books.
Clara: Folks on a regular basis, will are available and usher in a kind or need assistance navigating totally different techniques and, and even simply wanting and making an attempt to see the place to begin.
Dan: So, she went and located her hospital’s monetary help coverage on-line. Noticed that her household met their revenue necessities. Discovered the shape. Submitted it. Acquired supplied a reduction… that also left her household on the hook for greater than they may comfortably pay.
And determined to see if she might ask for extra. Was there an appeals course of? There was.
However she didn’t discover the entire data she wanted on-line. The method wasn’t fast.
Clara: Lots of cellphone tag. And I don’t know if the invoice pay cellphone strains are staffed higher than the monetary help cellphone strains. However, , you get an answering machine quite a bit. You must name again. The individual doesn’t keep in mind you. They’re not in a position to hyperlink your account.
All of 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 help and attraction course of.
Dan: Clara hung in there. Right here’s what she instructed 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 kind of maneuvering by means of the loopy healthcare system. And I do form of have Dan’s voice in my head, like, that is nuts. This isn’t your fault. That is loopy and never proper.
Dan: Additionally, when she was angling for extra assistance on her husband’s ER invoice, she knew something she realized might turn out to be useful: She was on account of give start on the similar hospital fairly quickly.
Her persistence paid off. Ultimately, the hospital diminished 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 realized the primary time by means of as a playbook. Apply, then attraction to ask for extra assist. She says that made it a bit of less complicated. However 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 resolution about her attraction. Was it gonna be permitted?
Clara: Within the occasion that it’s not, I believe we simply put it on just like the longest cost plan we are able to. Perhaps we’d ask household for assist.
Dan: Replace: A number of days after that dialog, the hospital mentioned sure to Clara’s attraction. Her new whole, 650 {dollars}. A couple of tenth of that preliminary quantity.
Which, sure, is a pleasant story for Clara and her household. However the purpose I’m so happy to share her story is that this:
Clara: Really, 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 is likely to 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 speculated to make it versus how technical
Dan: Right 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 every thing else. making an attempt to place myself of their sneakers, studying it, what can be helpful to form of add extra depth to our story than simply the invoice. After which additionally I simply tried to be actually grateful and categorical genuine gratitude for the good care we obtained.
Dan: She additionally included a sensible 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 publish 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 assist you this a lot” 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 apprehensive. ” I didn’t ship it in time. It is likely to be off by a pair days. Is that this going to be an enormous downside? They usually mentioned, No, don’t fear about it.
It’s completely nice. Simply ship it. So I’m considering, Okay, wait. There are such a lot of people who find themselves going to get minimize off or get their invoice and notice, Oh, properly, I completely missed the window. So let’s go for the cost plan choice. When truly,
Dan: If you happen to’ve acquired the chutzpah, and the time, and the endurance to make the subsequent name and ask… chances are you’ll get a unique reply.
It sucks that it’s this tough. However I admire each clue that it’s not unattainable. And I admire Clara sharing her story — and her template with us.
I instructed 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 gotten this affected person that’s going by means of all of these things and is so busy making an attempt to concentrate on 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 , , 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?
However how wonderful is it that you’ve got, you’ve gotten constructed a group of individuals which might be, , prepared to, uh, take these form of crappy, not form 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 a great factor going. We’ve acquired a lot to do in 2025, and your donations have all the time been our greatest supply of assist. 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, assist.
That’s arm and a leg present dot com, slash, assist .
We’ll have a hyperlink wherever you’re listening.
Thanks a lot for pitching in should you can.
We’ll be again with a model new episode in just a few weeks.
Until 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 Periods. 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 Well being Information. 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 Well being Information. He’s editorial liaison to this present.
And due to the Institute for Nonprofit Information for serving as our fiscal sponsor. They permit us to simply accept tax-exempt donations. You possibly can study extra about INN at INN.org.
Lastly, thanks to everyone who helps this present financially.
“An Arm and a Leg” is a co-production of KFF Well being Information and Public Highway Productions.
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