Four years ago Cori Roberts, a newly returned worker in her mid-40s living in a rented basement in St. Cloud, Minn., was diagnosed with early-stage cervical cancer. Her job in human resources paid about $41,000 a year and she had insurance, but bills from her treatment topped $8,000. CentraCare, the nonprofit system that treated her, told her she earned too much to qualify for its charity assistance.
Roberts scraped together money by cutting essentials and worked for two years to pay down more than $6,000. When she still owed a balance, CentraCare sued. The system later dropped the suit, after Roberts took a loan against her retirement to settle the debt. Her story illustrates how hospital charity programs can fail patients who are insured but still unable to afford care.
A joint investigation by the Minnesota Star Tribune and KFF Health News looked at every hospital charity care program in Minnesota, analyzed five years of hospital financial records, and interviewed patients, hospital leaders and state officials. It found that Minnesota hospitals, on average, devote far less of their operating budgets to charity care than hospitals in most other states.
Nationally, federal hospital data compiled by researcher Hossein Zare at Johns Hopkins show hospitals spend roughly 2.4% of operating budgets on charity care. Minnesota hospitals spend about a third of that amount on average. Of the state’s 123 general hospitals, 62 devoted less than 0.5% of their operating budgets to charity care from 2020 through 2024. CentraCare’s flagship St. Cloud hospital spent under 0.25%—roughly $25 in patient aid for every $10,000 it spent on operations.
The need for charity care is growing. The uninsured rate has been rising, and many insured people face higher copays and deductibles that push medical bills beyond their means. Nationwide, an estimated 100 million people are burdened by health care debt, much of it stemming from hospital bills. Historically charity care targeted the uninsured; today it often helps insured patients who cannot manage their out-of-pocket costs.
Investigators found wide variation across Minnesota hospitals in who qualifies for free or reduced-cost care and how easy it is to apply. Because the state has not standardized charity care criteria, a patient might qualify at one hospital and be ineligible at another nearby. Some hospitals set income cutoffs around $47,000 for free care; others cap eligibility at roughly $15,000.
Many systems require lengthy, intrusive documentation: tax returns, pay stubs, bank statements and detailed asset inventories. More than two-thirds of Minnesota hospitals ask applicants about retirement accounts, life insurance, property and vehicles. One example is Hendricks Community Hospital, which asks aid applicants 53 financial questions, including the make and value of vehicles and the market value of farm equipment, livestock and land.
Advocates and nonprofit groups that help patients say these extensive requirements discourage applications. Drop-off rates rise as applications become more burdensome, while hospitals have optimized online billing and payment processes to encourage prompt payment. As one organizer put it, it is often much easier to find a button to pay a bill online than to find straightforward help getting it reduced or forgiven.
Hospital leaders and trade groups push back, saying hospitals operate with tight margins, face rising labor and supply costs, and are constrained by underpayment from public programs. Rural hospitals also emphasize their role as major local employers and the financial fragility of maintaining essential but unprofitable services such as obstetrics and behavioral health. ‘‘No amount of charity care from hospitals will ever fully meet the needs of uninsured or underinsured people,’’ a Minnesota Hospital Association spokesperson said.
Minnesota’s attorney general, Keith Ellison, argued hospitals receiving tax breaks and other nonprofit benefits have a corresponding duty to increase charitable help for needy patients. State and consumer advocates say hospitals should do more to align charity care policies with community needs, simplify enrollment and stop suing patients who are trying to pay but can’t afford full bills.
Hospitals say they provide other kinds of community benefit beyond forgiving bills—training clinicians, sustaining unprofitable services, and helping patients enroll in insurance coverage—which can offer longer-term protection. CentraCare also pointed to programs that assist patients with insurance enrollment. But critics argue that these community benefits do not replace immediate financial relief for people facing medical debt.
The investigation also found that geographic differences matter: in Minnesota, a person might be eligible for free care at a provider 30 miles away but not at their local hospital—information many patients do not know when urgent care is needed. The variation mirrors findings in other states and metropolitan areas: researchers, including the Lown Institute, have documented wide disparities in financial assistance policies even among hospitals located blocks apart.
For Roberts, seeing CentraCare’s major expansion in St. Cloud after her experience heightened the sense of unfairness. ‘‘They have all the money,’’ she said, ‘‘but they can’t grant a good person some grace?’’
As more Americans face medical bills they cannot pay, statewide and national debates are intensifying over how to ensure nonprofit hospitals that benefit from tax exemptions provide sufficient, accessible charity care. Advocates urge clearer, standardized eligibility rules, simpler applications, and stronger reporting or enforcement to ensure taxpayers and patients see the public benefit hospitals are meant to provide.
This story was produced by KFF Health News in collaboration with the Minnesota Star Tribune.