ST. CLOUD, Minn. — Four years ago, Cori Roberts, a 45‑year‑old returning to the workforce after a divorce, was diagnosed with early‑stage cervical cancer. Although she had insurance and a human resources job that paid about $41,000 a year, the treatment left her with more than $8,000 in medical bills she says she could not afford.
Roberts applied for financial assistance from CentraCare, the nonprofit health system that treated her. CentraCare, like other nonprofit hospitals, receives tax breaks in exchange for providing charity care to patients who cannot pay. Roberts says she was told she earned too much to qualify. She scrimped on essentials, paid off more than $6,000 over two years and was later sued by the health system for the remaining balance. She ultimately cleared the debt by borrowing against a retirement account; CentraCare has since dropped the lawsuit.
Her experience is central to a Minnesota Star Tribune and KFF Health News investigation that found hospitals across Minnesota provide only a sliver of their budgets for charity care and often make it difficult for patients to claim help.
How much hospitals spend
National hospital data show hospitals across the country devote an average of about 2.4% of operating budgets to charity care. Minnesota hospitals, by comparison, spend roughly a third of that amount on average. Of the state’s 123 general hospitals, 62 spent less than 0.5% of operating budgets on 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 of operations, the analysis found.
Investigators reached these conclusions by reviewing each hospital charity care policy in the state, analyzing five years of financial data and interviewing patients, hospital leaders and state officials.
A growing need
Charity care is becoming more important as rising numbers of people face coverage gaps, higher copays and larger deductibles. The country’s uninsured rate has been rising and could increase further, the reporting notes, if proposed budget cuts force states to pare back Medicaid and other safety‑net programs. An estimated 100 million Americans carry healthcare debt, much of it tied to hospital bills, and many insured patients now rely on charity assistance to afford care.
Hospital leaders say they cannot be expected to shoulder the entire affordability problem while operating on thin margins. “No amount of charity care from hospitals will ever fully meet the needs of uninsured or underinsured Minnesotans,” a Minnesota Hospital Association spokesperson said, noting the financial strain many hospitals face. Rural hospital executives stressed the local role their facilities play as employers and providers of unprofitable services such as obstetrics and mental health care.
Minnesota’s attorney general, though, argues hospitals should increase charity help in return for tax benefits. “There is a benefit you get from being a nonprofit hospital in the state of Minnesota,” he said. “But do the people get the benefit?”
Barriers to access
The investigation found large variation in how hospitals set eligibility rules and how easy—or hard—it is for patients to apply.
Some hospitals judge applicants only by income; many demand extensive documentation of assets and liabilities, including pay stubs, tax returns, bank statements and the value of retirement accounts, life insurance, homes, vehicles, farm equipment or livestock. One hospital’s application asks 53 questions about finances and property. Across the state, policies granting free care range from household income limits of about $15,000 to as high as $47,000.
Advocates say these burdensome requirements deter patients. Organizations that assist applicants report high drop‑off rates when forms and documentation demands grow. By contrast, hospital billing portals are often streamlined to accept payments and set up payment plans easily.
Consequences
For patients like Roberts, restrictive eligibility rules and administrative hurdles can mean months or years of debt, strained family budgets and the risk of collections or lawsuits. Patient advocates say this outcome undermines the purpose of nonprofit hospitals’ community benefit obligations.
Hospital officials counter that they provide community value in many ways beyond charity write‑offs, including workforce training and maintaining services that lose money but are essential locally. They also point to programs to help patients enroll in insurance as another form of assistance.
What varies most
The investigation highlights three main drivers of inconsistent patient experiences:
– Low overall spending on charity care in Minnesota compared with national averages.
– Wide variation in eligibility standards among hospitals, so the same patient could be helped at one facility and turned away at another.
– Lengthy, intrusive application processes that discourage or prevent people from applying.
The result: charity care that is too small, too inconsistent and sometimes too hard to access for people already least able to absorb medical bills.
This reporting was produced by KFF Health News in collaboration with the Minnesota Star Tribune.