Most hospitals offer financial assistance to patients who struggle to afford their bills, often referred to as charity care. But many people are stymied by cumbersome aid applications. Others don’t even know help exists.

Hospitals can proactively screen patients to see if they’re eligible for aid and, if so, automatically wipe out or reduce their bills — a process known as presumptive eligibility.

This story is part of Hidden Help, an investigative series from Tradeoffs and KFF Health News about how hospitals can protect their patients from the life-altering harms of medical debt. Explore the series →

A growing number of state policymakers and researchers believe requiring hospitals to use presumptive eligibility would protect low-income Americans from falling into medical debt, especially with federal funding cuts expected to increase the number of people without health insurance. Some hospital leaders resist new requirements, arguing in part that they put unfair responsibility on hospitals to address rising patient costs and a shrinking safety net.

Oregon passed the most comprehensive presumptive eligibility law in 2023. A similar law in California — originally opposed by hospitals — is set to take effect in July 2027. Los Angeles County public health officials have been working with local hospitals to make the new rules easier for them to implement.

On Thursday, Oct. 22, Tradeoffs’ executive editor Dan Gorenstein moderated a conversation about the promise and challenges of presumptive eligibility. The panelists included:

Watch the conversation here:

We also wanted to answer a few additional questions asked by our audience that we could not get to during the conversation:

How is eligibility for presumptive eligibility determined?

In most states, hospitals decide which patients can skip the application. 

Common groups automatically screened include people who are homeless, deceased, or already enrolled in state or federal programs to help low-income households with housing, food, or prescriptions. Other hospitals have more unique criteria, like Christus Health, which will write off bills for anyone in a religious order who took a vow of poverty.

Across the half-dozen states with presumptive eligibility mandates, eligibility rules vary. Maryland, for example, requires hospitals to proactively wipe out bills only for patients who already get government help for food or utilities but are ineligible for Medicaid. In Illinois, lawmakers created less-stringent requirements for rural hospitals compared with urban facilities.

In Oregon, hospitals had to, starting in 2024, screen anyone who owed more than $500 and every patient on Medicaid or who is uninsured. The state’s legislature this year raised the screening dollar amount threshold to patients who owe at least $1,500 for a single visit.

Eligibility criteria are often buried in official policies and hard to find or decipher. Some hospitals share little to no public information about whom they will proactively screen. We pulled together the details of every Texas nonprofit hospitals’ presumptive eligibility policy, including who is eligible, as part of our investigation.

What platform or vendors manage this tool? 

Typically, hospitals turn to public records, any information patients have previously volunteered, or tools from consumer credit companies to estimate whether patients qualify to have bills reduced.

For example, if a hospital sees that a patient lives in a high-poverty ZIP code or has no address listed, that could be enough to deem them eligible. Many pay companies to run employment and credit checks on patients to determine if they qualify for free care.

What is the prospect of more conservative states passing such a law?

Rep. Tom Oliverson, a Republican legislator in Texas, proposed legislation in his state in 2025 that would require nonprofit hospitals to screen patients and provide aid before sending bills. Those that don’t would face penalties, including potentially losing their tax-exempt status.

The legislation failed, but Oliverson said he plans to reintroduce it in 2027. “This is clearly an industry that is not policing itself very well,” Oliverson said.

This summer, the bipartisan National Council of Insurance Legislators, passed model legislation that would require hospitals to use presumptive eligibility before sending bills.

What reporting is required at the federal and state levels on presumptively applied financial assistance?

There are no federal requirements for hospitals to use presumptive eligibility.

Under the Affordable Care Act, nonprofit hospitals must make reasonable efforts to find people who are eligible for help before they take patients to court, sell their debt to collection agencies, or take other extraordinary action to collect bills. Presumptive eligibility is one way hospitals can comply with the regulation, which took effect in 2016. 

Nonprofit hospitals report their use of presumptive eligibility to comply with the ACA on annual filings to the Internal Revenue Service. 

The federal law doesn’t apply to for-profit and public hospitals, which don’t have to report the actions they take before going after patients for unpaid bills.

By July 2027, six states will require hospitals to use presumptive eligibility and skip applications for certain patients. Those states are California, Delaware, Illinois, Maryland, North Carolina, and Oregon.

In Oregon, hospitals must report to the state the number of people who they approved for help presumptively. Hospitals in Illinois must disclose the number of presumptive approvals for financial assistance. Delaware hospitals will be required to report how many times they presumptively screen patients and how many patients get automatic relief. 

Has Oregon’s law helped reduce medical debt? Are fewer patients ending up in collections or borrowing money to pay hospital bills?

We don’t know yet.

What we do know is that many more people in Oregon are getting financial aid than before the law. In their first full fiscal year under the law, spending by Oregon hospitals on financial assistance more than doubled, on average, according to federal financial reports from about two-thirds of the state’s hospitals. That’s compared with their last full year before the change.

Oregon Health & Science University, which includes one of the state’s largest hospitals, saw 64% of its patients qualify for financial assistance in the early months of the new law, up from 12% previously.

Oregon hospitals’ spending on free and discounted care increased to 2.7% of all operating expenses, on average, from 1.4%, among the roughly two-thirds of hospitals with available federal data. That brings hospitals in Oregon closer to the national average for nonprofit hospitals, which from 2021 to 2024 was about 2.4%, according to an analysis by Johns Hopkins University researcher Hossein Zare, who studies the industry.

In the absence of presumptive eligibility, how can we reduce medical debt post-accrual?

This 2025 report from the Commonwealth Fund breaks down several ways in addition to presumptive eligibility that states can protect patients from medical debt.

Nearly 30 state and local governments have used public funds to forgive people’s medical debt, according to one 2026 analysis. Many have partnered with the nonprofit Undue Medical Debt to facilitate the debt relief.

A 2022 study found that patients who received hospital financial aid within weeks of care were much more likely to return to the doctor and get treatment for conditions like diabetes and depression. Conversely, a landmark study published in 2024 found that wiping out people’s medical debt years later had no effect on their mental and physical health, health care use, or financial situation. 

This has led researchers and advocates to push for more preventive strategies, including making sure people have health insurance and presumptive eligibility.   

Ryan is the managing editor for Tradeoffs, helping lead the newsroom’s editorial strategy and guide its coverage on its flagship podcast, digital articles, newsletters and live events. Ryan spent six...

Melanie is a reporter and producer for Tradeoffs. She spent eight years at The Wall Street Journal, where she reported on hospital costs, health care quality and the Covid-19 pandemic. Before the Journal,...