Rose S. never thought a hospital bill would ruin her life, but she discovered that without health insurance, getting sick is a costly proposition. Rose, a registered nurse, works two jobs in order to make ends meet. She serves as director of nursing at a long-term care facility in Chicago, and she also has a part-time nursing position. Her full-time job provides her with health coverage. It was a different story in 2000 though, when Rose was working at a home health agency that did not provide health coverage. In October of that year, Rose suffered a major heart attack. She was rushed to one Chicago-area nonprofit hospital, where she was kept for two nights, then transferred to an affiliated hospital where she stayed for another night. Her hospital bill for those 3 nights totaled $18,000. When she expressed concern about how she was going to pay her bill, a hospital social worker promised to send her a financial assistance application, but the form never arrived. Rose called the hospital to track it down, but none of the people she spoke with knew anything about free care or any other kind of financial assistance. The hospital bills kept coming, and Rose tried to keep them at bay by making small payments, but that didn’t work. Less than a year after her heart attack, she was served with a summons to appear in court for non-payment of the hospital bill.

On the day she went to court, Rose never saw a judge. “We went into the hall with the hospital’s lawyer. We tried to get him to work out a payment plan, but the lawyer said he wasn’t authorized to do that. My heart attack and the bills threw my whole life out of kilter — my house was in foreclosure, my debts were climbing.” But things only got worse. The next thing she knew, the hospital began to garnish $350 from each paycheck. With the help of local consumer health advocates, Rose ultimately was able to reduce her debt to an amount she could manage, but without that outside intervention, Rose would still be struggling to get out of her financial hole.

Unfortunately, Rose’s experience is not unique. Cutbacks in public programs and employer health coverage have increased the number of people without adequate health insurance. More and more of these people are turning to their local hospitals to provide them with care. Several years ago, we at Community Catalyst, a nonprofit national consumer advocacy agency based in Boston, started hearing stories from across the country of people being turned away from their local hospitals or being asked to pay deposits before they were seen. There were also stories of people being pushed into bankruptcy after receiving hospital bills for thousands of dollars and others too ashamed to go back to the hospital where they owed money.

The stories of people falling through the cracks of the health care safety net and hospitals failing to provide free or reduced cost care was not on the radar screen of policy makers. Hospital trade associations at the state and national level were touting the amount of free care the industry provided as a principal justification for higher Medicaid and Medicare reimbursements. 1 But research made it clear that no one was carefully monitoring hospital policies. There was a conflict between the rhetoric of the industry and the reality of people trying to get care. It appeared that in most localities hospitals could charge uninsured people whatever they wanted and dun people with impunity. No agency on a local, state, or federal level seemed willing or able to address the problem.

The situation was an ideal one for a community monitoring project. The mission of Community Catalyst is to give voice to health care consumers, particularly those who are falling through the cracks of the health care system. Over the years, we have developed a network of organizations fighting for health care for all. These organizations were calling us asking for our help in addressing the problems related to hospital free care. They were ideal partners; grounded in the realities of their communities, they were both political, savvy, and well respected. Together, we created the Free Care Monitoring Project to test how easy — or difficult  — it was to get information about the availability of free care and other financial assistance at local hospitals. The goal of the project was to expose the problem, engage local consumer health leaders and hospitals management in problem solving discussions while working for more systemic solutions. The centerpiece of the project was a survey of local hospitals’ free care policies and practices, conducted by community members — called here “community monitors.”

Between 1999 and 2003, eight grassroots organizations in nine communities across the country participated in the project. The survey methodology was simple. In each site, the local organization recruited and trained community members — including people with and without health coverage and employees of social service and faith-based organizations — to make telephone inquiries and personal visits to local hospitals, asking about the availability of free care and the policies for providing it. Using protocols designed by Community Catalyst, the community monitors called and visited the hospitals and recorded the responses. Calls were made to the hospitals’ general information numbers, their patient accounts offices, their admitting offices, and their emergency rooms. At least one monitor also visited each hospital to look for signs publicizing the availability of free care or other financial assistance. In communities with large non-English speaking populations, there was an effort to ensure that at least one of the calls was made in a language commonly spoken within the community.

The expectation that hospitals will provide at least some free care to those in need arises from a number of sources. In some cases, communities have established public hospitals that have explicit missions to serve those who don’t have financial resources. In the case of nonprofit hospitals, the obligation is rooted in their tax-exempt status. The quid pro quo for relieving an institution of its tax burden — federal, state, and local — is the expectation that it will provide benefits to the community that forgoes the tax revenue. In addition, several states require hospitals to provide some level of free care, generally in exchange for receiving various public funds.

There is also a growing expectation that special responsibilities attach even to for-profit institutions that provide health care and other essential services. For-profit hospital ownership is becoming more prevalent — and for-profit hospitals are becoming major forces in some communities. An analogy can be made to banks that, like for-profit hospitals, operate pursuant to publicly granted charters.

Long Island, NY / Long Island Health Access Monitoring Project

Columbus, OH  /  Universal Health Care Action Network of Ohio

Washington, DC / Health Care Now

Chicago, IL  /  Campaign For Better Health Care

Marion and Polk Counties, OR / Oregon Health Action Campaign

Portland, OR  /  Oregon Health Action Campaign

Champaign County, IL  /  Champaign County Health Care Consumers

Alexandria, VA / Tenants’and Workers’Support Committee

Hartford, CT  /  Building Parent Power

Despite the diversity among the nine sites, the findings of the community monitors were surprisingly consistent.

Most callers were told that free care and other financial assistance were not available. If there was a policy, front-line hospital staff were almost universally unaware of its existence. Nor did these staff members know whom to refer callers to for information about free care. Moreover, in the majority of hospitals there was no signage.

One woman told me that she didn’t think there was such a thing as free care because if there was the hospitals wouldn’t be able to go on. She told me to go to a clinic.

Community monitor, Hartford, CT

A typical response from hospital staff was that emergency care would be provided without proof of ability to pay, but the patient would be billed for those services.

They told me ‘If it was a life threatening emergency, we would take you to stabilize you, but you would be billed for everything.’

Community monitor, Chicago, IL

If the community had a public “safety net” hospital, the staff typically told the monitors to go there for free care.

The hospital person told me ‘If someone doesn’t have the $36 deposit, we wouldn’t see them. If they needed service, we would discontinue it if there was no way the hospital would get paid. If they can’t pay anything, they should go to Cook County Hospital.’

Community monitor, Chicago, IL

Monitors who were not fluent in English generally were out of luck. They were almost never connected with a hospital staff person who spoke their language, even if the language was a common one like Spanish. Hospital personnel often hung up on non-English-speaking callers or transferred them to other departments where the staff could not speak their language.

The Follow Up

Once each of the groups compiled their survey findings, they developed their own strategies for using the data. Some groups met hospital leaders to discuss the findings. Others released the report publicly, first offering the hospital the opportunity to address the problems identified. The organization’s press release would note when the hospital agreed to that cooperation. One group opted simply to release its report to the community because it thought the local hospitals would be unresponsive.

The hospitals’ responses were mixed. Some were angry. Several hospitals felt the reports questioned their commitment to providing care to everyone in the community, even though the survey’s focus was whether hospitals had policies and processes in place that made it easy for consumers to get information about free care.

Private health care providers already provide over two-thirds of the uncompensated care in the city . . . I will not waste a minute defending [the hospital] against your foolish accusations.

Hospital CEO, Washington, DC

We’re providers of care. We’re not the U.N.

Ohio Hospital Association executive

Other hospitals were exemplary though. Several hospital executives admitted that they had been unaware of the barriers to free care or other financial assistance.

The policy is to provide access to care. If there are hospital employees who are not communicating that policy clearly, we have got to make changes and we will make changes.

Long Island hospital executive

We learned there was a lot of weakness in the implementation [of free care programs].

Oregon Health and Hospital Association official

Hospital leaders in Marion and Polk Counties in Oregon, Columbus, Ohio, and Suffolk and Nassau Counties in New York agreed to address some issues raised by the monitoring projects.

In Oregon for example, hospital leadership in Marion and Polk County worked with the community group to develop a publicly accessible free care policy that included eligibility for full free care at 150% of the Federal Poverty Level (FPL) and a sliding fee scale above that, a commitment to negotiate reasonable payment arrangements, a uniform application, and staff training on free care policies and the application process.

In Columbus, the hospitals came together as a group to work with the community organization. Together they agreed to do more to publicize the availability of free care and other financial assistance both in English and other languages commonly spoken in the community, and to train staff on free care policies and the application process. The community and hospitals are continuing to work to develop uniform income eligibility standards for free care — potentially up to 200% FPL for full free care.

In Nassau and Suffolk Counties in New York, individual hospitals met with the community monitors and reached some agreements around free care standards, the application process, and publicizing the availability of free care. The Nassau Medical Center convened a consumer advisory board to address community/hospital relations and other areas of community concern related to hospital performance. North Shore University Hospital revised and expanded its free care policy, and it is working with its affiliate hospitals to adopt it as well. The Long Island Health Access Monitoring Project went further and generated enough community support to get laws passed in both Suffolk and Nassau County. The laws require the hospitals to develop financial assistance policies, make them readily available, and post clearly visible notices about free care. The Nassau law also requires hospitals to file annual reports with the county’s department of health that include enough data to enable community members to evaluate hospital free care performance.

Although a number of implementation issues remain, advocates feel that the hospitals can and will address them, and that they will do so in a collaborative fashion. Thus, another positive project outcome is that it has opened new lines of communication between institutions and their communities. In some cases, these relationships already have proven to be mutually beneficial. A number of hospitals appreciate the closer connection to the communities they serve, and they have achieved a better understanding of community concerns. The community organizations, in turn, better appreciate the constraints under which local hospitals operate. The collaboration between the Oregon Health Action Campaign and local hospitals has led to joint efforts to reach out to the low-income uninsured — who otherwise might need free care — and enroll them in the Oregon Health Plan, the state’s Medicaid program. It has also led to better linkages between hospitals and community health centers. Hospitals benefit because they have a place to refer the uninsured who they treat in their emergency rooms who then need follow-up care. Community health centers benefit because they have a place to refer their patients who may need inpatient or specialty care. In Columbus, the hospitals asked for — and got — UHCAN’s support in promoting a bill that would put a moratorium on the building of so-called boutique hospitals.

If not for the community monitors, the gap between institutional rhetoric and institutional performance — as experienced by people “on the ground” — would not have come to light. Nor is it likely that any of these very important improvements would have occurred. In places where communities and hospitals have come together, there is a now a recognition of the potential for these collaborations to lead to a whole range of mutual aid and support, including grant applications, certificate of need proceedings, and special health access initiatives. Moreover, in communities where hospitals refused to come to the table, the experience has strengthened the resolve of community members to force those institutions to deal with them. The project proved to be an important part of broader efforts to address the problems facing low-income people in accessing hospital free care and has prompted state and even national attention to the issue. In this case, citizen monitoring connected the experience of the people to policymakers in a powerful and effective way.

1. American Hospital Association, “The Case for Hospital Payment Improvement” (2003),

BETSY STOLL is Community Catalyst’s director of development and policy. A former legal services lawyer, she has more than 20 years’ experience in health care policy. ROB RESTUCCIA, who has been the executive director of Community Catalyst since 2000, has worked to improve and expand access to health care for vulnerable populations for over 30 years.