In some states, hospitals are experimenting with something called presumptive eligibility. It will automatically screen patients for financial assistance needs.
High healthcare costs continue to be a top concern for voters ahead of next month’s midterm elections. A recent study from the Urban Institute found that more than one in four adults in the U.S. had medical debt in 2025.
For many, those overdue bills started with a trip to the hospital. Some states are pushing hospitals to do more to prevent their patients from falling into debt. It has to do with requiring financial aid earlier in the process.
For more, “Marketplace Morning Report” host Kimberly Adams spoke with Melanie Evans, a reporter and producer with the nonprofit health policy news organization Tradeoffs. She’s been looking into what states are up to. Her reporting was part of a series called Hidden Help, done in collaboration with KFF Health News.
Kimberly Adams: So, most hospitals do offer free or discounted care to low-income patients, but a lot of folks usually have to complete these lengthy applications, and they don’t, or they do it wrong, and they miss out on aid. So, what are some states doing to handle this differently?
Melanie Evans: It’s called presumptive eligibility. Hospitals automatically screen patients. They find those who qualify for help, and then they give it to them. But in most of the U.S., they get to sort of pick and choose; there are few state or federal regulations here.
So, what we did is we looked at policies of nonprofit hospitals in Texas, and we found a lot of variation. Nearly half say they will bill patients before screening for financial aid, and most won’t refund patients who pay some of their bill and eventually qualify for aid. So, this gives you a sense of some of the current limitations. By July 2027, six states will have requirements for hospitals to do the screening for certain patients, often before sending bills.
Adams: Now, among the places experimenting with this kind of change is Oregon. It was one of the first states to require this kind of earlier screening in the process, and the state told hospitals that they had to screen almost all of the patients and do it up front. How did that play out there?
Evans: At OHSU Hospital, which is one of the state’s largest, the share of patients who got financial assistance jumped to 64% from 12% prior to the law. I also dug into some of the available financial reporting for about two-thirds of Oregon hospitals, and spending on financial assistance at those hospitals doubled on average during their first full year under the law. So that was music to Lisa Reynolds’ ears. She’s the Oregon lawmaker who spearheaded the new law.
Lisa Reynolds: It felt like we were really standing up for working families in Oregon, and we were holding hospitals accountable for what they should have been doing all along.
Adams: Now, she says they should have been doing this all along, but Oregon lawmakers rolled this back some earlier this year, reducing the number of people that hospitals are required to screen automatically. Why did they do that?
Evans: So, I spoke with lawmakers who told me they heard two big concerns from hospitals. One, the screening tools they were using, which generally come from consumer credit reporting agencies, needed some work. They ended up giving aid to people who didn’t qualify. And two, all of that extra aid was increasing costs for hospitals. So, State Representative Rob Nosse told me he voted to scale back the law because federal cuts to the Affordable Care Act subsidies and cuts from the Big Beautiful Bill are squeezing hospitals.
Rob Nosse: I don’t want any suburban or rural hospitals to close on my watch. I don’t want somebody who lives in a remote area of Oregon, where it’s already difficult to deliver a baby, to now have to drive four hours instead of two.
Adams: All that said, do you expect that more states will try to take this approach to mitigating medical debt?
Evans: Patient advocates are really pushing for it. A Republican lawmaker in Texas plans to reintroduce a bill that’s tougher than Oregon’s next year, and he’s trying to get more states on board as well.
