ST. CLOUD, Minn. — Cori Roberts was living in a rented basement four years ago when she was diagnosed with early-stage cervical cancer.
Recently divorced, the former stay-at-home mother had returned to work in her mid-40s, taking a human resources job that paid $41,000 a year. Then, despite having insurance, she was hit with more than $8,000 in medical bills.
"I had my car and a basket of clothes," Roberts recalled. "Medical bills were not something I could have afforded."
Roberts sought financial assistance from CentraCare, the St. Cloud-based health system that treated her. It's a nonprofit charity that receives millions of dollars in federal, state, and local tax breaks. In exchange, it's obliged to offer charity care to patients who can't afford their medical bills.
But Roberts said CentraCare told her she made too much to qualify.
Roberts instead scrimped on groceries and Christmas gifts for her kids and paid off more than $6,000 over two years. Then CentraCare sued her last year because she hadn't paid off all the debt.
"They're supposed to be a nonprofit," Roberts said. "It's like, 'Come on!'"
This story was a collaboration between KFF Health News and the Minnesota Star Tribune.
A sliver of financial aid
CentraCare earmarks just a tiny fraction of its budget for helping patients with medical bills they can't pay, but it's not alone in that, a Minnesota Star Tribune-KFF Health News investigation found.
Minnesota's hospitals and health systems are among the least charitable in the country, the investigation found, providing less financial aid as a percentage of their operating budgets on average than hospitals in almost every other state.
The investigation drew on a detailed review of every hospital charity care program in the state, an analysis of five years of hospital financial data, and dozens of interviews with patients, hospital executives and state officials.
Nationally, hospitals spend an average of about 2.4% of their operating budgets on charity care, according to federal hospital data compiled by Hossein Zare, a researcher at Johns Hopkins University. Minnesota hospitals spend about a third of that, on average.
Some spend considerably less. Of Minnesota's 123 general hospitals, 62 devoted less than 0.5% of their operating budgets to charity care from 2020 through 2024, the Star Tribune-KFF Health News investigation found.
"The system is not working," said Erin Hartung, director of legal services at Cancer Legal Care, a Minnesota nonprofit that helps patients with medical debt and other financial challenges. "And the burden is falling hardest on the people who are least able to bear it."
CentraCare's flagship St. Cloud Hospital spent less than 0.25% on charity care, according to the analysis. That works out to $25 in patient aid for every $10,000 spent on hospital operations.
A growing burden
Charity care will become even more vital in coming years as Americans lose health coverage or can't afford rising copays and deductibles. The nation's uninsured rate has been ticking up and is expected to increase further as budget cuts pushed by President Trump force states to pare back Medicaid and other safety net programs.
Nationwide, healthcare debt — much of it from hospitals — burdens an estimated 100 million people. And charity care, which was historically aimed at the uninsured, is now critical to many people with health insurance who can't afford their bills.
Hospital officials say it's unfair to expect them to solve this affordability problem when many of their facilities are financially strained. "No amount of charity care from hospitals will ever fully meet the needs of uninsured or underinsured Minnesotans. The need is simply too great," Minnesota Hospital Association spokesperson Tim Nelson said in a statement.
But Minnesota Attorney General Keith Ellison said hospitals have a duty to increase charitable help for all needy patients in exchange for the tax breaks they receive.
"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?"
Several factors help explain why Minnesota hospitals provide so little financial aid. For one, job-based insurance and an expanded Medicaid program offer broad coverage. Hospitals in states with less government assistance and more uninsured people typically spend more on charity care.
Eligibility standards vary
But patients also face significant barriers accessing financial aid at many hospitals, including inconsistent eligibility standards and extensive applications, the Star Tribune-KFF Health News investigation found.
To qualify at many hospitals, patients must submit detailed personal information, including bank statements, retirement accounts, mortgage documents and estimates of other assets such as cars, homes or livestock.
And because Minnesota has not standardized the criteria for charity care, patients might receive aid at one hospital but not another. The investigation found that some hospitals give free care to patients with an annual household income of $47,000, while others cap it at about $15,000.
There are similar variations in charity care standards at hospitals nationwide, KFF Health News and other researchers have found. A recent analysis by the nonprofit Lown Institute found that one hospital in Boston set the limit for free care at less than half the level as another hospital just a few block away.
In Minnesota, had Roberts driven 30 miles east or 35 miles north, she would have found medical providers with more generous financial aid policies than CentraCare. But she didn't know to look.
Roberts, now 49, has remarried and lives in a split-level home in St. Cloud decorated with inspirational plaques such as "Faith, Family, Friends." CentraCare recently dropped the lawsuit against her, but only after she took out a loan against her retirement plan to pay off the medical debt. "It just feels very unfair," she said.
CentraCare spokesperson Karna Fronden said medical privacy laws prevented her from discussing Roberts' case. She also declined interview requests about the health system's charity care spending.
In a statement, Fronden said CentraCare provides assistance in addition to charity care, such as helping enroll patients in insurance. "This helps provide broader, longer-term protection for patients," she said.
Other hospital leaders said they serve their communities in ways besides forgiving medical bills, including training doctors and nurses and preserving money-losing services such as obstetrics and mental health care.
Hospitals in rural communities specifically also play an important role as employers, said Robert Pastor, chief executive of Rainy Lake Medical Center in International Falls, Minn.
"We are the second- or third-largest employer in town, running on razor-thin margins while navigating escalating labor and supply costs and routine underpayment by public programs," Pastor said. "Meanwhile, many health insurers post billions in profits."
"Rural hospitals like ours are often portrayed as though we are sitting on piles of cash and simply choosing not to spend it on charity care. That is far from the reality," he said.
Hospital executives say they have a responsibility to ensure that limited resources for charity care go to patients who need them, said Travis Olsen, chief executive of Hendricks Community Hospital, near the South Dakota border.
Burdensome application process
To determine eligibility, some Minnesota hospitals consider only income, the Star Tribune-KFF Health News investigation found. But most demand information about patients' bank accounts as well. More than two-thirds require even more information, including the value of retirement accounts, life insurance policies, property and vehicles.
In addition to copies of tax returns, W-2 forms, pay stubs and bank statements, Hendricks asks aid applicants 53 questions about their finances. These include questions about the make, model and value of vehicles; the current market value of farm equipment, livestock and land; and the purchase price and square footage of homes.
Other hospital applications ask patients to detail their monthly spending on food, utilities and other medical bills.
All these questions discourage patients from seeking assistance, said Jared Walker, founder of Dollar For, a nonprofit that helps people apply for charity care.
"The drop-off rates are much higher the more questions you ask and the more documentation you have to provide," he said.
By contrast, most hospitals make it very easy for patients to click a button on the hospital website to pay their bills, Walker said. "Hospitals have optimized to get payment," he said. "If you want to get on a payment plan, if you want to get on a credit card, it's so easy."
Back in St. Cloud, Roberts said that when she drives past CentraCare's $200 million expansion at its Plaza campus in St. Cloud, she wonders why Minnesota hospitals don't live up to higher standards.
"They have all the money," she said. "But they can't grant a good person some grace?"
This story was produced by KFF Health News and the Minnesota Star Tribune.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF.
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