In California, hospitals looking to collect on bills cant seize wages or put liens on the homes where patients live.
In Texas, nonprofit hospitals are required to provide a minimum amount of charity care.
In Washington state, hospitals must provide free or discounted care to indigent patients and report to the state how much they spend to provide that treatment.
No such laws protect North Carolinas patients.
An investigation by the Observer and The News & Observer (of Raleigh) found that N.C. hospitals get tax breaks worth hundreds of millions, but most are doing little to help the poor. Instead, many hospitals are pursuing uninsured patients with lawsuits or collections agencies that can destroy their credit.
Patient advocates say the state could do far more.
North Carolina is not in good shape, said Jessica Curtis, a hospital expert for Community Catalyst, a Boston group working to improve access to health care. If youre a consumer in North Carolina and you need free care, theres nothing in the state law or the regulations that would protect you.
Changing the regulatory landscape in North Carolina wont be easy. Any lawmakers attempting to bring about significant change will likely find themselves hearing from well-connected hospital lobbyists.
But consumer advocates and industry experts say clear rules and better information are crucial to protecting patients.
Why it might help: While most N.C. hospitals have charity care policies, uninsured patients dont always learn about them.
More than a third of N.C. hospitals including Gaston Memorial Hospital in Gastonia and Lake Norman Regional Medical Center in Mooresville provide no details about their charity care policies on their websites.
About two-thirds of the more than 30 uninsured patients interviewed by the newspapers say they were never informed about charity care when they sought treatment from N.C. hospitals.
And during visits to emergency rooms at several area hospitals, an Observer reporter found no information about the hospitals charity care policies.
Advocates say more patients would learn about what help is available if hospitals were required to put information about their policies on their websites, their bills and the walls of their waiting areas and business offices.
Thats just a no-brainer, said Jessica Curtis, a hospital expert for Community Catalyst, a Boston group working to improve access to health care. That should be something very easy for hospitals to comply with. If they can send a bill, they can also send a note about financial assistance or charity care.
Whom it might help: People like Tiffany Barnes. When Barnes was treated for kidney stones at Stanly Regional Medical Center in Albemarle in 2008, she and her husband, Jeremy, had no insurance.
The couple said they couldnt afford to pay the $3,300 bill. The hospital filed suit to collect on it.
The family of five was surviving on about $15,000 a year, so they appeared to qualify for financial assistance; the hospitals financial assistance policy stated that poor and uninsured people earning less than 150 percent of federal poverty guidelines were entitled to free care.
But the couple from Albemarle said they were unaware Stanly Regional had a financial assistance policy, and that no one at the hospital mentioned it.
This right here Ive never seen that, Jeremy Barnes said when a reporter showed a description of the hospitals charity care policy.
What hospitals say:
The North Carolina Hospital Association notes that it provides links to charity care policies for most hospitals on its website: https://www.ncha.org/issues/community-benefit
The vast majority of hospitals already post policies online, providing detailed information on eligibility requirements and whom to contact for information about financial assistance and charity care, wrote hospital association spokesman Don Dalton. Hospitals also post notices in their buildings that lead people to charity care policies and people eager to assist them. These postings are done without legislative mandate.
Why it might help: Some hospitals ask patients to supply extensive documentation such as multiple years of tax returns and the tax values and loan amounts of any vehicles owned.
For those suffering serious medical problems, retrieving such documents often isnt easy.
Said Adam Linker, an analyst at the N.C. Health Access Coalition: Its not really charity care if you require that much reporting and make it that difficult.
Some hospitals and hospital systems including Novant Health run soft credit checks on uninsured patients, making it easier for patients to qualify for charity care. That system gathers financial information so that patients dont have to provide as much documentation. The checks dont affect patients credit scores.
What hospitals say: Without documentation of income and assets, its difficult to qualify a patient for all the financial assistance to which they might be entitled, Dalton wrote.
More importantly, we dont believe there is a hospital in our state that is denying anyone emergency treatment either because they cannot pay or because they do not have documentation readily available. After treatment, patients have ample opportunity to provide documentation that would qualify them for financial assistance.
Why it might help: Patient advocates recommend that the state require hospitals to provide charity care to all making less than 200 percent of the federal poverty guideline. Rhode Island is among the states that have taken that step.
They say individuals earning that amount which is equivalent to earning less than about $11 an hour or $22,340 per year often lack the resources or insurance to pay expensive medical bills.
A number of major hospitals in the state meet that, and it doesnt seem unreasonable to me, said Adam Searing, director of the N.C. Health Access Coalition.
Novant Health, for example, gives free care at all of its hospitals to patients earning less than 300 percent of the federal poverty guideline.
Whom it might help: People like Thomas and Edith Sprufera. The Wilkesboro couple brings home about $18,000 a year. Edith is uninsured.
When Edith got a colonoscopy and other tests at Wilkes Regional Medical Center, in North Wilkesboro, a hospital official told them they didnt qualify for financial assistance because they made too much money, Thomas said.
Under the hospitals financial assistance policy, only patients whose family income is less than 125 percent of federal poverty guidelines can qualify for free care.
The Spruferas offered to pay the hospital $20 a month, but the hospital refused and sued to collect on bills totaling more than $9,000, Thomas said.
Were not looking for free health care, Thomas said. But why cant they cut people some slack when they dont have the money and work with them?
What hospitals say: Dalton, from the NCHA, said the associations board members discussed that issue several years ago at the urging of the N.C. Medical Care Commission
We learned once again that North Carolina is not a one-size-fits-all state, Dalton wrote. Some hospitals are in prosperous and diverse enough communities to make the 200 percent goal reachable. Others are not. For those, a 200 percent mandate would seriously undermine the hospitals ability to collect enough revenue to remain open.
Why it might help: The N.C. Hospital Association now asks its members to report information about their charity care spending to: https://www.ncha.org/issues/community-benefit
But reporting is voluntary, and a number of hospitals dont comply.
Patient advocates say better disclosure would likely encourage some N.C. hospitals to provide more financial help to uninsured patients.
Requiring hospitals to report the extent of their charitable spending isnt a new idea. Missouri, Connecticut and Illinois are among the nine states that require that an accounting of charity care be made public.
What hospitals say: Charity care spending is already voluntarily reported on the NCHA website, Dalton wrote. We expended significant resources to make this data available to everyone. We see little value in the state spending the same resources again to accomplish a redundancy. A state agency would be free to use the information on our website.
Why it might help: The Observer and (Raleigh) News and Observer found that some N.C. hospitals are filing thousands of suits against patients to collect on unpaid bills. In many cases, the hospitals place liens against patients property. Interviews and records suggest a significant number of those patients have no insurance and little income.
N.C. law allows public hospitals to garnishee up to 10 percent of patients wages if they dont pay their bills and if their income exceeds 200 percent of the federal poverty level. At least one N.C. hospital Wilkes Regional Medical Center in North Wilkesboro does that.
Says Jessica Curtis: If a person cant pay a bill, why squeeze blood from a stone? Why go after the little bit of security they have in their income or owning their own home?
Whom it might help: People like Kenny Miller. Suffering from an irregular heartbeat, the Charlotte resident got emergency surgery at Carolinas Medical Center in 2007.
Miller, a Vietnam veteran, had no health insurance other than his coverage from the Department of Veterans Affairs. That pays only a limited amount each year for medical care outside the VA system.
He and his wife were living on the $650 in monthly disability payments he received.
When CMC mailed a bill for $48,000, Miller said he had no way to pay it. Carolinas HealthCare System, the multibillion-dollar chain that owns CMC, sued, won a judgment and put a lien on Millers three-bedroom house on Charlottes westside. The homes tax value: less than $70,000.
If a man is sick, he doesnt stand a chance, Miller said.
What hospitals say: Hospitals contend they have a responsibility to try to collect from those who can afford to pay their bills.
Without reasonable attempts to collect, hospital costs would continue to soar beyond the reach of more and more payors, wrote Dalton, of the hospital association. Placing a lien on a property enables a hospital to collect at a time when resources from the sale of that property are available.
Why it might help: Once-delinquent medical bills can remain on a credit report for up to seven years, even if the bill has been paid in full .
U.S. Rep. Heath Shuler, a Waynesville Democrat, has introduced a bill to change that. His legislation would require credit reporting agencies to remove medical debts of less than $2,500 from credit reports 45 days after the balance goes to zero.
Mark Rukavina, a patient advocate who heads a Boston-based nonprofit called the Access Project, said: Here you have people doing the right thing paying off their bill and it can hurt their credit for up to seven years. Its wrong that people can have their credit ruined simply because they got sick and then paid their bill.
Linker says he doesnt think Shulers bill goes far enough: I dont think medical debt should go on credit reports, period.
Whom it might help: People like Ronald Stephan.
Stephan said that a collections agency wrongly reported that he owed $370 to Cleveland Regional Medical Center, when in fact his bill had been paid in full. It took him a year to get the bill off his credit report, he said.
Stephan said he has always prided himself on paying his bills, so it angered him to be treated like a deadbeat.
If I owe people, I pay them, the former Shelby resident said.
What credit bureaus say: Norm Magnuson of the Consumer Data Industry Association cautioned that lenders would likely want all information about a consumers credit history in deciding whether to lend. He said his members have not taken a position on the bill.
Why it might help: Some experts recommend that the state collect insurance claims data for price estimates of common hospital procedures. Transparency could help patients find more affordable hospital care and put pressure on hospitals to cut prices.
Fourteen states but not the Carolinas require collection of health care cost data for use by consumers. New Hampshire and Maine have websites that show estimated prices of medical care for both insured and uninsured consumers. See New Hampshire: www.nhhealthcost.org. See Maine: www.healthweb.maine.gov.
Both Aetna and Blue Cross and Blue Shield of North Carolina have voluntarily created cost estimators for their customers.
What hospitals say: Help for consumers in this area is quickly evolving without the need for additional legislation, wrote the NCHAs Dalton.
Dalton said hospitals work with patients in advance to help determine costs, the state collects information from each hospital on the top 35 inpatient procedures, and the hospital association publishes that information on its website.
Former Novant Health CEO Paul Wiles said his system supports more transparency on cost. That will have an impact on changing our behavior, he said. Right now, its next to impossible to do real price comparison.