Dollar For Fights For Low-Income Patients to Access Charity Care

Americans owe an estimated $220 billion in medical debt and potential changes in Medicaid, Medicare and the Affordable Care Act being considered by Congress could raise that number significantly. Yet, hospitals are required to offer financial assistance to eligible low-income patients—a policy most patients aren’t aware of and which many hospitals intentionally make difficult to access. Dollar For is devoted to helping low-income patients access these funds, and founder Jared Walker spoke with Spotlight recently about their efforts. The transcript of that conversation has been lightly edited for length and clarity.

Let’s start with how Dollar For got started

I originally had this idea in 2012. My wife and I were sitting at home, and she got a phone call, and her aunt had passed away from cancer. And then a couple minutes later, I got a phone call. My cousin had gone into labor seven weeks premature, and the baby needed heart surgery to live. So, on the same day, same hour, both of our families were hit with these medical emergencies. And I realized that when you have a medical emergency, you have a financial emergency. I was 23 at the time and it was my first run-in with the U.S. healthcare system. And this idea that you can just lose everything because you get sick really, really weighed on me. And I was pretty frustrated by it. So, I wanted to help people in that situation.

In 2015, I started a crowdfunding platform, Dollar for Portland (OR) and was running around Portland doing small-dollar events—coffee shops, breweries, music venues. And every month I would pull the money together and pay medical bills for a local family. So, that is how this all started. I did that from 2015 to about 2020. And I met a guy named Eli (Rushbanks), who is now our general counsel and Director of Policy, and he asked me if I’d ever heard of hospital charity care or hospital financial assistance.

He mentioned Section 501r of the Affordable Care Act, and I had no idea what he was talking about. But it is a law that requires nonprofit hospitals to have these programs—basically they get to be tax exempt in exchange for offering community benefit. And how they do that, or at least how they should be doing that, is through their charity care programs. If you are within a certain income range that the hospital determines, they’re legally required to write off or reduce the bills. A lot of people don’t know about this. They don’t do a great job of telling people.

So, when I learned of that information, I realized that I had been paying medical bills for the last five years for low-income families that all would’ve been eligible for these programs. Again, I was frustrated by the system, and I started to jump into these programs and reading all these policies, realizing that none of it is standardized, and they’re all hidden. The applications are difficult. They make you fax the applications into a hidden fax number. It’s just an absolute mess.

And so, I started helping patients through this process, and in a few months, I got like a million dollars of medical debt to be waived for low-income families, and I couldn’t believe it. I started trying to get the word out and tell more people and help more people At the beginning of 2021, nothing was really working. But I ended up posting a TikTok video and that TikTok video went on to get like 30 million views. It just went crazy viral. And I had tens of thousands of people reaching out asking for help with their medical bills. And I was the entire organization!

That is how it all started. Since 2021, we’ve created a database of every hospital in the country—all of their charity care policy information and eligibility criteria. We’ve automated the application process and made it digital so that a patient can fill it out on their phone, tablet, computer. We look it over, send it to the hospital and advocate on their behalf. Since 2021, we’ve been able to eliminate over $94 million in medical debt for people all over the country and then even do some policy work to strengthen charity care laws.

Is there anything in the reconciliation bill Congress is considering that would alter this process?

Nothing that I’ve seen so far. I know that the administration has had some strong opinions about the Affordable Care Act. And cutting Medicaid would obviously drastically increase the amount of people that need charity care and would leave a lot of patients with out-of-pocket expenses that they can’t pay. I think that there are downstream effects from, from it, but nothing that would take away charity care. The other thing is that there are a lot of states like Oregon and North Carolina, and hopefully California here in the next couple months that have created laws that would protect charity care.

It sounds like you have a great system, but how do you get over the initial hurdle? If I have a heart attack and can’t pay for my care, how do you help me know that this policy even exists, so that I can then seek you out for help?

I would say three main ways. One, social media. We’ve done a really good job at getting the word out through social media so people see our videos or whatever, and they see if they qualify. The next thing would be media in general. The second thing is partnerships with other non-profits—we have referral partners that range from the American Cancer Society to groups helping with affordable housing. Any of these groups that are helping low- or middle-income individuals can refer patients to Dollar For. And then the third way is ads, and we spend on Google, for example.

And just walk me through the process—I’m the patient and I find Dollar For. What happens next?

Step number one would be seeing if you’re eligible. If you go to our home page, the first thing you’ll see will be establishing if you qualify. You select your state, your city, the hospital and provide your income, how much the bill is for and your insurance status. If you are, then, we immediately help you fill out the application. You fill out all your stuff and then once you hit submit, it goes over to our patient advocates, we’ll look it over and then submit it to the hospital.

And what’s the timeline for that process, once you submit?

The application usually takes about 15 minutes to do, as you have to provide your proof of income and a couple of things that the hospital requires. On average it’s like four to five weeks to get this approved. It depends on the state though, because in Washington, Oregon, California, Colorado, there’s some pretty good laws that require hospitals to respond fairly quickly. And there might be states like Texas or Florida where you’re waiting for six to seven months on a reply and you’re fighting.

And so, there’s no overall federal guidelines that require hospitals to respond within a certain time? It’s all state by state?

The one thing that they’ve defined is that you have to give patients a reasonable amount of time to apply. And what they’ve determined a reasonable amount of time is 240 days. And so, when you get the first bill, the clock starts ticking. You have 240 days to apply. There are states like California and Colorado that have extended that timeline, but that’s really the only thing. There’s no federal law that says the hospital has to respond within a certain amount of time.

And once you apply, does that mean your bill is put on hold until you get a response one way or the other?

It should mean that, but it’s really hard because hospital financial assistance departments and billing departments seem to have some communication issues.

Probably deliberately so in some cases.

Yeah, a lot of this is difficult by design, I would say. But that being said, once you apply, once that application is in, that account should kind of freeze. Although you’re still going to get the statements from the hospital saying, hey, you owe us money, or whatever. You might even get a final notice. But you can kind of put those aside until you get a determination on the bill, even if they send you to collections. Most hospitals will send you to collections after 120 days of no payment. But as I said before, the charity care deadline is 240 days. So, you can be sent to collections and still be eligible for charity care and apply.

And are there other factors that hospitals will weigh, like types of procedures that qualify and others that don’t?

Great question. I would say every charity care program is going to be for medically necessary procedures. The other qualifying things that hospitals will throw into their policies might be whether or not you have insurance. If you have some type of commercial insurance, some hospitals would say you don’t qualify at all for charity care. Other hospitals might not consider that at all. For those hospitals, charity care could cover your deductible, your out-of-pocket, your co-pays. Other things that they might factor would be assets—what is the make and model of your car, or how much do you have in your 401K.

Another thing that is considered would be residency. Sometimes hospitals will say, hey, if you’re not from this state, if you’re not from this county, you don’t qualify for a charity care program.

And your program is there to help people if they hit a snag, which probably most people do.

Yes, we’re pretty good at it at this point. I mean, we’ve submitted over 30,000 financial assistance applications for patients. Hospitals kind of see us coming; we know the rules usually better than they do. When we submit the applications, our patient advocates are following through and making sure that we get a response. We are also texting and emailing the patient all throughout the process, giving them updates. We really try to give patients peace of mind.

If I have Medicare or Medicaid, am I still eligible?

If you have Medicaid, hopefully you don’t have big out-of-pocket expenses, but I would say it shouldn’t disqualify you. On Medicare, there’s actually an added incentive for hospitals to help people on Medicare. There’s something called Medicare bad debt, where if a hospital can prove that a Medicare patient received financial assistance for their out-of-pocket expenses, Medicare will reimburse 65 cents on the dollar for providing that.

With charity care, for most of these patients, hospitals are never going to collect. These are low-income patients that do not have the money to pay these bills. So, the hospital is going to end up sending 99% of all of this to bad debt, into collections. And you think about how much money it costs a hospital to do their entire collections process from start to finish, it would actually financially benefit the hospitals to identify who is eligible for charity care upfront.