{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,2]],"date-time":"2026-10-02T03:50:29Z","timestamp":1790913029089,"version":"4.1.0"},"reference-count":34,"publisher":"American Medical Association (AMA)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"<jats:sec id=\"ab-zoi251480-4\">\n                    <jats:title>Importance<\/jats:title>\n                    <jats:p>Medical debt is a public health crisis. Hospital bills represent the majority of medical debt and present an opportunity for policy intervention. State financial assistance policies (FAPs) require hospitals to expand patient eligibility. However, it is unknown whether these policies alleviate medical debt.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"ab-zoi251480-5\">\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To estimate the association of Oregon\u2019s FAP with medical debt in collections and hospitals\u2019 charity care (ie, free or discounted care for patients qualified for FAPs) and bad debt (ie, total amount of uncollectible patient accounts) expenditures.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"ab-zoi251480-6\">\n                    <jats:title>Design, Setting, and Participants<\/jats:title>\n                    <jats:p>This cohort study examined county- and hospital-level difference-in-differences and event study models covering the period from 2015 to 2022. This study included 689 counties and 582 hospitals located in Oregon and states that expanded Medicaid in 2014 but did not implement any FAPs. Data were analyzed from January to July 2025.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"ab-zoi251480-7\">\n                    <jats:title>Exposure<\/jats:title>\n                    <jats:p>Oregon FAP.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"ab-zoi251480-8\">\n                    <jats:title>Main Outcomes and Measures<\/jats:title>\n                    <jats:p>Percentage of the county population with medical debt in collections, and hospital charity care and bad debt expenditures as a percentage of operating expenses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"ab-zoi251480-9\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The sample included 540 hospitals in the control group (43 teaching [7.9%], 199 critical access [36.8%], and 279 metropolitan hospitals [51.6%]) and 42 hospitals in Oregon (3 teaching [7.1%], 15 critical access [35.7%], and 27 metropolitan hospitals [64.3%]) as well as 656 counties in the control group and 33 counties in Oregon. Relative to control states, Oregon\u2019s FAP was associated with a larger decrease in the percentage of the county population with medical debt in collections (\u22121.67% [95% CI, \u22123.26% to \u22120.10%];\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      \u2009=\u2009.04), equivalent to 872 to 1180 fewer individuals with medical debt in collections per county. Oregon\u2019s FAP was also associated with larger charity care expenditures (0.31% [95% CI, 0.16% to 0.45%];\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      \u2009=\u2009.001), or $227\u202f200 to $639\u202f000 per hospital, compared with the control states. There were no changes in bad debt expenditures.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"ab-zoi251480-10\">\n                    <jats:title>Conclusions and Relevance<\/jats:title>\n                    <jats:p>In this cohort study, Oregon\u2019s FAP was associated with a larger decrease in the percentage of the population with medical debt in collections and larger hospital charity care expenditures. State efforts like that of Oregon\u2019s have the potential to alleviate medical debt, especially in light of federal policy changes that are likely to exacerbate the medical debt crisis.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.55698","type":"journal-article","created":{"date-parts":[[2026,1,27]],"date-time":"2026-01-27T16:00:26Z","timestamp":1769529626000},"page":"e2555698","source":"Crossref","is-referenced-by-count":2,"title":["Financial Assistance Policy, Hospital Charity Care, and Medical Debt in Collections"],"prefix":"10.1001","volume":"9","author":[{"given":"Tatiane","family":"Santos","sequence":"first","affiliation":[{"name":"Celia Scott Weatherhead School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard C.","family":"Lindrooth","sequence":"additional","affiliation":[{"name":"Colorado School of Public Health, Aurora"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gary J.","family":"Young","sequence":"additional","affiliation":[{"name":"Center for Health Policy and Healthcare Research, Northeastern University, Boston, Massachusetts"},{"name":"D\u2019Amore-McKim School of Business, Northeastern University, Boston, Massachusetts"},{"name":"Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shoou-Yih","family":"Lee","sequence":"additional","affiliation":[{"name":"Virginia Commonwealth University College of Health Professions, Richmond"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2026,1,27]]},"reference":[{"issue":"3","key":"zoi251480r1","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.54707","article-title":"Medical debt\u2014an iatrogenic epidemic with mortal consequences.","volume":"7","author":"Su","year":"2024","journal-title":"JAMA Netw Open"},{"issue":"3","key":"zoi251480r2","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.54766","article-title":"Associations of medical debt with health status, premature death, and mortality in the US.","volume":"7","author":"Han","year":"2024","journal-title":"JAMA Netw Open"},{"issue":"2","key":"zoi251480r12","doi-asserted-by":"publisher","first-page":"196","DOI":"10.1377\/hlthaff.2024.00760","article-title":"Oregon community benefit reform influenced not-for-profit hospitals\u2019 charity care and medical debt write-off.","volume":"44","author":"Santos","year":"2025","journal-title":"Health Aff (Millwood)"},{"issue":"12","key":"zoi251480r13","doi-asserted-by":"publisher","first-page":"1495","DOI":"10.1016\/j.ijsu.2014.07.013","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies.","volume":"12","author":"von Elm","year":"2014","journal-title":"Int J Surg"},{"issue":"6","key":"zoi251480r22","doi-asserted-by":"publisher","first-page":"942","DOI":"10.1377\/hlthaff.2019.01545","article-title":"Varying trends in the financial viability of US rural hospitals, 2011-17.","volume":"39","author":"Bai","year":"2020","journal-title":"Health Aff (Millwood)"},{"issue":"3","key":"zoi251480r23","doi-asserted-by":"publisher","DOI":"10.1093\/haschl\/qxad034","article-title":"Hospitals\u2019 uneven recovery from the COVID-19 pandemic.","volume":"1","author":"Rhodes","year":"2023","journal-title":"Health Aff Sch"},{"issue":"1","key":"zoi251480r24","doi-asserted-by":"publisher","first-page":"38","DOI":"10.1097\/JHM-D-22-00037","article-title":"The early impact of the COVID-19 pandemic on hospital finances.","volume":"68","author":"Rhodes","year":"2023","journal-title":"J Healthc Manag"},{"issue":"3","key":"zoi251480r26","doi-asserted-by":"publisher","DOI":"10.1016\/j.jaccpubpol.2009.10.010","article-title":"Do non-profit hospitals provide more charity care when faced with a mandatory minimum standard? evidence from Texas.","volume":"29","author":"Kennedy","year":"2010","journal-title":"J Account Public Policy"},{"issue":"1","key":"zoi251480r31","doi-asserted-by":"publisher","first-page":"111","DOI":"10.1377\/hlthaff.2017.0976","article-title":"Understanding the relationship between Medicaid expansions and hospital closures.","volume":"37","author":"Lindrooth","year":"2018","journal-title":"Health Aff (Millwood)"},{"key":"zoi251480r3","unstructured":"Medical debt burden in the United States. Consumer Financial Protection Bureau. Accessed March 15, 2025. https:\/\/files.consumerfinance.gov\/f\/documents\/cfpb_medical-debt-burden-in-the-united-states_report_2022-03.pdf"},{"key":"zoi251480r4","unstructured":"The burden of medical debt in the United States.  Peterson Center on Healthcare, Kaiser Family Foundation. Accessed September 28, 2024. https:\/\/www.healthsystemtracker.org\/brief\/the-burden-of-medical-debt-in-the-united-states\/"},{"key":"zoi251480r5","unstructured":"Collection Actions, 6th ed. National Consumer Law Center. Accessed March 15, 2025. https:\/\/www.nclc.org\/library"},{"key":"zoi251480r6","unstructured":"The federal rule on medical debt. Commonwealth Fund. Accessed March 15, 2025. https:\/\/www.commonwealthfund.org\/publications\/explainer\/2025\/feb\/federal-rule-on-medical-debt"},{"key":"zoi251480r7","unstructured":"Karpman? M. Most adults with past-due medical debt owe money to hospitals. Urban Institute. Accessed March 15, 2025. https:\/\/www.urban.org\/research\/publication\/most-adults-past-due-medical-debt-owe-money-hospitals"},{"key":"zoi251480r8","unstructured":"Internal Revenue Service. Requirements for 501(c)(3) hospitals under the Affordable Care Act\u2014Section 501(r). Accessed February 18, 2023. https:\/\/www.irs.gov\/charities-non-profits\/charitable-organizations\/requirements-for-501c3-hospitals-under-the-affordable-care-act-section-501r"},{"key":"zoi251480r9","unstructured":"Oregon House Bill 3076; 80th Oregon Legislative Assembly. House of Representatives. 2019. Accessed April 17, 2024. https:\/\/olis.oregonlegislature.gov\/liz\/2019R1\/Downloads\/MeasureDocument\/HB3076"},{"key":"zoi251480r10","unstructured":"Oregon Health Authority. Hospital Reporting Program. Accessed April 17, 2024. https:\/\/www.oregon.gov\/oha\/hpa\/analytics\/pages\/hospital-reporting.aspx"},{"key":"zoi251480r11","unstructured":"Oregon Health Authority. 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Accessed February 6, 2024. https:\/\/www.oregon.gov\/oha\/HPA\/ANALYTICS\/HospitalReporting\/HB-3076-Comm-Benefit-Leg-Report.pdf?utm_medium=email&utm_source=govdelivery#:~:text=HB%203076%20targets%20the%20burden,called%20for%20in%20HB%203076"},{"key":"zoi251480r28","unstructured":"Colorado\u2019s medical debt credit reporting law takes effect. Colorado Center on Law and Policy. Accessed May 27, 2025. https:\/\/copolicy.org\/news\/colorados-medical-debt-credit-reporting-law-takes-effect\/"},{"key":"zoi251480r29","unstructured":"Fair credit reporting act; preemption of state laws. Consumer Financial Protection Bureau. Accessed November 7, 2025. https:\/\/www.federalregister.gov\/documents\/2025\/10\/28\/2025-19671\/fair-credit-reporting-act-preemption-of-state-laws"},{"key":"zoi251480r30","unstructured":"Oregon House Bill 3320; 82nd Oregon Legislative Assembly. Oregon Legislature. 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