Comparison of US Hospital Charity Care Policies Before vs After Onset of the COVID-19 Pandemic

IMPORTANCE: Tax-exempt hospitals are required to provide charity care to maintain their tax-exempt status; charity care policies must be published online with clear eligibility criteria. Prior research has shown wide variability in charity care policy content; it is unknown how hospitals change their charity care policies over time. OBJECTIVE: To examine changes to tax-exempt hospital charity care policies before vs after the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used downloaded charity care policies from a geographically representative sample of 170 tax-exempt hospitals from December 1 to 31, 2019, and December 1 to 31, 2021, and categorized the policy changes made as more restrictive, more generous, indeterminate, minimal, or not updated. EXPOSURES: Onset of the COVID-19 pandemic. MAIN OUTCOMES AND MEASURES: The primary outcome was charity care policy content changes from 2019 to 2021. Also examined were the effects of hospital ownership type, state Medicaid expansion status, and hospital consolidation on policy changes. RESULTS: In this sample of 170 hospitals, 151 published documents available for comparison. Among these hospitals, 127 (84.1%) updated their charity care policies and 77 (51.0%) made substantial changes, with 242 distinct policy changes to categories such as income eligibility cutoffs, asset limitations, and service exclusions. Although the majority of hospitals expanded charity care (47 [31.1%]), a sizable minority restricted charity care (12 [7.9%]). Medicaid expansion during the study period and hospital consolidations were not associated with expansion of charity care; the largest merger in this sample led to reduced charity care at all 4 hospitals involved. CONCLUSIONS AND RELEVANCE: Tax-exempt hospitals appear to have updated their policies with mostly positive changes during and after the onset of the COVID-19 pandemic; however, some hospitals restricted charity care in 2021 documents. Unpublicized or vague eligibility criteria may limit patients’ understanding of charity care policies and conceal the full extent of charity care policy changes over time. Policy makers should consider requiring greater transparency and simplification for hospital charity care policies to ensure adequate access to care for uninsured and underinsured patients.