Oregon hospitals doubled financial aid after a law required automatic screening
Once Oregon made hospitals check patients for aid without waiting for an application, the free and discounted care they gave rose sharply, a Tradeoffs analysis found, while many Texas hospitals still bill patients first.
Oregon hospitals more than doubled their spending on free and discounted care, on average, in the first full fiscal year after a state law required them to screen patients for financial aid automatically, according to an analysis by the health policy outlet Tradeoffs published October 21 with KFF Health News2. The analysis drew on federal financial reports from about two-thirds of the state's hospitals.
Nonprofit hospitals must have financial assistance policies under federal tax rules. Automatic screening, known as presumptive eligibility, lets a hospital cut or erase a qualifying patient's bill without waiting for an application, before the bill can turn into debt.
Oregon's law, House Bill 3320, passed in 2023, and its rules took effect in July 2024, according to Tradeoffs. It originally required hospitals to screen patients on Medicaid, uninsured patients and anyone who owed $500 or more, and to skip applications for nearly all patients, a step Tradeoffs describes as rare nationally. Among the hospitals with federal data, spending on free and discounted care rose to 2.7% of operating expenses, on average, from 1.4%. Nonprofit hospitals nationally averaged about 2.4% from 2021 to 2024, according to Johns Hopkins researcher Hossein Zare.
At Oregon Health & Science University (OHSU), 64% of patients automatically qualified for aid in the law's early months, up from 12% before, Tradeoffs reported. The hospital spent about $64 million on free and discounted care in its first year under the law, about 1% of its operating spending, and its aid for insured patients reached about $39 million.
OHSU's audited financial statements1 for the year ended June 30, 2025, show the jump. Charity care measured at forgone charges was $116.3 million in fiscal 2025, compared with $39.4 million a year earlier. The university said the additional assistance required under House Bill 3320 reduced its net patient service revenue by $66 million.
Hospitals asked for relief, citing growing financial strain from federal policy changes and screening that proved less accurate for higher-income patients. In April 2026, Oregon enacted House Bill 4040, which raised the screening threshold for a single visit to $1,500, Tradeoffs reported. The requirement to screen Medicaid and uninsured patients stayed in place.
The Hospital Association of Oregon supported the screening approach, according to Tradeoffs. It expects the state's uninsured rate to climb to 10% or higher in coming years, from about 3% before the law passed.
A companion Tradeoffs analysis published October 153 reviewed the policies of 166 nonprofit general hospitals in Texas. Nearly half said they will bill patients before screening them for aid, and about 8% have policies requiring screening first. Roughly two in three said patients who pay before qualifying will not receive full refunds, and about 40% said they will not tell patients when a balance has been cleared.
One patient described in that report paid $5,500 up front to schedule surgery at Texas Health Resources, later qualified for aid, and had the rest of her bill written off, but the hospital kept the $5,500. Anna Stelter, vice president of policy at the Texas Hospital Association, said automatic screening can help some patients but that screening tools can be unreliable.
By July 2027, six states will require hospitals to use presumptive eligibility for certain patients: California, Delaware, Illinois, Maryland, North Carolina and Oregon, according to Tradeoffs. In Texas, state Rep. Tom Oliverson, whose 2025 bill to require screening before billing failed, said he plans to reintroduce it in 2027.
