More evidence is needed to assess the impact of financial assistance programs for healthcare costs on healthcare cost, utilization, and value, health outcomes, and social impacts.
This assessment was made possible through support from Elevance Health. HealthBegins retains full editorial independence, and the content herein reflects its sole views and conclusions.
The findings below synthesize the results of the studies on programs to reduce or eliminate medical debt across three domains of measurement:
Medical debt is a pervasive challenge in the United States. In 2024, an estimated 36% of US households had medical debt, 21% had a past-due medical bill, and 23% were paying a medical bill over time to a provider[1]. An analysis by the Census Bureau found that Americans owed at least $220 billion in medical debt in 2021, with approximately 14 million people, or 6% of adults, owing over $1,000[2]. High deductibles and other forms of cost sharing can result in individuals receiving medical bills they are unable to pay, despite being insured[2]. Young adults, people with low incomes, and Black and Hispanic/Latino people disproportionately carry medical debt, with these rates being the highest in Southern states[3]. Additionally, people living with chronic conditions like cancer or people with disabilities are more likely to face significant challenges paying for healthcare[4],[5].
The consequences of medical debt extend well beyond finances, sometimes leading to impacts on physical and mental health, which also translate to years of life lost and higher mortality rates[6]. In a nationally representative cohort of U.S. adults, those with medical debt were reportedly five times more likely to forgo mental health care due to the cost of care, with 33.8% forgoing care compared to 6.3% of those without medical debt[7]. People with current medical debt report skipping doctor visits and reducing or skipping prescriptions to avoid accruing further debt[8]. In addition, medical debt impacts overall social wellbeing by increasing rates of housing instability, for example[9]. For payers and providers, the challenge that people face in continuing their care leads to higher costs downstream, while also disrupting the continuity of care essential to managing chronic conditions.
The affordability of health care is a significant barrier to accessing needed care, particularly for individuals with low incomes[10]. When care is unaffordable, individuals often delay or forgo needed medical care and prescriptions, leading to worsening health outcomes[10]. Unmet social needs including food insecurity, housing instability, and lack of transportation further compound this burden and have been linked to adverse health outcomes among low-income populations[11].
Patient financial assistance programs are one mechanism to address the burden of health care costs for low-income individuals. Programs to reduce or eliminate medical debt may include preemptive financial assistance to reduce out-of-pocket costs at the point of care or retrospective debt relief, which forgives existing unpaid bills. This Evidence Assessment focuses solely on Patient Financial Assistance Programs and does not address retrospective debt relief.
Patient financial assistance programs are offered by a range of organizations, including hospitals, pharmaceutical manufacturers, and philanthropic foundations, with varying eligibility criteria and levels of support[12]. An analysis of six charity foundations found that 61% covered only co-payments, 97% required insurance coverage for eligibility, and the most common therapeutic area was cancer, covered by 41% of the foundations[13]. Other common forms of financial assistance include pharmaceutical manufacturer-funded co-pay support, free drug programs and philanthropic programs that provide co-pays or other non-medical expenses[14]. These interventions tend to be for specific populations and services.
The Affordable Care Act requires all nonprofit hospitals to maintain a written Financial Assistance Policy that is widely publicized and includes eligibility criteria and the basis for calculating charges[15]. Federal regulations do not currently define or set minimum standards for hospitals to determine who is eligible for charity care or the level of assistance to be provided, resulting in significant variation and underutilization across institutions. The national nonprofit, Dollar for Dollar, found that only 29% of people who qualify for hospital financial assistance receive it[16]. Nineteen states and the District of Columbia have aimed to fill this gap by setting their own standards for determining people’s eligibility for financial assistance as well as the required levels of care[17],[18].
Counties and hospitals located in Oregon that were subject to a state Financial Assistance Policy (FAP) and states that expanded Medicaid in 2014 but did not implement any FAPs.
Under the FAP, insured and uninsured individuals with household incomes below 200% of the Federal Poverty Level (FPL) qualify for 100% coverage of their out-of-pocket costs, and individuals falling between 200% to 300%, 300% to 350%, and 350% to 400% FPL qualify for a 75%, 50%, and 25% reduction of their out-of-pocket costs, respectively. Additionally, hospitals could not charge interest on the medical debt of patients who qualified for financial assistance.
Observational study with a comparison group.
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 the treatment group in Oregon (3 teaching [7.1%], 15 critical access [35.7%], and 27 metropolitan hospitals [64.3%]). The hospitals in the control group were located in 656 counties and the hospitals in the treatment group were in 33 counties in Oregon. It covered the period from 2015 to 2022. Data were analyzed from January to July 2025.
Healthcare Cost, Utilization & Value: Relative to control states, Oregon’s FAP was associated with a larger decrease in the percentage of the county population with medical debt in collections (−1.67% [95% Confidence Interval [CI]: −3.26%-−0.10%]; p = .04), equivalent to 872 to 1180 fewer individuals with medical debt in collections per county. Oregon’s FAP was also associated with larger charity care expenditures (0.31% [95% CI: 0.16%-0.45%]; p = .001), or $227,200 to $639,000 per hospital, compared with the control states. There were no changes in bad debt expenditures.
Oregon’s 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 have the potential to alleviate medical debt, especially in light of federal policy changes that are likely to exacerbate the medical debt crisis.
Patients with cancer.
Financial assistance programs for patients with cancer.
Literature review. Five articles met the inclusion criteria.
Healthcare Cost, Utilization & Value: Only one of the programs successfully reduced actual out-of-pocket costs for patients, though others were associated with psychosocial benefits or increased knowledge of financial resources. Four of the five programs evaluated to date were pilot studies with small sample sizes, and most lacked control groups for comparison.
Patients in the U.S. with cancer.
Oncology financial navigation (OFN), which involved clinical interventions to reduce financial hardship in cancer patients or caregivers by facilitating access to resources.
Scoping review. Six articles met the inclusion criteria.
Healthcare Cost, Utilization & Value: The studies showed that OFN implementation and evaluation are feasible, though efficacy was difficult to evaluate because the studies were limited by small sample sizes (attributed to low patient participation).
Patients with cancer.
Interventions to address cancer-related financial hardship (FH).
Scoping review. 44 publications reporting on 43 interventions were included in the final analysis.
Healthcare Cost, Utilization & Value: Studies reporting on financial navigation programs (N=17) and specialty pharmacy assistance programs (N=11) were most common. Enrolled patients received concrete assistance with direct medical costs and cost-of-living expenses, such as transportation and food. In addition, several of these programs improved overall patient-reported financial hardship, decreased appointment no-shows, and improved enrollment in clinical trials.
[1] Fulford, S. L., Wilson, E. (2025). Medical Debt and Collections in the United States. Health Aff Sch., 3(8). doi:10.1093/haschl/qxaf159
[2] Rakshit, S., Rae, M., Claxton, G., Amin, K., Cox, C. (2024, February). The Burden of Medical Debt in the United States. Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/
[3] Consumer Financial Protection Bureau. (2022, February). Medical Debt Burden in the United States. https://files.consumerfinance.gov/f/documents/cfpb_medical-debt-burden-in-the-united-states_report_2022-03.pdf
[4] PDQ® Adult Treatment Editorial Board. (2024, June). Financial toxicity (financial distress) and cancer treatment (PDQ®)–patient version. National Cancer Institute. https://www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-pdq
[5] Wilson, B. G., Killick, C. (2024, October). Paying the Price: How Medical Debt Disproportionately Hurts People with Disabilities. Community Catalyst. https://communitycatalyst.org/posts/paying-the-price-how-medical-debt-disproportionately-hurts-people-with-disabilities/
[6] Han, X., Hu, X., Zheng, Z., Shi, K. S., Yabroff, K. R. (2024). Associations of Medical Debt With Health Status, Premature Death, and Mortality in the US. JAMA Netw Open, 7(3). doi:10.1001/jamanetworkopen.2023.54766
[7] Moon, K. J., Miller, K. E., Galea, S., Ettman, C. K. (2025)). Medical Debt and Forgone Mental Health Care Due to Cost among Adults. JAMA Health Forum, 6(4). doi:10.1001/jamahealthforum.2025.0383
[8] Undue Medical Debt. (2024, September). Medical Debt, Money, and Mental Health. https://unduemedicaldebt.org/medical-debt-money-and-mental-health/
[9] Moon, K. J., Linton, S. L., Stuart, E. A., Galea, S., Ettman, C. K. (2026). Housing Instability Following Medical Debt Exposure Among US Adults, 2023 to 2025. JAMA Netw Open, 9(1). doi:10.1001/jamanetworkopen.2025.53617
[10] Rakshit, S., Rae, M., Claxton, G., et al. (2023, October). Paying for It: How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer. Commonwealth Fund. https://www.commonwealthfund.org/publications/surveys/2023/oct/paying-for-it-costs-debt-americans-sicker-poorer-2023-affordability-survey
[11] Cole, M., Nguyen, K. H. (2020). Unmet Social Needs among Low-Income Adults in the United States: Associations with Health Care Access and Quality. Health Serv Res., 55(S2). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7518813/
[12] Rigas, M. (2023). The Economics of Patient Assistance Programs: What Patients Need to Know. International Pemphigus and Pemphigoid Foundation. https://www.pemphigus.org/the-economics-of-patient-assistance-programs-what-patients-need-to-know/
[13] Kang, S., Sen, A., Bai, G., Anderson, G. F. (2020). Financial Eligibility Criteria and Medication Coverage for Independent Charity Patient Assistance Programs. JAMA., 322(5):422–429. doi:10.1001/jama.2019.9943
[14] Zafar, S. Y., Peppercorn, J. M. (2017). Patient Financial Assistance Programs: A Path to Affordability or a Barrier to Accessible Cancer Care?. Journal of Clinical Oncology, 35(19), 2113–2116. https://doi.org/10.1200/JCO.2016.71.7280
[15] Consumer Financial Protection Bureau. (2023, December). Is There Financial Help for My Medical Bills? https://www.consumerfinance.gov/ask-cfpb/is-there-financial-help-for-my-medical-bills-en-2124/
[16] Dollar For. (2024). The Path to Charity Care: Exploring the Journey & Roadblocks to Financial Assistance for Medical Bills. https://dollarfor.org/the-path-to-charity-care/
[17] Levinson, Z., Hulver, S., Neuman, T. (2022, November). Hospital Charity Care: How It Works and Why It Matters. Kaiser Family Foundation. https://www.kff.org/health-costs/hospital-charity-care-how-it-works-and-why-it-matters/
[18] Kona, M. (2024, January). State Options for Making Hospital Financial Assistance Programs More Accessible. The Commonwealth Fund. https://www.commonwealthfund.org/blog/2024/state-options-making-hospital-financial-assistance-programs-more-accessible
