How do U.S. hospitals bill uninsured or undocumented patients for emergency care?
Executive summary
U.S. hospitals must provide emergency screening and stabilizing care to anyone who arrives at an emergency department, regardless of insurance or immigration status — a federal requirement under EMTALA that Medicare-participating hospitals follow [1]. Hospitals then use a mix of charity-financial-assistance policies, state rules, Emergency Medicaid reimbursements for eligible noncitizens, billing at charged (list) rates with steep discounts for some uninsured patients, and debt collection or lawsuits when bills go unpaid [2] [3] [4] [5].
1. The legal floor: hospitals must treat first, sort out payment later
Federal law (EMTALA) requires hospitals with EDs to medically screen and provide stabilizing treatment for emergency conditions regardless of ability to pay or immigration status; this mandate is a condition of Medicare participation and is the primary reason undocumented and uninsured people get emergency care [1]. CMS guidance reiterates that hospitals should not ask about citizenship or immigration status as a condition of providing emergency stabilizing care [4].
2. How hospitals translate care into a bill
After stabilization, hospitals typically generate bills using their internal “charges” or billed rates — numbers often far above what insurers actually pay — and uninsured or out‑of‑network patients can be billed those full charges [3]. Many hospitals publish uninsured-patient discount policies that set self-pay or uninsured liability at a reduced rate relative to billed charges; for example, Stanford Health Care’s policy describes an uninsured discount tied to an “average discount from billed charges” and specifically mentions applicability for emergency physician services in some state law contexts [2].
3. Safety nets: Emergency Medicaid, charity care, and state rules
Emergency Medicaid exists to reimburse hospitals for emergency services for people who meet Medicaid financial and non‑financial criteria but are ineligible due to immigration status; this program offsets a portion of uncompensated emergency care costs [6] [7]. Hospitals also run charity care and financial assistance programs — with eligibility often tied to income thresholds — and some states have laws adding protections and uniform application requirements that can limit collection actions and even forgive remaining balances after set payment schedules [8] [9] [10].
4. Collection practices, lawsuits and the “default judgment” problem
When bills go unpaid, hospitals or third‑party collection firms may sue to recover debt; reporting and research show some hospital systems have pursued thousands of suits, producing default judgments when patients do not respond — outcomes that can lead to wage garnishment and other harms [5]. Investigations cited by reporters and academics found that use of debt intermediaries can obscure hospitals’ direct involvement and that some billing records used in suits were “unsubstantiated and inaccurate” in the researchers’ view [5].
5. Price transparency, good-faith estimates and regulatory shifts
Congress and CMS have pushed price‑transparency and good‑faith estimate rules aimed at protecting self‑pay and uninsured patients; the No Surprises Act and hospital price‑transparency rules require certain estimates for scheduled services and envision combining unaffiliated providers’ estimates for an uninsured patient into a single episode-of-care estimate in future regulation [11] [12]. Enforcement has been uneven: CMS audited many hospitals but had issued relatively few fines as of mid‑2025 [12].
6. Immigration status: who pays, who’s eligible, and political framing
Immigration status changes which public programs can help pay after emergency care: undocumented immigrants are generally ineligible for routine Medicaid but may qualify for Emergency Medicaid for stabilizing care; overall Emergency Medicaid spending for noncitizen emergency care represents a small fraction of Medicaid spending, often under 1% in recent analyses [13] [6]. Political narratives sometimes overstate fiscal impacts; fact-checking and research groups note Emergency Medicaid’s share of Medicaid spending is minor and that hospitals shoulder much uncompensated care [14] [6].
7. Practical options for patients and the gaps in reporting
Uninsured or undocumented patients can request hospital financial-assistance applications, negotiate bills, seek charity care, and ask for good‑faith estimates for non‑urgent procedures — but practices differ widely across hospitals and states [9] [12]. Available sources do not mention uniform national enforcement guaranteeing every self‑pay patient receives the same discounts; instead, state laws (e.g., Colorado’s Hospital Discounted Care) and individual hospital policies shape protections and collection limits [10].
8. Why this matters: policy tensions and where pressure points lie
Hospitals face financial pressure because public programs often pay below cost while uninsured patients and underpaid programs drive uncompensated care; this creates incentives to bill list prices, push for collections, or seek state or federal reimbursement mechanisms [3] [15]. Advocates and researchers call for stronger, consistent enforcement of financial-assistance rules and transparency because current patchwork practices leave patients vulnerable to high bills, lawsuits, and credit harm — a theme underscored by reporting and academic studies [5] [16].
Limitations: reporting and guidance cited here document federal rules, program types, hospital policies, and examples of collection behavior, but available sources do not provide a single comprehensive national playbook describing exactly how every U.S. hospital bills every uninsured or undocumented patient; practices vary by hospital, state law, and individual case (not found in current reporting).