Fact check: How do US hospitals determine eligibility for charity care for undocumented patients?

Executive summary — What matters now

US hospitals use widely varying, often opaque rules to decide charity care eligibility, creating uneven access for undocumented patients; some hospitals explicitly exclude noncitizens while others apply income- and residency-based criteria that can include asset reviews and proof requirements ^{[1] [2]}. State policy and hospital ownership shape outcomes: a handful of states have expanded immigrant coverage or set protections, but most nonprofit hospitals still set their own financial assistance rules, producing geographic and institutional disparities ^{[3] [1]}. Recent studies and briefs from 2024–2025 document these variations and the real-world access problems undocumented patients face ^{[4] [5]}.

1. Hospitals’ charity-care rules are a patchwork that decides who gets help

Nonprofit hospitals commonly use income thresholds, residency requirements, and asset investigations to determine charity care eligibility, but the specific thresholds and verification steps differ widely between institutions, producing inconsistent access even within the same region ^[1]. Research published in late 2024 showed private nonprofit hospitals spent modest portions of their budgets on charity care while maintaining diverse criteria to decide who qualifies; these criteria often include proof of local residency and documentation that can disadvantage mobile or undocumented populations ^[1]. The result is a fragmented system where similar patients may be accepted at one hospital and denied at another.

2. Immigration status is an explicit bar in some policies and a de facto barrier in others

Some hospitals explicitly exclude noncitizens from charity-care programs, creating formal barriers for undocumented patients, while others do not state citizenship requirements yet still impose documentation or residency proofs that effectively screen out undocumented people ^{[2] [1]}. Advocacy analyses argue this produces systemic inequity, and call for legal or policy interventions at state or federal levels to prevent discrimination; conversely, hospitals cite compliance, fraud prevention, and budgetary constraints when defending stringent verification practices ^{[2] [1]}. The tension between institutional risk management and equitable access underlies much of the policy debate.

3. State actions tilt the playing field but leave most gaps intact

A minority of states have expanded coverage for lawfully present immigrants or created state-funded programs to reduce gaps, showing that legislative choices materially affect eligibility for immigrant populations ^[3]. However, many states have not adopted such programs and some have scaled back due to budget pressures; where state policy is absent, hospitals’ own charity-care rules fill the vacuum, leading to greater variability and often fewer protections for undocumented patients ^[3]. This creates a two-tier system across states: places with supportive state policy and those dependent on hospital discretion.

4. Emergency Medicaid and clinics are stopgaps, not comprehensive solutions

Undocumented patients frequently rely on emergency departments and community clinics because they lack routine insurance and access to charity care, leading to patterns of acute care use for non-emergent needs ^[5]. Studies from 2024–2025 document this reliance but also show these settings cannot substitute for stable primary care; emergency Medicaid covers only life‑ or limb‑threatening conditions, and clinics often operate with limited capacity and funding, leaving gaps in chronic care and preventive services for undocumented populations ^{[4] [5]}. These dynamics increase health inequities and medical debt exposure.

5. Evidence shows varied charitable spending and limited reach to undocumented patients

Analyses of nonprofit hospital finances reveal charity-care spending is modest and uneven, with private nonprofit hospitals spending around 2.3% of expenses on charity care in studies cited, and eligibility rules that shift over time ^[1]. Historical case studies—such as an analysis of a university hospital system from 2014—highlight how undocumented, low-income families face persistent barriers in accessing charity programs, showing continuity in problems despite some policy evolution ^[6]. Financial assistance thus often fails to fully mitigate medical debt for undocumented patients.

6. Advocates, hospitals, and policymakers frame the problem differently

Advocates frame restrictive charity-care rules as discriminatory and urge legislative bans on status-based exclusions, arguing hospitals and states should guarantee access to financial assistance regardless of immigration status ^[2]. Hospitals and some policymakers emphasize fiscal sustainability, fraud prevention, and regulatory compliance as reasons for documentation and residency requirements, asserting that universal charity care without verification could strain limited resources ^[1]. These competing frames shape proposals—from targeted state programs to calls for federal safeguards—each with different fiscal and operational implications.

7. What the recent research converges on and what remains unresolved

Recent studies and briefs from 2024–2025 converge on the fact that the system is decentralized, variable, and produces access gaps for undocumented patients, with emergency and clinic care filling critical but inadequate roles ^{[1] [4] [5]}. Key unresolved items include standardized federal guidance on nondiscrimination in charity care, the fiscal impact of broadening eligibility, and systematic data on how many undocumented patients are denied versus served under existing programs ^{[2] [3]}. Closing these evidence gaps will be necessary for informed policy choices.