202306us_nonprofithospitals_cover_illustration

In Sheep’s Clothing

United States’ Poorly Regulated Nonprofit Hospitals Undermine Health Care Access

© 2023 Brian Stauffer for Human Rights Watch

Summary

In the United States, tens of millions of people who are uninsured or underinsured are exposed to the country’s high and rising costs of medical treatment. As a result, the US healthcare system has persistent problems with both high out-of-pocket costs for accessing health care and the indebtedness that these costs create. Together, these form sometimes insurmountable barriers to accessing health care and adversely affect people’s enjoyment of other human rights, including the rights to housing, food, and education.

A nationally representative survey conducted by the Kaiser Family Foundation in 2022 found that 41 percent of US adults had some form of outstanding debt due to medical or dental bills, while 24 percent of adults were either past due or unable to pay their health care bills at the time of the survey.

Hospital services, in particular, significantly contribute to the country’s medical debt crisis, with a March 2023 survey conducted by the Urban Institute finding that about 73 percent of adults with past-due medical debt reported owing at least some of that debt to hospitals.

However, nearly 60 percent of the more than 5,000 community hospitals across the US are privately operated nonprofits, which collectively receive public subsidies worth billions each year, largely in the form of tax exemptions, in exchange for providing “community benefits” like free or reduced-price health care. In other countries, such free or subsidized health care is the norm and widely understood as a key way that a government meets its right to health obligations. But in the US, this is tellingly referred to as “charity care.”

The US heavily relies on these privately operated nonprofit hospitals’ charity care to increase access to health care for patients who cannot pay for hospital services, such as emergency treatment, diagnostic work, and inpatient surgeries. But given the high prevalence of hospital-related medical debt in the US, this system is clearly not working.

This report documents how the US government’s lack of guidance and oversight gives private nonprofit hospitals wide discretion over how much they spend on making health care accessible for people who cannot pay, who qualifies for this assistance, and how far they will go to collect debts from patients who cannot pay their bills.

As the US government considers potential reforms to improve health care access and reduce medical debt, this report outlines how existing nonprofit hospital regulations undermine rights and explores the untenable costs of inaction.

While nonprofit hospitals have certain clear policy and reporting obligations, there are no clear federal standards defining either “community benefits” or “charity care,” allowing nonprofit hospitals to follow their own definition of these terms with little public oversight.

As a result of inadequate regulation, many nonprofit hospitals operate more like for-profit corporations, charging high fees and aggressively pursuing medical bills against people who cannot pay, including through lawsuits and selling debt to third-party debt collectors.

Media accounts and studies from across the US, compiled in Section IV below, document tens of thousands of lawsuits brought by nonprofit hospitals against patients in recent years, although the true scale of these practices is poorly understood.

Like wolves in sheep’s clothing, unscrupulous nonprofit hospitals can hide among their responsible peers, benefiting from their public perception and tax-status as charitable institutions while engaging in extractive and exploitative practices.

Many of these nonprofit hospitals also spend far less on making healthcare services accessible for people without the means to pay than the value of the public subsidies they receive. In 2020, for example, nonprofit hospitals received about $28 billion in tax benefits, but only spent about $16 billion on free or reduced-price charity care, according to the Kaiser Family Foundation.

This lack of spending on free or reduced-price care occurs despite hundreds of millions of dollars of additional tax-funded subsidies that some nonprofit hospitals receive, in addition to their valuable tax exemptions, which can cover some or even all of their charity care costs.

Despite nonprofit hospitals receiving public subsidies to support such aid, on aggregate, there seems to be little difference between how much for-profit and nonprofit hospitals spend on free and reduced-price care. For example, in 2018, a study from the National Bureau of Economic Research found that charity care accounted for only 1.5 percent of the median nonprofit hospital’s expenses, while the median for-profit hospital spent 1.4 percent of its expenses on charity care.

Not all nonprofit hospitals in the US are engaged in these practices. They are also not alone in contributing to the country’s medical debt crisis, as the practices of for-profit hospitals and private health insurance providers also warrant scrutiny. However, far too many of these ostensibly charitable institutions, which have special obligations to their communities, are failing to fund accessible health care in equal measure to the public subsidies they receive.

This report finds that, when combined with its inadequate regulation, the US model of subsidizing privately operated hospitals with tax exemptions in the hope that they will increase the accessibility of hospital care for un- and underinsured patients allows for abusive medical billing and debt collection practices and undermines human rights, including the right to health and the right to social security.

This profoundly flawed, charity-based hospital care system also impacts other rights, as the money required to access expensive hospital care or service medical debt can come at the expense of other goods and services essential to rights, such as housing, education, and food. These human rights harms also reinforce existing forms of structural discrimination, disproportionately impacting women, communities of color, and people with low incomes or disabilities.

To realize the right of everyone to enjoy the highest attainable standard of health, governments should ensure equal access to quality health care for all, regardless of a person’s ability to pay.

But the lack of federal regulation and enforcement, the structural shortcomings of this charity-based model, and the aggressive practices of hospitals that pursue medical bills against patients, including through abusive debt collection, all contribute to the failure of the US government to meet this standard.

To fulfil the right to health, the US should move away from its current, charity-dependent model of hospital services. In particular, it should consider adopting measures taken by many other high-income countries to realize the right to health through a public healthcare system that is universally accessible for all, regardless of people’s ability to pay, universal health insurance coverage, or some combination of these two.

In the short term, alongside needed reforms to the healthcare system to realize the right to health, the US government should ensure, at a minimum, that nonprofit hospitals’ charity care is, in practice, easily obtainable, and adequately inclusive and robust to reflect community need.

The Internal Revenue Service and Centers for Medicare and Medicaid Services should also adopt and amend policies to ensure that nonprofit hospitals’ community benefits and charity care provide benefits to their communities that are at least commensurate with the value of the tax exemptions these commercial actors receive.

Additionally, although the Consumer Financial Protection Bureau considers medical debt a priority and has previously written about the practices of private nonprofit hospitals, it has so far not used its enforcement capacity to improve patients’ access to these commercial entities’ services, something that should change.

Both nonprofit hospitals and third-party debt collectors should also be regulated to prohibit the seizure of people’s primary residences and imprisonment for noncompliance with civil debt proceedings. Laws and regulations should also establish strict safeguards against other abusive collection practices for medical debt.

Notwithstanding regulation, these commercial entities are also failing to meet their responsibilities to respect human rights and ensure that they do not cause or contribute to human rights abuses, including through their medical billing and debt collection practices.

The US should begin treating health care as a right, not a privilege. In the meantime, the US should ensure that the nonprofit hospitals it currently depends on to do its job of ensuring access to health care are not saddling people with debts they can never repay, just because they had the bad luck of being human and needing medical treatment.

Recommendations

Overarching Recommendation: The US should move away from its current, charity-dependent model of hospital services and ensure that health care is affordable to all. In particular, it should consider adopting measures taken by many other high-income countries, such as creating a public healthcare system that is universally accessible for all, regardless of people’s ability to pay, universal health insurance coverage, or some combination of these two. While building toward a rights-aligned healthcare system, US authorities should take the following steps to protect the rights of tens of millions of people who will remain exposed to the high and rising costs of hospital care in the US:

Federal Legislators

  • Enact legislation to ensure that any public subsidies for healthcare providers, whether direct subsidies and indirect tax exemptions, benefit actors that actually increase access to health care for everyone, regardless of one’s ability to pay. At a minimum, recipients of public subsidies should demonstrate that they fund available and accessible health care in at least equal measure to the subsidies that they receive. Additionally, this should include additional funding for publicly administered hospital systems that can provide medical care to everyone who cannot pay for treatment at no cost or, at a minimum, at progressively scaled costs that do not create barriers to access.
  • Expand coverage for existing public health insurance programs like Medicaid and Medicare.

Internal Revenue Service (IRS)

  • Strengthen the oversight and enforcement of nonprofit hospitals’ compliance with sections 501(c)(3) and 501(r) of the Internal Revenue Code to ensure that their community benefits and charity care actually provide benefits to their communities that are at least commensurate with the value of the tax exemptions they receive. This should include specifying minimum financial eligibility criteria for nonprofit hospitals’ financial assistance policies, and renewing community benefits guidance for nonprofit hospitals to ensure that exempt activities appropriately reflect modern community needs, such as by requiring that surplus revenue be reinvested into healthcare services. Additionally, the IRS should redefine the circumstances under which a nonprofit hospitals’ violations of 501(r) “shall be excused,” to focus on the harm that those violations caused, rather than the intent of the hospital.
  • Ensure that nonprofit hospitals’ charity care policies are consistent with the right to health, including being inclusive and accessible. This should include prohibiting certain non-financial eligibility limitations, such as residency or lawful presence requirements and other barriers to providing assistance for people who are underinsured, such as blanket bans against patients with insurance. Additionally, the IRS should require hospitals to use, and assist with the use of, a uniform and easily accessible financial assistance application, available in languages used by the communities served.
  • Increase transparency of both nonprofit hospitals’ practices and the IRS’ oversight of the industry. This should include publicly disclosing section 501(r) violations and requiring that violating hospitals publish a public remediation plan. Additionally, nonprofit hospitals should be required to submit their financial assistance policies within their community health needs assessments.
  • Prohibit rights-impacting practices arising from nonprofit hospitals’ extraordinary collection actions, such as foreclosures, bank account seizures, and the charging of interest on debt, as well as strengthening the definition of “reasonable effort,” and prohibiting delaying or denying future medical care due to nonpayment.

State Legislators

  • Address the absence of financial assistance protections for patients by passing laws that specify clear minimum standards for eligibility for free or reduced-cost care for both uninsured and underinsured patients under hospitals’ financial assistance policies. States should also implement laws and policies that require hospitals to adopt practices to effectively and proactively identify patients eligible to receive financial assistance and ensure that they provide such assistance. Additionally, states should prohibit nonprofit hospitals’ financial assistance policies from denying coverage for patients with irregular immigration status.
  • Where states are providing direct, tax-funded subsidies for nonprofit hospitals’ charity care, strengthen the oversight of these programs to ensure that subsidized institutions are not engaging in abusive medical billing and debt collection practices, or failing to provide benefits to their communities that are at least commensurate with the value of the tax exemptions they receive.
  • States that have not implemented the so-called Medicaid expansion, which, among other things, expands the public health plan’s coverage to single persons without dependents, should also adopt legislation integrating these components of the program into state laws.
  • Additionally, state legislators should consider adopting the National Consumer Law Center’s Model Medical Debt Protection Act, in whole or in part, which has relevant statutory language that can address many of the issues described in this report, including simplifying the financial assistance application process; creating a mechanism or private right of action that allows patients who are denied financial assistance despite their eligibility to be reimbursed; improving transparency around hospitals’ charitable expenditures and the value of subsidies that they receive, such as exemptions from state and local taxes; and requiring for-profit hospitals to also provide financial assistance for low- or no-income patients.

Consumer Financial Protection Bureau (CFPB)

  • Undertake enforcement against unfair, deceptive, or abusive acts or practices among nonprofit hospitals and collectors of medical debt accrued at nonprofit hospitals.
  • In particular, prioritize enforcement actions against debt collectors that fail to ensure that patients have been fully informed about and screened for financial assistance before pursuing collection.
  • Work with state attorneys general and other consumer financial regulators to bring actions against nonprofit hospitals and debt collection agencies that violate state laws related to medical billing and medical debt collection practices.

Centers for Medicare and Medicaid Services (CMS)

  • Establish and enforce adequate penalties for hospitals that fail to comply with their existing obligations under CMS rules to “provide all or a portion of services free of charge to patients who meet the hospital’s charity care policy.”
  • Adopt other policies, potentially through new rulemaking, to further limit the human rights impacts of nonprofit hospitals’ medical billing practices. For example, require hospitals to comply with relevant consumer financial protection laws, such as the Dodd-Frank Wall Street Reform and Consumer Protection Act and IRC Section 501(r), within the definition of “applicable Federal laws” under 42 CFR § 482.11(a), in order to receive compensation from CMS under the Conditions of Participation and Conditions for Coverage to continue participating in the Medicare and Medicaid programs.
  • Set new conditions for disproportionate share hospital (DSH) payments to require hospitals to identify and respond to the unmet health needs of the communities they serve. For example, to get DSH payments, hospitals should be required to assess community needs regularly and devise ways to address them, involving representatives of underserved populations in this process.

Nonprofit Hospitals

  • Notwithstanding regulation, nonprofit hospitals also have responsibilities to respect human rights and ensure that they do not cause or contribute to human rights abuses, including through their medical billing and collections practices. In particular, they should adopt policies to limit the human rights impacts of medical billing and debt collection, such as by ensuring that financial assistance is, in practice, easily accessible, and adequately inclusive and robust to reflect community need.
 

Methodology

This report is based primarily on analysis of data and other publicly available secondary sources of information conducted between October 2022 and March 2023. It extensively draws from reports from nongovernmental organizations, government and academic studies, data from federal departments and agencies, medical literature, nationally representative surveys, and relevant local and national reporting. Where relevant, the methodology for charts and data included in this report is explained in the footnotes.

Human Rights Watch wrote letters to three large trade associations representing hospitals in the US: Federation of American Hospitals, which represents for-profit hospitals; American Hospital Association, which represents both nonprofit and for-profit hospitals; and Catholic Health Association of the United States, which represents faith-based nonprofit hospitals. Human Rights Watch also wrote letters to the three federal agencies covered in this report: Internal Revenue Service, Centers for Medicare and Medicaid Services, and Consumer Financial Protection Bureau.

These letters requested information and clarification regarding their practices. Of the 6 entities we contacted, only the Catholic Health Association of the United States and American Hospital Association provided written response. Their responses are reflected throughout the report, where relevant, including in some places to provide important contextual information about industry policies and practices. The complete correspondence with these 6 entities can be found in an online Annex to this report.

In addition to these 6 letters, Human Rights Watch also contacted 11 nonprofit hospitals and hospital systems, and 7 state-based trade associations, seeking their comment on publicly reported accounts of nonprofit hospitals’ debt collection practices. Their responses are reflected throughout Section IV. The complete correspondence with these entities can also be found in the online Annex to this report.

I. Background

Everyone has the right under international human rights law to enjoy the highest attainable standard of health.[1] To fulfil this right, governments should dedicate the maximum of their available resources towards ensuring the availability and accessibility of acceptable, quality healthcare facilities, goods and services.[2] Ensuring access to health care that is consistent with this right, whether privately or publicly provided, requires that governments ensure that poorer households are not disproportionately burdened with health expenses.[3]

Most high-income countries have taken measures to meet this standard by funding some combination of robust public health care services, including public hospitals, and social security programs like universal public health insurance.[4]

While the US has two federally administered public hospital systems that can provide medical care at no or minimal cost—the Veterans Administration and Indian Health Service—they are only accessible to eligible military veterans or American Indians and Alaska Natives, respectively, and both of these systems are vastly underfunded and under-resourced.[5]

Similarly, while the country has some public health insurance schemes that can help pay for medical care, including Medicare and Medicaid, these can still involve substantial cost sharing or user fees and are only available to citizens and so-called “lawfully present immigrants” who are above or below a certain age, have a permanent disability, or earn very low incomes alongside various other state-based eligibility limitations.[6]

For example, to qualify for Medicaid in 2023, a single person without dependents would need to earn below $20,120 in most states.[7] But in the 10 states that have not yet adopted the 2010 Patient Protection and Affordable Care Act’s so-called “Medicaid expansion,” no single-person households without dependents are eligible for this crucial social security program.[8] About 2 million uninsured adults fall into this coverage gap nationwide, which disproportionately impacts Black, Indigenous, and other communities of color.[9]

This absence of either a universally accessible public healthcare system or universal health insurance coverage leaves tens of millions of people who are uninsured or underinsured exposed to the high and rising costs of medical treatment in the US.[10]

More than 8 percent of the US population, or approximately 30 million people, did not have any health insurance in 2021, the most recent year for which robust national-level data is available.[11]

But these already high numbers of uninsured people are likely to rise over the coming year, as certain policies passed in response to the Covid-19 pandemic end, such as the continuous enrollment provision of Medicaid, the US public health insurance scheme for people with low incomes, which expired in March 2023.[12] The termination of this provision will likely cause between 5 and 14 million people to lose health insurance coverage in the coming months, according to recent estimates by the Kaiser Family Foundation.[13]

According to a biennial survey conducted by the Commonwealth Fund, a private foundation that supports an equitable healthcare system, another 34 percent of people in the US were underinsured in 2022.[14] This means that they had gaps in coverage during the year or still had significant non-premium out-of-pocket costs, despite being covered by a health insurance plan.[15]

Because of this absence of universally accessible and adequate health care for everyone, in 2021, about 20 percent of US adults experienced a major, unexpected medical expense that had a median out-of-pocket cost between $1,000 and $1,900, according to a nationally representative survey from the central bank of the US.[16]

When out-of-pocket health expenditures and health insurance reimbursements are combined, people in the US pay more for health care, both per person and as a share of GDP, than 37 other high-income countries in the Organization for Economic Cooperation and Development (OECD).[17] According to OECD data, which weighs prices based on local purchasing power, the per capita out-of-pocket cost for health care in the US was $1,172 in 2020, about 67 percent higher than OECD’s median per capita out-of-pocket costs that year.[18]

Despite paying more than double what the median OECD country pays per capita for health care, when compared to these countries, the US has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest suicide rates.[19] In some cases, such as maternal mortality, the United States’ health care outcomes are worsening.[20]

Human Rights Impacts of Medical Debt

These high out-of-pocket costs for accessing health care fuel the nation’s medical debt crisis and undermine human rights.

Medical debt is highly prevalent in the US, with a nationally representative survey conducted by the Kaiser Family Foundation in 2022 finding that 41 percent of US adults had some form of outstanding debt due to medical or dental bills, while 24 percent of adults were either past due or unable to pay their health care bills at the time of the survey.[21]

As Human Rights Watch research in the US has documented, people facing steep out-of-pocket costs for health care are more likely to ration essential medicines like insulin and are more likely to avoid medical treatment that can detect and treat preventable diseases like cervical cancer, risking dangerous and potentially lethal health complications.[22]

These findings are consistent with the results of numerous surveys conducted by the Commonwealth Fund in recent years, which have regularly found that people in the US are much more likely to avoid seeking needed medical care or treatment because of its cost than residents of other high-income countries.[23]

But the expense of the US healthcare system undermines more than just the right to health, as the money required to access health care or service medical debt can come at the expense of other goods and services essential to rights, such as housing and food. For example, a 2022 analysis of more than 142,000 survey results from the US Census Bureau, conducted by researchers from the City University of New York and Harvard Medical School, found that people who acquired medical debt between 2017 and 2019 were about 2.2 times more likely to become food insecure and nearly 3 times more likely to experience an eviction or foreclosure.[24]

However, the burdens of medical debt are not shared equally. Women and people who have low incomes or disabilities, or are Black, Indigenous, or people of color (BIPOC) are disproportionately burdened by medical debt in the US.[25] For example, a 2022 nationally representative survey conducted by the US Census Bureau found that most people in the US with incomes below $40,000—roughly the national median personal income—had some kind of outstanding medical debt.[26]

According to data collected by the US Census Bureau and Centers for Disease Control and Prevention, people who are Native American or Alaskan Native, Latinx, or Black are much more likely to be uninsured than white people and much more likely to have chronic medical conditions like hypertension or diabetes, two of the primary risk factors for incurring medical debt.[27]

As a result, people from these communities are also much more likely to be burdened by medical debt. For example, about 28 percent of Black households in the US had medical debt in 2017 compared to 17 percent of white, non-Hispanic households, according to data collected by the US Census Bureau.[28] This disparity is also reflected in the share of the population with medical debt in collections, which is about 36 percent higher in BIPOC-majority communities than in majority-white communities, according to a nationally representative review of credit reports conducted by the Urban Institute in 2022.[29]

Hospital Costs Contribute to the US Medical Debt Crisis

Hospital services, in particular, significantly contribute to the country’s medical debt crisis.[30] A 2022 Kaiser Family Foundation survey found that emergency room visits and hospitalizations led to 50 and 35 percent of US adults’ medical debt, respectively.[31] More recently, a March 2023 survey conducted by the Urban Institute found that about 73 percent of adults with past-due medical debt reported owing at least some of that debt to hospitals.[32]

The prices that hospitals charge for their services in the US are both exceptionally expensive and rising, having more than tripled since 2000 when adjusted for inflation, according to a Human Rights Watch analysis of federal consumer price index data.[33]

According to OECD data, which weighs prices to reflect local purchasing power, when out-of-pocket health expenditures and health insurance reimbursements are combined, the US paid about $3,380 per person for hospital care in 2020, about 140 percent above the average per capita cost for hospital care across 32 other countries in the OECD with data available for that year—around $1,590.[34]

Despite these uniquely high prices, many hospitals in the US face significant financial challenges.[35] For example, in response to a letter from Human Rights Watch, the Catholic Health Association of the United States, a trade association that represents faith-based nonprofit hospitals, wrote:

In 2022, historic inflation driven costs of medical supplies, equipment and labor led to the year being one of the most financially challenging since the pandemic. As a result, numerous nonprofit hospitals have reported significant operating losses (some over $1 billion). Despite this, nonprofit hospitals, including Catholic hospitals, continue to provide low-margin services at rates higher than for-profit hospitals and cost increases were less than half of the rate of inflation in 2022.[36]

The drivers behind the United States’ exceptionally high prices for hospital services are many and mixed, and largely outside of the scope of this report, although they appear to reflect increasing concentration within, and inadequate regulation of, the nation’s heavily market-based healthcare system.[37]

In letters to Human Rights Watch, trade associations representing nonprofit hospitals in the US noted how the practices of both public and private health insurance providers have influenced hospital prices and contributed to the country’s medical debt crisis.[38] While the drivers of these high prices complex, as shown in the sections below, their results are predictable.[39]

 

II. Vague Tax Rules for Nonprofit Hospitals

Most community hospitals in the US are privately operated nonprofits.[40] As private hospitals, they are not owned or operated by the government on any level, whether federal, state, or local. As nonprofits, they are also exempt from federal taxes under Section 501(c)(3) of the Internal Revenue Code, as well as other state and local taxes under various state laws, which together save these commercial actors billions of dollars each year.[41]

A 501(c)(3) organization—also called a nonprofit or not-for-profit organization—must be organized for an exempt purpose, such as charity, religion, science, or education.[42] The Internal Revenue Service (IRS), the agency responsible for overseeing the US federal tax system, allows hospitals to demonstrate that they qualify for this tax-exempt status as a charitable organization by providing so-called “community benefit.”[43]

But the IRS does not have a definition of “community benefit” that nonprofit hospitals must meet.[44] Rather, the agency relies on a four-page document published in 1969, which articulated six examples of activities that could demonstrate a hospital’s community benefit:[45]

  • Operating an emergency room open to all, regardless of ability to pay;
  • Maintaining a board of directors drawn from the community;
  • Maintaining an open medical staff policy;
  • Providing hospital care for all patients able to pay, including those who pay their bills through public programs such as Medicaid and Medicare;
  • Using surplus funds to improve facilities, equipment, and patient care; and
  • Using surplus funds to advance medical training, education, and research.

Fundamentally, these loosely defined examples and guidance are too vague to ensure that nonprofit hospitals deliver on the right to health.[46] To meet international human rights standards, the US government should ensure that everyone enjoys the highest attainable standard of health, regardless of their ability to pay.

If the US government were to rely on nonprofit hospitals to provide accessible health care to everyone, regardless of their ability to pay, it should require them to, in at least some cases, deliver free health care, something which is tellingly referred to as “charity care” in the US.[47] But conspicuously, to qualify for tax exemption as a charitable organization under this IRS guidance, hospitals are not technically required to provide this so-called charity care.[48]

While the IRS considers a hospital’s provision of charity care to be a significant factor indicating their community benefit, the lack of clear guidance allows for a wide variety of practices.[49] As a 2020 study by the Government Accountability Office (GAO) summarized: “Given this [regulatory] ambiguity, a hospital could, in theory, maintain a tax exemption … while spending little to no money on charity care or other community benefit activities.”[50]

In 2010, the Patient Protection and Affordable Care Act (ACA) attempted to address the lack of clarity around community benefits by adding four additional requirements for nonprofit hospitals under Section 501(r) of the Internal Revenue Code:

  • Community Health Needs Assessments: every three years, each nonprofit hospital must produce a community health needs assessment and develop an implementation plan for how it will address those needs.
  • Financial Assistance and Emergency Medical Care Policy: each nonprofit hospital must publish a written financial assistance policy that outlines who can qualify for financial assistance for medical services, how the hospital calculates costs for those services, and the actions the hospital will take in the event of nonpayment.
  • Limitation on Charges: nonprofit hospitals cannot charge individuals eligible for financial assistance more for medical services than they charge patients with insurance.
  • Billing and Collection Requirements: nonprofit hospitals cannot engage in so-called extraordinary collection actions against people who owe them medical debt, such as filing a lawsuit, before the hospital determines whether that individual is ineligible for assistance under their financial assistance policy.[51]

While a significant step forward, these four requirements from the 2010 ACA, which nonprofit hospitals must also satisfy in addition to their community benefit obligations outlined by the IRS in 1969, still fall far short of what is needed to realize the right to health.[52]

For example, although the 2010 ACA required all nonprofit hospitals to produce a written and publicly available Financial Assistance Policy, which outlines their charity care practices, these regulations do not specify any requirements for this charity care, such as eligibility criteria or minimum coverage standards.[53] Accordingly, a nonprofit hospital’s charity care policy satisfies federal regulations merely by being written and publicly available, regardless of whether the policies actually make health care affordable for people who cannot pay for treatment.

Several states have attempted to address this regulatory gap by implementing laws and regulations that specify the criteria nonprofit hospitals should use to determine who is eligible for charity care and how fully to cover their costs.[54] Some states, such as California and Illinois, even compel a certain amount of charity care spending by for-profit hospitals.[55] But these state-based eligibility requirements, which are typically means-tested based on the patient’s income, vary widely.[56]

Because nonprofit hospitals are generally allowed to define who is eligible for their “charity care,” they are allowed to set standards that exclude significant numbers of patients who cannot pay for medical treatment.[57] As shown in Section III below, this results in nonprofit hospitals spending relatively little, on aggregate, on free or reduced-price care for people who cannot pay for it.

About one in five nonprofit hospitals across the US even have policies to deny nonemergency medical care to patients who owe them money.[58]

IRS’ Lax Enforcement of Existing Rules

In 2020, the Government Accountability Office (GAO), a nonpartisan agency of the federal government that provides auditing, evaluative, and investigative services for the US Congress, reviewed tax documents that nonprofit hospitals submitted to the IRS in 2016.[59] These data, which included forms that self-reported how much money these nonprofit hospitals claimed to have spent on community benefits that year, revealed that 30 nonprofit hospitals had reported no spending at all on any community benefits to federal regulators.[60]

When the GAO asked the IRS whether it had conducted any reviews related to these hospitals, the IRS was unable to provide any evidence that such reviews had occurred because it did not have a system in place to track them.[61] But even if audits of these hospitals that reported no community benefit expenditures in 2016 had occurred, the IRS has been historically reluctant to use its enforcement powers to increase hospitals’ investment in community benefits.[62]

The IRS reserves the right to revoke the tax-exempt status of any nonprofit organization that fails to meet its obligations under the tax code.[63] But in its entire history, the IRS has only revoked the tax-exempt status of a nonprofit hospital once.[64] This singular revocation was based on a very clear binary failure to produce a community health needs assessment, one of the additional requirements mandated by the 2010 ACA.[65] When it comes to ensuring that nonprofit hospitals are adequately spending on community benefits, which does not have a clear definition or requirements, the IRS has never used its revocation authority.

It is also unclear exactly how often the agency has used less severe sanctions like investigations, settlements, or cash penalties to improve the community benefits of tax-exempt hospitals.[66] Although, in response to a letter from Human Rights Watch, the Catholic Health Association of the United States, a trade association that represents faith-based nonprofit hospitals, wrote that the IRS “assessed over 100 $50,000 excise taxes for CHNA violations” through its 2018 fiscal year.[67]

In part, the lack of clarity around intermediary sanctions is because the IRS neither publicly reports nor requires hospitals to report violations of either their community benefit obligations or any of the 2010 ACA’s 501(r) rules. As further discussed in Section IV, under current IRS rules, the agency will also excuse any hospital’s violation of these additional requirements from the 2010 ACA, so long as a correction is made and the violation was “neither willful nor egregious.”[68] This standard further complicates public access to information regarding nonprofit hospitals’ practices.

Human Rights Watch wrote a letter to the Department of the Treasury and IRS, which can be found in an online Annex to this report, requesting comment and clarification regarding their interpretation and enforcement of nonprofit hospitals’ community benefits and 2010 ACA’s 501(r) obligations. However, neither the Department of the Treasury nor IRS provided a response at time of publication.

III. Voluntary Charity Care Failsto Realize Right to Health

The combination of unclear community benefit obligations and limited enforcement allows for wide variation between nonprofit hospitals in what activities and services are considered a community benefit and how their value is measured.

The primary sources for data on how much hospitals spend on community benefits, including “charity care,” are the IRS and the Centers for Medicaid and Medicare Services (CMS), a federal agency that administers the United States’ public health insurance programs.[69]

Each year, all nonprofit organizations are required to submit relevant tax information to the IRS.[70] But privately operated nonprofit hospitals must also submit a so-called “Schedule H” form, which includes, among other things, self-reported information about how much money these hospitals claimed to have spent on community benefits that year.[71] While this Schedule H form requests data from hospitals on their spending across 17 different possible types of community benefits, shown below, the IRS does not systematically consider the adequacy of these claimed expenses.[72] Rather, the IRS primarily assesses their accuracy.[73]

Similarly, CMS requires all short-term acute care hospitals to submit so-called “cost reports” each year, which include data on four types of community benefit expenditures.[74] Like the IRS, CMS also does not judge whether this hospital-defined community benefit spending should actually be considered a community benefit, such as whether the hospitals’ charity care spending was adequate to meet community needs.[75]

This lax regulation gives nonprofit hospitals an enormous amount of discretion over both how much they spend on community benefits, in general, and how much they spend on specific types of community benefit, like “charity care.”

For example, a 2021 study of more than 1,900 private nonprofit hospitals’ tax filings from 2017, conducted by researchers at the Johns Hopkins University Bloomberg School of Public Health, found that, on average, these hospitals reported spending about 8 percent of their expenses on activities or services that they considered to benefit the community that year.[76]

Private Nonprofit Hospitals’ Average Community Benefit Expenditures in 2017

Rank

Type of Community Benefit (CB)

Avg. % of CB Expenses

Avg. % of Total Expenses

1

Unreimbursed Costs from Medicaid

46.15

3.78

2

Charity Care

18.32

1.5

3

Subsidized Health Services (Not Means-Tested)

17.95

1.47

4

Unreimbursed Health Professions Education

6.72

0.55

5

Community Health Improvement Services and Operations

4.15

0.34

6

Unreimbursed Costs (From Other Means-Tested Programs)

2.81

0.23

7

Cash and In-Kind Contributions for Community Benefit

2.08

0.17

8

Unfunded Research

0.98

0.08

9

Community Support

0.24

0.02

10

Workforce Development

0.24

0.02

11

Community Health Improvement Advocacy

0.12

0.01

12

Physical Improvements and Housing

0.12

0.01

13

Economic Development

0.05

0.004

14

Coalition Building

0.05

0.004

15

Other

0.05

0.004

16

Environmental Improvements

0.01

0.001

17

Leadership Development and Training

0.01

0.001

Source: Hossein Zare, et al., “Charity Care and Community Benefit in Non-Profit Hospitals: Definition and Requirements,”
Inquiry: The Journal of Health Care Organization, Provision, and Financing, Vol. 58, 2021, https://journals.sagepub.com/doi/10.1177/00469580211028180 (accessed March 14, 2023).

In a letter to Human Rights Watch, the American Hospital Association, which represents both nonprofit and for-profit hospitals in the US, suggested that this average spending was higher, writing that nonprofit hospitals spent 13.9% of their total expenses on community benefits in 2019.[77]

However, charity care, which is the clearest form of community benefit and has the greatest impact on people’s ability to access health care, accounted for less than one-fifth of the average nonprofit hospital’s claimed community benefit expenditures in 2017, or about 1.5 percent of the average nonprofit hospital’s total expenses that year.[78]

Private nonprofit hospitals’ spending on charity care has also declined in recent years, according to a separate 2021 study conducted by these researchers from Johns Hopkins.[79] Although these nonprofit hospitals’ claimed spending on community benefits remained relatively constant between 2011 and 2018, this study found that the amount spent on charity care roughly halved, declining from 33 percent of the average nonprofit hospital’s total community benefit expenditures in 2011 to just 18 percent in 2018.[80]

While the causes of this decline in charity care expenditures are unclear, it suggests that nonprofit hospitals have, on aggregate, provided less free-of-cost care to uninsured patients over recent years. Although this may also reflect the decline in the rate of the uninsured population over this period, which fell from about 17.4 percent to 10.4 percent of the US between 2011 and 2018.[81]

This decline has occurred despite additional forms of public subsidy, aside from valuable tax exemptions, which can in some cases cover some or even all of their charity care costs. For example, several states spend hundreds of millions of dollars each year to help finance nonprofit hospitals’ charity care through dedicated public support funds.[82]

Both Medicare and Medicaid also provide so-called “disproportionate share hospital (DSH) payments” to both for-profit and nonprofit hospitals that care for a disproportionate share of low-income patients, which are partly intended to offset the costs of charity care and other uncompensated care.[83] According to estimates by the Kaiser Family Foundation, the total value of these DSH payments was $31.9 billion in 2020.[84]

Despite nonprofit hospitals receiving public subsidies to support such aid, on aggregate, there seems to be little difference between how much for-profit and nonprofit hospitals spend on free and reduced-price care. For example, in 2018, a study from the National Bureau of Economic Research found that charity care accounted for only 1.5 percent of the median nonprofit hospital’s expenses, while the median for-profit hospital spent 1.4 percent of its expenses on charity care.[85]

Similarly, a 2020 study by researchers at the Harvard University School of Public Health, which analyzed Medicare cost data from 2018, found “no significant difference between for-profit and nonprofit hospitals in charity care as percent of total expenses,” leading the authors to conclude that “nonprofit hospitals may not be providing the level of charity care warranted by their tax exemption status, and in some cases may be spending relatively less than their for-profit counterparts.”[86]

A 2021 study of 2018 Medicare cost reports by researchers from Johns Hopkins University suggests that nonprofit hospitals actually spend less on charity care, on aggregate, than their for-profit counterparts.[87] This study analyzed data from more than 4,600 hospitals and found that, on aggregate, nonprofit hospitals spent about $2.30 of every $100 in total expenses on charity care, which was less than publicly administered and for-profit hospitals, which spent $4.10 and $3.80 on charity care per every $100 of expenses, respectively.[88]

One of the 2021 studies by researchers from Johns Hopkins, discussed above, estimated that 86 percent of nonprofit hospitals spent less on charity care than the value of their tax exemptions.[89] Similarly, a 2022 study by the Lown Institute found that 80 percent of the 275 largest private nonprofit hospital systems spent less on charity care and community investment than the estimated value of their tax breaks.[90]

More recently, the Kaiser Family Foundation reported that nonprofit hospitals’ tax exemptions were worth approximately US$28 billion in 2020 while the value of their charity care was only $16 billion, or about 57 percent of the tax benefits they received.[91]

These studies suggest that, on aggregate, nonprofit hospitals’ tax exemptions are not leading to increased charity care, and that the billions of dollars these commercial entities save in taxes are being diverted to other uses, such as growth, executive compensation, and sizeable investment portfolios.[92]

In letters to Human Rights Watch, trade associations representing nonprofit hospitals in the US suggested that their tax exemptions were adequately justified by their community benefit spending. For example, in response to a letter from Human Rights Watch, the Catholic Health Association of the United States wrote:

We find it unfortunate that some recent reports and media coverage on non-profits hospitals explicitly ignore several categories when comparing community benefit expenses and taxes not collected from nonprofit hospitals, giving an incomplete picture of hospitals’ investments in their communities…. The value of community benefit activities cannot be measured solely by the amount spent. Many may be relatively low cost, especially when provided in coalition with public health agencies and community organizations but can play a significant role in improving community health. The resulting community value of programs (impact) in most instances is far greater than the cost (spending) reported by hospitals.[93]

Similarly, in response to a letter from Human Rights Watch, the American Hospital Association (AHA), which represents both nonprofit and for-profit hospitals in the US, wrote:

As a field, hospitals provide more benefit to their communities than any other sector in health care…. tax-exempt hospitals provide more than sufficient benefits to their communities to merit that exemption under any reasonable standard.[94]

In its letter to Human Rights Watch, the AHA further cited to an AHA-funded report from the international accounting form EY, which found that “for every one dollar in tax exemption, hospitals provided nine dollars in community benefit.”[95]

While many nonprofit hospitals are vital to ensuring the availability of health care services in their communities, the lack of clear guidance allows unscrupulous nonprofit hospitals to spend far less on making healthcare services accessible for people without the means to pay than the value of the tax exemptions and other public subsidies they receive. Additionally, as discussed below, the single largest form of community benefit expenditure claimed by nonprofit hospitals may not be a clear-cut reason for tax exemption.

Private Nonprofit Hospitals’ Largest Self-Reported Community Benefit

According to the 2021 study by researchers from Johns Hopkins University Bloomberg School of Public Health, detailed above, nearly half of nonprofit hospitals’ self-reported community benefit expenditures in 2017 were for so-called “unreimbursed Medicaid costs.”[96]

Unlike private insurers in the US, which negotiate with hospitals to determine how much they will pay for certain services, the amount that Medicaid—the United States’ public health insurance system for low-income adults—pays for hospital services is set by law.[97]

In brief, these “unreimbursed Medicaid costs”—also referred to as a “Medicaid shortfall”—are the amount of money that the hospital believes that Medicaid’s legally set reimbursement amounts underpaid for medical care that the hospital rendered to people covered by the program.[98] In other words, if a privately operated nonprofit hospital charges prices for their services that are above the amounts that Medicaid will reimburse, they can list the difference as charitable spending.

According to another study by researchers from Johns Hopkins University, between 2011 and 2018, the average nonprofit hospital’s claimed “unreimbursed Medicaid costs” increased, as a share of both their total community benefit expenditures and overall expenses, by 31.8 percent and 32.4 percent, respectively.[99]

While these unreimbursed Medicaid costs form the foundation of nonprofit hospitals’ claimed charitable community benefits, which justify their valuable tax exemptions, nonprofit hospitals seem to spend similar amounts on unreimbursed Medicaid costs as their for-profit, tax-paying counterparts.[100]

A 2022 study of more than 3,400 private hospitals’ Medicare cost reports, conducted by researchers from Johns Hopkins University, found that nonprofit and for-profit hospitals had, on average, similar “unreimbursed Medicaid costs” when measured as a share of their expenses.[101] In over half of the 45 states these researchers studied, nonprofit hospitals actually spent less on unreimbursed Medicaid costs, on average, than for-profit hospitals, leading the researchers to conclude that “the largest component of community benefit supposedly provided by nonprofit hospitals … is poorly aligned with the (effectively automatic) tax subsidy that these institutions receive.”[102]

In a letter to Human Rights Watch, the American Hospital Association contested these findings, writing that unreimbursed Medicaid costs are “a widely recognized and important component of community benefit that is reported every year by tax-exempt hospitals and unquestionably benefits the poor and elderly thereby relieving a significant government burden.”[103]

 

IV. Nonprofit Hospitals Fail to Comply with Their Own Charity Care Policies

Nonprofit hospitals’ charity care practices also regularly fail to ensure that patients who should qualify for free or reduced-price care under their self-defined eligibility policies actually receive this treatment. Rather, they sometimes bill, and even sue, patients who should have been eligible for charity care.

How Medical Bills Become Debt Collection Lawsuits

There are several key reasons why patients who should be eligible for charity care under a nonprofit hospital’s policies may not receive it.[104] For example, they may not have known that such charity care programs existed, or that they were eligible, or may have had issues with applying, or possibly had an application improperly denied.[105]

In a letter to Human Rights Watch, the American Hospital Association wrote, “We recognize that some patient debt is incurred when patients who would otherwise qualify for financial assistance decline to apply.”[106] However, research and investigations, many of which are compiled below, indicate that many such exclusions are driven more by hospital practices than patient choices.

Whatever the cause, a 2019 analysis of tax reports from 1,651 nonprofit hospitals, conducted by Kaiser Health News, found that 45 percent routinely sent medical bills to patients “who probably would have qualified for [charity care] under the hospitals’ own policies.”[107]

This so-called “bad debt,” which is the remaining amount of a patient’s bills that hospitals write off after attempting to collect, is another expense that nonprofit hospitals can claim as a part of their community benefit.[108] In other words, under current tax rules, a nonprofit hospital can hound charity-care-eligible patients for unpaid debts, driving low-income people into extreme financial distress as they try to pay these bills, and then turn around and write off the remainder of these bills as a form of community benefit.[109]

When medical bills like these go unpaid for an extended period, they become delinquent and enter an onerous process called collections, where creditors or third-party debt collectors that have purchased a patients’ debt can sue in civil and small claims courts to collect on this debt.[110]

One of the additional requirements from the 2010 ACA mandates that nonprofit hospitals make a reasonable effort to determine if a patient is eligible for charity care under the hospital's policy before engaging in so-called “extraordinary collection actions,” such as initiating a legal or judicial process against them or selling their debts to third-party debt collectors.[111] The Centers for Medicare and Medicaid Services similarly requires hospitals to “provide all or a portion of services free of charge to patients who meet the hospital’s charity care policy.”[112]

However, a 2022 research brief by the Consumer Financial Protection Bureau found “little evidence that compliance with [charity care] rules is systematically monitored and enforced at the federal level.”[113]

This inadequate federal oversight of nonprofit hospitals’ compliance with already weak charity care rules is partly the result of their lack of specificity, as discussed in Section II, as well as a certain regulatory limitation on when and how the IRS can penalize violators.

Under current IRS rules, the agency will excuse any hospital’s violation of these additional requirements from the 2010 ACA, so long as a correction is made and the violation was “neither willful nor egregious.”[114] As it can be difficult to establish that a nonprofit hospital willfully intended to violate these rules when it, for example, sued patients who should have been eligible for charity care under its own policies, the ability of the IRS to penalize and deter violators is severely limited.

Debt Collection Lawsuits Impact Rights

According to a nationally representative review of consumer credit reports conducted by the Urban Institute in 2022, about one in eight people in the US currently have medical debt in collections.[115]

While it is unclear exactly how much of this medical debt in collections comes from nonprofit hospitals, which account for most community hospitals in the US, available research indicates that they are major contributors. For example, a 2021 study of nearly 20 years of court records in Wisconsin, conducted by researchers from Yale and Stanford University, found that nonprofit hospitals in the state were actually more likely to sue patients to collect on medical debt than for-profit hospitals over this period.[116]

As Human Rights Watch has documented, many courts across the US routinely award default judgments in these kinds of debt collection cases, issuing no-questions-asked judgments without requiring meaningful evidence.[117]

Under federal law, third-party debt collectors are not prohibited from suing patients who should have been eligible for charity care under a nonprofit hospital’s policies. As such, once a patients’ debt has been sold by a nonprofit hospital, they may rapidly find themselves on the other side of a rubber-stamped legal judgment that can cause significant financial hardship.

Federal law allows creditors with a judgment to take up to 25 percent of a worker’s disposable earnings from their paycheck, although some state laws further limit this amount.[118] There are also no federal regulations limiting the amount of money that creditors can seize from a person’s bank account, and few limitations on the ability of creditors to place liens on people’s homes.[119]

In New York, for example, research by the Community Service Society of New York found that 56 nonprofit hospitals in the state imposed 4,808 liens against patients’ homes to satisfy outstanding medical bills between 2017 and 2018.[120] Over this same period, these 56 hospitals received $442 million in state funds to support their charity care, on top of the value of their tax exemptions.[121]

In some states, debt collection judgments can even lead to jail time. Although it is illegal under federal law to jail people for failing to pay debts, 44 states allow people to be jailed for failing to appear at post-judgment civil court hearings or for failing to provide court-requested documentation.[122] Across the US, thousands of people are jailed each year under these circumstances, which can effectively criminalize civil debt collection proceedings, the majority of which involve medical bills.[123]

Nonprofit Hospitals Suing Patients Across the US

There are no comprehensive data available on the exact number of people who have been sued for medical debt by nonprofit hospitals in the US despite being eligible for free or reduced-price charity care under the hospital's policies.

In part, this is because lawsuits involving nonprofit hospitals are spread out over thousands of civil and small-claims courts across the US, which have no central reporting mechanism.[124] Additionally, if a nonprofit hospital outsources or sells a patients’ medical debt to a third-party debt collector, which then sues the patient in their own name, the source of this debt is often obscured from public records.

But research and investigations, many of which are compiled below, indicate that an unknown number of patients who should have been eligible for free or reduced-price care under their hospital’s self-determined charity care policy never had their medical bills written off and were forced to deal with the potentially devastating impacts of medical debt, including debt collection lawsuits.

California

In 2022, the New York Times interviewed patients from California and Oregon who had low enough incomes to qualify for free care under the self-defined policies of Providence, one of the country’s largest nonprofit hospital chains, but were charged thousands of dollars and then harassed by collection agents after their hospital visit.[125]

At the time, representatives from Providence responded to the Times’s findings, stating that they were “very concerning and have our attention” and that Providence had also instructed the debt collection firms it worked with to not use “any aggressive tactics such as garnishing wages or reporting delinquent accounts to credit agencies.”[126] Human Rights Watch wrote to Providence, seeking comment, but it did not respond at time of writing.[127]

Connecticut

A 2019 report by researchers from the University of Connecticut’s Health Disparities Institute found that hospitals filed 81,136 lawsuits in small claims courts in the state between 2011 and 2016 to recover unpaid medical debts.[128] Although this study did not disaggregate by hospital ownership type, only 1 of Connecticut’s 31 community hospitals is for-profit.[129] In response to a letter from Human Rights Watch, the Connecticut Hospital Association wrote, “Inability to pay for services should not deter anyone from seeking needed medical care. That is why Connecticut hospitals and health systems have voluntarily adopted principles and guidelines for assisting uninsured patients, as well as underinsured patients, and guidelines for debt collection, that provide significant patient assistance and protection beyond Connecticut’s statutory protections to ensure that debt does not become a barrier to access Connecticut hospitals are supportive of exploring programs as recently proposed by Connecticut’s Governor to provide immediate medical debt relief, and continue to advocate for long term solutions, including insurance designs that better protect families against medical debt.” [130]

Kansas

A 2019 ProPublica investigation profiled patients indebted to the nonprofit hospital Coffeyville Regional Medical Center (CRMC), which is the only hospital within about a 40-minute radius of the town of Coffeyville, Kansas, near the border with Oklahoma.[131] CRMC reported $1.5 million in uncollectable patient debt in 2017, according to ProPublica, and accounted for the vast majority of the roughly 2,000 medical debt lawsuits in the county between 2014 and 2019, as well as the majority of debt-related warrants for arrest.[132]

At the time, a representative for CRMC said that its only motivation was to continue to serve the area, and that Kansas’ decision not to expand Medicaid under the Affordable Care Act had a “dramatic effect on the economic liability of small rural hospitals.”[133] Human Rights Watch wrote to the CRMC, seeking comment, but it did not respond at time of writing.[134]

Maryland

A 2020 report by National Nurses United found that Maryland hospitals, “all of which are classified as not-for-profits,” filed 145,746 medical debt lawsuits between 2009 and 2018, seeking to collect more than $268 million from patients.[135] In response to a letter from Human Rights Watch, a representative of the Maryland Hospital Association wrote: “Hospitals in Maryland have some of the most robust practices in place to ensure that regardless of people’s ability to pay, everyone receives the same, high-quality level of care … [and] have financial assistance policies that are readily shared with patients and actively work with them to address financial constraints.”[136]

A May 2019 report by the Baltimore Sun found that Johns Hopkins Hospital in Baltimore filed more than 2,400 lawsuits in Maryland courts since 2009 against patients with unpaid bills, including a large number against patients residing in distressed neighborhoods surrounding the East Baltimore medical campus.[137] A spokesperson for John Hopkins replied to the report at the time: “It is always our priority to provide the best possible care to every patient who comes to us. We have an extraordinary community benefits program and charity care policy, and it is our practice to inform our patients about our programs for free and discounted services.”[138] In response to a letter from Human Rights Watch, a representative wrote that Johns Hopkins Medicine “has not filed any lawsuits or pursued other types of legal action (i.e., garnishments) related to unpaid bills since April 2020,” and in the past two years, “have counseled and assisted approximately 10,000 patients in obtaining Medicaid.”[139]

Missouri

In 2014, National Public Radio reported that nonprofit Heartland Regional Medical Center, the only hospital for the small city of St. Joseph, sued thousands of people, including some that could have qualified to get their bill forgiven entirely given their income, but who instead had their wages garnished to pay for medical bills.[140] After NPR and ProPublica jointly brought this story to Heartland hospital's board of directors, the board said it was reviewing the hospital's debt collection practices.[141] In response to a letter from Human Rights Watch, a representative of Heartland Regional Medical Center, now a part of Mosaic Life Care, wrote: “In Fiscal Year 2022, [we] provided $158,687,657 in community benefit to St. Joseph, MO…. [and] [w]e seek to provide quality care to individuals, regardless of their ability to pay and have established a financial assistance program to help qualifying residents of our service area, with limited financial resources, in paying for their medical care.”[142]

Minnesota

In November 2022, the Post Bulletin interviewed 14 patients in Minnesota who were sued by the nonprofit hospital system Mayo Clinic for unpaid medical bills, even though these patients could have qualified for charity care based on the household income information provided during the interview.[143] In response to this reporting, in January 2023, the Minnesota Attorney General launched an investigation into Mayo Clinic’s medical billing and debt collection practices.[144] At the time, a representative for Mayo Clinic responded, saying that, "We are confident that our response [to the Attorney General’s inquiry] will demonstrate that financial assistance is an important part of Mayo Clinic’s relationship with patients and is shared with them at points before, during and after care is provided.”[145] Human Rights Watch wrote to the Mayo Clinic, seeking comment, but it did not respond at time of writing.[146]

New York

A 2020 study published by researchers from Johns Hopkins University studied court actions filed against patients for unpaid medical bills in New York between 2018 and 2020, finding that 51 hospitals—of which 94 percent were nonprofit—sued 18,200 patients over this period.[147] A separate 2020 report from the Community Service Society reviewed nearly 31,000 civil cases filed against individuals by 139 nonprofit hospitals located in 26 counties throughout New York, finding that the median amount hospitals sued for was $1,900 and that “defendants [were] more likely to be people of color.”[148]

In response to a letter from Human Rights Watch, a representative of the Healthcare Association of New York State, which represents New York hospitals, wrote: “New York’s hospitals offer robust financial assistance programs. Adhering to their charitable mission, hospitals cover the cost of care provided to people in need; subsidize care and services to low-income, elderly and under-served communities; and continuously invest in many community health initiatives.”[149] Human Rights Watch also wrote to the Greater New York Hospital Association, seeking comment, but it did not respond at time of writing.[150]

North Carolina

In 2022, the North Carolina State Health Plan, a publicly administered health insurance system for North Carolina teachers, and the National Academy for State Health Policy released a joint report, which found that nonprofit hospitals in the state were billing patients living in poverty at three times the national average.[151] According to the report’s findings, in 2019, 18 nonprofit hospitals in the state billed almost $150 million to patients who should have qualified for charity care under the hospitals’ own policies.[152] In response to a letter from Human Rights Watch, a representative of the North Carolina Healthcare Association, which represents North Carolina hospitals, shared their statement on this study, which said: “Hospitals’ charity care spending and community benefit investment activity is transparent and accountable. Through federal oversight by the Internal Revenue Service, it is regulated, reported, and audited. Enforcement is the responsibility of the secretary of the United States Treasury…. There should be no doubt that nonprofit hospitals are proudly fulfilling their charity care and community benefit commitments to North Carolinians.”[153]

Ohio

In 2012, Kaiser Health News reported that Mount Carmel Health System in Columbus had sued nearly 1,600 people in county court between 2009 and 2011. At the time, a representative for the hospital stated: “In order to provide charity in the community—and we provide a lot and do a lot of good—we have to collect payment from those who can afford to pay us.”[154] However, a lawyer at the Legal Aid Society of Columbus, which represented six patients being sued by Mount Carmel at the time, charged that the hospital had sued patients “at 100 percent of the poverty level who are working to try to support their children.”[155] In response to a letter from Human Rights Watch, Trinity Health, which now operates Mount Carmel, wrote: “We take our commitment seriously and hold ourselves accountable in many ways including transparent financial practices and detailed financial reporting. We do all we can to educate and assist patients in understanding and identifying their options for coverage and resolution of financial responsibility…. Trinity Health understands the trust that has been given to us— to care for our communities – but we must balance that with responsible stewardship of our resources so that we can sustain our ability to provide care to our communities.”[156]

Oklahoma

In 2019, an Oklahoma Watch review of court records from 2016 to 2019 found that dozens of hospitals across the state filed at least 22,250 lawsuits against their former patients over unpaid medical bills.[157] Saint Francis Health System, a Catholic nonprofit group with eight hospitals, filed nearly 5,000 lawsuits over the period, accounting for about 22 percent of the hospital lawsuits identified by Oklahoma Watch over this period.[158] In a statement to the Oklahoman at the time, a representative for the Saint Francis Health System said that the hospital had sued less than 1 percent of its patients over unpaid debts since 2016 and that the hospital system “only seeks legal intervention when all other attempts to work on a solution with the patient have been exhausted…. We work with patients early in the process to set up a payment plan that meets their individual needs.”[159] Human Rights Watch wrote to Saint Francis Health System, seeking comment, but it did not respond at time of writing.[160]

Oregon

As noted above, a New York Times investigation from 2021 interviewed patients from California and Oregon who qualified for free care but were charged thousands of dollars and then harassed by collection agents after visiting a hospital owned by Providence, one of the country’s largest nonprofit hospital chains, which operates more than 51 hospitals and more than 900 clinics across the US.[161] Human Rights Watch wrote to Providence, seeking comment, but it did not respond at time of writing.[162]

Tennessee

In Memphis, a city where nearly one in four residents lives below the federal poverty guidelines, Methodist Le Bonheur Healthcare, the city’s largest nonprofit hospital system, filed more than 8,300 lawsuits for unpaid medical debt from 2014 through 2018, according to joint reporting from MLK50 and ProPublica.[163] After its practices of suing patients who had little ability to pay were revealed in 2019, Methodist Le Bonheur erased the debts owed by more than 6,500 patients and announced an overhaul of its debt collection processes.[164] In response to a letter from the Senate Finance Committee in 2020, the hospital wrote that it had dismissed all pending debt-collection lawsuits so they “could be reassessed based upon … enhanced financial aid programs,” including permanent dismissal of cases involving patients who fall below 250 percent of the federal poverty level.[165] Human Rights Watch wrote to Methodist Le Bonheur Healthcare, seeking comment, but it did not respond at time of writing.[166]

Texas

A 2020 study published by researchers from Johns Hopkins University studied court actions filed against patients for unpaid medical bills in Texas between 2018 and 2020, finding that over 1,000 lawsuits were filed by 28 hospitals, 27 percent of which were Texas-based nonprofit hospitals.[167] Notably, these researchers found that “just under 50% of the medical debt filings included default judgments in favor of the hospital because the patient was unable to appear in court [resulting in] over $1.2 million garnished from these patients.”[168] Human Rights Watch wrote to the Texas Hospital Association, seeking comment, but it did not respond at time of writing.[169]

Virginia

A 2019 study by Kaiser Health News found that that the University of Virginia (UVA) Health System filed 36,000 lawsuits against patients between 2012 and 2018, seizing wages and bank accounts, putting liens on property and homes and forcing families into bankruptcy.[170] A spokesperson for UVA responded at the time, stating that, “Sending unpaid bills to a collection agency or pursuing a civil claim is a last resort,” and that the health system was “making a comprehensive review” of its charity care rules and “considering policies to provide additional financial assistance to low-income patients not covered by our existing charity care policies.”[171] In response to a letter from Human Rights Watch, a representative of UVA Health wrote: “Between 2019 and 2021, UVA Health developed new billing policies and practices that reflect fair and financially responsible guidelines based upon a patient’s ability to pay. These changes included significantly larger discounts for low-income and uninsured patients, as well as releasing all liens and judgments for patients who are at or below 400% of the federal poverty level…. Since announcing our initial round of improvements to our billing process in 2019, we have not filed any lawsuits against patients for not making payments for their care.”[172]

In 2019, research from Johns Hopkins University found that Mary Washington Healthcare in Fredericksburg, Virginia, “sues so many patients that the court reserves a morning every month for its cases.”[173] The day after this story was published by National Public Radio, Mary Washington Healthcare announced it would suspend its practice of suing patients for unpaid bills, stating: "We are committed to a complete re-evaluation of our entire payment process to ensure that all patients know they have access to care… We are happy to try to work with that patient and the courts and their employer to try to eliminate the garnishment.”[174] In response to a letter from Human Rights Watch, a representative of Mary Washington Healthcare wrote: “We viewed the 2019 coverage of our collection practices as an opportunity to do better, and we have done just that. After a thorough review of our billing processes … we updated our financial assistance policy … to increase discounts, expand assistance to more patients, and introduce a cap on an individual’s payment responsibility…. [and] [w]e changed our collection escalation procedures to ensure that legal action is an absolute last resort. In fact, since 2020, we have not pursued legal action for payment with any patients.”[175]

Washington

In 2019, St. Joseph Medical Center in Tacoma and its parent company, CHI Franciscan, settled a lawsuit from the state’s attorney general, which asserted that the nonprofit hospital system violated state law by failing to make charity care accessible to tens of thousands of low-income patients between 2012 and 2017.[176] In a statement to Kaiser Health News following the settlement, a representative of CHI Franciscan said: “We are exceeding the requirements of state law and providing charity care compensation to patients who may be in most need, even if they never applied for charity care or did not actually qualify at the time of service.”[177] In response to a letter from Human Rights Watch, a representative of Virginia Mason Franciscan Health, which now operates St. Joseph, wrote: “Our generous financial assistance policy supports thousands of patients every year, providing assistance for patients up to 400% of the Federal Poverty Level. However, as a non-profit hospital, we operate on razor thin margins and reimbursement that often doesn’t cover the cost of providing care. For patients in need of financial assistance, we do not sue them, send them to collections or send surprise bills.”[178]

Wisconsin

A 2021 study of nearly 20 years of court records in Wisconsin found that nonprofit hospitals were more likely to sue patients to collect on medical debt than for-profit hospitals.[179] A separate 2021 study published by researchers from Johns Hopkins University studied court actions filed against patients for unpaid medical bills in Wisconsin between 2018 and 2020, finding that 69 hospitals—of which 96 percent were nonprofit—filed a total of 17,908 medical debt lawsuits, receiving 4,144 wage garnishments and 746 liens against property.[180] In response to a letter from Human Rights Watch, a representative of the Wisconsin Hospital Association wrote: “Wisconsin hospitals, 92% of which are nonprofit, provided … $536.6 million in charity care … in 2021 … As good stewards of community resources, but also being the safety net of Wisconsin’s health care system and seeing all patients regardless of their ability to pay, hospitals must collect from those with the ability to pay and Wisconsin hospitals follow their very generous and transparent financial assistance policies to provide write offs where appropriate, but to also collect payments where appropriate.”[181]

 

V. Human Rights Standards

The Rights to Health and Social Security

When combined with its inadequate regulation, the United States’ model of subsidizing privately operated hospitals with tax exemptions in the hope that they will increase the accessibility of hospital care for un- and underinsured patients, while failing to regulate these hospitals to ensure accessibility, undermines rights protected under international human rights law, including the right to the highest attainable standard of health and the right to social security.[182]

Health is a human right indispensable to the exercise of other human rights, and every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity.[183]

The Universal Declaration of Human Rights (UDHR) recognizes that all people have “the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”[184]

Similarly, the International Covenant on Economic, Social and Cultural Rights (ICESCR) guarantees the rights to “an adequate standard of living” and “the enjoyment of the highest attainable standard of physical and mental health,” including the “prevention, treatment and control of epidemic, endemic, occupational and other diseases” and the “creation of conditions which would assure to all medical service and medical attention in the event of sickness.”[185]

The United States has signed, but not ratified, the ICESCR. As a signatory, the US is obligated to refrain from acts that would defeat the treaty’s object and purpose.[186]

The Committee on Economic, Social and Cultural Rights (CESCR), which interprets the ICESCR, has also affirmed that states have “a minimum core obligation to ensure the satisfaction of, at the very least, minimum essential levels of each of the [treaty’s] rights.”[187] This duty extends to preventing and protecting against deprivations of individuals’ human rights by non-state actors, including effective regulation of their activities.[188]

Governments have obligations to ensure health facilities, goods, and services are accessible to everyone without discrimination and affordable for all.[189] The right to health facilities, goods, and services includes “the provision of equal and timely access to basic preventive” services and “appropriate treatment of prevalent diseases.”[190] States should ensure these health services are economically accessible, meaning “affordable for all” and of good quality, the CESCR has clarified.[191]

Access to health care is also a fundamental component of the human right to social security, which is reaffirmed in the Universal Declaration of Human Rights and reflected in the ICESCR, other international conventions, and regional frameworks.[192] The CESCR, interpreting the ICESCR, has clarified that the right to social security requires states parties to “guarantee that health systems are established to provide adequate access to health services for all,” including “general and practical medical care, together with hospitalization.”[193]

Governments should ensure that everyone has access to the highest possible standard of health care, regardless of their ability to pay.[194]

The United States is an outlier among high-income countries with respect to its high healthcare costs and poor healthcare outcomes. It is currently failing to regulate the actions of private entities that are undermining access to health care. Its current approach is failing to realize the rights to health and social security.

Additionally, many state constitutions contain provisions that require the state to promote and protect the public health or even require legislative action to fund health care services for specific activities or for certain groups, such as indigent persons.[195] In some states, state-based regulations on nonprofit hospitals’ financial assistance policies may be required to give effect to these constitutional provisions.

Equal Protection and Non-Discrimination

Both the International Covenant on Civil and Political Rights (ICCPR), which the United States has ratified, and the ICESCR guarantee the right to equal treatment and protection under law, without discrimination on the basis of race, ethnicity, national origin, gender, property, or other status, including economic status.[196] The International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), which the United States has ratified, spells out in more detail protections against discrimination on the basis of race, ethnicity, and national origin, among others.[197]

US constitutional law requires a finding of discriminatory intent before courts will rule unconstitutional discriminatory practices that disproportionately burden a racial group.[198] But ICERD goes further, prohibiting policies and practices that have either the purpose or effect of restricting rights because of race.[199] It proscribes apparently race-neutral practices that affect fundamental rights, regardless of racist intent, if those practices create unwarranted racial disparities.

The Committee on the Elimination of Racial Discrimination, which interprets the ICERD, has specifically stated that “indirect—or de facto—discrimination occurs where an apparently neutral provision, criterion or practice would put persons of a particular racial, ethnic or national origin at a disadvantage compared with other persons, unless that provision, criterion or practice is objectively justified by a legitimate aim and the means of achieving that aim are appropriate and necessary.”[200]

Under the ICERD, governments may not ignore the need to secure equal treatment of all racial and ethnic groups, but rather must act affirmatively to prevent or end policies with unjustified discriminatory impacts.[201] Governments are obligated to “undertake to prohibit and to eliminate racial discrimination ... notably in the enjoyment of … the right to public health [and] medical care.”[202]

The ostensibly neutral policies of nonprofit hospitals and government agencies that have discriminatory impacts on particular racial and ethnic groups’ ability to access hospital services, regardless of their ability to pay, should therefore be substantially revised to eliminate such discriminatory impacts. Additionally, as discussed above, non-citizens are generally unable to access public health insurance schemes, impacting their access to health care.[203]

Corporate Human Rights Responsibilities

Even in the absence of regulations, under the UN Guiding Principles on Business and Human Rights (UN Guiding Principles), all businesses have a responsibility to respect human rights and ensure that they do not cause or contribute to actual or potential adverse human rights impacts.[204]

Fundamental to this responsibility is the requirement that companies carry out human rights due diligence to identify the possible and actual human rights impacts of their operations, and to establish meaningful processes to prevent and mitigate those risks and remedy adverse impacts.[205] The process should be ongoing and continuous.[206]

Companies should meaningfully consult with potentially affected groups and other relevant stakeholders at all stages of human rights due diligence.[207] This consultation should be meaningful and go beyond engaging with a few patient representatives.

Human rights due diligence also entails identifying and rectifying business practices with adverse human rights impacts that are part of a company’s operations. The UN Guiding Principles state that businesses should look at their “own activities” and embed human rights policies across “all relevant business functions.”[208]

 

Acknowledgments

This report was researched and written by Matt McConnell, researcher in the Economic Justice and Rights Division of Human Rights Watch.

It was edited by Sylvain Aubry and Arvind Ganesan, deputy director and director, respectively, in the Economic Justice and Rights Division. Additional reviews were conducted by A. Kayum Ahmed, special advisor on the right to health; Laura Pitter, deputy director in the US Program; and Skye Wheeler, emergencies researcher for the Women's Rights Division. Quynh Chi Nguyen, associate director for Community Catalyst’s Center for Community Engagement in Health Innovation and Berneta Haynes, senior attorney for the National Consumer Law Center, also provided external specialist review of this report. Maria McFarland Sánchez-Moreno, deputy program director, and Michael Bochenek, senior legal advisor, provided program and legal review, respectively.

The charts and figures included in this report were reviewed by Brian Root, senior quantitative analyst; and Travis Carr, publications officer. Additional editorial assistance was provided by Jack Spehn, associate in the Economic Justice and Rights Division, who also prepared this report for publication.

We are very grateful to the advocates and non-governmental organizations that assisted with our research.

 

 

[1] See UN Committee on Economic, Social and Cultural Rights (CESCR), “General Comment No. 14, The Right to the Highest Attainable Standard of Health,” UN Doc. E/C.12/2000/4, August 11, 2000, https://www.refworld.org/pdfid/4538838d0.pdf (accessed April 18, 2023).

[2] The right to health must include healthcare facilities that are: available, accessible, acceptable, and quality. On accessibility, the CESCR notes that health facilities, goods and services have to be accessible to everyone, without discrimination or exclusion based on physical ability, economic status, or information. Ibid., para. 12.

[3] Ibid.

[4] See, for example, The Commonwealth Fund, “International Profiles of Health Care Systems,” https://www.commonwealthfund.org/international-health-policy-center/system-features/how-does-universal-health-coverage-work (accessed April 18, 2023) (comparing various healthcare systems internationally).

[5] See “Veterans Health Administration,” US Department of Veterans Affairs, March 17, 2023, https://www.va.gov/health/ (accessed April 18, 2023); “About IHS,” US Department of Health and Human Services, https://www.ihs.gov/aboutihs/ (accessed April 18, 2023); Lawrence J. Korb and Kaveh Toofan, “ The Challenges Facing the Department of Veterans Affairs in 2021,” Center for American Progress, May 17, 2021, https://www.americanprogress.org/article/challenges-facing-department-veterans-affairs-2021/ (accessed April 18, 2023); Matt McConnell, “US Court Ruling Furthers South Dakota Tribe’s Right to Health,” Human Rights Watch, August 31, 2021, https://www.hrw.org/news/2021/08/31/us-court-ruling-furthers-south-dakota-tribes-right-health (accessed April 18, 2023) (“Chronic underfunding of the IHS has contributed to serious health disparities for AIAN communities for decades.”).

[6] Regarding Medicare, see “Parts of Medicare,” Centers for Medicare and Medicaid Services, https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of-medicare (accessed April 18, 2023); and Juliette Cubanski, Tricia Neuman, and Anthony Damico, “Medicare's Role for People Under Age 65 with Disabilities,” Kaiser Family Foundation, August 12, 2016, https://www.kff.org/medicare/issue-brief/medicares-role-for-people-under-age-65-with-disabilities/ (accessed April 18, 2023). Regarding Medicaid and the Children's Health Insurance Program (CHIP), see “Medicaid & CHIP,” Centers for Medicare and Medicaid Services, https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/ (accessed April 18, 2023); Tricia Brooks, Allexa Gardner, Jennifer Tolbert, Rachel Dolan, and Olivia Pham, “Medicaid and CHIP Eligibility and Enrollment Policies as of January 2021: Findings from a 50-State Survey,” Kaiser Family Foundation, March 8, 2021, https://www.kff.org/report-section/medicaid-and-chip-eligibility-and-enrollment-policies-as-of-january-2021-findings-from-a-50-state-survey-report/ (accessed April 18, 2023); Madeline Guth Follow and MaryBeth Musumeci, “An Overview of Medicaid Work Requirements: What Happened Under the Trump and Biden Administrations?,” Kaiser Family Foundation, May 3, 2022, https://www.kff.org/medicaid/issue-brief/an-overview-of-medicaid-work-requirements-what-happened-under-the-trump-and-biden-administrations/ (accessed April 18, 2023); and “Coverage for lawfully present immigrants,” HealthCare.gov, https://www.healthcare.gov/immigrants/lawfully-present-immigrants/ (accessed April 18, 2023).

[7] Eligibility for Medicaid is determined by each state and often involves various eligibility metrics, such as household size, number of dependents, and immigration status, but typically requires an otherwise-qualified individual to earn under a certain percentage of the Federal Poverty Level (FPL) to be eligible. See Brooks, Gardner, et al., “Medicaid and CHIP Eligibility and Enrollment Policies as of January 2021: Findings from a 50-State Survey,” Kaiser Family Foundation, March 16, 2022, https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-and-enrollment-policies-as-of-january-2022-findings-from-a-50-state-survey/ (accessed April 18, 2023). The FPL for a single-person household in 2021 was $14,580. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, “HHS Poverty Guidelines for 2023,” https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines (accessed April 18, 2023). In most states that have adopted the so-called Medicaid expansion, the Medicaid FPL limit for unmarried adults without dependents is 138 percent of the FPL—or $20,120 in 2023. See Kaiser Family Foundation, “Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level,” January 1, 2023, https://www.kff.org/health-reform/state-indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level/ (accessed April 18, 2023).

[8] As of time of writing, the 10 states that have not expanded Medicaid coverage to single-person households without dependents are: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, South Dakota, Tennessee, Texas, and Wyoming. See Kaiser Family Foundation, “Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level,” January 1, 2023, https://www.kff.org/health-reform/state-indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level/ (accessed April 18, 2023). Although Wisconsin has not adopted the Medicaid Expansion under the Affordable Care Act, they have a section 1115 demonstration, which provides Medicaid coverage to some additional low-income adults earning up to 100 percent of the FPL. Note that North Carolina has adopted but not implemented the Medicaid expansion. See Brooks, Gardner, et al., “Medicaid and CHIP Eligibility and Enrollment Policies as of January 2021: Findings from a 50-State Survey,” Kaiser Family Foundation, March 16, 2022, https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-and-enrollment-policies-as-of-january-2022-findings-from-a-50-state-survey/ (accessed April 18, 2023); and Rudowitz, Drake, et al., “How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion?,” Kaiser Family Foundation, March 31, 2023, https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/ (accessed April 18, 2023).

[9] See Rudowitz, Drake, et al., “How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion?,” Kaiser Family Foundation, March 31, 2023, https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/ (accessed April 18, 2023); Samantha Artiga, Latoya Hill, Kendal Orgera, and Anthony Damico, “Health Coverage by Race and Ethnicity, 2010-2021,” December 20, 2022, https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/ (accessed April 18, 2023) (“Most racial/ethnic groups are more likely to be uninsured in non-expansions states compared to expansion states. Further, the gaps in coverage rates between Black and Hispanic people and White people are larger in non-expansion states. However, the relative risk of being uninsured for people of color compared with White people is similar in expansion and non-expansion states.”).

[10] Katherine Keisler-Starkey and Lisa N. Bunch, “Health Insurance Coverage in the United States: 2021,” US Census Bureau, September 14, 2021, https://www.census.gov/library/publications/2022/demo/p60-278.html (accessed April 18, 2023) (“More people were insured in 2021 than 2020. In 2021, 8.3 percent of people, or 27.2 million, did not have health insurance at any point during the year, representing a decrease in the uninsured rate and number of uninsured from 2020 (8.6 percent or 28.3 million).”). Regarding the high and rising costs of medical treatment in the US, see, for example, OECD.stat, “Health expenditure and financing,” November 2022, https://stats.oecd.org/ (accessed April 18, 2023) (comparing “Current expenditure on health (all functions)” from “All providers” as a measure of “Per capita, current prices, current PPPs,” for all countries with available data across “Household out-of-pocket payments,” “Voluntary health care payment schemes,” and “Government/compulsory schemes,” for the year 2020) (showing that the US’ total per capita health expenditures in 2020 when “Household out-of-pocket payments,” “Voluntary health care payment schemes,” and “Government/compulsory schemes” are combined was $11,859.2 and that the median across all 36 OECD countries that have data available for that year was $3,776.1). See also Munira Z. Gunja, Evan D. Gumas, Reginald D. Williams II, “US Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes,” The Commonwealth Fund, January 31, 2023, https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022 (accessed April 18, 2023). See also Letter to the Honorable Rohit Chopra, Director of the Consumer Financial Protection Bureau, Monday, March 6, 2023, https://communitycatalyst.org/wp-content/uploads/2023/03/Medical-Debt-Sign-On-Letter-to-CFPB-March-6.pdf (accessed April 18, 2023); and Letter to the Honorable Janet Yellen, Secretary of the Department of the Treasury, Monday, March 6, 2023, https://communitycatalyst.org/wp-content/uploads/2023/03/Medical-Debt-Sign-On-Letter-to-IRS-and-Treasury-March-6.pdf (accessed April 18, 2023).

[11] Compare Katherine Keisler-Starkey and Lisa N. Bunch, “Health Insurance Coverage in the United States: 2021,” US Census Bureau, September 14, 2021, https://www.census.gov/library/publications/2022/demo/p60-278.html (accessed April 18, 2023) (“In 2021, 8.3 percent of people, or 27.2 million, did not have health insurance at any point during the year”) and “Health Insurance Coverage of the Total Population,” Kaiser Family Foundation, https://www.kff.org/other/state-indicator/total-population (accessed April 18, 2023) (citing US Census Bureau, “American Community Survey,” 2021, https://www.census.gov/programs-surveys/acs (accessed April 18, 2023)) (estimating that 8.6 percent of the US population was uninsured in 2023).

[12] Jennifer Tolbert, Robin Rudowitz, and Meghana Ammula, “Unwinding the Continuous Enrollment Provision: Perspectives from Current Medicaid Enrollees,” Kaiser Family Foundation, March 9, 2023, https://www.kff.org/medicaid/issue-brief/unwinding-the-continuous-enrollment-provision-perspectives-from-current-medicaid-enrollees/ (accessed April 18, 2023). Regarding the sunsetting of social protection programs passed in the US in response to Covid-19, generally, see also Matt McConnell, “Expiring Assistance Threatens Affordable Health Care in the US,” Human Rights Watch, June 6, 2022, https://www.hrw.org/news/2022/06/06/expiring-assistance-threatens-affordable-health-care-us (accessed April 18, 2023).

[13] Jennifer Tolbert and Meghana Ammula, “10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision,” Kaiser Family Foundation, April 5, 2023, https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/ (accessed April 18, 2023).

[14] “The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey,” The Commonwealth Fund, September 29, 2022, https://www.commonwealthfund.org/publications/issue-briefs/2022/sep/state-us-health-insurance-2022-biennial-survey (accessed April 18, 2023).

[15] Ibid.

[16] “Economic Well-Being of US Households in 2021,” Board Of Governors of the Federal Reserve System, May 2022, https://www.federalreserve.gov/publications/files/2021-report-economic-well-being-us-households-202205.pdf (accessed April 18, 2023), p. 38.

[17] Munira Z. Gunja, Evan D. Gumas, Reginald D. Williams II, “US Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes,” The Commonwealth Fund, January 31, 2023, https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022 (accessed April 18, 2023).

[18] The OECD’s median per capita out-of-pocket expenditure on health care across providers in 2020 was US$701.3. OECD.stat, “Health expenditure and financing,” November 2022, https://stats.oecd.org/ (accessed April 18, 2023) (comparing “Current expenditure on health (all functions)” from “All providers” as a measure of “Per capita, current prices, current PPPs,” for all countries with available data across “Household out-of-pocket payments,” “Voluntary health care payment schemes,” and “Government/compulsory schemes,” for the year 2020). Notably, according to these data, the only country with higher per capita out-of-pocket expenditures on healthcare services is Switzerland, which has a highly privatized health insurance system. For more information about the Swiss health care model, see The Commonwealth Fund, “International Profiles of Health Care Systems,” https://www.commonwealthfund.org/international-health-policy-center/system-features/how-does-universal-health-coverage-work (accessed April 18, 2023).

[19] The US’ total per capita health expenditures in 2020 was $11859.2 when “Household out-of-pocket payments,” “Voluntary health care payment schemes,” and “Government/compulsory schemes” are combined. Compare this to the median across all 36 OECD countries that have data available for that year, which was $3776.1. See also Munira Z. Gunja, Evan D. Gumas, Reginald D. Williams II, “US Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes,” The Commonwealth Fund, January 31, 2023, https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022 (accessed April 18, 2023) (discussing health care outcomes across OECD states).

[20] “Pregnancy Mortality Surveillance System,” US Centers for Disease Control and Prevention, March 23, 2023, https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm#trends (accessed April 18, 2023) (“Since the Pregnancy Mortality Surveillance System was implemented, the number of reported pregnancy-related deaths in the United States increased from 7.2 deaths per 100,000 live births in 1987 to 17.6 deaths per 100,000 live births in 2019.”).

[21] Lunna Lopes, Audrey Kearney, Alex Montero, Liz Hamel, and Mollyann Brodie, “Health Care Debt In The U.S.: The Broad Consequences Of Medical And Dental Bills,” Kaiser Family Foundation, June 16, 2022, https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/ (accessed April 18, 2023).

[22] See Human Rights Watch, “US: Unaffordable Insulin Endangers Lives,” April 12, 2022, https://www.hrw.org/news/2022/04/12/us-unaffordable-insulin-endangers-lives (accessed April 18, 2023); Human Rights Watch, “’We Need Access:’ Ending Preventable Deaths from Cervical Cancer in Rural Georgia,” January 20, 2022, https://www.hrw.org/report/2022/01/20/we-need-access/ending-preventable-deaths-cervical-cancer-rural-georgia (accessed April 18, 2023); and Human Rights Watch, “Should Not Happen: Alabama’s Failure to Prevent Cervical Cancer Death in the Black Belt,” November 29, 2018, https://www.hrw.org/report/2018/11/29/it-should-not-happen/alabamas-failure-prevent-cervical-cancer-death-black-belt (accessed April 18, 2023).

[23] See Munira Z. Gunja, Evan D. Gumas, Reginald D. Williams II, “ US Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes,” The Commonwealth Fund, January 31, 2023, https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022 (accessed April 18, 2023); and Robin Osborn, David Squires, Michelle M. Doty, Dana O. Sarnak, and Eric C. Schneider, “In New Survey Of Eleven Countries, US Adults Still Struggle With Access To And Affordability Of Health Care,” Health Affairs, December 2016, Vol. 35, No. 12, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.1088 (accessed April 18, 2023). See also Michelle M. Doty, Roosa S. Tikkanen, Molly FitzGerald, Katharine Fields, and Reginald D. Williams II, “Income-Related Inequality In Affordability And Access To Primary Care In Eleven High-Income Countries,” Health Affairs, December 9, 2020, Vol. 40, No. 1, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.01566 (accessed April 18, 2023) (“Results indicate that among adults with lower incomes, those in the US fare relatively worse on affordability and access to primary care than those in other countries, and income-related disparities across domains are relatively greater throughout.”).

[24] See David U. Himmelstein, Samuel L. Dickman, Danny McCormick, et al., “Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US,” Journal of the American Medical Association Network Open, September 16, 2022, Vol. 5, No. 9, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796358 (accessed April 18, 2023).

[25] See, for example, Matthew Rae, Gary Claxton, Krutika Amin, Emma Wager, Jared Ortaliza, and Cynthia Cox, “The burden of medical debt in the United States,” Peterson-KFF Health System Tracker, March 10, 2022, https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/ (accessed April 18, 2023) (finding that Black Americans are far more likely than people of other racial and ethnic groups to report significant medical debt, that women are also more likely to report having medical debt (11%) than men (8%), and that “people with lower and modest incomes are more likely to have significant medical debt”); Lunna Lopes, Audrey Kearney, Alex Montero, Liz Hamel, and Mollyann Brodie, “Health Care Debt In The U.S.: The Broad Consequences Of Medical And Dental Bills,” Kaiser Family Foundation, June 16, 2022, https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/ (accessed April 18, 2023); Munira Z. Gunja, Shanoor Seervai, Laurie Zephyrin, Reginald D. Williams II, “Health and Health Care for Women of Reproductive Age,” The Commonwealth Fund, April 5, 2022, https://www.commonwealthfund.org/publications/issue-briefs/2022/apr/health-and-health-care-women-reproductive-age (accessed April 18, 2023) (discussing potential drivers of medical debt disparities for women in the US and Black women, in particular); Jenny Chiang, “Medical Debt Implications in Native American Communities,” Community Catalyst, https://communitycatalyst.org/posts/medical-debt-implications-in-native-american-communities/ (accessed April 18, 2023) (discussing the prevalence of medical debt among American Indian and Alaskan Native communities); Andre M. Perry, Joia Crear-Perry, Carl Romer, and Nana Adjeiwaa-Manu, “The racial implications of medical debt: How moving toward universal health care and other reforms can address them,” Brookings, October 5, 2021, https://www.brookings.edu/research/the-racial-implications-of-medical-debt-how-moving-toward-universal-health-care-and-other-reforms-can-address-them/ (accessed April 18, 2023) (discussing the disparate burden of medical debt on Black households in the US); and Kaiser Family Foundation, “1 in 10 Adults Owe Medical Debt, With Millions Owing More Than $10,000,” March 10, 2022, https://www.kff.org/health-costs/press-release/1-in-10-adults-owe-medical-debt-with-millions-owing-more-than-10000/ (accessed April 18, 2023) (“Larger shares of people in poor health (21%) and living with a disability (15%) report medical debt.”).

[26] US Census Bureau, “Real Median Personal Income in the United States,” Federal Reserve Bank of St. Louis, September 13, 2022, https://fred.stlouisfed.org/series/MEPAINUSA672N (accessed April 18, 2023). See also Lunna Lopes, Audrey Kearney, Alex Montero, Liz Hamel, and Mollyann Brodie, “Health Care Debt In The U.S.: The Broad Consequences Of Medical And Dental Bills,” Kaiser Family Foundation, June 16, 2022, https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/ (accessed April 18, 2023) (“Notably, about one in four Black adults (24%), adults with household incomes under $40,000 (26%), and those who are uninsured (25%) say they don’t think they will ever pay off their health care debt.”).

[27] Regarding differing uninsured rates, see Kaiser Family Foundation, “Uninsured Rates for the Nonelderly by Race/Ethnicity,” https://www.kff.org/uninsured/state-indicator/nonelderly-uninsured-rate-by-raceethnicity (accessed April 18, 2023); and Jennifer Tolbert, Patrick Drake, and Anthony Damico, “Key Facts about the Uninsured Population,” Kaiser Family Foundation, December 19, 2022, https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/ (accessed April 18, 2023). Regarding the prevalence of chronic health conditions, see, for example, César Caraballo, Jeph Herrin, Shiwani Mahajan, et al., “Temporal Trends in Racial and Ethnic Disparities in Multimorbidity Prevalence in the United States, 1999-2018,” The American Journal of Medicine, Vol. 135, Issue 9, September 2022, https://www.amjmed.com/article/S0002-9343(22)00330-8/fulltext (accessed April 18, 2023) (studying 20 years of National Health Interview Survey data for more than half a million patients in the US and estimating that the prevalence of multimorbidity for patients was “5.9% among Asian, 17.4% among Black, 10.7% among Latino/Hispanic, and 13.5% among White individuals.”); Rahul Aggarwal, Nicholas Chiu, Rishi K. Wadhera, et al., “Racial/Ethnic Disparities in Hypertension Prevalence, Awareness, Treatment, and Control in the United States, 2013 to 2018,” Hypertension, Vol. 78, No. 6, August 9, 2021, https://www.ahajournals.org/doi/full/
10.1161/HYPERTENSIONAHA.121.17570
(accessed April 18, 2023) (“Black Americans, Hispanic Americans, and Asian Americans have substantially lower rates of [blood pressure] control than White Americans.”); Centers for Disease Control and Prevention, “Prevalence of Both Diagnosed and Undiagnosed Diabetes,” https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-undiagnosed-diabetes.html (accessed April 18, 2023) (discussing disparate rates of diabetes among BIPOC communities in the US); Latoya Hill, Nambi Ndugga, and Samantha Artiga, “Key Data on Health and Health Care by Race and Ethnicity,” Kaiser Family Foundation, March 15, 2023, https://www.kff.org/racial-equity-and-health-policy/report/key-data-on-health-and-health-care-by-race-and-ethnicity (accessed April 18, 2023) (“Overall, this analysis found that Black, Hispanic, and AIAN people fared worse than White people across the majority of examined measures of health and health care and social determinants of health.”). See also Berneta L. Haynes, “The Racial Health and Wealth Gap: Impact of Medical Debt on Black Families,” National Consumer Law Center, March 2022, https://www.nclc.org/wp-content/uploads/2022/09/RacialHealth-Rpt-2022.pdf (accessed April 18, 2023) (noting that uninsured rates and prevalence of chronic health conditions are two primary risk factors for medical debt).

[28] Berneta L. Haynes, “The Racial Health and Wealth Gap: Impact of Medical Debt on Black Families,” National Consumer Law Center, March 2022, https://www.nclc.org/wp-content/uploads/2022/09/RacialHealth-Rpt-2022.pdf (accessed April 18, 2023), p. 2.

[29] Urban Institute, “Debt in America: An Interactive Map,” June 23, 2022, https://apps.urban.org/features/debt-interactive-map/?type=medical&variable=medcoll (accessed April 18, 2023) (finding that the share of national population with medical debt in collections is 13 percent, but 11 percent among White communities and 15 percent of communities of color).

[30] See, for example, Consumer Financial Protection Bureau, “Medical Debt Burden in the United States,” February 2022, https://files.consumerfinance.gov/f/documents/cfpb_medical-debt-burden-in-the-united-states_report_2022-03.pdf (accessed April 18, 2023) (discussing throughout how hospital practices contribute to medical debt in the US).

[31] Lunna Lopes, Audrey Kearney, Alex Montero, Liz Hamel, and Mollyann Brodie, “Health Care Debt In The U.S.: The Broad Consequences Of Medical And Dental Bills,” Kaiser Family Foundation, June 16, 2022, https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/ (accessed April 18, 2023).

[32] Michael Karpman, “Most Adults with Past-Due Medical Debt Owe Money to Hospitals,” Urban Institute, March 13, 2023, https://www.urban.org/research/publication/most-adults-past-due-medical-debt-owe-money-hospitals (accessed April 18, 2023).

[33] US Bureau of Labor Statistics, “Databases, Tables & Calculators by Subject,” https://www.bls.gov/data/ (accessed April 18, 2023) (searching for “Hospital services in U.S. city average, all urban consumers, seasonally adjusted,” which increased from 112.3 in January 2000 to 383.15 in December 2022).

[34] OECD.stat, “Health expenditure and financing,” November 2022, https://stats.oecd.org/ (accessed April 18, 2023) (comparing “Current expenditure on health (all functions)” from “Hospitals” providers as a measure of “Per capita, current prices, current PPPs,” for all countries with available data across “Household out-of-pocket payments,” “Voluntary health care payment schemes,” and “Government/compulsory schemes,” for the year 2020). Notably, according to these data, the only country with higher per capita out-of-pocket expenditures on hospital services is Switzerland, which has a highly privatized health insurance system. For more information about the Swiss health care model, see The Commonwealth Fund, “International Profiles of Health Care Systems,” https://www.commonwealthfund.org/international-health-policy-center/system-features/how-does-universal-health-coverage-work (accessed April 18, 2023).

[35] See, for example, Zachary Levinson Follow, Jamie Godwin, and Scott Hulver, “Rural Hospitals Face Renewed Financial Challenges, Especially in States That Have Not Expanded Medicaid,” February 23, 2023, https://www.kff.org/health-costs/issue-brief/rural-hospitals-face-renewed-financial-challenges-especially-in-states-that-have-not-expanded-medicaid/ (accessed April 18, 2023) (“Rural hospital finances improved during the COVID-19 pandemic as a result of government relief funds. However, industry reports suggest that the outlook for the hospital sector as a whole deteriorated in 2022 as these funds have gone away and due to ongoing effects of the pandemic (such as labor shortages), rising prices, and investment losses.”).

[36] All Human Rights Watch’s correspondence for this research can be found in an online annex to the report. See Letter from Sr. Mary Haddad, President/CEO, Catholic Health Association of the United States, to Arvind Ganesan, Director, Economic Justice and Rights Division, Human Rights Watch, June 1, 2023. See also See, for example, Zachary Levinson Follow, Jamie Godwin , and Scott Hulver, “Rural Hospitals Face Renewed Financial Challenges, Especially in States That Have Not Expanded Medicaid,” February 23, 2023, https://www.kff.org/health-costs/issue-brief/rural-hospitals-face-renewed-financial-challenges-especially-in-states-that-have-not-expanded-medicaid/ (accessed April 18, 2023) (“We find that median operating margins among the rural hospitals in our analysis increased earlier in the COVID-19 pandemic, likely as a result of government relief funds, but that these facilities face renewed financial challenges, especially in states that have not expanded Medicaid (Figure 1). Among rural hospitals in non-expansion states, median operating margins were 2.1 percent during the July 2021-June 2022 period and were -0.7 percent when excluding documented relief funds. In Medicaid expansion states, median operating margins dropped, but remained positive even after excluding documented relief funds.”).

[37] See, for example, Christopher M. Whaley, Brian Briscombe, Rose Kerber, Brenna O'Neill, Aaron Kofner, “Prices Paid to Hospitals by Private Health Plans,” RAND Corporation, July 1, 2022, https://www.rand.org/pubs/research_reports/RRA1144-1.html (accessed April 18, 2023) (“The divergence in prices between private and public plans has been linked to provider consolidation that increases hospital price negotiation leverage … Despite higher prices, hospital consolidation has not been linked to improved quality outcomes or to operating efficiency, and higher-priced providers often do not have higher quality than lower-priced providers.”); and Emily Gee and Thomas Waldrop, “Policies To Hold Nonprofit Hospitals Accountable,” Center for American Progress, October 18, 2022, https://www.americanprogress.org/article/policies-to-hold-nonprofit-hospitals-accountable/ (accessed April 18, 2023) (“[I]f a hospital has a regional monopoly or has built up a strong reputation, it can successfully demand higher payment rates from private payers.”).

[38] All Human Rights Watch’s correspondence for this research can be found in an online annex to the report. See Letter from Sr. Mary Haddad, President/CEO, Catholic Health Association of the United States, to Arvind Ganesan, Director, Economic Justice and Rights Division, Human Rights Watch, June 1, 2023; Letter from Melinda Hatton, General Counsel, American Hospital Association, to Arvind Ganesan, Director, Economic Justice and Rights Division, Human Rights Watch, June 1, 2023 (“hospitals do not set their own prices for the vast majority of their services. Fifty percent or more of the reimbursements hospitals receive are set by the government for programs such as Medicare and Medicaid. Both those programs underpay hospital significantly (based on costs) for their services and have done so for decades…. Nearly all of the remainder of a hospital’s reimbursement is from commercial insurers that have immense market power in every state. Those prices are negotiated and then commercial insurers determine how much of those costs to pass on to their customers…. If there is a concentration issue of concern, the focus should be on commercial insurers and the way in which that industry wields its market power in a manner that adversely impacts both hospitals and patients…. Two trends in health insurance coverage are driving an increase in medical debt: inadequate enrollment in comprehensive health care coverage, and high-deductible health plans that intentionally push more costs onto patients. These plans leave individuals financially vulnerable when seeking medical care, despite being insured.”).

[39] For additional information on how the Internal Revenue Service and Consumer Financial Protection Bureau can help prevent the rights-impacting effects of high hospital costs, see Letter to the Honorable Rohit Chopra, Director of the Consumer Financial Protection Bureau, Monday, March 6, 2023, https://communitycatalyst.org/wp-content/uploads/2023/03/Medical-Debt-Sign-On-Letter-to-CFPB-March-6.pdf (accessed April 18, 2023); Letter to the Honorable Janet Yellen, Secretary of the Department of the Treasury, Monday, March 6, 2023, https://communitycatalyst.org/wp-content/uploads/2023/03/Medical-Debt-Sign-On-Letter-to-IRS-and-Treasury-March-6.pdf (accessed April 18, 2023).

[40] The American Hospital Association’s annual survey of community hospitals found that 2,960 of the 5,139 community hospitals across the US in 2022 were organized as not-for-profit entities. American Hospital Association, “Fast Facts on US Hospitals, 2022,” January 2022, https://www.aha.org/statistics/fast-facts-us-hospitals (accessed April 18, 2023).

[41] “Exemption Requirements - 501(c)(3) Organizations,” Internal Revenue Service, February 6, 2023, https://www.irs.gov/charities-non-profits/charitable-organizations/exemption-requirements-501c3-organizations (accessed April 18, 2023). See also, Craig Palosky, “Nonprofit Hospitals’ Tax-Exempt Status Worth About $28 Billion, New KFF Analysis Finds,” Kaiser Family Foundation, March 14, 2023, https://www.kff.org/health-costs/press-release/nonprofit-hospitals-tax-exempt-status-worth-nearly-28-billion-new-kff-analysis-finds/ (accessed April 18, 2023).

[42] “Exempt Purposes - Internal Revenue Code Section 501(c)(3),” Internal Revenue Service, June 17, 2022, https://www.irs.gov/charities-non-profits/charitable-organizations/exempt-purposes-internal-revenue-code-section-501c3 (accessed April 18, 2023).

[43] Julia James, “Nonprofit Hospitals' Community Benefit Requirements,” Health Affairs, February 25, 2016, https://www.healthaffairs.org/do/10.1377/hpb20160225.954803/ (accessed April 18, 2023). See also State of California, Franchise Tax Board, “Types of exemptions: Charities and nonprofits,” https://www.ftb.ca.gov/file/business/types/charities-nonprofits/types-of-exemptions.html (accessed April 18, 2023) (“Charitable organizations are organized and operated for purposes that are beneficial to the public interest. The definition of charitable in its generally accepted legal sense includes: relief of the poor and distressed or of the underprivileged; advancement of religion; advancement of education or science; erection or maintenance of public buildings, monuments, or works; lessening of the burdens of government; and promotion of social welfare.”).

[44] US Government Accountability Office, “Tax Administration: Opportunities Exist to Improve Oversight of Hospitals’ Tax-Exempt Status,” September 2020, https://www.gao.gov/assets/gao-20-679.pdf (accessed April 18, 2023), p. 5 (“There is no specific definition of community benefit. These six factors currently serve as the primary examples of community benefits that hospitals can provide to obtain and maintain a tax exemption.”). See also Julia James, “Nonprofit Hospitals' Community Benefit Requirements,” Health Affairs, February 25, 2016, https://www.healthaffairs.org/do/10.1377/hpb20160225.954803/ (accessed April 18, 2023) (discussing the history of federal community benefit requirements).

[45] US Internal Revenue Service, “Rev. Rul. 69-545, 1969-2 C.B. 117,” 1969, https://www.irs.gov/pub/irs-tege/rr69-545.pdf (accessed April 18, 2023). “Exempt Purposes - Internal Revenue Code Section 501(c)(3),” Internal Revenue Service, June 17, 2022, https://www.irs.gov/charities-non-profits/charitable-organizations/exempt-purposes-internal-revenue-code-section-501c3 (accessed April 18, 2023).

[46] The “community benefit” standard, as articulated by IRS Rev. Rul. 69-545 is a test that the agency uses to determine whether a hospital is organized and operated for the charitable purpose of promoting health. See US Internal Revenue Service, “Charitable Hospitals - General Requirements for Tax-Exemption Under Section 501(c)(3),” July 15, 2022, https://www.irs.gov/charities-non-profits/charitable-hospitals-general-requirements-for-tax-exemption-under-section-501c3 (accessed April 18, 2023). However, under Reg. 1.501(c)(3)-1(d)(2), some nonprofit hospitals may also claim to meet the charitability standard described in IRC 501(c)(3) by “lessening of the burdens of government.” State of California, Franchise Tax Board, “Types of exemptions: Charities and nonprofits,” https://www.ftb.ca.gov/file/business/types/charities-nonprofits/types-of-exemptions.html (accessed April 18, 2023).

[47] For more information on charity care requirements, in general, see Congressional Research Service, “Hospital Charity Care and Related Reporting Requirements Under Medicare and the Internal Revenue Code,” June 28, 2018, https://sgp.fas.org/crs/misc/IF10918.pdf (accessed April 18, 2023).

[48] US Government Accountability Office, “Tax Administration: Opportunities Exist to Improve Oversight of Hospitals’ Tax-Exempt Status,” September 2020, https://www.gao.gov/assets/gao-20-679.pdf (accessed April 18, 2023), p. 7. See also US Internal Revenue Service, “Charitable Hospitals - General Requirements for Tax-Exemption Under Section 501(c)(3),” July 15, 2022, https://www.irs.gov/charities-non-profits/charitable-hospitals-general-requirements-for-tax-exemption-under-section-501c3 (accessed April 18, 2023) (“Rev. Rul. 56-185, modified by Rev. Rul. 69-545, set forth more restrictive requirements for exemption of hospitals under Section 501(c)(3). Those more restrictive requirements included patient care without charge or at rates below cost. Though a hospital is no longer required to operate under those requirements, doing so continues to be a significant factor indicating that the hospital is operated for the benefit of the community.”).

[49] US Government Accountability Office, “Tax Administration: Opportunities Exist to Improve Oversight of Hospitals’ Tax-Exempt Status,” September 2020, https://www.gao.gov/assets/gao-20-679.pdf (accessed April 18, 2023), p. 7.

[50] Ibid., p. 11.

[51] “Requirements for 501(c)(3) Hospitals Under the Affordable Care Act – Section 501(r),” Internal Revenue Service, July 15, 2022, https://www.irs.gov/charities-non-profits/charitable-organizations/requirements-for-501c3-hospitals-under-the-affordable-care-act-section-501r (accessed April 18, 2023). See also Julia James, “Nonprofit Hospitals' Community Benefit Requirements,” Health Affairs, February 25, 2016, https://www.healthaffairs.org/do/10.1377/hpb20160225.954803/ (accessed April 18, 2023) (discussing the history of federal community benefit requirements).

[52] For information on nonprofit hospitals’ community benefit obligations, see US Internal Revenue Service, “Rev. Rul. 69-545, 1969-2 C.B. 117,” 1969, https://www.irs.gov/pub/irs-tege/rr69-545.pdf (accessed April 18, 2023).

[53] Susan Singer, Eric Wilson, and Tavi Carare, “Understanding Required Financial Assistance in Medical Care,” US Consumer Financial Protection Bureau, July 28, 2022, https://www.consumerfinance.gov/data-research/research-reports/understanding-required-financial-assistance-in-medical-care/ (accessed April 18, 2023).

[54] See “Community Benefit State Law Profiles: A 50-State Survey of State Community Benefit Laws through the Lens of the ACA,” Hilltop Institute, University of Maryland, Baltimore, https://hilltopinstitute.org/our-work/hospital-community-benefit/hospital-community-benefit-state-law-profiles/ (accessed April 18, 2023).

[55] Andrea Bopp Stark and Jenifer Bosco, “An Ounce Of Prevention: A Review Of Hospital Financial Assistance Policies In The States,” National Consumer Law Center, November 2021, https://www.nclc.org/wp-content/uploads/2022/09/Rpt_Ounce_of_Prevention.pdf (accessed April 18, 2023), pp. 22-37 (summarizing state-based financial assistance regulations).

[56] Ibid.

[57] As further described below, there is significant diversity among nonprofit hospitals with respect to their financial assistance policies. For example, for additional information on the financial assistance policies of faith-based nonprofit hospitals, see Letter from Sr. Mary Haddad, President/CEO, Catholic Health Association of the United States, to Arvind Ganesan, Director, Economic Justice and Rights Division, Human Rights Watch, June 1, 2023 (“A review of IRS 990 Schedule H forms shows that Catholic hospitals, on average, provide free care with income eligibility up to 230% of the Federal Poverty Level (FPL) and discounted care with incomes up to 380% of the FPL.”).

[58] See Noam N. Levey, “Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds. Does Yours?,” Kaiser Family Foundation Health News, December 21, 2022, https://kffhealthnews.org/news/article/medical-debt-hospitals-sue-patients-threaten-credit-khn-investigation/ (accessed April 18, 2023).

[59] US Government Accountability Office, “Tax Administration: Opportunities Exist to Improve Oversight of Hospitals’ Tax-Exempt Status,” September 2020, https://www.gao.gov/assets/gao-20-679.pdf (accessed April 18, 2023), pp. 21-23.

[60] Ibid.

[61] Ibid.

[62] Ibid.

[63] See “Revoked? Reinstated? Learn More,” US Internal Revenue Service, March 14, 2023, https://www.irs.gov/charities-non-profits/automatic-revocation-of-exemption (accessed April 18, 2023).

[64] Letter from Department of the Treasury, Internal Revenue Service, Tax Exempt and Government Entities Division, “UIL: 501.03-00,” February 14, 2017, https://www.irs.gov/pub/irs-wd/201731014.pdf (accessed April 18, 2023).

[65] Ibid. See also “Requirements for 501(c)(3) Hospitals Under the Affordable Care Act – Section 501(r),” Internal Revenue Service, July 15, 2022, https://www.irs.gov/charities-non-profits/charitable-organizations/requirements-for-501c3-hospitals-under-the-affordable-care-act-section-501r (accessed April 18, 2023).

[66] “Intermediate sanctions - excess benefit transactions,” US Internal Revenue Service, June 16, 2022, https://www.irs.gov/charities-non-profits/charitable-organizations/intermediate-sanctions-excess-benefit-transactions (accessed April 18, 2023).

[67] All Human Rights Watch’s correspondence for this research can be found in an online annex to the report. See Letter from Sr. Mary Haddad, President/CEO, Catholic Health Association of the United States, to Arvind Ganesan, Director, Economic Justice and Rights Division, Human Rights Watch, June 1, 2023.

[68] 26 CFR § 1.501(r), https://www.govinfo.gov/content/pkg/CFR-2015-title26-vol9/pdf/CFR-2015-title26-vol9-sec1-501r-3.pdf (accessed April 18, 2023). “Billing and Collections – Section 501(r)(6),” US Internal Revenue Service, July 15, 2022, https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6 (accessed April 18, 2023).

[69] See Congressional Research Service, “Hospital Charity Care and Related Reporting Requirements Under Medicare and the Internal Revenue Code,” June 28, 2018, https://sgp.fas.org/crs/misc/IF10918.pdf (accessed April 18, 2023).

[70] “Form 990 Resources and Tools,” US Internal Revenue Service, February 8, 2023, https://www.irs.gov/charities-non-profits/form-990-resources-and-tools (accessed April 18, 2023).

[71] US Internal Revenue Service, “Schedule H (Form 990),” 2022, https://www.irs.gov/pub/irs-pdf/f990sh.pdf (accessed April 18, 2023).See also, Community Benefits Insight, “Hospital Classifications,” https://www.communitybenefitinsight.org/?page=info.hospital_types (accessed April 18, 2023) (“Some public hospitals with 501(c)(3) tax status … must comply with 501(r) [but] are not required to file IRS Form 990 including Schedule H.”). See also “2018 Instructions for Schedule H (Form 990),” US Internal Revenue Service, November 15, 2018, https://www.irs.gov/pub/irs-prior/i990sh--2018.pdf (accessed April 18, 2023).

[72] Hossein Zare, Matthew D. Eisenberg, and Gerard Anderson, “Comparing the value of community benefit and Tax-Exemption in non-profit hospitals,” Health Services Research, May 9, 2021, Vol. 57, Issue 2, https://onlinelibrary.wiley.com/doi/full/10.1111/1475-6773.13668 (accessed April 18, 2023) (“The IRS collects data on 17 different possible types of community benefits, but it does not make a judgment as to which ones should be considered a community benefit. The only penalty is when a hospital fails to file its annual return (Form 990) for three consecutive years; then the IRS will automatically revoke the organization's tax-exempt status.”). See also US Government Accountability Office, “Tax Administration: Opportunities Exist to Improve Oversight of Hospitals’ Tax-Exempt Status,” September 2020, https://www.gao.gov/assets/gao-20-679.pdf (accessed April 18, 2023), pp. 19-27 (discussing how the IRS could improve oversight of 2010 ACA’s community benefit requirements).

[73] US Government Accountability Office, “Tax Administration: Opportunities Exist to Improve Oversight of Hospitals’ Tax-Exempt Status,” September 2020, https://www.gao.gov/assets/gao-20-679.pdf (accessed April 18, 2023), pp. 19-20 (“IRS requires hospitals to self-report compliance with all four [2010 ACA] requirements on Form 990, Schedule H … The Tax Exempt and Government Entities (TE/GE) division of IRS verifies many aspects of the hospitals’ reports during its triennial Community Benefit Activity Reviews (CBAR) … If the revenue agent cannot verify a hospital’s compliance with all the [2010 ACA] requirements, the hospital is to be referred for audit…. Over the period from fiscal years 2015 through 2019, TE/GE conducted more than 4,700 CBARs and referred almost 1,000 tax-exempt hospitals for audit because they identified a potential … violation.”), pp. 11-12 (“However, IRS officials told us that they could not identify whether any tax-exempt hospitals were referred to its audit division during the period from fiscal years 2015 through 2019 for potentially providing insufficient community benefits because, as discussed later, the agency does not track this information. Furthermore, IRS officials told us that the agency has not revoked a hospital’s tax-exempt status for failing to provide sufficient community benefits in the last 10 years.”). See also “Charity and Nonprofit Audits: Scope of Audits and Compliance Checks,” US Internal Revenue Service, February 8, 2023, https://www.irs.gov/charities-non-profits/scope-of-audits-and-compliance-checks-of-exempt-organizations (accessed April 18, 2023) (discussing IRS auditing procedures in general).

[74] “Form CMS-2552-10,” US Centers for Medicare and Medicaid Services, December 2022, https://www.costreportdata.com/instructions/Instr_S100.pdf (accessed April 18, 2023). See also Hossein Zare, Matthew D. Eisenberg, and Gerard Anderson, “Comparing the value of community benefit and Tax-Exemption in non-profit hospitals,” Health Services Research, May 9, 2021, Vol. 57, Issue 2, https://onlinelibrary.wiley.com/doi/full/10.1111/1475-6773.13668 (accessed April 18, 2023).

[75] Hossein Zare, Matthew D. Eisenberg, and Gerard Anderson, “Comparing the value of community benefit and Tax-Exemption in non-profit hospitals,” Health Services Research, May 9, 2021, Vol. 57, Issue 2, https://onlinelibrary.wiley.com/doi/full/10.1111/1475-6773.13668 (accessed April 18, 2023).

[76] Hossein Zare, Matthew Eisenberg, and Gerard Anderson, “Charity Care and Community Benefit in Non-Profit Hospitals: Definition and Requirements,” Inquiry: The Journal of Health Care Organization, Provision, and Financing, June 24, 2021, Vol. 58, https://journals.sagepub.com/doi/10.1177/00469580211028180 (accessed April 18, 2023).

[77] All Human Rights Watch’s correspondence for this research can be found in an online annex to the report. See Letter from Melinda Hatton, General Counsel, American Hospital Association, to Arvind Ganesan, Director, Economic Justice and Rights Division, Human Rights Watch, June 1, 2023.

[78] Ibid.

[79] Hossein Zare, Matthew D. Eisenberg, and Gerard Anderson, “Comparing the value of community benefit and Tax-Exemption in non-profit hospitals,” Health Services Research, May 9, 2021, Vol. 57, Issue 2, https://onlinelibrary.wiley.com/doi/full/10.1111/1475-6773.13668 (accessed April 18, 2023).

[80] Ibid.

[81] See Jennifer Tolbert , Patrick Drake, and Anthony Damico, “Key Facts about the Uninsured Population,” December 19, 2022, https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population (accessed April 18, 2022).

[82] Susan Singer, Eric Wilson and Tavi Carare, “Understanding Required Financial Assistance in Medical Care,” July 28, 2022, https://www.consumerfinance.gov/data-research/research-reports/understanding-required-financial-assistance-in-medical-care/ (accessed April 18, 2023).

[83] See Jamie Godwin, Zachary Levinson, and Scott Hulver, “The Estimated Value of Tax Exemption for Nonprofit Hospitals Was About $28 Billion in 2020,” March 14, 2023, https://www.kff.org/health-costs/issue-brief/the-estimated-value-of-tax-exemption-for-nonprofit-hospitals-was-about-28-billion-in-2020/ (accessed April 18, 2023) (citing Allison K. Hoffman, “Supreme Court Will Decide How Medicare’s Extra Payments to Hospitals Treating Low-Income Patients Are Calculated,” The Commonwealth Fund, November 23, 2021, https://www.commonwealthfund.org/blog/2021/supreme-court--medicares-extra-payments-hospitals (accessed April 18, 2023) and Medicaid and CHIP Payment and Access Commission, “Report to Congress on Medicaid and CHIP, Chapter 3: Annual Analysis of Disproportionate Share Hospital Allotments to States,” March 2022, https://www.macpac.gov/wp-content/uploads/2022/03/Chapter-3-Annual-Analysis-of-Disproportionate-Share-Hospital-Allotments-to-States.pdf (accessed April 18, 2023).

[84] Ibid.

[85] Alyce S. Adams, Raymond Kluender, Neale Mahoney, Jinglin Wang, Francis Wong and Wesley Yin, “The Impact of Financial Assistance Programs on Health Care Utilization,” National Bureau of Economic Research, September 2021, https://www.nber.org/papers/w29227 (accessed April 18, 2023). See also Anna Wilde Matthews, Tom McGinty, and Melanie Evans, “Big Hospitals Provide Skimpy Charity Care—Despite Billions in Tax Breaks,” Wall Street Journal, July 25, 2022, https://www.wsj.com/articles/nonprofit-hospitals-vs-for-profit-charity-care-spending-11657936777 (accessed April 18, 2023) “nonprofits [are] falling short of for profits in how much they spend on charity for every dollar of net patient revenue.”).

[86] Joseph D. Bruch and David Bellamy, “Charity Care: Do Nonprofit Hospitals Give More than For-Profit Hospitals?,” Journal of General Internal Medicine, September 1, 2020, Vol. 36, No. 10, https://link.springer.com/article/10.1007/s11606-020-06147-9 (accessed April 18, 2023).

[87] Ge Bai, Hossein Zare, Matthew D. Eisenberg, Daniel Polsky, and Gerard F. Anderson, "Analysis Suggests Government And Nonprofit Hospitals’ Charity Care Is Not Aligned With Their Favorable Tax Treatment," Health Affairs Vol, 40, No. 4, April 2021, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.01627 (accessed April 18, 2023). See also Emily Gee and Thomas Waldrop, “Policies To Hold Nonprofit Hospitals Accountable,” Center for American Progress, October 18, 2022, https://www.americanprogress.org/article/policies-to-hold-nonprofit-hospitals-accountable/ (accessed April 18, 2023).

[88] Ge Bai, Hossein Zare, Matthew D. Eisenberg, Daniel Polsky, and Gerard F. Anderson, "Analysis Suggests Government And Nonprofit Hospitals’ Charity Care Is Not Aligned With Their Favorable Tax Treatment," Health Affairs Vol, 40, No. 4, April 2021, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.01627 (accessed April 18, 2023). See also Emily Gee and Thomas Waldrop, “Policies To Hold Nonprofit Hospitals Accountable,” Center for American Progress, October 18, 2022, https://www.americanprogress.org/article/policies-to-hold-nonprofit-hospitals-accountable/ (accessed April 18, 2023).

[89] Hossein Zare, Matthew D. Eisenberg, and Gerard Anderson, “Comparing the value of community benefit and Tax-Exemption in non-profit hospitals,” Health Services Research, May 9, 2021, Vol. 57, Issue 2, https://onlinelibrary.wiley.com/doi/full/10.1111/1475-6773.13668 (accessed April 18, 2023).

[90] Lown Institute, “Fair Share Spending: How much are hospitals giving back to their communities?,” April 12, 2022, https://lownhospitalsindex.org/2022-fair-share-spending/ (accessed April 18, 2023).

[91] Craig Palosky, “Nonprofit Hospitals’ Tax-Exempt Status Worth About $28 Billion, New KFF Analysis Finds,” Kaiser Family Foundation, March 14, 2023, https://www.kff.org/health-costs/press-release/nonprofit-hospitals-tax-exempt-status-worth-nearly-28-billion-new-kff-analysis-finds/ (accessed April 18, 2023).

[92] Regarding nonprofit hospitals’ consolidation and growth, see, for example, Allan Sloan, Carson Kessler, “How Effective Is the Government’s Campaign Against Hospital Mergers?,” ProPublica, October 28, 2022, https://www.propublica.org/article/ftc-campaign-against-hospital-mergers (accessed April 18, 2023) (“There were 1,887 hospital mergers announced from 1998 through the end of last year … Absent those mergers, we’d have about 8,000 hospitals in the U.S. rather than the 6,093”); Hoag Levins, “Hospital Consolidation Continues to Boost Costs, Narrow Access, and Impact Care Quality,” University of Pennsylvania, Leonard Davis Institute of Health Economics, January 19, 2023, https://ldi.upenn.edu/our-work/research-updates/hospital-consolidation-continues-to-boost-costs-narrow-access-and-impact-care-quality/ (accessed April 18, 2023) (“Judges [in the 1990s] seemed skeptical that hospitals would ever act anti-competitively—that those institutions would ever raise prices, or reduce services to their patients, especially with nonprofit hospitals. So, [federal authorities] took a step back as economists studied the effect of hospital mergers on prices and were able to show empirically that even nonprofit hospitals took advantage of the market power when they could.”); and Judith Garber, “Tackling health care consolidation to build a better health system,” Lown Institute, August 24, 2020, https://lowninstitute.org/tackling-health-care-consolidation-to-build-a-better-health-system/ (accessed April 18, 2023). Regarding nonprofit hospitals’ executive compensation practices, see, for example, Alia Paavola, “Top 5 nonprofit hospitals for executive pay,” Becker’s Hospital Review, June 26, 2019, https://www.beckershospitalreview.com/compensation-issues/top-5-nonprofit-hospitals-for-executive-pay.html (accessed April 18, 2023) (citing OpenTheBooks, “Top 82 US Nonprofit Hospitals: Quantifying Government Payments and Financial Assets,” American Transparency, June 2019, https://issuu.com/openthebooks/docs/top_82_largest_u.s._non-profit_hosp (accessed April 18, 2023)) (finding that the average compensation for a chief executive at one of the 82 largest nonprofit hospitals in the US was worth about $3.5 million annually); Jerry Du, Alexander Rascoe, Randall Marcus, “The Growing Executive-Physician Wage Gap in Major US Nonprofit Hospitals and Burden of Nonclinical Workers on the US Healthcare System,” Clinical Orthopaedics and Related Research, October 2018, Vol. 476, No. 10, https://pubmed.ncbi.nlm.nih.gov/30001293/ (accessed April 18, 2023) (studying 22 major nonprofit hospitals’ executive compensation practices and finding that the average CEO’s compensation nearly doubled between 2005 and 2015); Vikas Saini Judith Garber, and Shannon Brownlee, “Nonprofit Hospital CEO Compensation: How Much Is Enough?,” Health Affairs, February 10, 2022, https://www.healthaffairs.org/do/10.1377/forefront.20220208.925255 (accessed April 18, 2023) (citing Economic Research Institute, “2021 CEO Pay Trends in the Nonprofit World,” 2021, https://resources.erieri.com/whitepaper/2021-ceo-pay-trends-in-the-nonprofit-world (accessed April 18, 2023)) (finding that the average annual pay for a CEO in most nonprofit industries was between $100,000 and $200,000 in 2018, but hospital CEOs were paid about $600,000, on average, that year; and that the bottom quartile of nonprofit hospital CEOs had an annual compensation of about $185,000 that year, which was still higher than the top quarter for CEOs of nonprofits dealing with arts and culture, the environment, human services, and religion); and National Nurses United, “Preying On Patients: Maryland’s Not-for-Profit Hospitals and Medical Debt Lawsuits,” February 2020, https://www.nationalnursesunited.org/sites/default/files/nnu/documents/0220_JHH_PreyingOnPatients_Report-opt.pdf (accessed April 18, 2023) (analyzing compensation for 1,068 executives of nonprofit hospitals in Maryland and finding that these executives received $1.66 billion in aggregate compensation between 2013 and 2018, which was about 10-times larger than the value of medical debt that these hospitals sought to collect from patients over this period through tens of thousands of lawsuits, and thousands of wage garnishments and property seizures). Regarding nonprofit hospitals’ investments, see, for example, Bob Herman, “Hospitals are making a fortune on Wall Street,” Axios, December 7, 2017, https://www.axios.com/2017/12/16/hospitals-are-making-a-fortune-on-wall-street-1513388345 (accessed April 18, 2023) (studying financial documents for 84 of the largest nonprofit hospital systems in the country in 2017 and finding that these hospitals earned $21 billion from investments alone that year); Bob Herman, “Hospitals are swimming in cash,” AXIOS, May 21, 2019, https://www.axios.com/2019/05/21/hospitals-are-swimming-in-cash (accessed April 18, 2023) (studying financial statements for 31 prominent nonprofit hospital systems and finding that “Hospitals are feasting on bigger investment returns, boosted by the stock market's run, but they also are profiting more from commercial and public health insurer payments … But that money is often directed toward building new patient towers, other construction projects and executive pay instead of charity care or other forms of "community benefit”); and Jordan Rau, “Mission and Money Clash in Nonprofit Hospitals’ Venture Capital Ambitions,” Kaiser Health News, August 24, 2021, https://khn.org/news/article/mission-and-money-clash-in-nonprofit-hospitals-venture-capital-ambitions/ (accessed April 18, 2023) (analyzing nonprofit hospital tax filings from 2019 and finding that nonprofit hospitals collectively held more than $283 billion in stocks, private equity, and other investment assets, only about 7 percent of which was classified as investments devoted to furthering their mission rather than generating income.).

[93] All Human Rights Watch’s correspondence for this research can be found in an online annex to the report. See Letter from Sr. Mary Haddad, President/CEO, Catholic Health Association of the United States, to Arvind Ganesan, Director, Economic Justice and Rights Division, Human Rights Watch, June 1, 2023.

[94] See Letter from Melinda Hatton, General Counsel, American Hospital Association, to Arvind Ganesan, Director, Economic Justice and Rights Division, Human Rights Watch, June 1, 2023.

[95] Ibid. See EY, “Estimates of the federal revenue forgone due to the tax-exemption of non-profit hospitals compared to the community benefit they provide, 2019: Prepared for the American Hospital Association,” https://www.aha.org/system/files/media/file/2022/06/E%26Y-Benefit-of-of-Tax-Exemption-Report-FY2019-FINAL-with-links.pdf (accessed April 18, 2023).

[96] Hossein Zare, et al., “Charity Care and Community Benefit in Non-Profit Hospitals: Definition and Requirements,” Inquiry: The Journal of Health Care Organization, Provision, and Financing, Vol. 58, 2021, https://journals.sagepub.com/doi/10.1177/00469580211028180 (accessed March 14, 2023).

[97] See American Hospital Association, “Fact Sheet: Underpayment by Medicare and Medicaid,” February 2022, https://www.aha.org/fact-sheets/2020-01-07-fact-sheet-underpayment-medicare-and-medicaid (accessed April 18, 2023) (“Payment rates for Medicare and Medicaid, with the exception of managed care plans, are set by law rather than through a negotiation process, as with private insurers.”).

[98] See “Medicaid and CHIP Payment Commission, “Report to Congress on Medicaid and CHIP,” March 2022, https://www.macpac.gov/wp-content/uploads/2022/03/March-2022-Report-to-Congress-on-Medicaid-and-CHIP.pdf (accessed April 18, 2023) (finding that “Medicaid shortfall, the difference between the Medicaid base payments a hospital receives and its costs of providing services to Medicaid-enrolled patients, decreased 700 million (4 percent) between 2018 and 2019, according to the American Hospital Association (AHA) annual survey. In 2019, total Medicaid shortfall for all U.S. hospitals was $19 billion.”).

[99] Hossein Zare, Matthew D. Eisenberg, and Gerard Anderson, “Comparing the value of community benefit and Tax-Exemption in non-profit hospitals,” Health Services Research, May 9, 2021, Vol. 57, Issue 2, https://onlinelibrary.wiley.com/doi/full/10.1111/1475-6773.13668 (accessed April 18, 2023).

[100] See Ge Bai, Hossein Zare, and David A. Hyman, “Evaluation of Unreimbursed Medicaid Costs Among Nonprofit and For-Profit US Hospitals,” Journal of the American Medical Association Open Network, February 14, 2022, Vol. 5, No. 2, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2789009 (accessed April 18, 2023).

[101] Ibid.

[102] Ibid.

[103] See Letter from Melinda Hatton, General Counsel, American Hospital Association, to Arvind Ganesan, Director, Economic Justice and Rights Division, Human Rights Watch, June 1, 2023.

[104] See Andrea Bopp Stark and Jenifer Bosco, “An Ounce Of Prevention: A Review Of Hospital Financial Assistance Policies In The States,” National Consumer Law Center, November 2021, https://www.nclc.org/wp-content/uploads/2022/09/Rpt_Ounce_of_Prevention.pdf (accessed April 18, 2023).

[105] Ibid.

[106] See Letter from Melinda Hatton, General Counsel, American Hospital Association, to Arvind Ganesan, Director, Economic Justice and Rights Division, Human Rights Watch, June 1, 2023.

[107] Jordan Rau, “Patients Eligible For Charity Care Instead Get Big Bills,” Kaiser Family Foundation Health News, October 14, 2019, https://khn.org/news/patients-eligible-for-charity-care-instead-get-big-bills/ (accessed April 18, 2023).

[108] See Zachary Levinson, Scott Hulver, and Tricia Neuman, “Hospital Charity Care: How It Works and Why It Matters,” Kaiser Family Foundation, November 3, 2022, https://www.kff.org/health-costs/issue-brief/hospital-charity-care-how-it-works-and-why-it-matters/ (accessed April 18, 2023). Internal Revenue Service, “Hospital Compliance Project Interim Report, Chapter VI. Other Community Benefit Reporting - Bad Debt And Shortfalls, Research, Income And Health Insurance Coverage Levels,” July 19, 2007, https://www.irs.gov/pub/irs-tege/OtherCB_HospProjRept.pdf (accessed April 18, 2023).

[109] Ibid.

[110] See PEW Charitable Trusts, “How Debt Collectors Are Transforming the Business of State Courts: Lawsuit trends highlight need to modernize civil legal systems,” May 2020, https://www.pewtrusts.org/-/media/assets/2020/06/debt-collectors-to-consumers.pdf (accessed April 18, 2023).

[111] “Billing and Collections – Section 501(r)(6),” US Internal Revenue Service, July 15, 2022, https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6 (accessed April 18, 2023).

[112] Congressional Research Service, “Hospital Charity Care and Related Reporting Requirements Under Medicare and the Internal Revenue Code,” June 28, 2018, https://sgp.fas.org/crs/misc/IF10918.pdf (accessed April 18, 2023).

[113] Susan Singer, Eric Wilson and Tavi Carare, “Understanding Required Financial Assistance in Medical Care,” US Consumer Financial Protection Bureau, July 28, 2022, https://www.consumerfinance.gov/data-research/research-reports/understanding-required-financial-assistance-in-medical-care/ (accessed April 18, 2023).

[114] 26 CFR § 1.501(r), https://www.govinfo.gov/content/pkg/CFR-2015-title26-vol9/pdf/CFR-2015-title26-vol9-sec1-501r-3.pdf (accessed April 18, 2023). “Billing and Collections – Section 501(r)(6),” US Internal Revenue Service, July 15, 2022, https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6 (accessed April 18, 2023).

[115] Urban Institute, “Debt in America: An Interactive Map,” June 23, 2022, https://apps.urban.org/features/debt-interactive-map/?type=medical&variable=medcoll (accessed April 18, 2023).

[116] Zack Cooper, James Han, and Neale Mahoney, “Hospital Lawsuits Over Unpaid Bills Increased By 37 Percent In Wisconsin From 2001 To 2018,” Health Affairs, December 2021, Vol. 40, No. 12, https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.01130 (accessed April 18, 2023).

[117] Human Rights Watch, “Rubber Stamp Justice: US Courts, Debt Buying Corporations, and the Poor,” January 20, 2016, https://www.hrw.org/node/285470/ (accessed April 18, 2023) (“Many individual courts issue thousands or even tens of thousands of no questions asked default judgments in favor of debt buyers every year”).

[118] Carolyn Carter, “Protecting Wages, Benefits, and Bank Accounts from Judgment Creditors,” National Consumer Law Center, October 29, 2020, https://library.nclc.org/article/protecting-wages-benefits-and-bank-accounts-judgment-creditors (accessed April 18, 2023).

[119] Consumer Financial Protection Bureau, “Medical Debt Burden in the United States,” February 2022, https://files.consumerfinance.gov/f/documents/cfpb_medical-debt-burden-in-the-united-states_report_2022-03.pdf (accessed April 18, 2023).

[120] Community Service Society of New York, “Discharged Into Debt: Nonprofit Hospitals File Liens On Patients’ Home,” November 2021, https://smhttp-ssl-58547.nexcesscdn.net/nycss/images/uploads/pubs/Liens.pdf (accessed April 18, 2023).

[121] Ibid.

[122] Consumer Financial Protection Bureau, “Medical Debt Burden in the United States,” February 2022, https://files.consumerfinance.gov/f/documents/cfpb_medical-debt-burden-in-the-united-states_report_2022-03.pdf (accessed April 18, 2023). Lizzie Presser and Edmund D. Fountain, “When Medical Debt Collectors Decide Who Gets Arrested,” ProPublica, https://features.propublica.org/medical-debt/when-medical-debt-collectors-decide-who-gets-arrested-coffeyville-kansas/ (accessed April 18, 2023).

[123] “The Criminalization Of Private Debt,” American Civil Liberty Union, https://www.aclu.org/issues/smart-justice/mass-incarceration/criminalization-private-debt (accessed April 18, 2023).

[124] PEW Charitable Trusts, “How Debt Collectors Are Transforming the Business of State Courts: Lawsuit trends highlight need to modernize civil legal systems,” May 2020, https://www.pewtrusts.org/-/media/assets/2020/06/debt-collectors-to-consumers.pdf (accessed April 18, 2023).

[125] Jessica Silver-Greenberg and Katie Thomas, “They Were Entitled to Free Care. Hospitals Hounded Them to Pay,” The New York Times, September 24, 2022, https://www.nytimes.com/2022/09/24/business/nonprofit-hospitals-poor-patients.html (accessed April 18, 2023).

[126] Ibid.

[127] All Human Rights Watch’s correspondence for this research can be found in an online annex to the report. See Letter from Human Rights Watch to Rod Hochman and Orest Holubec, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023.

[128] Victor G. Villagra, Mario Felix, Emil Coman, Denise O. Smith, Allison Joslyn, Trisha Pitter, and Wizdom Powell, “When Hospitals and Doctors Sue Their Patients: The Medical Debt Crisis Through a New Lens,” UConn Health Disparities Institute, June 18, 2019, https://health.uconn.edu/health-disparities/wp-content/uploads/sites/260/2019/06/HDI-Issue-Brief_When-Hospitals-and-Doctors-Sue-Their-Patients.pdf (accessed April 18, 2023).

[129] Ibid. See also “Hospitals by Ownership Type,” Kaiser Family Foundation, 2021, https://www.kff.org/other/state-indicator/hospitals-by-ownership/ (accessed April 18, 2023).

[130] See Letter from Human Rights Watch to Christopher O’Connor and Patrick Charmel, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023; Email from Paul Kidwell, Senior Vice President, Connecticut Hospital Association, to Matt McConnell, May 19, 2023.

[131] Lizzie Presser and Edmund D. Fountain, “When Medical Debt Collectors Decide Who Gets Arrested,” ProPublica, https://features.propublica.org/medical-debt/when-medical-debt-collectors-decide-who-gets-arrested-coffeyville-kansas/ (accessed April 18, 2023).

[132] Ibid.

[133] Ibid.

[134] See Letter from Human Rights Watch to Mary Stout, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023.

[135] National Nurses United, “Preying On Patients: Maryland’s Not-for-Profit Hospitals and Medical Debt Lawsuits,” February 2020, https://www.nationalnursesunited.org/sites/default/files/nnu/documents/0220_JHH_PreyingOnPatients_Report-opt.pdf (accessed April 18, 2023).

[136] Note that the entirety of this exchange is available in an online annex to this report. See Letter from Human Rights Watch to Nicole Dempsey Stallings and Meghan McClelland, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023; Email from Amy Goodwin, Vice President of Communication, Maryland Hospital Association, to Matt McConnell, May 19, 2023.

[137] Meredith Cohn and Lorraine Mirabella, “Johns Hopkins Hospital sues patients, many low income, for medical debt,” The Baltimore Sun, May 17, 2019, https://www.baltimoresun.com/health/bs-hs-hopkins-sues-patients-20190516-story.html (accessed April 18, 2023).

[138] Ibid.

[139] Note that the entirety of this exchange is available in an online annex to this report. See Letter from Human Rights Watch to Nicole Dempsey Stallings and Meghan McClelland, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023; Email from Liz Vandendriessche, Director of Strategic Communications, Johns Hopkins Medicine, to Matt McConnell, May 16, 2023.

[140] Chris Arnold, Paul Kiel, “When Nonprofit Hospitals Sue Their Poorest Patients,” NPR and ProPublica, December 18, 2014, https://www.npr.org/2014/12/19/371202059/when-a-hospital-bill-becomes-a-decade-long-pay-cut (accessed April 18, 2023).

[141] Ibid. See also “Mosaic Life Care Responds to Senator Grassley's Inquiry,” Mosaic Life Care, February 11, 2015, https://www.mymlc.com/Main/About-Mosaic-Life-Care/Media-and-Public-Relations/Press-Releases/grassley/ (accessed April 18, 2023).

[142] Note that the entirety of this exchange is available in an online annex to this report. See Letter from Human Rights Watch to Nicole Dempsey Stallings and Meghan McClelland, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023; Email from Joey Austin, Public Information Officer, Mosaic Life Care, to Matt McConnell, May 18, 2023. See also “Heartland Health Becomes Mosaic Life Care,” Mosaic Life Care, November 12, 2014, https://www.mymlc.com/Main/About-Mosaic-Life-Care/Media-and-Public-Relations/Press-Releases/heartland-health-becomes-mosaic-life-care/ (accessed April 18, 2023) (“Heartland Health celebrates the next chapter with a reinvention into Mosaic Life Care”).

[143] See Molly Castle Work, “They could have qualified for charity care. But Mayo Clinic sued them,” November 22, 2022, https://www.postbulletin.com/newsmd/they-could-have-qualified-for-charity-care-but-mayo-clinic-sued-them?ajs_aid=426d4b69-a6c1-45a4-97d9-386b0d9a34b7 (accessed April 18, 2023).

[144] See Molly Castle Work, “AG Keith Ellison’s office calls Mayo Clinic’s apparent bill-collection conduct 'aggressive',” The Bemidji Pioneer, December 15, 2022, https://www.bemidjipioneer.com/news/minnesota/ag-keith-ellisons-office-calls-mayo-clinics-apparent-bill-collection-conduct-aggressive (accessed April 18, 2023).

[145] Ibid.

[146] See Letter from Human Rights Watch to Gianrico Farrugia and Traci Klein, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023.

[147] Johns Hopkins University, “Predatory Medical Billing in New York: New York Hospitals Sue Patients for Unpaid Medical Bill,” December 2020, https://www.restoringmedicine.org/_files/ugd/29ca8c_eb280af312db4195b60a017b9469467e.pdf (accessed April 18, 2023).

[148] Community Service Society of New York, “Discharged Into Debt: New York’s Nonprofit Hospitals Are Suing Patients,” March 2020, https://smhttp-ssl-58547.nexcesscdn.net/nycss/images/uploads/pubs/2020_Hospital_Report_V3_web.pdf (accessed April 18, 2023).

[149] Note that the entirety of this exchange is available in an online annex to this report. See Letter from Human Rights Watch to Bea Grause and Sandi Toll, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023; Email from Michael Pauley, Vice President, Communication and Marketing Strategy, Healthcare Association of New York State, to Matt McConnell, May 18, 2023.

[150] See Letter from Human Rights Watch to David C. Rich and Lloyd C. Bishop, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023.

[151] North Carolina State Health Plan, “NC Nonprofit Hospitals Bill the Poor,” January 26, 2022, https://www.shpnc.org/media/2692/download?attachment (accessed April 18, 2023).

[152] Ibid.

[153] Note that the entirety of this exchange is available in an online annex to this report. See Letter from Human Rights Watch to Steve Lawler and Cynthia Charles, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023; Email from Cynthia Charles, Vice President, Communications and Public Relations, North Carolina Healthcare Association, to Matt McConnell, May 18, 2023. See also Stephanie Strickland, “NCHA Statement on North Carolina State Health Plan and National Academy of State Health Policy Report,” North Carolina Healthcare Association, January 26, 2022, https://www.ncha.org/2022/01/ncha-statement-on-north-carolina-state-health-plan-and-national-academy-of-state-health-policy-report/ (accessed May 22, 2023).

[154] Jenny Gold, “Sued Over An $1,800 Hospital Bill,” Kaiser Family Foundation Health News and NPR, April 27, 2012, https://khn.org/news/charity-care-nonprofit-hospitals-patient-debt/ (accessed April 18, 2023).

[155] Ibid.

[156] See Letter from Human Rights Watch to Michael A. Slubowski and Julie Spencer Washington, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023. Email from Unnamed Trinity Health Spokesperson to Matt McConnell, June 2, 2023.

[157] Trevor Brown, “Oklahoma hospitals sue thousands each year over unpaid medical bills,” The Oklahoman, August 13, 2019, https://www.oklahoman.com/story/lifestyle/health-fitness/2019/08/13/oklahoma-hospitals-sue-thousands-each-year-over-unpaid-medical-bills/60441270007/ (accessed April 18, 2023).

[158] Ibid.

[159] Ibid.

[160] See Letter from Human Rights Watch to Cliff Robertson and Mike Lissau, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023.

[161] Jessica Silver-Greenberg and Katie Thomas, “They Were Entitled to Free Care. Hospitals Hounded Them to Pay,” The New York Times, September 24, 2022, https://www.nytimes.com/2022/09/24/business/nonprofit-hospitals-poor-patients.html (accessed April 18, 2023).

[162] See Letter from Human Rights Watch to Rod Hochman and Orest Holubec, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023.

[163] Elena Delavega and Gregory M. Blumenthal, “2022 Memphis Poverty Fact Sheet,” University of Memphis, 2022, https://www.memphis.edu/socialwork/research/2022_poverty_fact_sheet_web.pdf (accessed April 18, 2023). See “Profiting from the Poor: Inside Memphis’ Debt Machine,” ProPublica, 2019-2020, https://www.propublica.org/series/profiting-from-the-poor (accessed April 18, 2023).

[164] Wendi C. Thomas, “We reported on Methodist Le Bonheur suing patients. It erased the debts of more than 6,500 patients,” MLK50, September 24, 2019, https://mlk50.com/2019/09/24/we-reported-on-methodist-le-bonheur-suing-patients-it-erased-the-debts-of-more-than-6500-patients/ (accessed April 18, 2023).

[165] Letter from Senator Grassley, Chairman of the Finance Committee, to Members of the Senate Finance and Judiciary Committees, “Re: UVA Medical Center and Methodist Le Bonheur Healthcare Hospital,” December 2, 2020, https://www.finance.senate.gov/imo/media/doc/2020-12-02%20CEG%20to%20Colleagues%20letter%20only%20(Non-profit%20Hospitals).pdf (accessed April 18, 2023).

[166] See Letter from Human Rights Watch to Michael Ugwueke and Kate Dowd, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023.

[167] Farah Hashim, Frank Migliarese, Sarah Blakemore, et al., “Eroding the Public Trust: A Report of Texas Hospitals Suing Patients,” Johns Hopkins University, Mount Sinai School of Medicine, Georgetown University, and the University of Texas, Austin, 2020, https://a2e0dcdc-3168-4345-9e39-788b0a5bb779.filesusr.com/ugd/29ca8c_095296028da54e778dbfb34987c3cc9c.pdf (accessed April 18, 2023).

[168] Ibid.

[169] See Letter from Human Rights Watch to Brad D. Holland and Erin S. Asprec, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023.

[170] Jay Hancock and Elizabeth Lucas, “‘UVA Has Ruined Us’: Health System Sues Thousands Of Patients, Seizing Paychecks And Claiming Homes,” Kaiser Family Foundation Health News, September 10, 2019, https://khn.org/news/uva-health-system-sues-patients-virginia-courts-garnishment-liens-bankruptcy/ (accessed April 18, 2023).

[171] Ibid.

[172] Note that the entirety of this exchange is available in an online annex to this report. See Letter from Human Rights Watch to K. Craig Kent and Wendy Horton, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023; Email from Eric Swensen, Public Information Officer, UVA Health, to Matt McConnell, May 19, 2023. See also Stephanie Strickland, “NCHA Statement on North Carolina State Health Plan and National Academy of State Health Policy Report,” North Carolina Healthcare Association, January 26, 2022, https://www.ncha.org/2022/01/ncha-statement-on-north-carolina-state-health-plan-and-national-academy-of-state-health-policy-report/ (accessed May 22, 2023).

[173] Selena Simmons-Duffin, “When Hospitals Sue For Unpaid Bills, It Can Be 'Ruinous' For Patients,” NPR, June 25, 2019, https://www.npr.org/sections/health-shots/2019/06/25/735385283/hospitals-earn-little-from-suing-for-unpaid-bills-for-patients-it-can-be-ruinous (accessed April 18, 2023).

[174] Twitter Post, @MWHCConnection, June 26, 2019, https://twitter.com/MWHCConnection/status/1143923198007943171 (accessed April 18, 2023).

[175] Note that the entirety of this exchange is available in an online annex to this report. See Letter from Human Rights Watch to Mike McDermott and Christopher Newman, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023; Letter from Michael McDermott, President and Chief Executive Officer, Mary Washington Healthcare, to Arvind Ganesan, May 18, 2023.

[176] Jordan Rau, “Patients Eligible For Charity Care Instead Get Big Bills,” Kaiser Family Foundation Health News, October 14, 2019, https://khn.org/news/patients-eligible-for-charity-care-instead-get-big-bills/ (accessed April 18, 2023). “Following AG’s charity care lawsuit, St. Joseph parent company CHI Franciscan will provide up to $25 million in restitution, debt relief and fees,” Washington State Office of the Attorney General, April 29, 2019, https://www.atg.wa.gov/news/news-releases/following-ag-s-charity-care-lawsuit-st-joseph-parent-company-chi-franciscan-will (accessed April 18, 2023).

[177] Jordan Rau, “Patients Eligible For Charity Care Instead Get Big Bills,” Kaiser Family Foundation Health News, October 14, 2019, https://khn.org/news/patients-eligible-for-charity-care-instead-get-big-bills/ (accessed April 18, 2023).

[178] Note that the entirety of this exchange is available in an online annex to this report. See Letter from Human Rights Watch to Ketul J. Patel and Frank Cardinale, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023; Email from Kelly Campbell, Vice President of Marketing & Communications, Virginia Mason Franciscan Health, to Matt McConnell, May 22, 2023.

[179] Zack Cooper, James Han, and Neale Mahoney, “Hospital Lawsuits Over Unpaid Bills Increased By 37 Percent In Wisconsin From 2001 To 2018,” Health Affairs, December 2021, Vol. 40, No. 12, https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.01130 (accessed April 18, 2023).

[180] Farah Hashim, Joseph Paturzo, Cynthia C. Swartzel, et al., “Predatory Medical Billing in Wisconsin,” Johns Hopkins University, 2021, https://www.restoringmedicine.org/_files/ugd/29ca8c_07964dc6479245bc938a9e98c2a45c21.pdf (accessed April 18, 2023).

[181] Note that the entirety of this exchange is available in an online annex to this report. See Letter from Human Rights Watch to Eric Borgerding and Kari Hofer, “Re: Upcoming Human Rights Watch Report on US Nonprofit Hospitals,” May 2, 2023; Email from Rusty Shultz, Wisconsin Hospital Association, to Matt McConnell, May 24, 2023.

[182] Universal Declaration of Human Rights, arts. 25, 22.

[183] UN Committee on Economic, Social and Cultural Rights, “General Comment No. 14, The Right to the Highest Attainable Standard of Health,” UN Doc. E/C.12/2000/4, August 11, 2000, https://www.refworld.org/pdfid/4538838d0.pdf (accessed April 18, 2023), para. 1.

[184] Universal Declaration of Human Rights (UDHR), adopted December 10, 1948, G.A. Res. 217A(III), U.N. Doc. A/810, https://www.un.org/sites/un2.un.org/files/udhr.pdf (accessed April 18, 2023), art. 25(1).

[185] The US signed the covenant in 1977. International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, 993 U.N.T.S. 3, entered into force January 3, 1976, https://www.ohchr.org/en/professionalinterest/pages/cescr.aspx (accessed April 18, 2023), arts. 11(1), 12(c)(d).

[186] The Vienna Convention is widely viewed as being reflective of customary international law. Vienna Convention on the Law of Treaties adopted May 22, 1969, G.A. Res. 2166 (XXI), 2287 (XXII), 1155 U.N.T.S. 331, U.N. Doc, https://legal.un.org/ilc/texts/instruments/english/conventions/1_1_1969.pdf (accessed April 18, 2023), Art. 18.

[187] UN Committee on Economic, Social and Cultural Rights, “General Comment No. 3, The Nature of States Parties Obligations,” UN Doc. E/1991/23, December 14, 1990, https://www.refworld.org/pdfid/4538838e10.pdf (accessed April 18, 2023), para. 10.

[188] UN Committee on Economic, Social and Cultural Rights, “The Maastricht Guidelines on Violations of Economic, Social and Cultural Rights,” U.N. Doc. E/C.12/2000/13, October 2, 2000, para. 18.

[189] UN Committee on Economic, Social and Cultural Rights, “General Comment No. 14, The Right to the Highest Attainable Standard of Health,” UN Doc. E/C.12/2000/4, August 11, 2000, https://www.refworld.org/pdfid/4538838d0.pdf (accessed April 18, 2023), para. 39.

[190] Ibid., para. 17.

[191] Ibid., paras. 12(b)(ii), 12(d).

[192] Universal Declaration of Human Rights (UDHR), adopted December 10, 1948, G.A. Res. 217A(III), U.N. Doc. A/810, https://www.un.org/sites/un2.un.org/files/udhr.pdf (accessed April 18, 2023), art. 22. International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAORR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976, https://www.ohchr.org/en/professionalinterest/pages/cescr.aspx (accessed April 18, 2023), arts. 9, 10.

[193] UN Committee on Economic, Social and Cultural Rights, “General Comment No. 19: The right to social security (Art. 9 of the Covenant),” UN Doc. E/C.12/GC/19, February 4, 2008, https://www.refworld.org/docid/47b17b5b39c.html (accessed April 18, 2023), paras. 12, 13. See also, Ibid., FN. 9.

[194] UN Committee on Economic, Social and Cultural Rights, “General Comment No. 14, The Right to the Highest Attainable Standard of Health,” UN Doc. E/C.12/2000/4, August 11, 2000, https://www.refworld.org/pdfid/4538838d0.pdf (accessed April 18, 2023),

[195] See, for example, Congressional Research Services, “Health Care: Constitutional Rights and Legislative Powers,” July 9, 2012, https://www.everycrsreport.com/files/20120709_R40846_27d29c09b692d83ed3386e207cb0e31b58775fcc.pdf (accessed April 18, 2023) (analyzing the 13 state constitutions that contained provisions that referred to health care).

[196] International Covenant on Civil and Political Rights (ICCPR), adopted December 16, 1966, G.A. Res. 2200A (XXI), entered into force 23 March 1976, ratified by the United States on June 8, 1992, https://www.ohchr.org/en/professionalinterest/pages/ccpr.aspx (accessed April 18, 2023), arts. 2, 26.

[197] International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), adopted December 21, 1965, G.A. Res. 2106 (XX), 20 U.N. GAOR Supp. (No. 14) at 47, U.N. Doc. A/6014 (1966), entered into force January 4, 1969, ratified by the United States on October 21, 1994, https://www.ohchr.org/en/professionalinterest/pages/cerd.aspx (accessed April 18, 2023), art. 1; US Constitution, art. XIV.

[198] See Human Rights Watch, “Targeting Blacks: Drug Law Enforcement and Race in the United States,” May 2008, https://www.hrw.org/sites/default/files/reports/us0508_1.pdf (accessed April 18, 2023), pp. 56-58. See also Jody Feder, “Racial Profiling: Legal and Constitutional Issues,” Congressional Research Service, April 16, 2012, https://fas.org/sgp/crs/misc/RL31130.pdf, pp. 4-9 (summarizing caselaw). In certain other contexts—such as statutory claims of employment or housing discrimination under civil rights laws—practices and procedures that have a disparate impact on a racial group can also trigger liability under United States law. See Lawrence Rosenthal, “Saving Disparate Impact,” Cardozo Law Review, Vol. 34, 2013, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2045688 (accessed April 18, 2023).

[199] Under ICERD, racial discrimination is defined as “any distinction, exclusion, restriction or preference based on race, colour, descent, or national or ethnic origin which has the purpose or effect of nullifying or impairing the recognition, enjoyment or exercise, on an equal footing, of human rights and fundamental freedoms in the political, economic, social, cultural or any other field of public life.” ICERD, Part I, Article 1(1).

[200] UN Committee on the Elimination of Racial Discrimination (CERD), “Consideration of Reports Submitted by State Parties under Article 9 of the Convention: Concluding Observations, United States of America,” CERD/C/USA/CO/6, February 2008, http://www2.ohchr.org/english/bodies/cerd/docs/co/CERD-C-USA-CO-6.pdf (accessed April 18, 2023), para. 10.

[201] ICERD, Part I, Article 2(1)(a).

[202] Ibid. Article 5(e)(iv).

[203] The ICESCR does not exclude non-nationals from its protections, except to note that “[d]eveloping countries, with due regard to human rights and their national economy, may determine to what extent they would guarantee the economic rights recognized in the present Covenant to non-nationals.” ICESCR, Art. 2(3).

[204] Office of the High Commissioner for Human Rights, “UN Guiding Principles on Business and Human Rights, Implementing the United Nations ‘Protect, Respect, and Remedy’ Framework,” 2011, http://www.ohchr.org/Documents/Publications/GuidingPrinciplesBusinessHR_EN.pdf (accessed April 18, 2023).

[205] Special Representative of the Secretary-General on the issue of human rights and transnational corporations and other business enterprises, “Guiding Principles on Business and Human Rights: Implementing the United Nations 'Protect, Respect and Remedy' Framework," UN document A/HRC/17/31, March 21, 2011, https://www.ohchr.org/Documents/Issues/Business/A-HRC-17-31_AEV.pdf (accessed April 18, 2023), principles 17, 18, 21. The UN Guiding Principles also call on businesses to externally communicate how they address their human rights impacts in “a form and frequency that … are accessible to its intended audiences.” Ibid., principle 21, p. 23.

[206] Ibid., principle 17(c).

[207] Ibid., principle 18.

[208] Ibid., principle 19. See also Ibid, p. 21.