Nonprofit Hospital Provision of Charity Care: The Role of Social Workers

Background and Purpose:
Nonprofit hospitals in the United States are required to maintain and publicize their charity care (also called financial assistance) policies. However, who is eligible and how much is spent on charity care remains at each hospital’s discretion. Many Americans experience medical debt, particularly those who are low-income, uninsured, underinsured, or managing chronic conditions and/or disabilities. Charity care has the potential to mitigate this financial burden, yet the policies and processes around accessing it vary widely. Hospital social workers are often responsible for screening patients for social needs, including financial concerns. We therefore posited they would likely have insight into the charity care screening process. Despite charity care’s importance in promoting health equity and reducing debt, little research has explored how it is screened for and provided. This study sought to address that gap by exploring hospital social workers’ experiences and perspectives on charity care screening and provision.

Methods:
We conducted a qualitative study using in-depth, semi-structured interviews with hospital social workers (n=18) across one U.S. state. Participants were recruited through purposive sampling. Interviews were conducted via Zoom, recorded, transcribed verbatim, and uploaded to Dedoose qualitative analysis software. Two researchers conducted inductive coding, writing analytic memos to document emerging insights and discuss discrepancies. Axial coding was then used to identify subcategories and synthesize higher-level themes. A thematic analysis approach guided the interpretation of findings.

Results:
Three major themes emerged through axial coding. First, financial assistance role delineation revealed that charity care responsibilities are typically assigned to financial counselors, while social workers play a limited or peripheral role. Although this division sometimes brought role clarity, it also constrained social workers’ ability to engage in advocacy. Second, participants described multiple barriers to accessing financial assistance, including difficulties in locating and understanding application materials, and the emotional toll placed on patients already navigating illness and crisis. These barriers often discouraged patients from pursuing available support. Third, many social workers expressed a lack of clarity surrounding hospital financial assistance policies, including confusion about eligibility criteria, referral procedures, and documentation requirements. This limited their ability to assist patients or intervene effectively when needs arose.

Conclusions and Implications:
Although hospital social workers are well-positioned to identify patients in need of financial assistance, they are often excluded from charity care screening processes. This exclusion reflects institutional role delineation that conflicts with the social work profession’s core values. Using a human rights framework, we argue that financial assistance should be reframed not as charity but as a right. Social workers’ limited involvement undermines both patient advocacy and systemic equity. Policy and organizational reforms should integrate social workers more meaningfully into charity care systems and clarify internal protocols. Further research should explore the effects of interdisciplinary collaboration on patient access to financial support.