{
  "study": {
    "slug": "hospital-charity-care",
    "title": "Hospital charity care, by the numbers: who actually gives the most free care",
    "standfirst": "Nonprofit hospitals — tax-exempt in exchange for community benefit — deliver charity care worth just 1.53% of their patient revenue, the lowest share of any ownership type, below for-profit hospitals (3.00%) and less than half the government rate (3.76%), across $27.68 billion in free care in the federal HCRIS cost reports.",
    "desk": "financial-distress",
    "article_type": "Original Research",
    "published": "2026-06-11",
    "issue": 55,
    "doi": "10.5072/fonteum/hospital-charity-care-2026",
    "url": "https://fonteum.com/research/hospital-charity-care",
    "methodology_version": "hospital-charity-care/v1"
  },
  "data_as_of": "2026-05-24",
  "datasets": [
    {
      "slug": "cms-hospital-compare",
      "name": "CMS Hospital Compare",
      "publisher": "CMS — Hospital quality (Care Compare)",
      "upstream_url": null
    }
  ],
  "key_findings": [
    {
      "number": "1.53%",
      "finding": "of patient revenue is delivered as charity care by tax-exempt nonprofit hospitals — the lowest share of any ownership type, below for-profit (3.00%) and government (3.76%)",
      "dataset": "cms-hospital-compare"
    },
    {
      "number": "$27.68B",
      "finding": "in charity care reported by 4,135 hospitals, alongside $12.38 billion in bad debt, in the 2026 HCRIS cost-report snapshot",
      "dataset": "cms-hospital-compare"
    },
    {
      "number": "65.4%",
      "finding": "of all charity care comes from just the top 10% of reporting hospitals; the entire bottom half together accounts for 3.1%",
      "dataset": "cms-hospital-compare"
    },
    {
      "number": "500",
      "finding": "of 1,064 large nonprofit hospitals (over $250M in patient revenue) deliver charity care worth under 1% of their own revenue",
      "dataset": "cms-hospital-compare"
    }
  ],
  "faqs": [
    {
      "q": "What is hospital charity care?",
      "a": "Charity care is medical care a hospital provides free or at a discount to patients who cannot afford to pay, under the hospital's written financial assistance policy, with no expectation of payment. On the federal cost report it is recorded at cost — what the care cost the hospital, not what it would have been billed."
    },
    {
      "q": "How much charity care do US hospitals provide?",
      "a": "Across the 6,019 Medicare hospitals in the 2026 HCRIS cost-report snapshot, 4,135 reported positive charity care totaling $27.68 billion, plus $12.38 billion in bad debt. The average reporting hospital provided $6.7 million, but the median was $1.5 million — most of the dollars come from a small number of very large hospitals."
    },
    {
      "q": "Do nonprofit hospitals provide more charity care than for-profit hospitals?",
      "a": "Not as a share of revenue. Tax-exempt nonprofit hospitals delivered charity care worth 1.53% of their patient revenue — below for-profit hospitals at 3.00% and government hospitals at 3.76%. Nonprofits report charity care far more consistently (87.9% of them do), but the share of revenue they devote to it is the smallest of the three ownership types."
    },
    {
      "q": "What is the difference between charity care and bad debt?",
      "a": "Charity care is care given free or discounted to patients the hospital has determined cannot pay, under its financial assistance policy. Bad debt is billed care the hospital expected to collect but never did — the patient neither paid nor qualified for assistance. The two are separate lines on the cost report; together they make up uncompensated care."
    },
    {
      "q": "Are nonprofit hospitals required to provide a minimum amount of charity care?",
      "a": "No. Section 501(r) of the tax code, added by the Affordable Care Act, requires tax-exempt hospitals to run a financial assistance policy, limit charges, and curb aggressive collections — but it sets no minimum dollar amount or percentage of charity care a hospital must provide. The community-benefit standard is judged on facts and circumstances, not a floor."
    },
    {
      "q": "Can I reproduce these numbers?",
      "a": "Yes. Every figure aggregates the 6,019-row hcris_facility_summary table from the frozen 2026-05-24 HCRIS snapshot, joined to hospital_directory for ownership type on the CCN key. Charity care and bad debt come from Worksheet S-10 of the cost report. The exact SQL is published in the reproducibility block below, and the dataset is downloadable."
    }
  ],
  "citation": {
    "apa": "Fonteum Research. (2026, June 11). Hospital charity care, by the numbers: who actually gives the most free care. Fonteum Research, Issue 55. https://doi.org/10.5072/fonteum/hospital-charity-care-2026",
    "url": "https://fonteum.com/research/hospital-charity-care"
  },
  "reproducible_sql": "-- Hospital Charity Care × Community Benefit — fully reproducible query.\n--\n-- Source:   CMS HCRIS Hospital Cost Reports (form CMS-2552-10), Worksheet S-10\n--           uncompensated-care lines (charity care cost, bad debt expense),\n--           FY2024 vintage.\n-- Snapshot: cms-hcris-hospital-2552-10 / 2026-05-24\n-- Archive:  https://downloads.cms.gov/FILES/HCRIS/HOSP10FY2024.ZIP\n-- SHA-256:  e9552da36dcdcf904c5c4d35ffffe843af5b38afac196ac9db7db101bc8a96a0\n-- Tables:   public.hcris_facility_summary  (public, read-only)\n--           public.hospital_directory      (CCN-keyed ownership_type, public, read-only)\n--\n-- Charity care = care provided free or discounted under a hospital's financial\n-- assistance policy (distinct from bad debt = billed care that went uncollected).\n-- \"Reporting\" = charity_care_cost > 0. Ownership-type ratios are revenue-weighted\n-- (sum of charity / sum of net patient revenue) over reporting hospitals.\n\n-- 1. National headline aggregates.\nSELECT\n  count(*)                                                         AS hospitals_total,        -- 6,019\n  count(*) FILTER (WHERE charity_care_cost > 0)                    AS reporting_charity,       -- 4,135\n  count(*) FILTER (WHERE bad_debt_expense  > 0)                    AS reporting_bad_debt,      -- 4,393\n  round(sum(charity_care_cost) FILTER (WHERE charity_care_cost > 0)/1e9, 2) AS charity_billion,-- 27.68\n  round(sum(bad_debt_expense)  FILTER (WHERE bad_debt_expense  > 0)/1e9, 2) AS bad_debt_billion,-- 12.38\n  round(avg(charity_care_cost) FILTER (WHERE charity_care_cost > 0)/1e6, 2) AS avg_charity_mn, -- 6.70\n  round((percentile_cont(0.5) WITHIN GROUP (ORDER BY charity_care_cost)\n         FILTER (WHERE charity_care_cost > 0)/1e6)::numeric, 2)    AS median_charity_mn        -- 1.47\nFROM public.hcris_facility_summary;\n\n-- 2. The central finding: charity care as a share of patient revenue, by\n--    ownership type. The tax-exempt nonprofit class gives the smallest share.\nWITH j AS (\n  SELECT d.ownership_type AS ot,\n         h.charity_care_cost AS cc,\n         h.net_patient_revenue AS npr\n  FROM public.hcris_facility_summary h\n  JOIN public.hospital_directory d ON d.ccn = h.ccn\n)\nSELECT\n  ot,\n  count(*)                                          AS facilities,            -- nonprofit 3,034 · proprietary 1,785 · government 1,200\n  count(*) FILTER (WHERE cc > 0)                    AS reporting_charity,     -- 2,667 · 610 · 858\n  round(100.0 * count(*) FILTER (WHERE cc > 0)\n        / count(*), 1)                              AS report_rate_pct,      -- 87.9 · 34.2 · 71.5\n  round(sum(cc) FILTER (WHERE cc > 0)/1e9, 2)       AS charity_billion,      -- 15.36 · 3.99 · 8.34\n  round(100.0 * sum(cc) FILTER (WHERE cc > 0 AND npr > 0)\n        / NULLIF(sum(npr) FILTER (WHERE cc > 0 AND npr > 0), 0), 2)\n                                                    AS charity_pct_of_npr    -- 1.53 · 3.00 · 3.76\nFROM j\nGROUP BY ot\nORDER BY charity_pct_of_npr;\n\n-- 3. Concentration: a small minority of hospitals carry most of the charity load.\nWITH r AS (\n  SELECT charity_care_cost AS cc,\n         row_number() OVER (ORDER BY charity_care_cost DESC) AS rn,\n         count(*)        OVER ()                              AS n,\n         sum(charity_care_cost) OVER ()                       AS tot\n  FROM public.hcris_facility_summary WHERE charity_care_cost > 0\n)\nSELECT\n  round(100.0 * sum(cc) FILTER (WHERE rn <= 0.10 * n)/max(tot), 1) AS top_decile_share,   -- 65.4\n  round(100.0 * sum(cc) FILTER (WHERE rn <= 50)/max(tot), 1)       AS top_50_share,       -- 26.5\n  round(100.0 * sum(cc) FILTER (WHERE rn >  0.50 * n)/max(tot), 1) AS bottom_half_share   -- 3.1\nFROM r;\n\n-- 4. Large nonprofits (net patient revenue > $250M) reporting charity care\n--    below 1% of revenue — the cohort the community-benefit debate centers on.\nSELECT\n  count(*) FILTER (WHERE cc > 0)                                   AS big_nonprofit_reporting,   -- 1,064\n  count(*) FILTER (WHERE cc > 0 AND cc/npr < 0.01)                 AS big_nonprofit_under_1pct   -- 500\nFROM public.hcris_facility_summary h\nJOIN public.hospital_directory d ON d.ccn = h.ccn\nWHERE d.ownership_type = 'nonprofit' AND h.net_patient_revenue > 250e6;",
  "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)",
  "generated_by": "Fonteum — https://fonteum.com",
  "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included."
}