Access to Medical Financial Assistance Programs Among Low-Wage Workers: Implications for the Affordable Care Act

Background and Purpose: The estimated loss of health coverage among over 11 million people due to the One Big Beautiful Bill Act will fall hardest on low-wage workers who will need access to financial assistance programs (FAPs), which nonprofit hospitals are legally required to offer per Section 501r4 of the Internal Revenue Code (as amended by the Affordable Care Act). Yet FAP eligibility requirements, application processes, and expenditures vary widely across hospitals (Bai et al, 2020; Messac et al., 2024). Nearly half of patients are unaware of FAPs and about a quarter of patients receive assistance (Goldstein et al., 2024; Perry Undem, 2023) suggesting considerable patient administrative burden (Herd & Moniyhan, 2019). Losing health coverage and encountering administrative burden in accessing FAPs will likely worsen other health challenges low wage workers face (Sherman, 2025). In this study, we assess the degree to which low-wage workers in the U.S. have access to FAPs, factors that explain variation in access, and how FAP access relates to health care access.

Methods: Data for this study are from wave one of a survey administered in November 2023 with a nationally representative sample (N=2,426) from the AmeriSpeak panel of workers in U.S. households that had income of 250% or less of the federal poverty level, which is just above the national average for FAP eligibility (Messac et al., 2024). Workers with outstanding medical and/or dental bills were asked whether they had applied for financial assistance and what the outcome was. Probit regression models were run to predict the receipt of financial assistance and probability of seven types of health care hardship based on assistance status, controlling for demographic, financial, and health factors.

Results: Among workers with outstanding medical and/or dental bills, 43% were unaware of FAPs, 20% said their provider did not offer a FAP, 19% applied and received assistance, 15% applied and were denied assistance, and 4% reported other outcomes. However, there were no differences in FAP outcomes based on demographic factors, income, employment, health insurance status, or health status. Receiving assistance reduced the probability that workers put off subsequent care they needed, including primary medical care, filling prescription medications, and getting eyeglasses (p < .01), and specialty medical care and dental care (p < .05), but not emergency care or mental health care.

Conclusions and Implications: Federal regulations fail to ensure that eligible patients are aware of and receive financial assistance from nonprofit hospitals. Policy makers should require that these hospitals proactively screen all patients for financial assistance – especially before referring unpaid balances to collections, simplify application forms, provide help in completing applications, and use presumptive eligibility, such as for patients who receive public benefits. Policy makers should also broaden the scope of FAPs by requiring all providers to offer assistance.