By Megan Garnai, Brookelyn Lambright, Avery Lowry, Edie Schwarb, Lauren Stickelmaier and Alayna Wilkening
Emily Meyer tries to hide medical bills from her children, stuffing them in her purse or a box under her desk at work.
A single mom of three who cares for another young adult, Meyer requires treatments for diabetes and an autoimmune disorder that is developing cancer cells. She’s only able to regulate her condition with constant medication and monthly blood tests. Her children also require medical care and see specialists often.
Opening one of her bills — $822.86 for an emergency room visit with her daughter — she sighs and throws it back in the pile. Even though Meyer works three jobs, she still doesn’t earn enough to keep up with the constant influx of medical bills.
“I cringe every time I have to open one up. I literally just hold my breath and almost cry because I don’t know what the amount is,” Meyer said. “And then when I open it, I’m like, ‘Well, now what do I do?”
Federal law provides an avenue for helping Hoosiers like Meyer. To maintain their tax-exempt status, nonprofit hospitals must direct some of their spending to fulfill a vague “community benefit” requirement that covers expenditures ranging from helping patients like Meyer struggling with bills to buying the naming rights for a sports stadium.
But an investigation by the Arnolt Center for Investigative Journalism, in partnership with IndyStar, found Indiana’s 64 nonprofit hospitals with emergency rooms spent $24.5 billion in 2022, yet only 1% went to directly help patients cover medical expenses. While that’s not an insignificant total — more than $220 million — it accounts for just 7% of what the hospitals designated as community benefit spending.
Meanwhile, according to an analysis of federal tax documents, those nonprofit hospitals spent another $3.6 billion on other community benefit projects — and still banked more than $1.8 billion in profits.
Emily Meyer flips through medical and utility bills March 27, 2025, in her office at the Dubois County Community Corrections Center in Jasper, Indiana. Meyer kept some bills in her home and stored some in a box under her desk at work. (Photo by Alayna Wilkening)
“Nonprofit hospitals’ tax benefits are intended to enable them to provide support to people,” said Erin Macey, director of the Indiana Community Poverty Institute. “The fact that they’re spending less than 2% on charity care is just wild.”
The schism between the amount of financial assistance hospitals provide and the profits they bank comes as Hoosiers face some of the highest health care costs in the U.S. Indiana residents experienced the 8th highest health care costs in the nation in 2022, the most recent year for which data is available.
Indiana Gov. Mike Braun signed an executive order in January calling on Indiana’s Health and Human Services to investigate nonprofit hospitals’ spending on community benefits.
During the 2025 legislative session, the Indiana House of Representatives also introduced a bill that would limit what counts as a community benefit and require larger nonprofit systems to cap health care prices.
“We have an opaque, dysfunctional health care system,” said Marni Jameson Carey, president of Power to the Patients, an organization that advocates for transparency in the health care system. “Hospitals have gotten away with this for too long.”
The Indiana Hospital Association doesn’t see it that way. A written statement said the state’s nonprofit hospitals provide above-adequate community benefits.
“In 2022, Indiana’s nonprofit hospitals provided $3.9 billion in total benefit to their local communities — that’s nearly two and a half times, or $2.3 billion more than the value of their tax exemptions,” IHA President Scott B. Tittle said in the statement.
At the crux of the dispute over charity care spending is the vague language defining what falls under the umbrella of community benefit. Illinois and many other states have tackled rising health care costs by establishing a community benefit threshold that nonprofit hospitals must meet, but Indiana has yet to set such standards.
Nonprofit hospitals define ‘community benefit’ on own terms
Nonprofit hospitals are tax-exempt nationally and in the state of Indiana under the assumption that they provide a benefit to the community. For more than 50 years, they have abided by vague regulations for remaining tax-exempt by contributing funding toward community benefits. But there are no strict requirements for how much a hospital should spend on financial aid.
Charitable care systems began when hospitals were led by nuns who predominantly cared for the sick and poor. The 1960s marked the beginning of hospitals being tax-exempt.
In 1965, when the U.S. federal government introduced the idea of Medicare and Medicaid, hospitals could no longer claim their community benefit as solely providing financial assistance, so they devised a new way to keep their tax-exempt status. Presently, hospitals call care that meets their community benefit standard “charitable care.”
Charitable care can be anything from providing health screenings and health professional education to sponsoring community events.
Matt Bell, chief advocacy officer for Hoosiers for Affordable Healthcare, said defining what counts toward a hospital’s community benefit is vague.
“A hospital can claim that anything from putting naming rights on a baseball stadium to building a community ice rink is a community benefit,” Bell said.
The Arnolt Center contacted 24 health systems, which manage multiple nonprofit hospitals, and individual hospitals for comment. Only two provided written statements, one declined to comment. The others never responded.
“We are committed to ensuring that financial barriers do not prevent access to necessary medical care,” Deaconess Health System said in a written statement. “Through our charity care and financial assistance programs, we provide free or discounted care to patients who qualify based on financial need.”
Ascension St. Vincent said it prioritizes assisting poor and vulnerable patients, writing that in the past three years, they have donated 3.4% of their total expenses to charity care deductions.
Throughout the state, nonprofit hospitals vary in how much they spend on community benefit, according to federal tax filings.
Cameron Memorial Community Hospital, a small facility with 25 staffed inpatient beds in Steuben County, spent the least amount of money on community care, with $13 million on community benefit or 0.07% of its total expenses to charity.
Memorial Hospital and Health Care Center in DuBois County, a facility with 114 inpatient beds, reported $30.6 million to community benefit in 2022 or 0.17% of its total expenses to charity.
Gibson General Hospital directed the largest portion of its spending on community benefit last year, with about 10% of its total expenses going toward charity in 2022.
IU Health in Lawrence County reported spending $19.2 million in 2022, with 7.13% of its total expenses going toward charity.
Lloyd Meyer, a Notre Dame University professor of law who studies nonprofit organizations, said hospitals’ community benefit vary. Some provide a lot of charity care, some focus more on education and others offer little financial assistance or do any medical research.
“And this is a normal, enormous variation across hospitals,” he said.
Finding, qualifying for assistance can be difficult for patients
Two years after her son’s birth, Ashlee Kennedy, 30, of Fort Wayne is still paying off medical bills. Kennedy’s son didn’t need special treatment, so she was shocked when a bill for over $7,000 came in the mail.
“I knew it was going to be expensive, but I was thinking, at most, maybe $3,000,” Kennedy said. “I really wasn’t prepared for how expensive it was going to be to have another child.”
Ashlee Kennedy poses with her 2-year-old son. Kennedy is still working to pay off her son’s $7,000 hospital bill. (Photo courtesy of Ashlee Kennedy)
When Kennedy went through an itemized list of what Parkview Hospital billed her, she claims some fees were not explained to her.
“It kind of, just like, it made me sad, because it really felt like I was being taken advantage of, and there’s seemingly nothing I could do about it,” Kennedy said.
The Internal Revenue Service (IRS) requires hospitals to show that they provide a benefit to the community, and that they serve a public rather than a private interest to qualify as a nonprofit. But the IRS does not set a specific monetary value that nonprofit hospitals must donate to charity care to maintain their tax-exempt status.
But part of a nonprofit hospital’s community benefit is providing financial assistance to patients in need. Financial assistance policies vary between each hospital system; however, most establish assistance guidelines according to a patient’s federal poverty level and type of care received.
The Ascension system’s policies state that patients at or below 250% of the Federal Poverty Level (FPL) receive a 100% charitable discount if their care is an emergency or deemed “medically necessary.”
A family of four can earn up to $78,000 and still qualify for care at or below 250% of the poverty level.
Factors like insurance status, a patient’s residency, retirement income, investment income, social security and number of dependents also can impact financial assistance even if patients are within the qualifying FPL.
Ultimately, the health care systems and hospitals determine who is eligible for charitable care — and how much, if any, they may receive.
Emily Meyer flips through old bills March 27, 2025, in her office at the Dubois County Community Corrections Center in Jasper, Indiana. She picked up two part-time jobs and often works double shifts on the weekends to afford her daily expenses. (Photo by Alayna Wilkening)
Financial information, help not always easy to find
Meyer, the southern Indiana mother with diabetes and autoimmune disorder, estimates her net annual income is around $30,000, but according to her, she was still unable to receive financial assistance.
Meyer sent a copy of her financial and employment records and a list of her medical bills to the hospital system where she received treatment. The incomes of her two adult children, ages 19 and 21, were also taken into consideration despite Meyer being solely responsible for paying their medical expenses.
Patients have also struggled to navigate unstandardized financial assistance policies, often experience difficulty accessing them entirely. Kennedy, the new mother, says she was never notified about her hospital’s financial assistance policies.
“I just had a little baby. I had my daughter. I was freaking out because I was going to lose my insurance, and so I had all these things on my mind,” Kennedy said. “I wasn’t really thinking about how I was going to essentially hack my health care costs. I shouldn’t have to do that.”
While nonprofit hospitals say they provide patients with a copy of their financial assistance policies, it’s unclear where each hospital’s policies are located. Some post their policies exclusively online, others send information with the patient’s bills, and others inform patients while they are receiving care, according to federal tax filings.
Lauren Murfree, a policy analyst at Indiana Community Action Poverty Institute, said patients often have issues applying for financial assistance because of its complexity.
“A chunk of [patients] are already negotiating. A chunk of them are trying to receive charity care and spending the time on it, but it is overly complex,” Murfree said. “Charity care paperwork is not really standardized, so every hospital is different.”
Patient advocacy groups say patients living in Indiana deserve transparent and affordable health care.
“This has happened for so long that Hoosiers have just shrugged their shoulders and said, ‘Well, you know, it’s inevitable. Hospital prices are just high,’” said Bell, of Hoosiers for Affordable Healthcare. “We don’t believe that we have to be content to pay some of the highest prices in the country. We think Indiana’s not-for-profit hospitals can and have to do better.”
Lawmakers, advocacy organizations, patients seek accountability
In February, Meyer took time off work and traveled to the Indiana statehouse to testify in favor of Senate Bill 317, which called for limitations on hospital payment plans. Under this proposed bill, the amount of any monthly payment could not exceed 10% of the patient’s gross monthly household income, and patients must be allowed to make payments over 24 months.
After its third reading, the bill was defeated in the Senate by a 26-23 vote.
State Sen. Travis Holdman, R-Markle, has been calling attention to nonprofit hospitals and charitable care at the state level. He said nonprofit hospitals in Indiana need to be held accountable for the large amounts of money they have in unrestricted assets.
“They pay no corporate tax, and that seems somewhat disparate, that they have billions of dollars invested on Wall Street, and we have some of the highest hospital costs in the country, in Indiana,” Holdman said. “Something doesn’t jive there.”
Holdman says that to fix the issue, nonprofit hospitals in the state need to be assessed for tax.
“We have researched the subject to find that we could, in fact, tax a not-for-profit in the state of Indiana. That’s a federal rule with the IRS,” Holdman said. “Just because you are a not-for-profit corporation domiciled in the state of Indiana doesn’t mean that you can’t be assessed to tax.”
Lawmakers and the governor did enact House Enrolled Act 1004, which calls for stronger regulations for nonprofit hospitals and containing costs levied on patients. The state will conduct a study to set average prices for procedures and if nonprofit hospitals exceed those figures, they could face fines or a loss of nonprofit status.
At the national level, senators Chuck Grassley, R-Iowa, and Elizabeth Warren, D-Mass, have called for the IRS to hold tax-exempt hospitals accountable.
Proposed actions in a Nov. 19, 2024, letter include additional oversight of nonprofit hospitals, clarified financial assistance policies, prohibition of aggressive collection practices and reinstating the 1969 requirement for nonprofits to uphold “community benefit standard.”
In February, President Donald Trump signed an executive order that aims to provide patients with “clear, accurate, and actionable health care pricing information.”
Hoosiers for Affordable Healthcare is advocating for state legislation that would incentivize nonprofit hospitals to either lower their prices or forfeit their nonprofit status and, therefore, pay property taxes.
“Property taxes alone would infuse local communities with tremendous amounts of cash if our not-for-profit hospitals chose to maintain their high prices and surrender that state privilege of not paying property taxes,” Bell said. “We expect more from our not-for-profit hospitals. We expect them to truly be about community benefit, not about their bottom line.”
National patient advocacy groups, like Power to the Patients, are calling for greater price transparency so independent practices and hospital associations can start competing in a fair marketplace.
“The market is going to start shifting patient behavior to the lower-cost, higher-value provider and that is going to cause the hospitals to do one of two things, divest themselves of the independent doctors that they’ve acquired or start dropping their prices, and maybe both,” said Carey of Power to the Patients.
Carey said price transparency gives patients the option to visit private, less expensive and more qualified doctors, potentially saving thousands of dollars.
“We can pull the curtains back, see what the prices really are, and create a competitive marketplace, but it’s going to be a painful correction,” Carey said.
High health costs leave Hoosiers balancing care, basic necessities
Meyer does most of her work on the weekends, working double shifts of 10 to 12 hours a day. On weeknights, after her shift as a case manager supervisor, she comes home to help her kids with their homework or make food for her family.
Every week, Meyer finds herself juggling between making her medical payments on time and meeting her family’s basic necessities.
“By the time I can unwind, it’s 12:30 a.m., 1 a.m.,” Meyer said. “So then I’m going to bed and getting up and doing it all over again, which isn’t helping when you’re absolutely exhausted and your body’s not functioning properly.”
High health care costs lead patients like Meyer to make tough choices about their medical care. Often, it leads them to forgo medical care completely. The Kaiser Family Foundation estimates that in 2024, nearly one in four adults postponed receiving health care because of the cost.
A canvas photo from a family vacation is seen on Emily Meyer’s desk March 27, 2025, in her office at the Dubois County Community Corrections Center in Jasper, Indiana. This was the only vacation Meyer had taken with her children. (Photo by Alayna Wilkening)
Helen Colby, assistant professor of marketing at IU Indianapolis, said that oftentimes, patients delay care when they hear that expenses are high at certain health care systems.
“The longer you delay care, the more likely people are to seriously have issues that would have been preventable,” Colby said. “In the long run, it’s actually more expensive for society in general to have people who are delaying care.”
High health care costs and medical debt also can take a toll on patients’ overall wellness, affecting their emotional and mental state.
“You sometimes forget that just by billing somebody something that they can’t afford, what a psychological burden they take on, right? And not only a burden, but it really affects their choice of getting any more care,” said Ruth Landé, vice president of the debt operations department for Undue Medical Debt.
Last year, Meyer took her first-ever vacation with her family to Destin, Florida. She put aside between $5 and $10 from each paycheck to help fund the vacation. For Meyer and her family, traveling is a rare luxury.
The rest of the time, Meyer is scraping by to provide necessities for her children.
“My job is to make sure they have clothes on their back, a roof over their head and food in their stomachs,” she said. “That’s priority, and that’s what I do.”
Brenna Polovina of the Arnolt Center contributed research. Megan Garnai, Brookelyn Lambright, Avery Lowry, Brenna Polovina, Edie Schwarb, Lauren Stickelmaier and Alayna Wilkening are students with the Arnolt Center.
