Missouri hospitals are providing less charity care than they did before the Affordable Care Act, according to a report by the Missouri Hospital Association.

But that's not necessarily a sign that hospitals are being stingy. According to the report's authors, that means more people can pay their medical bills.

“It’s indicative of more people having insurance,” said Dave Dillon, spokesperson for the MHA. “The numbers for 2015 show very good progress.”

Hospitals have long set aside money for "uncompensated care" each year. When a patient is treated but can’t pay their medical bills, a hospital has in its budget for charity care to forgive some bills for low-income patients. Uncompensated care also includes "bad debt" — bills that patients were unable to pay. Between 2004 and 2014, the amount of charity care provided by Missouri's hospitals more than quadrupled. In 2015, after health insurance marketplaces opened on Healthcare.gov, the total went down for the first time in at least a decade.

In 2015, Missouri hospitals saw a $98 million dip in the amount of uncompensated care — a 7.4 percent decline compared to 2014. That same year, Missouri’s uninsured rate dropped to about 9 percent under the Affordable Care Act, down from 13 percent in 2013.

Saint Louis University health management professor Kimberly Enard also pointed to a lesser-known part of the law that tightened rules for uncompensated care programs.

“[That] put in place policies and procedures to help people understand that there was financial assistance available, and to not have such excessive charges for their hospital bills, and to not have unreasonable debt collection practices,” Enard said.

Some of the decline is also due to hospitals revising the income thresholds for patients to qualify for charity care programs. In 2014, St. Louis-based BJC HealthCare cut its financial assistance to include only those earning up to 300 percent of the federal poverty level, down from 400 percent the year before. The 300 percent level is about $73,000 a year for a family of four.

Overall in Missouri, the gains were limited by the state’s decision not to expand Medicaid coverage to people with incomes below 138 percent of the federal poverty level.

“The projection for that would have been about $200 million,” said Enard, citing a report from the U.S. Department of Health and Human Services. “The states that did expand their Medicaid program experienced greater reductions in uncompensated care costs.”

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