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‘An Arm and a Leg’: How Charity Care Made It Into the ACA


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Charity care is one tiny provision in the giant Affordable Care Act, and it can make a big difference for patients who face huge bills. How did it get into the law? One Republican senator made sure the ACA required nonprofit hospitals to act more like charities — and less like loan sharks — but he still voted against the whole bill.

The national requirement to offer charity care emerged from the Obama White House’s failed courtship of GOP Sen. Chuck Grassley of Iowa. In this episode, we hear how that political tango almost tanked the ACA — and how the battle over the ACA “broke America.” Featured are David Axelrod, a former adviser to President Barack Obama; longtime health policy reporter and KHN chief Washington corrspondent Julie Rovner; and a top Grassley aide.

This is the second in a four-part series that looks at the (slow, uneven) development of legal protections for consumers (aka patients, aka people who just don’t want to die and aren’t Bill Gates) against outrageous medical bills and draconian collection practices.

Catch up on the first episode, before or after listening to this one. It’s about how a legendary lawyer — the guy who beat Big Tobacco in the 1990s — tried to sue nonprofit hospitals into acting more like charities and less like loan sharks. (He lost, but it wasn’t a total dead end; that’s where this episode picks up.) 

Here’s a transcript for this episode.


“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

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