This paper examines the growing burden of medical debt in the Mountain State and asks a simple question: Are non-profit hospitals holding up their end of the bargain? Despite receiving millions in tax exemptions and public subsidies, many West Virginia hospitals provide little direct charity care to patients who cannot afford treatment. Using federal and state data, the report shows that more than one in eight West Virginians carries medical debt, with rural Appalachia facing even higher rates. At the same time, hospitals devote less than 1% of their operating expenses to charity care.
The paper argues that this gap reflects a broken social contract. Weak transparency rules, lack of enforcement, and protection from competition allow hospital systems to prioritize expansion and collections over patient relief. Drawing on policy models from states like Texas, Illinois, and Oregon, the report outlines reforms to restore accountability, including enforceable charity care standards, clearer reporting requirements, protections against aggressive debt collection, and increased competition in healthcare markets. The goal is straightforward: if hospitals are treated as charities, they should act like charities, and West Virginia families deserve nothing less.