Most hospital financial assistance documents require a 10th-grade reading level, exceeding the skills of more than half of American adults.
Hospitals post policies few can read
A study of 336 U.S. hospitals revealed that financial assistance and billing policies demand a high-school reading level on average. Over half of Americans read at or below a sixth-grade level, leaving these documents out of reach for those who need them most.
The analysis, published in The American Journal of Managed Care, examined three document types: full financial assistance policies, simplified versions, and billing and collections policies. All categories averaged at least a 10th-grade reading level. Simplified policies were marginally easier but still required the same reading ability.
A 10th-grade level does not meet plain-language standards for most adults.
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Posting patterns vary by hospital type
Nonprofit hospitals posted financial documents far more often than for-profit ones. Nearly 94% of nonprofits had at least one document online, compared to 46% of for-profits. Hospitals in larger systems also shared more documents, likely due to shared resources across locations.
State requirements influenced readability. Hospitals in states with expanded financial assistance rules had documents about half a grade level easier. Teaching hospitals and those receiving Disproportionate Share Hospital payments, which serve more low-income patients, had billing policies roughly one grade level simpler than others.
The improvements remained small. Even the easiest documents still required a ninth-grade reading level, exceeding what most adults can read comfortably.
The gap creates real consequences. Medical debt is rising, and most of it comes from hospitals. Patients with low literacy are more likely to skip preventive care, face worse health outcomes, and endure financial strain.
To reach those who need help, hospitals may need to use simpler language or offer more in-person or phone support. The study indicates that without clearer documents, many will continue struggling.
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Study methods and scope
Researchers randomly selected 10% of general, non-governmental U.S. hospitals and searched their websites for financial assistance and billing policies. They used the Flesch-Kincaid Grade Level score, a standard readability measure based on sentence length and word complexity, to evaluate each document.
The sample included 286 nonprofit hospitals and 50 for-profit ones. About 77% belonged to larger systems, and 60% received Disproportionate Share Hospital payments. Nearly three-quarters operated in states with expanded financial assistance rules.
The study has limitations. It only reviewed documents posted online, not those available in person or by phone. It also did not test whether patients could actually understand the policies—only how difficult they were to read.
The results highlight a persistent issue: hospitals publish financial policies most Americans cannot easily read. For patients already burdened by medical debt, this adds another obstacle to accessing help.
