A growing number of Coloradans without health insurance are unable to pay their medical bills, according to a new analysis from the Center for Improving Value in Health Care, the nonprofit that administers the state's all-payer claims database. The finding lands as coverage losses accelerate and as hospitals in the state's rural regions absorb an increasing share of the cost.
Kristin Paulson, the center's president and chief executive, said the pattern follows a predictable sequence. People without coverage delay care, then arrive in emergency departments when a manageable problem has become an expensive one. "Especially in our rural areas, this can have a devastating effect on hospitals," Paulson told Public News Service. "And in fact, we've seen a number of hospital closures over the past several years because they just aren't able to make ends meet."
For Colorado households, the immediate question is not abstract. Uncompensated care costs do not disappear when a patient cannot pay. They shift onto hospital balance sheets, and hospitals respond by narrowing services, tightening which insurance they accept, or in the most strained cases closing entirely. Each of those responses changes what care is available to insured and uninsured residents alike, a pattern MedicalDaily has documented in rural hospital closures elsewhere.
The Difference Between Charity Care and Bad Debt
Uncompensated care is an umbrella term covering two very different things, and the distinction determines what actually happens to a patient's account.
Charity care is written off by the hospital under a financial assistance policy. A patient who qualifies, generally based on income relative to the federal poverty level, has some or all of the bill forgiven. The account does not go to collections and typically does not damage credit.
Bad debt is a bill the hospital expected to collect and did not. That account may be referred to a collection agency. The clinical care delivered is identical in both cases. What differs is whether the patient applied for and received financial assistance before the bill aged.
That difference is not automatic. Patients must generally apply, and many do not know the policy exists. Colorado law requires health care facilities to screen uninsured patients for eligibility for public insurance programs and discounted care, and patients who receive a bill they cannot pay can request a financial assistance application at any point, including after the bill has been issued.
The State Data Behind the Trend
Colorado's Department of Health Care Policy and Financing tracks these figures separately in its annual hospital financial transparency report, required under a 2019 transparency law and expanded by legislation in 2023. Its most recent report shows uncompensated care costs rising 31.0% between 2023 and 2024, or 27.3% after adjusting for inflation.
That inflation adjustment is the informative part. In earlier years, from 2019 through 2023, inflation was the driving factor behind rising uncompensated care. The 2024 increase held up after adjustment, which the department interpreted as evidence that the driver had shifted toward increasing demand for services from under- and uninsured individuals.
The composition also changed. Between 2019 and 2024, inflation-adjusted total uncompensated care costs rose $167.0 million, or 30.0%. Charity care costs rose $173.6 million, or 57.6%, while bad debt fell $6.5 million, or 2.6%. More patients are qualifying for and receiving assistance, which is the system working as designed, but the underlying volume of people who cannot pay has grown.
The new analysis draws on the Colorado All Payer Claims Database, which contains claims from commercial insurers, Medicaid, and Medicare. Readers should note a structural limitation common to claims databases: people without insurance generate no claims, so patterns involving uninsured patients are inferred from coverage transitions rather than observed directly.
Where Coverage Losses Are Concentrated
The analysis found that Colorado's rural Southeast, Northeast, and San Luis Valley regions saw the largest losses in Medicaid coverage between 2024 and 2025. Those are also the areas with the thinnest hospital margins and the fewest alternative sources of care.
Nationally, an additional 3 million people have lost coverage since January, after Congress declined to extend the enhanced marketplace subsidies that had reduced premium costs. Larger Medicaid reductions under the federal budget law enacted in 2025 are scheduled to take effect in 2027.
Paulson said the state's budget and revenue restrictions make it difficult to backfill lost federal Medicaid funding, and raised a specific access concern about what comes next. "As Medicaid rates go down, we're concerned that there may be hospitals or facilities across the state that are being forced to, or choosing to, accept fewer Medicaid patients," Paulson said. "This could prove to be a huge access issue if Medicaid patients aren't able to find a source of care."
She also described the center's role as descriptive rather than prescriptive, saying it is not the organization's job to comment on how policy should be crafted, but to highlight how policies are affecting Coloradans.
Practical Options for Patients Facing a Hospital Bill
Colorado residents who have lost coverage should first check eligibility through the state Medicaid program and through Connect for Health Colorado, since qualifying life events including loss of coverage open a special enrollment period outside the annual window.
Anyone holding a hospital bill they cannot pay should request the hospital's financial assistance policy and application in writing before the account ages toward collections. Federally qualified health centers offer primary care on a sliding fee scale regardless of insurance status and are generally a far less expensive entry point than an emergency department for non-urgent problems.
Patients should not delay emergency care over cost. Federal law requires hospitals to screen and stabilize anyone with an emergency medical condition regardless of ability to pay, and the health consequences of a delayed heart attack or stroke are substantially worse than the bill. The loss of obstetric services in particular has reshaped access across rural America, as MedicalDaily reported in its coverage of labor and delivery unit closures.
The center said it will continue monitoring federal and state policy changes and reporting the effects. What remains unmeasured is how much of the recent increase reflects people who lost coverage versus people who had none to begin with, and whether the 2027 Medicaid reductions will produce a further step change in uncompensated care.
Key Questions Answered
What is uncompensated care? Care a hospital delivers but is not paid for. It combines charity care, which the hospital forgives under a financial assistance policy, and bad debt, which the hospital expected to collect and did not.
Why does the difference matter to a patient? Charity care accounts are written off and generally do not go to collections. Bad debt accounts may be referred to a collection agency. The patient usually has to apply for financial assistance for a bill to be treated as charity care.
How much have these costs risen in Colorado? State data show uncompensated care costs rose 31.0% between 2023 and 2024, or 27.3% adjusted for inflation. Between 2019 and 2024, inflation-adjusted charity care rose 57.6% while bad debt fell 2.6%.
Which parts of Colorado are most affected? The analysis found the largest Medicaid coverage losses between 2024 and 2025 in the rural Southeast, Northeast, and San Luis Valley regions.
Does this affect people who have insurance? Indirectly. Hospitals under financial strain may reduce services, accept fewer Medicaid patients, or close, which changes what care is available locally to everyone.
What should someone do about a hospital bill they cannot pay? Request the hospital's financial assistance policy and application in writing before the account goes to collections, and check eligibility for Medicaid or a marketplace plan. Loss of coverage opens a special enrollment period.
Where can uninsured residents get non-emergency care? Federally qualified health centers provide primary care on a sliding fee scale regardless of insurance status, at substantially lower cost than an emergency department.
