Melissa Stapley still has crushing headaches and no sense of smell.
University of Utah doctors cracked open her skull last fall to take out a benign tumor that was causing her to lose sight in one eye and had spread to her scent glands, which had to be removed.
But recovery was the least of post-surgical woes for the 43-year-old West Valley City woman who, after seven days in the hospital, returned home to $118,000 in medical bills.
"No one ever said anything about my insurance not covering the procedure," said Stapley, who was encouraged to apply for charity care. "I was embarrassed to ask for help. But what do you do when you have no money coming in?"
The answer for many insured Utahns is increasingly to seek financial assistance.
The insured make up 40 percent of the people who qualify for financial assistance at the U. And at Intermountain Healthcare, the state's primary provider of charity care with 22 nonprofit hospitals, they make up nearly half -- 47 percent -- of charity cases.
Their numbers have been inching up because they can't afford ever-increasing deductibles and co-payments that employers are passing on to their employees, according to hospital administrators.
And that suggests that health care reform -- and the 2014 requirement that citizens and legal residents have health insurance -- won't do much to reduce the demand on free or reduced-cost care.
"Even if people have more insurance, about half end up as patients needing charitable assistance," said Daron Cowley, Intermountain Healthcare spokesman. "The way insurance plans are being designed, we're probably going to see more responsibility fall to the patient."
U. administrators agree. Even as the job market improves, predicts Kathy Delis, who oversees the U.'s billing office, "we don't think we'll see a big relief from our charity dollars."
Nonprofit hospitals, such as those in the Intermountain Healthcare system, must provide charity care because they don't pay taxes in exchange for helping the community. The University of Utah Hospitals & Clinics also provide charity care as a nonprofit, but under different rules because the system is government-owned.
New rules for nonprofits - In 2008, the first full year of the recession, Intermountain saw its biggest jump in charity care in the past several years -- and the demand continues. The amount of its financial assistance tripled from 2003 to 2009, to $238 million. A quarter of a million patients were provided charity care last year.
The demand is driven by the faltering economy as well as Utah's growing population and Intermountain's expansion. It opened two more hospitals last year.
At the U., which works on a fiscal calendar, charity care jumped 31 percent in fiscal year 2008-09.
Delis said the number of people applying for charity care at the U. has grown to 500 a month, double that in past years. Similar to Intermountain, half the patients who need financial help sought care in the emergency room.
The federal health reform law, recognizing charity care will still be needed, adds new rules to make certain nonprofits are more transparent and accountable: Starting in January, nonprofit hospitals must have written, widely publicized policies that explain who is eligible for help, whether assistance includes free or discounted care, the basis for calculating charges to patients, how to apply for assistance and what collection actions will follow unpaid bills.
Hospitals must limit what they charge uninsured patients for emergency or medically necessary care. While the Internal Revenue Service hasn't issued final rules, the law is being interpreted to mean hospitals must bill self-pay patients at the lowest rates that insurance companies have negotiated.
The goal, according to advocates, is to stop charging uninsured patients the most for care. They don't have the negotiating power of an insurance company to reduce costs and they are least likely to be able to afford the full cost of care.
And the law says hospitals must make "reasonable" efforts to determine whether patients qualify for assistance before they "engage in extraordinary collection actions." That's being interpreted to mean patients must be told about aid policies in writing and orally at admission.
These new rules for nonprofit hospitals don't apply to the U. because it is government-owned. Intermountain believes it meets the intent of the law, but will adjust if needed as rules are finalized.
Intermountain provides assistance information on its website, in its hospitals and on envelopes. An application is also available online. Cowley said patients are screened for eligibility before, during and after their care.
For uninsured patients, Intermountain already provides a 25 percent discount; the U. offers 30 percent off. Both cut bills even further when patients pay promptly or in full.
At the U., charity care is a last resort: Billing clerks ask patients to pay in full first, then offer payment plans. If that won't work, they offer to see whether patients qualify for assistance.
"Of course we would expect patients to pay for their services that were rendered," said Delis. "Even though we are nonprofit ... we still have to be able to keep our doors open and provide the services to our patients."
Leveling the playing field - Judi Hilman, executive director of the Utah Health Policy Project, wants all hospitals -- including for profits and government-owned -- to be as transparent as the federal law requires of nonprofits.
Patients deserve to know hospitals' policies upfront, she says, adding that people may avoid necessary care to avoid debt if they don't know they can receive financial help.
Hilman said patients who qualify for charity care seek help from her office when they aren't given the option by hospitals. "It's important for hospitals to have that level playing field and have model procedures for this so there's no mysteries and patients can get what they need," she said.
She found a Republican lawmaker to sponsor a state law last year requiring across-the-board transparency, but the bill stalled as the Utah Hospitals & Health Systems Association pushed for the requirement to be voluntary.
The hospital association spokeswoman acknowledged the efforts aren't a priority. "We do need to do a better job," said Jill Vicory.
Sen. Peter Knudson, the assistant majority whip, said all patients need help understanding hospital bills and collection policies. The orthodontist and Brigham City Republican said even he and his wife were confused by bills for her cancer treatments.
He believes hospitals rarely determine whether patients qualify for charity care early in the process.
"Certainly for people who are not in a position to pay, they need to know that there are policies that will allow them to have treatment," he said.
A survey of nearly 60 Utah hospitals by Hilman's group found wide variety about whether hospitals have policies and what they offer.
Many for-profit hospitals didn't disclose them or didn't have a policy, the group found. The exception was MountainStar, the system that includes St. Mark's Hospital, which has a "transparent" policy.
At another for-profit hospital, a person answering the survey referred Hilman's group to Intermountain for charity care. And a nonprofit employee told the surveyor, "People will say they're poor, but then they're driving a new car."
Stapley, a single mother of two teens, earned less than $10 an hour working part-time. She couldn't afford comprehensive, private coverage and instead got a bare-bones policy through Utah's Primary Care Network, a state insurance program that pays for doctor visits and some medications, but no specialty care.
She delayed care for more than a year. By the time she sought medical help for her loss of sight, she could see only shadows in one eye. And when an eye specialist, and later a neurologist, agreed to see her, she presumed the visits were covered.
In a matter of months, University Hospital wrote off all but $150.
"They were great to work with," said Stapley who remains embarrassed for being so "ill-informed."
"But what else could I have done?" she asked.