For the past six years, Mardi Chadwick has run a violence prevention program at Boston’s Brigham and Women’s Hospital. The program’s goal is to address broader, community-based health issues and social problems that make people ill or expose them to injury.
In Chadwick’s view, this endeavor has made a big difference in neighborhoods. But its profile in administrators’ eyes got a boost from an Affordable Care Act provision that requires nonprofit hospitals to conduct triennial assessments of local health needs and devise strategies to address them. Falling short triggers a financial penalty.
“Everyone, all of a sudden, cares about the social determinants of health,” she said. “Our expertise is being brought in … . We have a bigger seat at the table.”
But will programs such as this one continue to receive such attention? As the Republican-controlled Congress works to scrap the Affordable Care Act, the answer is uncertain.
Requiring “community health needs assessments” was part of a broader package of rules included in the 2010 law to ensure that nonprofit hospitals justify their tax exemption.
Another was that such facilities establish public, written policies about financial assistance available for medically necessary and emergency care and that they comply with limits on what qualified patients can be charged.
These directives are caught up in an ongoing controversy about whether all nonprofit hospitals do enough to deserve a tax break. People on one side of the issue view the assessment as an undue, unfunded burden, for example — others say it demands too little.
Iowa’s Sen. Chuck Grassley long has urged greater scrutiny of nonprofit hospitals’ tax status. His spokeswoman said he will continue to advocate for the requirement to remain in whatever new health legislation is passed. But the financial uncertainty surrounding an ACA overhaul could undermine some hospitals’ efforts.
The decades-old nonprofit tax status, granted by the Internal Revenue Service to institutions that meet a “community benefit” standard, spares hospitals from paying federal taxes and is collectively worth billions of dollars. Nonprofit hospitals generally have cited the uncompensated or “charity” care they provide, as well as initiatives they undertake to promote public health, as sufficient proof that they earn their exemption.
But for-profit hospitals, which do pay taxes, have cried foul, saying they make similar contributions.
The ACA requirements were meant to hold nonprofits to a higher standard — and penalize those that did not deliver. Under the law, hospitals that fail to complete the assessment and implementation strategy face a $50,000 fine, a penalty that could accumulate and jeopardize their tax exemption.
As of 2011, the most recent federal data show, nonprofit hospitals provided less than 10 percent of their operating expenses as community benefit — including charity care, unreimbursed costs from Medicaid and other government programs, and medical research and education.
Less than 1 percent went to community health improvement services such as Chadwick’s.
Advocates hoped the health law would change this. The idea was to push these facilities to invest more in public health initiatives that do not directly earn them money. But it is hard to gauge whether that has happened.
“You can find hospitals that have done this. But … are we seeing a real shift in the hospital community? Or are these a few hospitals that are outliers?” asked Gary Young, director of the Center for Health Policy and Healthcare Research at Northeastern University. “We’ve asked them to make a sea change in how they’re doing things. And that can’t happen overnight.”
Analysts say part of the problem is that the underlying idea — reaching into the community to help people navigate the social and economic factors that can influence health — goes beyond what hospitals have traditionally viewed as their mission. Administrators tend to focus on the immediate questions: How many beds are full? What medical services are being provided? How are they doing with their operating budget?
“It’s a new world out there in terms of the hospital not being the center of the universe,” said Lawrence Massa, president of the Minnesota Hospital Association, which has been tracking responses to the health assessment requirement.
The association found that the money the state’s nonprofit hospitals put toward “community needs” went up — from about $355 million in 2011 to $459 million in 2013. (The needs assessment requirement took effect for the tax year starting after March 2012.)
But the increase leveled off in 2014 — the most recent year for which data are available.
Massa’s conclusion: Caring for the health of people before they come into the hospital is unfamiliar territory. Not everyone took naturally to it.
“We saw some communities that embraced this and did a nice job … . In other communities, there’s been friction between public health and the acute setting — and lack of understanding.”
With continued time and sustained emphasis, that could evolve, said Sara Rosenbaum, a professor of health law and policy at George Washington University.
But even if the community benefit requirements remain intact, she and others fear this accountability effort could take a hit. Repeal of the health care law is likely to create fresh financial challenges for hospitals.
For example, although the House GOP’s American Health Care Act would restore some of the uncompensated-care funding cuts hospitals absorbed under the ACA, the coverage changes proposed in Republicans’ plan could mean tens of millions more uninsured people.
That scenario, policy experts and trade groups say, would increase the amount of free care nonprofit hospitals provide, creating new budget pressures that could lead them to tamp down on efforts to promote community health work.
The health assessment’s impact has been evident at Boston-based Massachusetts General Hospital. There, administrators used it to devise an intervention strategy around drug abuse, partnering with local schools and community organizations and hiring former addicts to help patients navigate recovery.
“There’s no question,” said Joan Quinlan, its vice president for community health, “the Affordable Care Act required us to bump up our game.”
Yet without the resources to continue such efforts, she added, “it’s going to be hard.”