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As part of the healthcare reform legislation known as the Affordable Care Act, or “Obamacare,” nonprofit hospitals are required to conduct community health needs assessments (CHNAs). Will these sometimes-lengthy reports prove worth the effort? In part, it may depend on whether anyone at the Internal Revenue Service (IRS), which is overseeing CHNAs, or the Department of Health and Human Services (HHS), which is nominally in charge of the implementation of the Affordable Care Act, reads and uses the reports.
There is certainly the possibility that CHNAs could devolve into yet another governmental requirement that accomplishes little more than the creation and maintenance of an industry of consultants ready and willing to churn out reports for their clients. In this case, CHNAs might become little more than a check-off requirement, an exercise in which participants will go through the motions and perhaps say that it opened their eyes to issues and new ideas.
Or…advocates could use CHNAs as a vital tool to advocate for and advance better healthcare delivery, coverage, and outcomes for all Americans. Those concerned about decent healthcare for all people, including poor people, might find these reports useful as organizing tools for community-based health campaigns—and as instruments for getting recalcitrant hospitals to ante up with needed health services. Based on a review of a dozen publicly available CHNAs, we find several important themes emerging for health advocates.
What Makes a Nonprofit Hospital a Nonprofit? Tax Exemptions on the Line
For the past several years, 501(c)(3) hospitals have endured the slings and arrows of critics, including the Senate Finance Committee’s Sen. Charles Grassley (R-Iowa), who have suggested that they weren’t devoting much of their program resources or financial assets to serving the poor. For some, a lack of services for the poor became a political and legal issue, epitomized by the decision of the Illinois Supreme Court to reject the property tax exemption for the Provena Covenant Medical Center because of its documented history of negligible service to the poor (including charging double the actual cost of medical services). Nonetheless, most of the nation’s 2,918 nonprofit hospitals have avoided debacles comparable to Provena’s as they debate what should constitute charity care.
The Affordable Care Act changes the game for nonprofit hospitals in a fundamental way. It requires tax-exempt hospitals to document the health needs of their communities and to demonstrate how their healthcare programs are addressing those needs. In addition, the Affordable Care Act requires nonprofit hospitals to establish and publicize policies as to when and how they will provide financial assistance to patients, when and how they will limit charges on patients receiving financial assistance, and when and how they will make serious efforts to determine whether patients might be eligible for financial assistance (rather than launching “extraordinary collection efforts”).
That the Internal Revenue Service will administer the CHNAs is a statement that the hospitals’ tax exemption in on the line in cases of noncompliance. Think of it like a bank’s relationship to the Community Reinvestment Act. A bank is supposed to explain how it is supporting a community’s reinvestment needs. Although banks almost automatically get good grades from oversight agencies for their CRA performance, advocates can still use the reviews to promote bank reinvestment strategies and sometimes, when banks acquire or merge with other banks, CRA performance may be used to exact commitments for enhanced community banking.
With the sanction of the Affordable Care Act, the CHNA becomes part of the defining rationale for what makes a nonprofit hospital a nonprofit. While we cannot guess what the hard-pressed, budget-slammed IRS and HHS will do with these documents, we would be surprised if community-based advocacy organizations don’t see the opportunity to elevate the discussion of community health issues by mobilizing people around the healthcare needs and gaps faced by poor people.
What’s Missing? Emerging Community Health Needs
There is no getting around the fact that the CHNAs present a healthcare environment that is generally grim. For example, the CHNA for Stoddard County, Mo., released by St. Francis Medical Center and Southeast Hospital, was “not a pretty picture,” according to the Daily Statesman. This was due to a combination of factors, including one-fourth of adults without high school diplomas, double the state’s rate; one-fourth of households on Medicaid, compared to 14.5 percent for the state; nearly one-fifth of the population pre-ACA uninsured; a shortage of primary care health providers and a critical lack of mental health care providers; and a stunning statistic showing a rate of infectious disease in Stoddard County of 1,896.6 per 100,000 residents compared to only 517.1 per 100,000 in the state. The bleak health conditions that will emerge in many CHNAs comprise a picture sufficient for an Occupy Healthcare movement, particularly due to the bare revelation of racial, ethnic, and income inequities.
In the Harrisburg, Pa. area, the five-county CHNA conducted for the region served by the Holy Spirit Health System, Penn State Milton S. Hershey Medical Center, and PinnacleHealth System, cited social and economic barriers to healthcare, such as poverty and unemployment. The latter was 12 percent in downtown Harrisburg and South Harrisburg, compared to five percent in the region. The Central Pennsylvania needs assessment observed that “there are multiple community organizations that residents can receive health and social services assistance from, [but] most often these organizations work independently of one another and/or in silos.”
The three priority needs identified in the Central Pennsylvania analysis were promotion of healthy lifestyles, health education, and healthcare access in areas such as dental care, mental health care, primary care, and specialty care. The CHNA notes that even for people with health insurance coverage, the poor are not guaranteed healthcare due to a number of issues. Those issues include the lack of proximity to health providers, patients’ out-of-pocket expenses, and the limited number of providers who will accept particular health insurance plans (not to mention Medicaid and Medicare). There is also the issue of the gap faced by the working poor who make too much to qualify for subsidized health services but not enough to be able to afford healthcare on their own, resulting in their foregoing medical treatments because of cost.
The CHNA for St. Anthony’s Memorial Hospital, which serves counties in Southern Illinois, points to other issues, such as the need for improved resources for mental disorders and, in one county, resources for dealing with child abuse. In Reading, Pa., which is known for having had the highest proportion of poverty among all U.S. cities with populations above 65,000 as of 2010, several organizations filed a joint CHNA. The report found that “only 38.5%” of those “diagnosed with a mental health condition” were “receiving treatment for their condition.”
In nearly every CHNA we examined, mental health resources were found to be clearly inadequate. The problem of physical exercise, identified in each needs analysis that we examined, seems to cry out for a shift in policies of cutting back on parks and recreation in many communities where local governments face budget crunches. The Harrisburg-area CHNA highlighted the importance of cross-organization collaboration, but in the Reading area, the county doesn’t even have a health department (which might be the logical body to coordinate such collaboration).
It is kind of remarkable how consistently the CHNAs—and other regional healthcare needs assessments—identify dental care as a high (if not top) priority healthcare need that is not being addressed, pre- and post-ACA. Dental ranked at the top of the needs identified by survey respondents in a CHNA conducted in Montgomery County, Ind., and each CHNA that we reviewed has brought attention to the issue of dental health. Some have identified programs that are attempting to address dental issues, but dental didn’t make it into the Affordable Care Act. We have documented the efforts of low-cost nonprofit dental care clinics around the nation, particularly the Sarrell Dental Clinic model in Alabama, but it is stunning how the American population sees dental care as a matter of whitened teeth for smiles as opposed to a core health issue. The CHNAs’ consistent inclusion of dental as one of the top-ranking unmet health needs should underscore the point that dental is health.
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These CHNAs are brimming with indicators that advocates can use to drive attention to community health issues. Advocates will be able to use CHNAs not only to identify unmet needs or various racial inequities, but to outline the existence or inadequacy of the infrastructure of health systems, either through a lack of necessary institutions or a lack of bodies capable of achieving the coordination and collaboration improved healthcare depends upon.
How CHNAs Can Transform Nonprofit Hospitals into Quality Healthcare Advocates
Advocates can use CHNA data not only to highlight areas of healthcare that merit more attention, like dental needs, but also to contrast the documented needs with what hospitals and governments are doing. For example, a Washington State needs assessment for Benton County and Franklin County identified a problem of limited access to prenatal care for pregnant women during the first trimester. That provides some important context with which to consider the two counties’ decision to cut a program that reportedly served approximately 1,000 pregnant women each year. The health district has received a $700,000 grant for a much-touted Social Innovation Fund program, the Nurse Family Partnership (NFP). But the NFP program will only serve 100 pregnant women at the outset. What about the other 900 or so pregnant women that will need services? When government or hospital decisions contradict an officially documented need, it should be a signal to advocates that it is time to deliver a wake-up call.
Policy advocates can also use CHNA findings for purposes that go beyond specific hospital policies and local issues. Each CHNA reviewed here more or less owned up to the healthcare access problems of families on Medicaid and poor families with incomes just a bit too high to qualify for Medicaid assistance. Yet many states, such as Texas, have spurned the ACA’s provision of additional Medicaid funding to assure coverage to people with incomes as high as 133 percent of the poverty level.
With the nation’s highest rate of people without health insurance, Texas Republicans, starting with Gov. Rick Perry, have opposed the option of drawing down an additional $100 billion over 10 years to expand Medicaid coverage. It’s typically discussed as a money issue: how much will it cost the state in the out years after the federal support for expanded coverage disappears? But research conducted by Methodist Healthcare Ministries of South Texas and the statewide health advocacy network Texas Impact finds that expanded Medicaid will generate improved healthcare access for two million Texans, saving the lives of 5,700 adults and 2,900 children annually in addition to generating new jobs and new investment.
If CHNAs incorporate such research, it could be very useful for advocates. In this way and with some degree of courage and commitment, nonprofit hospitals can themselves become advocates for state-level policy changes that could yield positive outcomes for poor people. Rather than hunkering down defensively behind community benefit formulas, nonprofit hospitals armed with CHNAs can join advocates as part of a movement to translate improved health insurance coverage into vastly improved healthcare.
The same goes for the racial divide that is so clearly evident in healthcare needs and outcomes. For instance, let’s revisit the CHNA in Reading, Pa., where the population is already more than half Latino and is expected to rise to almost three-fourths Latino by 2018. The CHNA showed that 8,000 Latinos didn’t seek medical care and more than one-fifth of the region’s Latinos didn’t buy prescribed medication because of out-of-pocket cost issues. Although in theory hospitals are offering the same services to all patients, the outcomes are so radically different, so racially inequitable, that there is no way but to see the problem as structural and thus meriting interventions that undo the disparate outcomes. Compare Reading to the nearby, suburban Berks County and the racial disparities are hard to ignore:
- Health status fair or poor: 15.9 percent in Berks County; 32.6 percent in Reading
- Visits to the ER because of no insurance: 24.8 percent in Berks; 44.1 percent in Reading
- No dental care due to cost: 21.1 percent in Berks; 33.2 percent in Reading
- No regular source of medical care: 11.8 percent in Berks; 18.9 percent in Reading
- Adolescent births per 1,000 births: 9.4 in Berks County; 28.1 percent in Reading
- Late or no prenatal care: 32.8 percent in Berks; 50.1 percent in Reading
- Mortality rate per 100,000: 731.3 in Berks; 926.6 in Reading
- Living below poverty level: 13 percent in Berks; 34 percent in Reading
These might look like urban/suburban or income-level disparities, but the fact that Reading is so overwhelmingly Latino compared to its surrounding communities cannot but leave one with the impression that these conditions reflect racial and ethnic disparities as well. Issues of institutional or structural racism are uncomfortable for many people, but in the context of CHNAs, they have to be confronted. As researchers have repeatedly documented, there is a long and continuing history of institutional or structural racism in the U.S. healthcare system. This is evidenced by indicators such as the disproportionate closing of hospitals that primarily serve minority populations, the practice of many physicians to reject Medicaid patients, racial disparities in medical treatment practices, and a lack of culturally competent healthcare, just to name a few.
A Brand New Day for Healthcare in America? The Choice Is Yours
The Affordable Care Act and its required CHNAs should be a time for all parties to step back and look at what they have and haven’t done to improve healthcare and health outcomes, particularly for poor Americans. That applies double for nonprofit hospitals, which the ACA enables to move beyond defending themselves against challenges to their charity care numbers and to start thinking differently about their roles in local healthcare systems. For whatever criticisms there might be about some of the Rube Goldberg-like components of the national health reform package, the ACA liberates nonprofit hospitals and empowers them to become leaders in revising healthcare delivery. Nonprofit hospitals won’t have to worry quite as much about sending bill collectors after poor people, threatening their homes and livelihoods if they don’t pay up for hospital treatments. Nonprofit hospitals can use the ACA—and speak through the CHNAs—about their potentially elevated roles as focal points in local arenas for ensuring that the world’s most expensive healthcare system delivers results for poor people commensurate with the need.
It is inaccurate and facile to suggest that CHNAs should only be viewed as “needs assessments,” or that this information is merely meant to highlight community-wide health shortcomings such as high rates of obesity, cholesterol, diabetes, and such. The CHNAs also posit where hospitals and health systems themselves have been deficient. After all, how can a needs assessment of healthcare not examine inadequacies in how the healthcare delivery system itself has functioned? Moreover, it is also not true that these needs assessments are confined to merely pointing at needs. CHNAs can suggest actions and solutions.
Each CHNA we have seen is dimpled with references to what the hospitals involved are doing in some situations to respond to needs. For example, in Grand Rapids, Mich., Spectrum Health’s CHNA identifies the problem of access to healthcare, establishes two key objectives for addressing the problem, and describes a plan for a community medicine clinic to be implemented in three phases over five years. To address health literacy and awareness among young people in Grand Rapids, Spectrum sets two key objectives, including improving the proportion of schools that have a full-time registered nurse, and proposes a school health advocacy project to be implemented in partnership with the Grand Rapids public schools.
Nonprofit hospitals can take the advent of the Affordable Care Act as a brand new day, one that moves them from mechanical charity care formulations into analyses of what their communities need, what they haven’t done in the absence of a national health care policy, and what they can do now, given the commitment of the federal government to redress health care inequities in the nation. Health care consultant Kurt Bennion described the CHNA challenge for hospitals. Bennion says that hospitals face the option to do the “bare minimum,” identifying needs but offering no proposed actions in response to those needs—or outlining possible actions but choosing to implement few or none. Alternately, Bennion says hospitals can opt for “taking it to the next level,” seeing the CHNA (and the ACA, obviously) as “an opportunity to make broader changes in their operations.”
Health advocates have that same choice. Will they give the nod to nonprofit hospitals that pursue the “bare minimum” path on the assumption that HHS and IRS will be hard-pressed to get them to do more? Or, regardless of what the federal government does or doesn’t do, will they seize the opportunity to transform CHNAs into frameworks for assessing how nonprofit hospitals ought to be responding to the healthcare needs of the underserved and unserved people in their communities and regions?
In the political brouhahas over the Affordable Care Act over the past couple of years, there has been much focus on how much health insurance coverage we will get, which is assuredly a critically important issue, particularly given the 15.7 percent of Americans (48.6 million people) who would lack insurance coverage but for the enactment of the ACA. But there is more to the issue of healthcare than insurance coverage.
The content of these CHNAs should wake everyone up to the fact that there is a problem with medical care in this nation and that the notion of healthy families and healthy communities is about more than the delivery of services from hospitals and doctors. The California Endowment’s “Healthy Communities” initiative, the nation’s largest health conversion foundation, begins with the premise that “all communities deserve health systems and physical, social, economic and service structures that support healthy living and choices.” The Centers for Disease Control and Prevention also has a Healthy Communities program; it is aimed at “effective population-based strategies that reduce the burden of chronic disease and achieve health equity.” In the state of Washington, the Municipal Research and Services Center observes that the elements of a healthy community include “access to health care services that focus on both treatment and prevention for all members of the community; a safe community; [and] the presence of roads, schools, playgrounds, and other services to meet the needs of the people in that community.”
A community health needs assessment should be a tool to help advocates argue for improved hospital care and guarantees that people who should receive healthcare coverage get it. But beyond that, CHNAs should also focus communities on splicing together the panoply of investments and policies needed to improve community life. Health advocates and hospitals should not let CHNAs become merely a paperwork requirement of no real benefit except to the legions of consultants who will make lucrative careers out of generating these reports. Instead, allow CHNAs to serve as the frameworks for organizing and mobilizing residents, community organizations, human service providers, and local governments around healthcare in the broadest sense of the word.