February 24, 2015; East Bay Express

The Affordable Care Act was about much more than health insurance, though coverage issues have been the arena for most of the public contention over the legislation. One important element of the act was the requirement that nonprofit hospitals conduct regular community health needs assessments (CHNA) so that the hospitals’ programs of healthcare delivery for all segments of the community, particularly low-income households, matched up with their needs. Although the Supreme Court’s decision in King v. Burwell could upset the ACA applecart, assuming it doesn’t, these CHNAs could and should become documents for activists to discuss what nonprofit hospitals and other healthcare institutions are doing to improve healthcare delivery. Some CHNAs are leading hospitals in new directions and programs.

For example, in Grand Haven, Michigan, the county seat of Ottawa County in a metropolitan area of just over 260,000 residents, the CHNA of the North Ottawa Community Health System identified access to healthcare as a priority issue—not surprising in an area of small communities. “The health system found that one in five visits to North Ottawa Community Hospital’s emergency department should have been handled in settings such as Urgent Care or a primary care office,” according to an article by Krystle Wagner, suggesting that wider accessibility to primary care physicians and improved transportation might be necessary. The hospital reported that in response, it is working with local nonprofits such as Love INC, Tri-Cities Ministries, and the Greater Ottawa County United Way, among others, to improve access and to address the socioeconomic issues that underlie many patients’ emergency room visits.

A bit south and west of Detroit, the Oakwood Health Systems CHNA has led to the creation of the Healthy Communities Initiative, with a strategic plan aimed at access for people with chronic diseases (diabetes, cardiovascular diseases, and obesity, for example). The hospital system’s coordinator for the initiative, Ruth Sebaly, pledged to emphasize community engagement and community “ownership” over the programs that will emerge from this effort.

CHNAs should be the venues for significant discussion around what constitutes health and how nonprofit hospitals and other institutions can best contribute to it. For example, the Peace Island Medical Center’s December 2014 CHNA is readable and digestible at 24 pages. The document highlighted three priority issues for the small island in Washington State: health promotion and disease prevention, care coordination (helping people “navigate” the healthcare system and find the resources they need), and increasing services and access for behavioral health issues such as mental health and substance abuse. In response, a former chair of the San Juan Island Community Foundation, Jim Skoog, wrote a piece in the local newspaper saying that the PIMC assessment omitted three important topics—“women’s reproductive healthcare, access to end-of-life care, and the lack of a viable urgent care model (walk-in clinic)”—and the “stakeholder meetings” held as part of the CNHA preparation process were not open to the public and did not include organizations like Planned Parenthood that should have been consulted. Whether Skoog is correct or not, this is the kind of public health dialogue that CHNAs should be stimulating in communities, educating the public about what might be elements of public or community health that they should be thinking about and acting on.

Part of the challenge is that there are really no specific standards that tell hospitals what they must do with their CHNA findings. In California, the Greenlining Institute and the California Rural Legal Assistance Foundation have combined to get a bill introduced in the state legislature, Senate Bill 346, sponsored by state senator Bob Wieckowski (D-Fremont), that would establish clear standards for the community benefits that nonprofit hospitals are supposed to deliver. The proposed legislation would define “charity care” as the direct provision of care to the uninsured or underinsured (which means excluding from charity care whatever the hospital writes off as charges that it was unable to collect from patients), require that hospital spending address community needs such as the root causes of poor health (including poor nutrition and bad housing), enhance hospital reporting requirements regarding how they are meeting their community benefit obligations, and change the composition of hospitals’ community benefit committees to include representation from underserved populations. While the legislation would exempt rural hospitals and public hospitals, the generation of clear standards would help everyone in the community health needs assessment process, not just the institutions charged with the delivery of healthcare services, but also the community residents who are the consumers in the process.

Let’s hope that the CHNAs being prepared elsewhere in the nation stimulate the kind of public dialogue that community health improvement merits. CHNAs shouldn’t be allowed to devolve into the healthcare equivalent of CDBG/HOME Consolidated Plans, which so often have become bureaucratic exercises without being used by city administrators or neighborhood residents as documents for debating what should be a community’s housing and community development priorities. CHNAs ought to be opportunities for the broad range of nonprofits attached to issues of healthcare writ large to shape how nonprofit hospitals and other healthcare providers respond to the needs of lower income households.—Rick Cohen