Hospital Community Benefits after the ACA - The Hilltop Institute

20 Pages·2014·0.52 MB·English

Issue Brief
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May 2014

Hospital Community Benefits after the ACA
Addressing Social and Economic Factors that Shape Health
Gayle D. Nelson, Jessica S. Skopac, Carl H. Mueller, Teneil K. Wells, Cynthia L. Boddie-Willis
Introduction
The Hilltop Institute’s Hospital Community Ben- tax-exempt organizations (IRS, n.d.a.). That brief
efit Program is a central, objective resource for explains the importance of a wide range of IRS-
state and local decision makers who seek to en- recognized community building activities in ad-
sure that tax-exempt hospital community benefit dressing the root causes of poor health. Subse-
activities are responsive to pressing community quent briefs and The Hilltop Institute Community
health needs. Benefit State Law Profiles (Profiles)2 address
the ongoing importance of state-level regulation
This brief is the ninth in the series, Hospital
of hospital community benefits and present com-
Community Benefits after the ACA. Earlier briefs
prehensive analyses of each state’s community
address the requirements for tax-exempt hospitals
benefit landscape as viewed through the lens of
established by §9007 of the Affordable Care Act
the major categories of federal community bene-
(ACA)1 and assessed federal and state approach-
fit requirements (Somerville, Nelson, & Mueller,
es to community benefit regulation (Nelson,
2013; Nelson, Somerville, Mueller, Boddie-
Somerville, Mueller, & Boddie-Willis, 2013;
Willis, 2013).
Somerville, Nelson, & Mueller, 2013; Folkemer,
Spicer, Mueller, Somerville, Brow, Milligan, & This issue brief continues the program’s exami-
Boddie-Willis, 2011). Another brief (Somerville, nation of state-level community benefit oversight
Nelson, Mueller, Boddie-Willis, & Folkemer, by focusing on the ten states that require hospi-
2012) explores hospital “community building” tals to develop implementation strategies: Cali-
activities that fall within categories specifically
fornia, Illinois, Indiana, Maryland, New Hamp-
recognized by Schedule H, which supplements
shire, New York, Rhode Island, Texas, Vermont,
IRS Form 990, the informational return filed by
and Washington. It identifies specific social and
Gayle D. Nelson, JD, MPH, is a Senior Policy Analyst at The Hilltop Institute at UMBC and directs Hilltop’s Hospital
Community Benefit Program. Jessica S. Skopac, JD, MA, PhD, is a Policy Analyst at The Hilltop Institute at UMBC.
Carl H. Mueller, MS, is a Policy Analyst at The Hilltop Institute at UMBC. Teneil K. Wells is a Graduate Research Assis-
tant at The Hilltop Institute at UMBC. Cynthia L. Boddie‐Willis, MD, MPH, is Director of Health Services Policy and
Research at The Hilltop Institute at UMBC.
economic factors that shape community health cific social and economic factors, as reflected in
and thus are of great importance to state and local more than 500 state-required implementation
policymakers. The implementation strategy re- strategies—or reports of implementation strate-
quirements of California, Illinois, Indiana, New gies—as well as the methodology Hilltop em-
Hampshire, Rhode Island, and Texas were enact- ployed in that review. This review provides a
ed prior to the ACA. Whether, how, and when baseline of currently reported activities, many of
these states will reassess state requirements in which may have been initiated prior to enactment
response to the ACA is unknown. Certain aspects of the ACA.
of the state implementation strategy requirements
of Maryland,3 New York,4 Vermont,5 and Wash- Based on the review, the brief identifies standard
ington6 were adopted post-ACA. regulatory tools and characteristics of implemen-
tation strategies used by those states that could
This brief begins by providing essential back- facilitate hospital investment in activities that
ground information and describes the regulatory address social and economic determinants. The
framework through which federal and state poli- final section offers conclusions, recommenda-
cymakers exercise oversight of hospital commu- tions, and policy options for state and local poli-
nity benefits. Next, it describes current hospital- cymakers and decision makers.
reported programs and initiatives that target spe-
Background
Today, there is broadening appreciation among factors (UWPHI, 2014a; Booske, Athens, Kindig,
researchers, government agencies, public interest Park, & Remington, 2010). Around the nation,
organizations, foundations, and health care pro- state and local officials, parents, public health
viders—including hospitals—that factors other workers, communities of all sizes, and other enti-
than medical care play important roles in shaping ties, including some tax-exempt hospitals, are
individual and community health. These factors acting together to improve the health of commu-
include income, education, employment, com- nities by addressing social and economic factors
munity safety, the availability of healthy foods, where community residents live, learn, work, and
the environment, access to recreational facilities, play.
socioeconomic conditions, housing, social cohe-
Below are a few examples of communities across
sion and supports, language, literacy, culture, and
the nation that are striving to create what RWJF
transportation options (U.S. Department of
is calling a “culture of health” to enable all indi-
Health and Human Services [HHS], 2013; Insti-
viduals to lead the healthiest possible lives
tute of Medicine, 2011; Robert Wood Johnson
(Lavizzo-Mourey, 2014).
Foundation® [RWJF] Commission to Build a
Healthier America, 2014; Levi, Segal, & Kohn,
 A nonprofit hospital system in Ohio is tack-
2011).
ling food insecurity by treating hunger as a
health issue. In just three years it has provid-
The conceptual model of population health em-
ed 10.5 million meals to residents who are
ployed by County Health Rankings & Roadmaps
(CHR&R),7 a widely recognized and authorita- considered “food insecure” (Gearon, 2014).
tive source of information on population health,  The Green & Healthy Homes Initiative is
assigns 40 percent of the responsibility for popu- implementing a “cost-effective and integrated
lation health outcomes to social and economic approach to housing interventions” by com-
2
bining federal and philanthropic investments rates by providing safe and convenient places
in weatherization, energy efficiency, health, for children to play, encourage walking ra-
and safety to create more sustainable, afford- ther than driving, and increase participation
able, and healthier homes. The 17 current in federally funded meal programs for chil-
sites include 15 cities, one county, and one dren (Healthy Communities Office, 2013).
Indian nation (Green & Healthy Homes Initi-
ative, 2014).8 It is against this backdrop of more than two dec-
ades of state regulation of community benefits
 The city of Providence, Rhode Island, estab-
that Hilltop undertook a review of state-level
lished the Healthy Communities Office in
oversight of hospital activities targeting the social
2012. Its goals are to lower chronic disease
and economic factors that shape health.
The Federal/State Framework
IRS/Treasury oversight of community benefits, For each item listed in Part II of Schedule H, a
first articulated in 1969, specified that a hospital hospital must describe “how its community
seeking exemption from federal taxation must building activities … promote the health of the
demonstrate that it promotes the health of “a communities it serves” (IRS, n.d.b.). This detail
class of persons that is broad enough to benefit is not required of activities listed in Part I.
the community” (Rev. Rul. 69-545). That stand-
ard remained essentially unchanged until 2009 Notably, some activities related to health may not
(Davis, 2011), when the IRS introduced a new be reportable in either Parts I or II. Each year’s
Schedule H to supplement the financial data col- Schedule H Instructions delineate what may be
lected from all tax-exempt organizations via reportable as community benefit in Part I and
Form 990 (IRS, 2007). Part I of the 2013 Sched- provide examples of community building activi-
ule H, “Charity Care and Certain Other Commu- ties that may be reportable in Part II. Additional
nity Benefits at Cost,” is where hospitals report guidance regarding “what counts” as community
specific categories of community benefit activi- benefit can be found in materials prepared by the
ties that would support federal tax exemption Catholic Health Association (2014).
(IRS, n.d.a.). Part II, labeled “Community Build-
States can separately establish community benefit
ing,” is where hospitals list expenditures for non-
standards for tax-exempt hospital licensees. The-
clinical activities that address community health
se standards need not align with federal commu-
within the following nine categories:
nity benefit requirements and can be more specif-
 Physical improvements and housing
ic and stringent than their federal counterparts.
 Economic development Thus, state policymakers seeking to encourage
 Community support and promote tax-exempt hospital activities that
 Environmental improvements address social and economic determinants may
wish to assess their state’s existing community
 Leadership development and training for
community members benefit regulatory framework.
 Coalition building
All nonprofit hospitals seeking exemption from
 Community health improvement advocacy
federal taxation must conform to the above-
 Workforce development described federal requirements. Hospitals in
 Other9 states that do not specify the types of hospital
3
activities that support exemption from state taxa- Community benefit transparency, another ACA
tion need only satisfy federal requirements. Poli- goal, underlies the Schedule H reporting re-
cymakers in these states may wish to consider quirements and CHNA. It also underlies the re-
whether the federal regulatory scheme, including quirement that federal implementation strategies
the community building categories specified, suf- are to be made publicly available. Pursuant to a
ficiently advances state health goals and priori- still-pending 2013 Notice of Proposed Rulemak-
ties. If it does not, then separate state require- ing (NPRM), a nonprofit hospital may either at-
ments may be appropriate. tach the implementation strategy to its Form 990
or provide on the Form 990 the URL(s) of the
Hospitals in states that do specify separate state
web page(s) where the implementation strategy is
requirements must comply with both sets of di- available (proposed rule §1.501(r)-3).10 The
rectives in order to be eligible for both federal
NPRM would further require that implementation
and state tax exemption. Policymakers in states
strategies delineate the anticipated impact of pro-
that separately specify the types of hospital activ-
posed actions and describe a plan to evaluate the
ities that support exemption from state taxes may
actual outcomes (IRS, 2013).
want to review the existing state regulatory
scheme to ensure that it is appropriately reflec- State Implementation Strategies. The laws of
tive of current state goals and priorities regarding California,11 Illinois,12 Indiana,13 Maryland,14
social and economic factors that influence health. New Hampshire,15 New York,16 Rhode Island,17
Texas,18 Vermont,19 and Washington20 require
Federal Implementation Strategies. Since its
that tax-exempt hospitals develop state imple-
implementation in 2010, ACA §9007(a), as codi-
mentation strategies (also referred to as commu-
fied in I.R.C. §501(r)(3)(A)(ii), additionally re-
nity benefit plans, community service plans, or
quires each tax-exempt hospital to adopt “an im-
implementation plans) to satisfy state regulatory
plementation strategy to meet the community
requirements. (In this brief, all such plans are
health needs identified through its Community
referred to as state implementation strategies.)
Health Needs Assessment, or CHNA.” In their
implementation strategies, tax-exempt hospitals Like federally required implementation strategies
identify, in response to needs identified in their under ACA §9007, state implementation strate-
CHNAs, the community benefit activities in gies further community benefit accountability
which they are (or plan to be) engaged. Federally and transparency. Also like their federal counter-
required implementation strategies are written parts, they typically address the costs associated
plans (also called action guides) that formulate with the provision of charity and discounted care.
nonprofit hospitals’ proposed approaches for ad- In addition, they delineate community benefit
dressing the significant health needs in their activities that a hospital plans to take to respond
communities (Spugnardi, 2013). to community health needs and describe activities
in which a hospital is presently engaged, includ-
Implementation strategies further the ACA’s goal
ing those activities that address the social and
of enhancing community benefit accountability
economic factors that shape health.
because they specify the actions that a nonprofit
hospital intends to take to address each signifi-
cant community health need.

4
Methodology
Using the Profiles, Hilltop identified the ten tion strategy in electronic format. Most docu-
aforementioned states that require tax-exempt ments were dated 2011, 2012 or 2013, although a
hospitals to develop implementation strategies. few were dated 2010 or older. The review and
Some states require hospitals to develop and/or categorization of each reported hospital initiative
submit a report of the implementation strategy to or activity was performed by Hilltop using a data
a state entity, whereas others require hospitals to collection tool it developed.
submit the implementation strategy itself.21
Finally, Hilltop used the Profile of each of the ten
Hilltop reviewed more than 500 electronically states that require implementation strategies to
available, state-required implementation strate- identify state laws, regulations, and other re-
gies and reports to find reported activities that quirements related to those strategies. Review
target social and economic measures. The goal and analysis of these primary source materials—
was to assess the degree to which hospitals re- including state community benefit laws, regula-
ported implementing community benefit and tions, and reporting requirements—was conduct-
community building activities targeting educa- ed by JD/MPH and JD/PhD credentialed staff
tion, income, employment, and community safe- using standard approaches to statutory construc-
ty, each of which is a social and economic focus tion and interpretation.
area identified by CHR&R. CHR&R is a widely
State-level requirements for implementation
regarded and familiar tool that employs specific
strategies and implementation strategy reports
factors and measures (available locally and which
generally predate the ACA. They differ from the
can be compared across county lines) in as-
federal approach and from each other in many
sessing the health of counties. Those factors and
respects. Comparing these various regulatory
measures have been developed and subjected to
regimes provides opportunities to identify types
input from experts. For these reasons Hilltop
of state policies, regulatory tools, and features of
used the following CHR&R measures to guide its
those tools that can facilitate hospital activities
review: education (high school graduation rates),
that address social and economic determinants.
income (children living in poverty), employment
(unemployment), and community safety (violent

crime rates) (UWPHI, 2014a). Hilltop reviewed
the most currently available hospital implementa-
Hospital-Reported Activities that Target Social and Economic Measures
A 2013 study of federal informational returns grams—generally Medicaid shortfall. The next
filed by tax-exempt hospitals found that they de- largest component is attributed to the cost of free
vote an average of 7.5 percent of their operating and discounted care for individuals who are una-
expenditures to community benefits. The largest ble to pay for needed hospital services (Young,
portion of those expenditures represents unreim- Chou, Alexander, Lee, & Raver, 2013).
bursed costs for means-tested government pro-
5
Beyond these two community benefit categories, tion, unemployment, and violent crime rates.
many tax-exempt hospitals provide additional Hospitals in the remaining states reported activi-
benefits to their communities, most typically ties addressing two or fewer of the four measures
health fairs and screenings, which can be consid- under review.
ered types of community health improvement
None of the reviewed state-required implementa-
services. A significant number of tax-exempt
tion strategies specified whether the reported ini-
hospitals also provide community health educa-
tiatives were either evidence-informed or evi-
tion on such topics as tobacco cessation and obe-
dence-based. A fuller discussion of evidence-
sity prevention (Catholic Health Association,
based initiatives can be found in the Conclusions
2012).
and Recommendations section of this brief.
However, only a few of the numerous community
Examples of hospital activities addressing the
benefit and community building activities report-
social and economic measures of high school
ed in electronically available state implementa-
graduation, children in poverty, unemployment,
tion strategies address the CHR&R measures of
and violent crime rates identified in this review
education, income, employment, and community
include the following:
safety (UWPHI, 2014a). Income and education,
in particular, are known to be two of the most
 Programs in Indiana and New York offer
important social factors that influence health
students college credit while in high school
(RWJF, 2011a; RWJF, 2011b; Center on Society
or provide scholarships to students seeking
and Health, 2014). Yet, as reported in electroni-
medical careers
cally accessible state implementation strategies
or reports of those strategies, very few hospital  A collaboration among Maryland hospitals
activities appear to address those important prepares individuals aged 18 to 21 years for
health measures. entry-level jobs in the health care industry
 Initiatives at several California hospitals ad-
Among the ten states that require development of
dress gang prevention and youth violence,
state implementation strategies, California was
and one program reports that it promotes
the only state in which hospitals reported initia-
change in attitudes and beliefs rearding sexu-
tives and programs addressing all four of these
al violence among high school students and
measures. Maryland and New York hospitals re-
builds leadership and mentoring among
ported activities addressing high school gradua-
youth
Use of State Regulatory Tools to Target Social and Economic Determinants
The regulatory schemes of several states that re- target social and economic determinants may
quire implementation strategies clearly contem- consider using similar standard regulatory tools
plate nonprofit hospital investment in activities such as these. Examples of these tools are dis-
that target social and economic factors. Those cussed below.
states use a variety of regulatory tools to articu-
late state expectations and thereby promote Express Policy Guidance. New York’s current
community benefit accountability. Policymakers state health improvement plan, The Prevention
in other states who are interested in encouraging Agenda 2013-2017, emphasizes the importance
nonprofit hospital investment in activities that of addressing the social determinants of health
6
(New York State Department of Health vices that help maintain a person’s health” (Cal.
[NYSDOH], 2012a). A 2012 guidance document Health & Safety Code §127345(c)). This lan-
“asks” that tax-exempt hospitals, local health de- guage appears to facilitate hospital investment in
partments, and community partners collaborate to activities that address the social and economic
develop state-required community health assess- factors that shape health. Maryland’s statute re-
ments, community health improvement plans, quires that each tax-exempt hospital’s implemen-
and hospital implementation strategies (referred tation strategy (referred to as a community bene-
to as community service plans) (NYSDOH, fit report) describe the hospital’s efforts to track
2012b). and reduce health disparities in its community
(Md. Code Ann. Health-Gen. 19-303(c)(vii)).
New York requires that implementation strate-
gies focus on at least two of the five state Preven- Community Benefit Reporting Documents.
tion Agenda priorities, at least one of which must A few of the ten states mandating implementa-
address a health disparity. For example, one of tion strategies require that reports of those strate-
the five priorities is “promote a healthy and safe gies be submitted on standardized forms. For ex-
environment” (NYSDOH, 2012b). Substantive ample, New Hampshire’s Community Benefit
goals established to effectuate this priority in- Reporting Guide classifies “community building”
clude 1) reducing exposure to outdoor air pollu- activities as a category of reportable community
tants; 2) improving the design and maintenance benefits and defines them as activities “intended
of the built environment to promote healthy life- to address social and economic determinants of
styles; and 3) improving the design and mainte- health” (New Hampshire Department of Justice,
nance of home environments to promote health 2008). Such activities might include adopt-a
and reduce illness (NYSDOH, 2012a). school efforts, mentoring programs, youth devel-
opment initiatives, home safety assessment and
The 2012 guidance document accompanying
installation, and welfare-to-work initiatives.
New York’s Prevention Agenda 2013-2017 “in-
corporates state and local experience developing New Hampshire’s required community benefit
and implementing” prior policy and is also reporting form reflects this expansive approach.
shaped by national accreditation of state and lo- The state supplies a chart that itemizes each
cal public health agencies. Its language more ex- community benefit reporting category, along with
plicitly supports hospital investment in activities a list of potential community health needs. In-
that address social, economic, and environmental cluded in the list of needs are socioeconomic fac-
factors (NYSDOH, 2012b). tors such as poverty, unemployment, educational
attainment, high school completion, vandal-
Statutes or Regulations. California and Mary-
ism/crime, homelessness, air quality, and water
land both define community benefit broadly as
quality (New Hampshire Department of Justice,
hospital activity “intended to address community
2008). To report the amount of dollars invested,
needs and priorities primarily through disease
hospitals match the category of each community
prevention and improvement of health status...”
benefit initiative with the specific need it ad-
(Cal. Health & Safety Code §127345(c); Md
dresses.
Code Ann. Health-Gen. 19-303(a)(3)). The Cali-
fornia statute provides the following examples of In Maryland, the Health Services Cost Review
community benefits: child care; sponsoring food, Commission (HSCRC) is the government entity
shelter, and clothing for the homeless; and “edu- that oversees state-required hospital community
cation, transportation, and other goods and ser- benefits. Maryland’s community benefit report-
7
ing guidance classifies many hospital activities programs on health care careers, and neighbor-
addressing social and economic factors as “com- hood watch groups, all of which may count as
munity building,” which is a category of commu- community benefit activities (HSCRC, 2013a).
nity benefit. Examples include, small business The activities themselves are reported on a pre-
development, mentoring programs, school-based formatted table.
Facilitative Implementation Strategy Approaches
Similar to federally required implementation in developing each implementation strategy.
strategies under ACA §9007, state implementa- Hospitals, in their implementation strategies,
tion strategies advance community benefit ac- must provide a brief explanation if they do not
countability and transparency. Like their federal accept community benefit proposals identified
counterparts, these strategies typically address through the stakeholder consultation process.
the costs associated with providing charity and (Wash. Rev. Code §70.41.470).
discounted care. They also delineate community
New Hampshire law contemplates that the views
benefit activities that a hospital plans to take to
of the community served by the hospital, com-
respond to significant health needs and describe
munity groups, members of the public, and local
existing activities in which a hospital is currently
government officials will be “solicited” during
engaged, including those addressing the social
implementation strategy development (N.H. Rev.
and economic factors that shape health.
Stat. Ann. Tit. I, §§7:32-e (vi)). The implementa-
The more accountability and transparency a state tion strategy report must include the means used
incorporates into its implementation strategy re- to solicit the views of the community served, and
quirements, the simpler it is for policymakers, must identify community groups, members of the
health departments, community organizations, public, and local government officials consulted
and the general public to assess the degree to on the development of the report.
which hospital activities target social and eco-
Rhode Island specifies that the communities that
nomic factors. As detailed below, there are sever-
are a focus of the strategy must be “involved” in
al approaches that states can utilize to facilitate
the planning and implementation process (23-
the goals of community benefit accountability
17.14 R.I. Code R. §11.5(b)(3)). If the state de-
and transparency.
partment of health receives “sufficient infor-
Community Engagement. Questions regarding mation” that a hospital has not complied with
accountability and transparency may arise during state community benefit requirements, including
the development phase of implementation strate- the requirement that communities are to be in-
gies. Neither the ACA nor the 2013 NPRM re- volved in the planning and implementation pro-
quire “real time” community engagement in the cess, the department is authorized to hold a hear-
development of implementation strategies.22 ing and impose penalties (23-17.14 R.I. Code R.
However, at least four states do establish such §11.5(b)(6)).
requirements along with a mechanism designed
New York State “asks” nonprofit hospitals to
to ensure that the required community engage-
“work with” local boards of health and communi-
ment occurs. Washington directs hospitals to
ty partners to complete their state-required im-
“consult” with community-based organizations,
plementation strategies. In connection with the
stakeholders, and local public health jurisdictions
8
two Prevention Agenda priorities required to be available to the public (proposed rule §1.6033-
included in the implementation strategy, hospitals 2(a)(2)(ii)(I)(2)). Of the ten states that require
must describe the organizations that participated hospitals to develop state implementation strate-
and the stakeholder sessions that were held gies, nine require that those documents be filed
(NYSDOH, 2012b). with a state agency. Washington is the outlier in
this regard, requiring that implementation strate-
Policymakers in some states may decide to align
gies be made “widely available to the public”
with the present federal standard, which does not
within the meaning of IRS regulations (Wash.
require direct community engagement during
Rev. Code §70.41.470(3)).
implementation strategy development. Officials
and decision makers in other states may wish to Electronic Availability. The current era of elec-
consider whether community engagement in im- tronic accessibility would seem to facilitate
plementation strategy development should be community benefit transparency. However, the
required. Some questions to consider include the IRS does not make Form 990, Schedule H, or the
following (Nelson et al., 2013): associated implementation strategies available
electronically.23 Several states, including Califor-
 What type(s) of engagement should be man-
nia, New Hampshire, and Vermont, do require
dated?
that state implementation strategy reports—or the
 Should tax-exempt hospitals be “required” or strategies themselves—be posted on a state web-
merely “encouraged” to “consult” with non- site (Cal. Health & Safety Code §127350(d);
hospital entities? If required, how will en- N.H. Rev. Stat. Ann. Tit. I, §7:32-g; Vt. Stat.
gagement be measured and enforced? Ann. Tit. 18 §9405b(c)). Under Maryland law,
the HSCRC is responsible for collecting hospital
 Should engagement with some entities, such
community benefit information from individual
as local boards of health, be mandated?
hospitals, which it compiles into a publicly avail-
 How much weight should hospitals give to able statewide Community Benefit Report (Md.
views from nonhospital entities that have Code Ann. §19-303(c)(1); (d)). This document is
been “solicited” and to the “involvement” of electronically available and contains a summary
outside groups? of statewide information, as well as information
from individual hospital community benefit re-
Permitting maximum input from all sectors and
ports (HSCRC, 2013b). Although it is apparently
the community at large certainly promotes com-
not required by state law, Indiana and Texas also
munity benefit accountability and transparency,
post implementation strategies on a state website.
but it must be weighed against considerations of
administrative efficiency and avoiding duplica- New York and Washington expressly require that
tive requirements. tax-exempt hospitals post their implementation
strategies on the hospital’s website (N.Y. Pub.
Filing with a State Entity. Federal requirements
Health Law §2803; Wash. Rev. Code
for filing federal implementation strategies differ
§70.41.470(3)(a)). Vermont requires posting on
from state requirements for filing state imple-
the hospital’s website as well as the state’s web-
mentation strategies. Tax-exempt hospitals must
site (Vt. Stat. Ann. Tit. 18 §9405b(b);(c)).
either file copies of their federally required im-
plementation strategies with Schedule H of IRS Ease of Comparison. One advantage of transpar-
Form 990 or provide the URL(s) of the web ency is the ease of comparing information about
page(s) on which the implementation strategy is community benefit initiatives. IRS Form 990 and
9
Schedule H are standardized forms that facilitate §11.5(b); Tex. Health and Safety Code
some degree of comparison. Maryland and New Ann.§311.044). New Hampshire and Rhode Is-
Hampshire also have prescribed formats for re- land further require hospitals to report activities
porting community benefit/community building that they anticipate undertaking in the near future
activities. (N.H. Rev. Stat. Ann., Tit. I §7:32-e); (23-17.14
R.I. Code R. §11.5(b)). In contrast, Vermont re-
Maryland requires hospitals to complete a pre-
quires hospitals to describe at least three—but
formatted table in which hospitals provide narra-
not necessarily all—initiatives that the hospital is
tive information about their community benefit
currently undertaking or planning to undertake
initiatives in the following categories: identified
(Vt. Reg. H-2009-05 §4 (B)(2)).
need, hospital initiative, primary objective of the
initiative, single or multi-year duration, key part- Policymakers who seek to encourage hospital
ners, evaluation dates, outcome, and continuation investment in activities that target social and
and cost of initiative. The use of a standardized economic determinants need to carefully assess
tabular format facilitates the comparison of dif- the transparency of their state community benefit
ferent hospitals’ initiatives. regulatory frameworks. Some decision makers
may determine that the federal scheme is suffi-
As previously described, a pre-formatted table is
cient to advance state goals and objectives. Fed-
also included in New Hampshire’s required im-
eral standards of community benefit transparency
plementation strategy reports, which facilitates
are an integral part of the federal regulatory
comparison of expenditures among hospitals;
scheme that recognizes the nine previously iden-
however, no narrative description is required.
tified community building categories (IRS,
n.d.a.). However, there is still some uncertainty
Specificity. The level of detail—including the
regarding which types of activities “count” as
minimum information hospitals must supply—
community benefits. States seeking to encourage
required in state implementation strategies and
hospitals to engage in a broader range of activi-
strategy reports varies from state to state. The
ties to address social and economic factors may
laws of California, Indiana, Maryland, Rhode
find that the degree of transparency established in
Island, and Texas appear to require tax-exempt
the federal system is not sufficient to afford ap-
hospitals to list all significant community benefit
propriate public understanding, oversight, and
activities (Cal. Health & Safety Code 127350(d);
monitoring.
Ind. Code §16-21-9-6; Md. Code Ann. Health-
Gen. §19-303(c)(1); 23-17.14 R.I. Code R.
Conclusions and Recommendations
This brief focuses on the state-level regulation of healthy foods, the environment, access to recrea-
hospital activities addressing social and econom- tional facilities, socioeconomic conditions, hous-
ic factors that shape health, in the ten states that ing, social cohesion and supports, language, liter-
require hospitals to develop implementation acy, culture, and transportation. Because all of
strategies. The four factors specifically addressed these factors are fundamental to healthy commu-
are: income, education, employment, and com- nities, they are likely of great importance to state
munity safety. But it is well established that other and local policymakers, as well as to tax-exempt
factors are also vitally important: availability of hospitals that are currently engaged in or plan-
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