Teaching hospitals are an essential component of the U.S. health care safety net: The teaching hospital members of the Association of American Medical Colleges (AAMC), for example, provide 31% of all hospital charity care and 25% of all Medicaid inpatient services, despite comprising only 5% of the acute care, general service hospitals in the United States.1 Since the passage and implementation of the Patient Protection and Affordable Care Act (ACA),2 new regulations, accreditation expectations, and research opportunities have driven teaching hospitals beyond their walls and deeper into the communities they serve to better understand and intervene on the social determinants of health (SDOH) that affect patient, population, and community well-being.
In addition to increasing patient access to health insurance, including Medicaid coverage, the ACA accelerated the development of value-based population health management strategies (e.g., accountable care organizations, patient-centered medical homes) and codified new requirements for 501(c)(3) hospitals (a not-for-profit designation that applies to the vast majority of teaching hospitals) to conduct a triennial community health needs assessment (CHNA), which is intended to deepen partnerships with public health entities and community residents in order to prioritize and address local heath and health care needs.2 (The first CHNA cycle began in 2012–2013, although the final regulations were not in place until December 2014.) The ACA also launched the Patient-Centered Outcomes Research Institute, elevated the status of the National Institute of Minority Health and Health Disparities within the National Institutes of Health (teaching hospitals and medical schools receive nearly 55% of all extramural NIH dollars3), and established the Innovation Center at the Centers for Medicare & Medicaid Services, which, among other projects, is testing the impact of collecting social risk factor data within clinical settings.4
Concomitant with these developments, payers and measure-endorsing bodies such as the National Quality Forum have been working since at least 2014 to develop metrics and road maps to incentivize health and health care equity via pay-for-performance programs,5 the Accreditation Council for Graduate Medical Education in 2014 introduced new expectations for resident trainee education on health and health care inequities,6 and the Medical College Admission Test (MCAT) in 2015 included for the first time questions related to social and cultural contributors to health.7
A measure often used to quantify not-for-profit hospitals’ commitment to improving community health and to addressing health and health care inequities is their formal community benefit spending as reported to the Internal Revenue Service (IRS). However, the impact of the multiple pressures tied to the ACA and its implementation on teaching hospitals’ community benefit spending has not been assessed.
Community benefit requirements for federally tax-exempt, not-for-profit hospitals were codified in 1954 by the IRS via Section 501(c)(3) of the Internal Revenue Code,8 which, in part, requires a hospital seeking tax-exempt status to be organized and operated exclusively for charitable, scientific, and/or educational purposes. In 1969 the IRS issued a revenue ruling that, in part, recognized that if a hospital were to generate any surplus funds, it would further its tax-exempt purpose if it used such funds to improve the quality of patient care, expand its facilities, and/or advance medical training, education, and research.9 In 2008 the IRS added Schedule H to Form 990 so that hospitals could report annually on “community benefit” activities and related spending.10 Analyses suggest that, annually, the average not-for-profit hospital spends roughly 7.6% of its operating budget, or 9.7% of its total functional expense (TFE), on community benefit.11–13
Prior to the implementation of the ACA, not-for-profit hospitals often found their federal tax-exempt status under scrutiny as critics argued either that hospital community benefit dollars were spent largely on charity care rather than on more fundamental contributors to community health such as the SDOH, or that the amount spent in service of community benefit was inadequate relative to the amount of tax that hospitals did not have to pay.14–17 These criticisms might have less applicability to teaching hospitals, however: Research has shown that teaching hospitals are more likely than nonteaching hospitals to allocate dollars to community health improvement activities and to be in the top quartile of the community benefit spending distribution.11 , 13 , 18
Since ACA implementation, many articles have been written about the promise the CHNA offers as a means of providing locally derived guidance for community benefit activity and, for teaching hospitals, as an organizing principle for community-relevant work across research, education, and clinical missions.18–22 However, recent reporting, particularly in the mainstream political press, has suggested that as ACA-driven Medicaid expansion has diminished the need for charity care in expansion states, select teaching hospitals in these states have pocketed, rather than diverted to other areas of community benefit, the charity care money they have saved as a result of increased Medicaid enrollment.23 , 24
A more comprehensive analysis than those completed to date is needed to better understand how America’s teaching hospitals are deploying their community benefit dollars as the need for charity care is declining. Because of the converging pressures and opportunities across teaching hospitals’ clinical, education, and research missions, as described above, it is an opportune time to quantify—and to develop a new, post-ACA baseline understanding of—how teaching hospitals are making investments in their communities as imperatives and expectations about their community commitments are growing and evolving.
This study aims to describe changes in community benefit allocation between 2012 (pre-ACA implementation) and 2015 (post-ACA implementation) at teaching hospitals across the United States. It also aims to explore differences in community benefit spending between teaching hospitals in states that chose to expand Medicaid coverage (Medicaid expansion states) compared with teaching hospitals in states that did not (nonexpansion states).
As of August 1, 2017, in addition to health systems, 310 individual teaching hospitals were members of the AAMC’s Council of Teaching Hospitals and Health Systems. Of these 310 teaching hospitals, 112 were exempt from Schedule H reporting: 55 were state or county affiliated and, as “government entities/instruments,”25 were either not required to submit a Schedule H with their Form 990 or only required to submit an abbreviated Form 990-T (which contains no Schedule H information); 47 were Veterans Affairs medical centers; 9 were for-profit hospitals; and 1 was part of the Indian Health Service. The other 198 AAMC member teaching hospitals were required to remit a Schedule H and therefore were included in our sampling frame.
Given that teaching hospitals use different date ranges for their tax years, for each of the eligible 198 hospitals we sought the first Form 990 that included at least six months in calendar year 2012 (pre-ACA implementation) and the first Form 990 that included at least six months in calendar year 2015 (post-ACA implementation).
If a teaching hospital is a member of a health system, it may remit its tax documents either independently or as part of a group return representing all or part of the parent health system. Any Form 990 that satisfied our inclusion criteria and contained community benefit data for an AAMC member teaching hospital was included in the sample, even if it was a group return that included financial data for nonteaching members of the parent health system.
Community benefit data
Using hospital and health system names and either employer identification numbers or taxpayer identification numbers, during June–September 2017 we searched three sources for the targeted Form 990s: ProPublica’s Nonprofit Explorer database,26 the GuideStar database,27 and individual teaching hospital websites.
The following Schedule H items defined each community benefit expense, as delineated in Part I, Table 7, “Financial Assistance and Certain Other Community Benefits at Cost”28 (where estimated costs are calculated by deflating charges for those services based on the hospital’s overall cost-to-charge ratio):
- charity care (line A, financial assistance at cost), defined in IRS instructions as “free or discounted services provided to persons who meet the organization’s criteria for financial assistance and are unable to pay for all or a portion of their services”;
- shortfalls for Medicaid (Line B) and other means-tested government programs (Line C), defined as the estimated cost of providing patient care to patients paid by Medicaid or other means-tested government programs (e.g., the State Children’s Health Insurance Program), minus all offsetting revenue;
- community health improvement activities and community benefit operations (line E), defined as “activities or programs, subsidized by the health care organization, carried out or supported for the express purpose of improving community health” that do not “generate inpatient or outpatient revenue”;
- health professions education (line F), defined as “educational programs that result in a degree, certificate, or training necessary to be licensed to practice as a health professional” but not “training programs available exclusively to the organization’s employees … or scholarships”;
- other subsidized health services (line G), defined as “clinical services provided despite a financial loss to the organization”;
- research (line H), defined as investigations that aim to “generate increased generalizable knowledge made available to the public”; and
- cash and in-kind contributions (line I), restricted, in writing, to “one or more of the community benefit activities described in the table.”
To appropriately compare pre- and post-ACA implementation expenses, we excluded research dollars (line H) when calculating total net community benefit expense because a reporting requirement change in 2013 removed restricted research grant funding from Schedule H reporting.29 We also excluded health professions education dollars (line F) to capture only near-term investments in community health. All other individual line items in Table 7 were aggregated.
Thus, pre- to post-ACA implementation changes in net community benefit spending were gleaned by subtracting the 2012 net aggregate expense (Table 7, lines A + B + C + E + G + I) from the 2015 net aggregate expense.
We recoded negative values as 0 in fields where IRS instructions28 disallowed negatives in line total values.
Medicaid expansion status was defined as all states that adopted the ACA’s expansion of Medicaid coverage for most low-income adults to 138% of the federal poverty line, current as of December 31, 2015. In total, 30 states (including the District of Columbia, considered a state in this analysis) had adopted and 21 states had not adopted Medicaid expansion in that time frame.30
For all community benefit values expressed as a percentage of total expenses, we used the teaching hospital’s own reported TFE as the denominator, derived from Form 990, Part IX, line 25, column A. We calculated change rates for all expenses and percentages by subtracting the 2012 rate from the 2015 rate.
To compute statistical significance, we used the following statistical tests:
- Paired t tests for 2012 and 2015 rates to compute whether a change from pre- to post-ACA implementation is greater or less than 0.
- Two-tailed t tests to compare the change rates between groups, testing for differences in the rates of change for teaching hospitals in Medicaid expansion states compared with those in nonexpansion states.
We used SAS 9.3 (SAS Institute Inc., Cary, North Carolina) to conduct the analyses. Statistical significance is indicated in the tables for the α = 0.01 (99% confidence level), the α = 0.05 (95% confidence level), and the α = 0.10 level (90% confidence level).
Of the 198 AAMC member teaching hospitals required to submit Schedule H, 14 were excluded from this analysis: 2 hospitals’ 2015 Form 990s did not meet the inclusion criteria, 5 hospitals only had Form 990-Ts available for one or both of the study years, and 7 hospitals were missing Form 990s for one or both of the study years.
The final study sample included 169 pairs of Form 990s (from 2012 and 2015) representing 184 teaching hospitals across the United States (93% of the 198 AAMC member teaching hospitals required to remit Schedule H). Of these 169 pairs, 129 corresponded to individual institutions and 40 to health system group returns representing 55 additional AAMC member teaching hospitals as well as other hospitals within the health system. Our analysis included hospitals in 35 states, of which 23 were Medicaid expansion states and 12 were nonexpansion states.
As Table 1 shows, while charity care spending decreased by $804 million (16.17%) between 2012 and 2015, there was a net increase in total community benefit dollars spent of $3.1 billion—an increase of 20.14%. Nearly $875 million of this increase was allocated for community health improvement activities, subsidized health services, and cash/in-kind contributions. As a percentage of total community benefit spending, the largest changes were two countervailing trends: net charity care decreased by 9.84%, while net Medicaid shortfall spending increased by 9.06% (or $3.05 billion dollars). (These two factors and their relationship to Medicaid expansion status are further explored below). After adjusting for inflation from 2012 to 2015 (approximately 4.17% three-year inflation factor according to the Consumer Price Index for All Urban Consumers31), the increase in total community benefit spending was 15%, or $2.4 billion in 2015 dollars.
Table 2 presents the mean community benefit values expressed as a percentage of the health care organization’s TFE. The increase in total community benefit as a percentage of TFE from 6.73% in 2012 to 6.87% in 2015 was not statistically significant at the 95% confidence level. When we included research and education dollars in community benefit totals (data not shown) for comparison with the average of 9.7% of TFE for federally tax-exempt hospitals reported in the literature for tax year 2011,12 AAMC member teaching hospitals contributed 11.3% of their TFE in 2012 and 9.4% in 2015 to community benefit, with the decrease in 2015 due to the changes in allowable research reporting (as described above).
Across all teaching hospitals in the sample, there was a significant decrease of 0.74% of TFE (P < .001) in the mean community benefit going to charity care, and a significant increase of 0.73% of TFE (P < .001) in the mean Medicaid shortfall spending. There were no significant changes at the 95% confidence level, either decreases or increases, in the proportional allocations of other forms of community benefit.
Table 3 presents a comparison of changes in community benefit spending as a percentage of TFE for AAMC member teaching hospitals in Medicaid expansion and nonexpansion states. Compared with spending changes by teaching hospitals in nonexpansion states, teaching hospitals in expansion states increased the proportion of community benefit dollars spent as a percentage of TFE on subsidized health services (by 0.34% more, P = .03) and Medicaid shortfall spending (by 0.82% more, P = .03). Conversely, relative to spending changes by teaching hospitals in Medicaid expansion states, teaching hospitals in nonexpansion states increased the proportion of community benefit dollars going toward cash/in-kind contributions (0.37% more, P = .004) and community health improvement services (0.26% more, P = .09).
The ACA sought to increase the number of Americans with health insurance, including Medicaid, and therefore decrease the need for charity care. The results presented here demonstrate that the implementation of the ACA had the desired effect: between 2012 and 2015, spending on uncompensated care at AAMC member teaching hospitals decreased by more than $800 million. However, this decrease was offset by $3.1 billion in increases in other forms of community benefit spending: New spending totaling nearly $875 million went to support community health improvement activities, cash/in-kind contributions, and subsidized health services, in addition to a $3 billion increase in Medicaid shortfall spending. Overall, our results indicate that AAMC member teaching hospitals increased their total community benefit spending by 20.14%, from $15.3 billion in 2012 to $18.4 billion in 2015 (a 15% increase in 2015-adjusted dollars31). Although the 0.15% increase from 2012 to 2015 in mean community benefit spending as a proportion of TFE was not statistically significant, it aligns with recent research showing a statistically significant increase of 0.5% between 2010 and 2012 in community benefit spending as a proportion of operating expense across all 1,500 not-for-profit hospitals in operation during those years.13
The impact of the ACA and other drivers on AAMC member teaching hospitals’ community benefit allocations did differ between Medicaid expansion and nonexpansion states. In states that chose to expand Medicaid, hospitals increased their spending on subsidized health services and Medicaid shortfalls. In states that declined Medicaid expansion, hospitals increased spending on community health improvement services and cash/in-kind contributions. In the absence of qualitative data, it is impossible to fully explain these differences; however, the kind of community benefit spending required to care for a large influx of newly insured patients necessarily differs from the community benefit reallocation opportunities in states wherein fewer people have access to health care services in the first place. In an environment with increased attention to issues of health care and community health, hospitals in nonexpansion states likely felt the need to do something: Indeed, Table 3 shows that Medicaid shortfall spending increased in nonexpansion states, potentially pointing to efforts to enroll eligible patients even as the pre-ACA Medicaid threshold remained in place.
Our results suggest that requiring that a specific, one-size-fits-all proportion of revenue be earmarked for Schedule H activities is unnecessary and, potentially, counterproductive. Considered together, the trends of increased community benefit spending at teaching hospitals across the nation, coupled with important differences in benefit spending between hospitals in states with distinct Medicaid policies, reinforce the view that further regulation and oversight of the community benefit process are not needed. Teaching hospitals are already deepening their commitment to community health and benefit by spending more, and they are doing so in response to locally defined needs and in the absence of required monetary thresholds. Teaching hospitals, in particular—which, as previously noted, provide more money for community benefit and community health improvement than do other types of not-for-profit health care organizations11 , 13—need the flexibility to determine the best ways to deploy their scientific, clinical, financial, and educational resources. Indeed, the increase in community benefit spending described in this study aligns with other analyses that demonstrate teaching hospitals’ commitment to addressing the SDOH through the CHNA process and to offering community-based programs and interventions more frequently than their nonteaching counterparts.1 , 32
However, opportunities exist for teaching hospitals to increase the impact of the community benefit and health improvement activities reported on their Schedule Hs, particularly through the CHNA. When viewed as a piece of community-engaged, health equity research, the CHNA could serve as the organizing principle not only for how and where community benefit dollars are spent but also for which research questions are asked, which service learning opportunities are developed, and where clinical services are provided in the community. Efforts to “systematize”—in ways unique to communities and their health care partners—community health activities are currently under way and are at the vanguard of ensuring the efficient, aligned, and authentic community partnerships necessary for maximum impact on community health and health inequities.33 For medical educators, the Schedule H provides a potential gateway for learner exposure to aspects of health policy, population health, and community partnership that simultaneously reinforce the new MCAT questions on sociocultural contributors to health and are quickly becoming essential knowledge for future physicians as they navigate the transition from volume to value.
Significant attention is placed on charity care spending by those who question whether health care organizations deserve their federal tax-exempt status. This study shows that teaching hospitals are devoting more money to community benefit following ACA implementation and are doing so in ways that respond to the unique challenges and opportunities in their states and local communities. As health care organizations develop expertise in CHNA requirements, and as the health care landscape continues to shift under the current administration, it will be instructive to compare future community benefit spending with the baseline reported here.
Limitations and strengths
The study analyses included only AAMC member teaching hospitals and may not generalize to the broader community of tax-exempt hospitals or the larger teaching hospital community. As noted above, state-affiliated teaching hospitals exempt from Schedule H reporting were excluded, undoubtedly diminishing the dollar amounts reported in terms of overall financial support by AAMC member teaching hospitals for community health improvement work. Because we included group returns, which did not specify which dollars were attributable to which health system member, not all of the data reported in the tables reflect only teaching hospital spending, though the vast majority do. An important potential confounder of the dollar amounts reported is the mergers and acquisitions that might have occurred at the individual institution and health system levels between 2012 and 2015. To address this concern, we expressed change rates as a percentage of TFE. Although Schedule H does provide not-for-profit health care organizations the opportunity to describe in free text their CHNA process and related implementation strategy, as well as other facets of their community health improvement work, qualitative analyses were beyond the scope of this research; however, results of such text-based analyses have been published elsewhere.15 , 32 Additionally, we decided not to include analysis of the “community building” activities reported on Part II of Form 990 because those data were inconsistently reported on the tax documents. Therefore, our results likely underestimate the financial and resource commitments that teaching hospitals bring to bear on the SDOH. Finally, we did not adjust for differences between Medicaid expansion and nonexpansion states that might influence hospital community benefit spending, such as community-level sociodemographic factors.
Despite these limitations, this research benefits from significant strengths. First, given the concentration of community-health-related drivers implemented between 2012 and 2015, as described above, this analysis presents a useful first snapshot of community benefit spending and allocation changes attributable to some degree to those legislative, regulatory, and accreditation imperatives and opportunities. Further, AAMC member teaching hospitals, while only comprising 5% of hospitals nationwide, provide 25% of Medicaid inpatient services. Thus, this research presents an important picture of how teaching hospitals serving the most underresourced and vulnerable patients and neighborhoods are meeting the needs of their communities via community benefit spending.
After ACA implementation, federally tax-exempt AAMC member teaching hospitals increased their overall community benefit spending even as their charity care spending declined. Teaching hospitals’ allocations of community benefit dollars differed by their states’ Medicaid expansion status, demonstrating hospitals’ responsiveness to their state and local realities.
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