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Provisions of the Affordable Care Act (ACA) encouraged tax-exempt hospitals to invest broadly in community health benefits. Four years after the ACA's enactment, hospitals had increased their average spending for all community benefits by 0.5 percentage point, from 7.6 percent of their operating expenses in 2010 to 8.1 percent in 2014.

Objectives: To identify how US tax-exempt hospitals are progressing in regard to community health needs assessment (CHNA) implementation following the Patient Protection and Affordable Care Act., Methods: We analyzed data on more than 1500 tax-exempt hospitals in 2013 to assess patterns in CHNA implementation and to determine whether a hospital's institutional and community characteristics are associated with greater progress., Results: Our findings show wide variation among hospitals in CHNA implementation. Hospitals operating as part of a health system as well as hospitals participating in a Medicare accountable care organization showed greater progress in CHNA implementation whereas hospitals serving a greater proportion of uninsured showed less progress. We also found that hospitals reporting the highest level of CHNA implementation progress spent more on community health improvement., Conclusions: Hospitals widely embraced the regulations to perform a CHNA. Less is known about how hospitals are moving forward to improve population health through the implementation of programs to meet identified community needs.

The current community benefit standard for nonprofit hospital tax exemption has been the subject of mounting criticism. Many different constituencies have advanced the view that in its present form it fails to ensure that nonprofit hospitals provide adequate benefits to their communities in exchange for their tax exemption. In contrast, hospitals have often expressed the concern that the community benefit standard in its current form is vague and therefore difficult to comply with. Various suggestions have been made regarding how the existing community benefit standard could be improved or even replaced. In this article, we first discuss the historical and legal development of the community benefit standard. We then present the key controversies that have emerged in recent years and the policy responses attempted thus far. Finally, we evaluate possible future policy directions, which reform efforts could follow.

The shift from local, community-based organizations to more complex delivery systems raises questions about the community orientation and accountability of health systems and their affiliates. This study examines whether hospitals affiliated with health care systems are more or less likely to engage in practices that reflect responsibility to their local communities by providing benefits in the form of uncompensated care, community engagement, Medicaid caseload, and accessible pricing policies. Using audited state data and other sources, we performed a longitudinal analysis on a pooled cross-sectional data file for the years 1989-2003 for all hospitals in Texas, California, and Florida. Results indicate that when compared to independent hospitals, system affiliation is associated with less community benefit. However, the level of community benefit varies depending on the type of community benefit examined and the structural characteristics of the system with which a hospital is affiliated. Results further suggest that the level and type of community benefit is conditioned by the market under which system-affiliated hospitals operate.

Recent investigations into the activities of nonprofit hospitals have pointed to weak or lax governance on the part of some of these organizations. As a result of these events, various federal and state initiatives are now either under way or under discussion to strengthen the governance of hospitals and other nonprofit corporations through mandatory board structures and practices. However, despite policy makers' growing interest in these types of governance reforms, there is in fact little empirical evidence to support their contribution to the effectiveness of hospital boards. The purpose of this article is to report the results of a study examining the relationship between the structure and practices of nonprofit hospital boards relative to the hospital's provision of community benefits. Our results point to modest relationships between these sets of variables, suggesting considerable limitations to what federal and state policy makers can accomplish through legislative initiatives to improve the governance of nonprofit hospitals.

Traditional control of nonprofit hospitals by the communities they serve has been offered as justification for restraining antitrust enforcement of mergers that involve nonprofit hospitals. The community is arguably a constraint on a nonprofit's inclination to exercise market power in the form of higher prices; however, community control is likely to be attenuated for hospitals that through merger or acquisition become members of hospital systems--particularly those that operate on a regional or multiregional basis. We report findings from a study in which we examined empirically the relationship between market concentration and pricing patterns for three types of nonprofit hospitals that are distinguishable based on degree of community control: an independent hospital, a member of a local hospital system, and a member of a nonlocal hospital system. Study results indicated that when conditions existed to create a more concentrated market, (1) all three types of nonprofit hospitals exercised market power in the form of higher prices, and (2) hospitals that were members of nonlocal systems were more aggressive in exercising market power than were either independent or local system hospitals. The results have important implications for antitrust enforcement policy.

This study focuses on the relationship between the business strategy of acute care hospitals and several organizational and environmental characteristics. Business strategy is assessed using the Miles and Snow (1978) typology. The organizational characteristics examined are size, system membership, type of ownership, and case-mix severity. The environmental characteristics examined are those of the local environment, which includes general economic factors and measures of market structure. General economic factors include family income, unemployment rate, percent of population over 65, and ratio of physicians to general population. The measures of market structure include the Herfindahl index and each hospital's individual market share. The results of our analysis using multiple regression indicate that organizational characteristics are more likely than environmental factors to influence the business strategy of hospitals. Specifically, hospitals that are relatively small or operate independently are less likely than other hospitals to follow a proactive strategic orientation.