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Objective: To determine if greater non-profit hospital spending for community benefits is associated with better health outcomes in the county where they are located. Data Sources and Study Setting: Community benefit data from IRS Form 990/Schedule H was linked to health outcome data from Area Health Resource Files, Map the Meal Gap, and Medicare claims from the Center for Medicare and Medicaid Services at the county level. Counties with at least one non-profit hospital in the United States from 2015 to 2019 (N = 5469 across the 5 years) were included. Study Design: We ran multiple regressions on community benefit expenditures linked with the number of health professionals, food insecurity, and adherence to diabetes and hypertension medication for each county. Data Collection: The three outcomes were chosen based on prior studies of community benefit and a recent survey sent to 12 health care executives across four regions of the U.S. Data on community benefit expenditures and health outcomes were aggregated at the county level. Principal Findings: Average hospital community benefit spending in 2019 was $63.6 million per county ($255 per capita). Multivariate regression results did not demonstrate significant associations of total community benefit spending with food insecurity or medication adherence for diabetes. Statistically significant associations with the number of health professionals per 1000 (coefficient, 12.10; SE, 0.32; p < 0.001) and medication adherence for hypertension (marginal effect, 0.27; SE, 0.09; p = 0.003) were identified, but both would require very large increases in community benefit spending to meaningfully improve outcomes. Conclusions: Despite varying levels of non-profit hospital community benefit investment across counties, higher community benefit expenditures are not associated with an improvement in the selected health outcomes at the county level. Hospitals can use this information to reassess community benefit strategies, while federal, state, and local governments can use these findings to redefine the measures of community benefit they use to monitor and grant tax exemption. KEYWORDS health care disparities, health care organizations and systems, health economics, health policy/politics/law/regulation, hospitals, state health policies What is known on this topic * Non-profit hospitals spend billions of dollars on community benefits with the expectation that they will provide benefits to their local communities. * The impact of these investments is not well known. What this study adds * Hospital community benefit expenditures are not associated with better health outcomes at the county level., 1 | INTRODUCTION In a report released by the American Hospital Association in 2021, non-profit hospitals claimed to be spending $105 billion on community benefit services in 2018. (1) Proponents [...]

Objective: We examined the characteristics of non-profit hospitals providing more community benefits and charity care than value of their tax exemptions and how this relationship changed between 2011 and 2018. Data sources: Primary dataset was schedule H Form IRS 990 data. This data was merged with the American Hospital Association, Medicare Hospital Cost Report, and the America Community Survey. Study design: We measured six categories of tax benefits and 17 types of community benefits. Subtracting the average value of community benefits provided by for-profit hospitals, we computed incremental community benefit and charity care provided by each non-profit hospital. Extraction methods: A nationally representative sample was created of 11 776 non-profit hospital-year observations from 1472 unique hospitals over the 2011 to 2018 period was created. Descriptive analyses and random effect logistic regression were used to show associations between hospital characteristics and difference between incremental net community benefits and the value of tax-exemption. Principal findings: After adjusting for community benefits provided by for-profits hospitals, on average, non-profit hospitals spent 5.9% (CI: 5.8%-6.0%) of their total expenses on community benefits; 1.3% (CI: 1.2%-1.3%) on charity care; and received 4.3% (CI: 4.2%-4.4%) of total expenses in tax exemptions. A total of 38.5% of non-profit hospitals did not provide more community benefit and 86% did not provide more charity care than the value of their tax exemption. Hospitals with fewer beds, providing residency education and located in high poverty communities were more likely to provide more incremental community benefits and charity care than the value of their tax exemption, while system affiliation had a negative association. Conclusion: The amount of community benefits and charity care provided by nonprofits varied substantially across non-profit hospitals. Establishing minimum requirements for non-profit hospitals or publicly ranking hospitals based on their community benefit or charity care contributions, could encourage greater community benefits and charity care. KEYWORDS charity care, community benefit, inequality, non-profit, tax-exemption, 1 | INTRODUCTION Community benefit is often cited as a justification for hospitals' taxexempt status. (1) Studies have examined the community benefit and the value of tax benefits and found [...]