At Community Catalyst we are often asked for lessons or insights into the Community Health Needs Assessments that non-profit hospitals have been generating. In fact, we are in regular communication with several groups around the country who are monitoring Community Health Needs Assessments (CHNAs) in their communities. We asked one of our partners, Georgia Watch, to share some highlights from their review of several first round CHNAs and implementation strategies produced in Georgia during 2012-2013. Their research offers valuable insights into the processes hospitals used and the opportunities for advocates and community-based organizations to engage with their hospitals as the next round of CHNAs are conducted in 2015-2016. For more resources and tools to support this work, please visit our website.

-Michele Craig, Hospital Accountability Project

Georgia Watch is a statewide consumer advocacy organization based in Atlanta, Georgia. The Nonprofit Hospital Community health Needs Assessments in Georgia report reflects our recent efforts to review the initial CHNAs and available implementation strategies for 38 non-profit hospital facilities throughout Georgia. Our goal was to understand whether hospitals were complying with the community benefit requirements established in the  Affordable Care Act (ACA). The ACA included important provisions around hospital community benefit and mandates that all 501(c)(3) non-profit hospitals conduct a CHNA and write a corresponding implementation strategy every three years. The ACA requires that hospitals seek input from community members and public health when conducting CHNAs. 

As part of our research for the report, we developed evaluation tools to assess hospital compliance with five major components of the new ACA requirements: 1) defining community; 2) collecting secondary data on community health; 3) gathering community input and primary data; 4) prioritizing community health needs; and 5) implementing strategies to address identified community health needs. We also conducted interviews with hospital leadership and surveyed those community members who provided input into their local hospital’s CHNA to gain a deeper understanding of the hospital processes used in 2012-2013.

The CHNAs varied tremendously. Some were very robust with a 200+ page length, while others were less than 10 pages and lacking in detail and transparency. From this review, we identified key takeaways and recommendations for moving forward.

Defining Community

  • When defining community, only 28 (74 percent) of the hospitals clearly articulated how they defined their communities, despite the IRS requirement that they do so.
  • Twenty-five hospitals (66 percent) used internal hospital utilization data, such as admissions and discharges, to either define their communities or assess the health needs of their communities in their CHNAs.

Community Input

  • All 38 hospitals gathered input from their community through surveys, interviews, focus groups or community meetings, but only seven (18 percent) explicitly and intentionally gathered input from members of vulnerable populations.
A green and grey pie chart shows that only 18% of hospitals gathered community input from vulnerable populations.
  • Only 12 hospitals incorporated community members into their CHNA project leadership teams.
  • Thirty-one hospitals (82 percent) stated that they collected input from county or regional health departments in their service areas.

Secondary Data Collected

  • Hospitals most frequently gathered and reported data on the following social determinants of health: education level, income, and healthy food access.
  • Only thirteen hospitals (34 percent) collected data on environmental health indicators, including public safety, transportation, parks, pollution, and water quality.
Green bar chart shows how many hospitals collected data in certain social determinants of health.

Prioritizing Needs

  • Seven of the 38 hospital CHNAs (18%) reviewed failed to describe how they prioritized community needs with any amount of detail, despite the IRS requirement that they do so.
  • Only eleven of the 31 hospitals that articulated how they prioritized community health needs clearly incorporated community representatives into their needs prioritization process.
  • No hospitals prioritized health needs related to physical environment, such as improving housing or building parks.
  • The most common community health needs prioritized by hospitals were those related to chronic diseases, such as heart disease, cancer, obesity, and diabetes.

Implementation Strategies

  • Only 16 of the 29 hospital implementation strategies (55 percent) reviewed included an anticipated impact or method of measuring the impact of their programs.

Recommendations

  • When defining community, hospitals should identify and focus on vulnerable populations, even if they are not the hospitals’ traditional service-seeking patients, and they should examine their emergency room utilization data to better understand the needs of the vulnerable community members they serve.
  • Hospitals should gather input from members of vulnerable populations when assessing community health needs and incorporate community members into their prioritization and implementation processes.
  • Hospitals should also engage in partnerships with local health departments and community-based organizations, as collaboration and coordination are keys to improving community health.

In order to improve transparency and inclusion in the CHNA process, it is critically important for individuals outside of hospital administration to understand what is required of hospitals in conducting CHNAs. Community groups and advocacy organizations must remain vigilant in order to keep non-profit hospitals working cooperatively with public health departments and community-based organizations to improve population health. 

We hope that our report provides community members with the knowledge they need to evaluate the adequacy of CHNAs from nonprofit hospitals within their communities, engage with hospitals in the CHNA process, and encourage their local hospitals to develop impactful community benefit programs. 

If interested, please also read our recently released companion report that traces the evolution of the IRS regulations governing the CHNA process, from the initial IRS Notice in 2011 to the final regulations published at the end of 2014.   

The project described in this post was funded solely by the Healthcare Georgia Foundation. Created in 1999 as an independent private foundation, the Healthcare Georgia Foundation's mission is to advance the health of all Georgians and to expand access to affordable, quality healthcare for underserved individuals and communities.

– Beth Stephens, J.D., Health Access Program Director, Georgia Watch

Last Thursday the Supreme Court ruled that millions of people can have tax credits to help them purchase health coverage. The next day the Court made marriage equality the law of the land. Both decisions are the culmination of years of policy and legal strategies, organizing, and advocacy. Both are about fundamental human rights. Both had strong connections to organizing efforts in Massachusetts. The two cases are also connected in their future impact. LGBT people face deep disparities in accessing comprehensive health care and marriage equality can help remove those barriers. The ACA ruling ensures that a married LGBT couple who meet the eligibility guidelines will be able to access tax credits to make health insurance more affordable.

Health Care For All in Massachusetts laid the groundwork for national reform not just in 2006, when the state passed health reform, but in 1985 when it began its work. Mass Equality organized an amazing campaign to make marriage equality a reality in the state in 2004. Community Catalyst, in its previous incarnation, The Villers Foundation, was the first funder of Health Care For All and partnered with the organization to expand access to health care in Massachusetts. Community Catalyst was also supportive of the marriage equality campaign. Marcia Hams, a long-time Community Catalyst staff member, and Susan Shepherd, her wife, were the first gay couple in the country to get a marriage license. Marcia was a leader in both winning efforts.

The Supreme Court’s decisions are not end points– they are victories in the long road toward a more just society. Marriage equality is already meeting resistance in pockets of the country and there is still work to do to ensure LGBT people achieve full equality. The calls for repeal of the ACA continue, and 22 states refuse to close the coverage gap by expanding Medicaid. But the Court decisions show that momentum is moving in our direction as the recent Kaiser Family Foundation poll shows.

The 2016 elections will be the next big test for both issues, which means new strategies and more organizing and advocacy.

We’re still celebrating the Supreme Court’s decisions regarding health care and marriage equality from last week. But, we’ve also now taken time to evaluate just what these decisions mean—together. In other words, how do the Affordable Care Act and marriage equality interact to shape whether LGBT consumers have access to equitable, affordable, and comprehensive health insurance and health care?

Kaiser Health News predicts that the marriage equality ruling will likely result in more consumers accessing employer-sponsored coverage because they will now be able to rely on their partners’ coverage. In addition to workers gaining coverage from their employers, the answer also lies in special enrollment periods and Medicaid coverage.

  1. Special Enrollment Periods (SEP): After the end of open enrollment, particular qualifying life events enable consumers to enroll in Marketplace coverage—in State Based and Federally-facilitated Marketplaces. One of these qualifying life events is marriage. However, prior to the marriage equality ruling, this left some consumers out of the running. The Federally-facilitated Marketplace could only recognize a same-sex marriage as a SEP so long as the marriage occurred in a state where it was legal. If a couple couldn’t travel to a marriage equality state to get married (place of celebration), and their home state (place of domicile) didn’t allow same sex marriage, they were out of luck, and forced to apply for Marketplace coverage as individuals during the open enrollment period.

    Now, with marriage equality standing as the law of the land, it seems plausible that we’ll see an increase in marriages between same-sex couples, many likely occurring outside of the open enrollment period. So now, regardless of where a same-sex couple resides, their marriage will qualify them for a SEP if it happens outside the open enrollment period. LGBT and consumer health advocates in Georgia have already launched a new “Say ‘I Do’ to Healthcare” campaign to encourage same-sex couples who get married this summer—or any other time outside of the November 1, 2015 to January 31, 2016 open enrollment period—to apply for coverage through a SEP.
     
  2. Medicaid: While the federal Marketplace previously recognized married same-sex couples as eligible for tax credits and Marketplace coverage, the same is not true for Medicaid. Because Medicaid is a shared state and federal program, it was left up to each state to determine if same-sex married couples were eligible to apply for Medicaid coverage together. Not surprisingly, those states that didn’t have marriage equality weren’t likely to allow same-sex couples married in other states to apply for Medicaid together in their home state. However, the Supreme Court’s ruling changes this; same-sex couples in all 50 states should now also be able to apply for Medicaid together.

This doesn’t, however, mean that the fight to close the coverage gap is over. We know that LGBT people, and especially LGBT people of color, are disproportionally lower income. In fact, more than 60 percent of LGBT people with incomes under $47,080 (400 percent of the federal poverty level) would qualify for Medicaid expansion. LGBT people across the country need all state governments to expand their Medicaid programs.

However, sweeping discrimination still exists for many lesbian, gay, bisexual and especially transgender people—in many states, for example, same-sex couples can now get married but can also still be legally fired for their sexual orientation. One way we can begin to counter disparities and discrimination in areas such as health care access, housing, and the workplace is by collecting data on the experiences of LGBT people.

Community Catalyst and the Center for American Progress teamed up to create a compilation of data collection opportunities that advocates can use around the country. For example, advocates can encourage states to begin to include sexual orientation and gender identity questions on their Marketplace applications. Many states also conduct population surveys that should collect LGBT data—for example, the Behavioral Risk Factor Surveillance System (BRFSS) now has a question set on sexual orientation and gender identity that states can choose to use, and in 2014 alone more than 15 states added this question set to their BRFSS questionnaire.

While we continue to celebrate the Supreme Court’s decisions from last week, we know there’s much more work to be done.

Failing to close the gap is a missed opportunity for consumers, hospitals and states. The uninsured rate in the 30 states (including D.C.) that have closed the gap fell from 18 percent to just below 11 percent. States have reaped billions in savings from new revenues and reduced costs of caring for the uninsured. And enrollment in new coverage options has saved hospitals across the country $7.4 billion in uncompensated care costs in 2014 – with hospitals in expansion states reaping double the savings as those in non-expansion states.

With all this evidence of the benefits of covering more people, we’d have to disagree with recent reports that suggest that closing the coverage gap is not helping hospitals’ bottom lines. First of all, it’s important to remember that Medicaid expansion was never intended to be a silver bullet for hospital finances. Nevertheless, evidence so far demonstrates that closing the coverage gap is a precondition for hospitals to thrive financially. This recent study illustrates the wide array of benefits to hospitals of closing the coverage gap:

  • Hospitals in states that have closed the coverage gap saw larger declines in uninsured patients and greater savings in uncompensated care. In expansion states, hospitals saw between a 32 to 72 percent decline in uninsured patients, compared to a 0 percent to 14 percent decline for hospitals in non-expansion states. One hospital system even reported a 40 percent drop in uncompensated care in expansion states compared to a 6 percent increase in non-expansion states.
  • Hospitals in states that closed the coverage gap find it less costly to provide care to poor patients. A study by Modern Healthcare has found that hospitals in expansion states saw a higher average year-over-year revenue increase compared with non-expansion states. And according to one large hospital system (located in 16 states and D.C.), expansion led to an overall decrease in cost of care to the poor as a result of lower uncompensated care and increases in Medicaid revenue from covering more low-income adults.

Likewise, the converse is true – hospitals are more likely to be struggling in states that have not closed the gap. By not covering people who would be eligible for Medicaid under the ACA, hospitals in those states will be vulnerable to federal-level changes to hospital funding. Rural hospitals are especially at risk. Since 2013, 24 rural hospitals have shut down across the nation, and most of those have been in states that have not extended coverage. By closing the gap, these states would boost the number of insured people, reduce uncompensated care costs and help struggling hospitals avoid closing their doors. Closing the gap is an opportunity that should not be missed by state policymakers. 

South Carolina Governor Nikki Haley has called for the removal of the Confederate flag from the State House. Yet, she remains adamantly opposed to accepting the federal dollars set aside to extend Medicaid coverage to low-income South Carolinians. In last week’s New Yorker, former South Carolina state representative and Community Catalyst Board member Anton Gunn points out: “If you take the flag down tomorrow, what is going to substantively change in the lives of black people and people affected by inequality in South Carolina?” 

Last week’s Supreme Court decision on the Affordable Care Act benefits South Carolinians by allowing more than 200,000 of them keep federal tax credits to support their health coverage. However, nearly the same number of South Carolinians fall into the “coverage gap” because of Governor Haley and the legislature’s refusal to expand Medicaid. 

Closing the gap would substantially change the lives of black people in South Carolina. It would provide health coverage to 178,000 uninsured South Carolinians – disproportionately made up of people of color. Nationally, over a quarter of the potential beneficiaries are black. Our Close the Gap campaign is working on closing the coverage gap in the 21 states that have not done so. The racial dynamics of the campaigns cannot be overlooked - most of those states were slave states. Of the states that were part of the Confederacy, only Kentucky and Arkansas have expanded Medicaid. 

We characterized the Close the Gap campaign largely as a struggle of the “Old South” versus the “New South.” Governor Haley’s change of heart regarding the flying the Confederate flag over the Capitol is a victory for the “New South” and could provide a roadmap for how to close the coverage gap in former slave states. Combining moral outrage and grassroots activism with an appreciation of the economics of the situation has changed the political dynamics around the Confederate flag. Five hundred people demonstrated in front of the South Carolina Capitol protesting the flag. Companies like Walmart and E-bay saw the potential impact on their bottom lines and decided to stop selling Confederate flags. Tourists threatened to boycott Charleston.

Closing the coverage gap will require the same combination of moral outrage, grassroots organizing and hard thinking about the economics. But moral outrage over refusing to close the coverage gap is growing, and business groups are increasingly demanding that states accept the federal funds set aside for this coverage. Since the federal government is paying 100 percent of the costs of coverage that will help millions of people and address a long history of inequality, this should be an offer that states such as South Carolina cannot refuse.