This post was written by Gary Cohen, President and Co-Founder of Health Care Without Harm, and opens with an introduction by Chris Kabel, Senior Program Officer, Health, at the Kresge Foundation:

We are witnessing some exciting changes in America’s approach to health and health care.  While most of our nation’s political and media attention has been focused on expansions of coverage and access to health care, the Affordable Care Act also includes components that encourage hospitals and health systems to engage and support their communities in a more robust and effective way. 

Innovative local and regional partnerships around the nation are beginning to transition health systems from a paradigm that has rewarded hospitals for maximizing billable services to one that provides incentives for keeping people healthy and out of the hospital.  The Kresge Foundation is supporting efforts to shift the national discourse and institutional practices toward a greater emphasis on prevention, efficiency and health equity.

Community advocates and the nonprofit hospitals that represent 85 percent of U.S. hospitals have several tools at their disposal to accelerate this shift. Two key tools are Community Health Needs Assessments (CHNAs) and Community Benefit (CB) programs. Hospitals can use their CB funds to address a host of non-medical community conditions that affect residents’ health – everything from housing to public safety, economic opportunity, early childhood development and the built environment.

Kresge grantees such as the Hilltop Institute, Community Catalyst and Health Care Without Harm are working with hospitals to redesign their community benefit programs, inform community advocates about how to access CB funds, publish research and share best practices.  Gary Cohen, the president and co-founder of Health Care Without Harm, will now share his perspectives on the most promising opportunities to use CB funds to achieve better community health outcomes. 

Health Care Without Harm President and Co-Founder Gary Cohen 

The Affordable Care Act (ACA) offers our country the opportunity to transform a healthcare system that has focused on sickness to one that prioritizes health. Under the ACA, non-profit hospitals are required to conduct community health needs assessments every three years and align their community benefit expenditures with community health priorities.

This is not a small thing. Last year, hospitals reported spending $13 billion on community benefit, with the lion’s share going toward charity care and discounted Medicaid expenses. As more and more people sign up and receive healthcare, the percentage of charity care is likely to go down, freeing up funds for programmatic investments that support community health. Moreover, since one of the pillars of ACA is to address population health, for the first time hospitals are being challenged to look beyond the four walls of their facilities and understand what is happening in the communities they serve.

These changes in healthcare policy create an opening to achieve three fundamental objectives that will have cascading benefits for the country as a whole:

1. Create an opportunity for community-based organizations to partner with local hospitals on neighborhood health issues.

Community organizations often lack political power and financial resources to address issues that impact community health. Violence prevention, food access, housing equity and other social service issues are all critical factors impacting people’s health. By partnering with local hospitals on these population health issues, community-based organizations can create greater leverage at the local level to move innovative programs toward wider adoption and also finance them through their healthcare partner’s community benefit money. With healthcare allies as validators and co-creators, programs that show strong outcomes that reduce healthcare costs can then become embedded in the core business strategy of the healthcare institution.

An example of using community benefit for this purpose is Health Leads, which trains college students to staff a desk in community clinics and hospitals to make social service referrals to low-income patients. Partners Healthcare in Boston has used community benefit funds to hire Health Leads because it frees up their clinical staff to focus on the patient’s medical issues while the Health Leads staff address their social care needs.

2.  Move upstream and address the environmental and social factors that make people sick.

The science continues to confirm that exposure to toxic chemicals as well as rising healthcare costs. Catholic Health Association and Health Care Without Harm worked with the Internal Revenue Service (IRS) on a guidance that allows upstream environmental health interventions to “count” as community benefit for hospital programs. When hospitals subsidize farmer’s markets on their grounds or in the community to create greater access for patients and the community, this can count as community benefit. Further, hospitals can incentivize patients and community members by doubling their food stamp (Supplemental Nutrition Assistance Program) benefits and providing prescriptions for fruits and vegetables.

Wholesome Wave’s Fruit and Vegetable Prescription pilot found that 90 percent of patients reported eating more fruits and vegetables and 38 percent of the children had reduced Body Mass Index (BMI) results. This kind of program not only strengthens work on obesity and nutrition in healthcare systems, but also uses healthcare as an important anchor for supporting a healthier and more sustainable local and regional food system.

Similarly effective programs exist to address home-related asthma triggers. Boston Children’s Hospital was concerned about repeat hospitalizations and emergency room visits for the same asthmatic children. Their working hypothesis was that the child’s home environment had asthma triggers in it and if the hospital could mitigate these factors, the health conditions for the kids would improve. The hospital contracted to hire environmental auditors to go into the homes and remove moldy carpet, provide HEPA air-filters and address other environmental triggers. As a result of the intervention, hospitalizations went down 81 percent, emergency room visits by 65 percent and loss school and work time about 50 percent each. The program not only improved asthma control but also created green jobs in the community for the home visit auditors.  Other model community benefit programs are highlighted in the report, “Healing Communities and the Environment: Opportunities for Community Benefit Programs.”

3. Heal the separation between public health and healthcare delivery.

For most of the twentieth century, public health has been the poor stepchild of the healthcare infrastructure, lacking resources and political clout to effectively address population level health issues. But when public health departments are given the resources to act, as they were to address smoking in the general population, they can have a powerful impact on addressing chronic disease and lowering health care costs. Since the ACA requires hospitals to address population health issues, local foundations can play a critical convening role to bring public health leaders into conversations with local healthcare institutions to collaborate on community health needs assessments and community programs. The foundation can also partner with hospitals in co-financing community health and environmental programs that address widespread issues facing the community.

A strong model for this kind of partnership occurred in King County, Washington, where 11 local hospitals came together with the local health department to create King County Hospitals for a Healthier Community. The Collaborative agreed to take on access to healthy and sustainable food in the Seattle area and are leveraging their collective resources to address food access issues as well as create a more sustainable and resilient regional food system. Local foundations are also joining in to support the NGOs that have the expertise to address these issues at a community level.

In this next period of our collective journey, we can begin to turn the vast enterprise of healthcare, which represents 18 percent of the U.S. economy, from being a system of chronic disease treatment to becoming anchors for community wellness. The challenge is taking the important opportunities embedded in the Affordable Care Act around community needs assessments and community benefit and bringing innovative programs to scale to help us all become healthier and help our communities thrive.