Putting the community back into the

Non-profit hospitals have long been viewed as the safety-net providers in our broken health care system. But nowadays some hospitals are bringing in large amounts of money, paying their CEOs record amounts of compensation, and engaging in aggressive debt recovery actions. Richard Scruggs, the high profile attorney who spearheaded the litigation against the tobacco companies, has filed a class action lawsuit against hospitals for their billing and collection practices. The Internal Revenue Service (IRS) and Congressional Budget Office (CBO) are engaged in national studies of non-profit hospitals and community benefits. With Senator Charles Grassley proposing federal legislation to establish minimum charity care standards for hospitals, and state and local authorities scrutinizing community benefit programs (and in some cases even revoking hospitals' tax-exempt status), this question has moved to the forefront of health reform debates. What obligations do hospitals have to provide charity care? If a system of universal health insurance coverage is established during the Obama administration, will charity care remain necessary? I argue that the longstanding focus on providing individual charity care to meet the community benefit standard is misguided. Instead, I determine that there are conceptual and practical arguments for requiring hospitals to provide population health benefits. I offer a detailed analysis for implementing a new standard, and a framework for quantifying community benefit under that standard that may be used at the federal, state and local levels. The suggestions set forth should result in better, more expansive benefits for communities and clearer guidance for health care institutions.