Structural Discrimination in Nonprofit Hospital Community Benefit Spending.

Area of Science:

• Health Services Research
• Health Economics
• Public Health Policy

Background:

• Nonprofit hospitals receive tax exemptions for providing community benefits.
• Distribution of community benefit spending (CBS) across socially vulnerable US communities is not well understood.
• Understanding CBS allocation is crucial for assessing equitable community benefit.

Purpose of the Study:

• To examine the association between community-level social determinants of health and per capita CBS.
• To identify patterns in CBS allocation across diverse US communities.
• To assess the equity of community benefit distribution by nonprofit hospitals.

Main Methods:

• Cross-sectional study using IRS Series 990 Tax Forms (2018-2023).
• Facility-level CBS allocated to counties based on inpatient utilization.
• Generalized linear regression models used to analyze associations between CBS per capita and social determinants (SVI, race/ethnicity, poverty, education).

Main Results:

• 2465 nonprofit hospitals across 3140 US counties analyzed.
• Significant variation in CBS per capita; highest quintile received $540 (SD $250) vs. lowest quintile $22 (SD $16).
• Lower CBS per capita observed in communities with higher proportions of non-Hispanic Black/Hispanic residents, lower educational attainment, higher poverty, and higher Social Vulnerability Index (SVI) scores.

Conclusions:

• Nonprofit hospital CBS is regressively allocated, favoring more affluent, White communities over socially vulnerable and minority communities.
• The current nonprofit tax exemption system may contribute to health disparities through discriminatory allocation of community benefits.
• Findings highlight the need to re-evaluate policies ensuring equitable distribution of community benefits to address health inequities.