Abstract
The 2010 Patient Protection and Affordable Care Act requires not-for-profit hospitals in the United States to conduct a community health needs assessment (CHNA) every three years. Hospitals are also required to develop an implementation plan addressing the needs observed in the CHNA, or provide reasons for not addressing these identified needs. The extent to which CHNAs account for the structural and social determinants of health is open to investigation, particularly when doing so may call on hospitals to go beyond a narrow focus on individual behaviours as the source of preventable morbidity and premature mortality. Our work examines CHNA reports from hospitals in Chicago, Illinois. Our analysis contrasts the first wave of reports (published in the 2012–2013 period) with a second wave of reports (published in the 2015–2016 period). Our results reveal considerable differences in how hospitals met their CHNA requirements, with only a small number of hospitals offering historically deep and community-driven reports in the first wave of CHNA. Important differences also existed in how hospitals conceptualised causality of health inequities in their service areas—in the first wave of reports, most hospitals focused on individual behaviours rather than the root causes of poor health in Chicago, including economic inequality, racism/discrimination, and other aspects of structural violence. By the second wave of the reports a more collaborative approach was taken and a substantially different message emerged, with more hospitals adopting the language of the structural determinants of health. We argue that CHNA reports—which are created at the link between public and private health systems—are an important vehicle through which to understand health inequities in the United States.
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Notes
- 1.
Under the Internal Revenue Service (IRS) guidelines for CHNA reports, a hospital may define its own community boundary: ‘a hospital facility may take into account all of the relevant facts and circumstances, including the geographic area served by the hospital facility, target population(s) served, and principal functions. However, a hospital facility may not define its community to exclude medically underserved, low-income, or minority populations who live in the geographic areas from which the hospital facility draws its patients’ (Internal Revenue Agency 2014). In practice, this has meant that hospitals are largely free to define their own community areas—some hospitals claim the entire city, others a smaller geographic section. Differences may also exist between community hospitals and larger academic health centres, since the former will have higher utilisation rates in local communities than the latter.
- 2.
These reports were written by the same consulting agency, which used identical text in the various reports.
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Acknowledgements
We are grateful to David Ansell, Maureen Benjamins, Fran Collyer, Marty Martin, John Mazzeo, and Karen Willis for helpful comments on early drafts of this work.
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De Maio, F., Shah, R.C., Burke, K. (2020). Chapter Four: ‘Looking Outside Their Walls’: Exploring Community Health in Chicago Hospitals. In: Collyer, F., Willis, K. (eds) Navigating Private and Public Healthcare. Palgrave Macmillan, Singapore. https://doi.org/10.1007/978-981-32-9208-6_4
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