Category: community benefit

Pitchfork 1

A pitchfork is perfect for moving hay, compost, and the messy ensemble of cow poo that accumulates in barns. And the five sharp tines get attention by someone angry when the banker and landlord are insufferably arrogant. The wealthy are usually surprised. I know I was surprised last month as my party and candidates were so rudely put aside in favor of….well, you know.

“Reasons You Need a Pitchfork” from the Minnesota Horticultural Society (not the book Frankenstein)

Once anger flames, rationality has nothing to do with what happens next. Righteous anger can open the way for cynics with very ugly intentions to do things nobody voted for. Who voted for polio, measles, coat-hanger abortions and run-amok preachers? This is why Project 2025 was buried during the election and whipped out immediately after. This is why North Carolina losers used anger’s shadow to change the job descriptions of those that won. Ugly. And predictable.

Even when it is obvious that anger is being used by opportunistic frauds; it does not mean the anger will subside. Or that it will suddently become smart and be redirected toward the billionaire blowhards that actually do deserve a pitchfork.

What to do? Don’t argue with angry people, especially by telling them they are foolish to trust such obvious frauds. They don’t want instruction, especially from people like me they see as part of the “elite” that reminds them of their stolen dignity every time they go to the grocery store, bank, school or hospital.

Let’s talk about the hospital part of the conflagration. That’s the one I know best, having been inside the beast for nearly twenty years until recently. Why would anyone be angry at a hospital since everyone is going to need one? Normal people (the angry ones) understand that the shiny medical castles are only partly there for them. Hospitals are one visible knot in a complicated web of privileged guilds and professions including, executives, bankers, doctors, nurses, suppliers, technology companies, insurance companies, pharma, ambulance drivers, all seamlessly integrated into the government and universities. All that feels quite personal one is  vulnerable and in pain with no possibility of negotiating anything.

All parts of the system—cruelly called “health”—seem to be more and more obviously about money—theirs—and less and less about those who need their “care” (the services people cannot not buy).  This system costs roughly a trillion dollars a year and yet wants more. It drives every in the economy cost higher while whining all the time that it isn’t enough. Ironically, many of these hospitals (including my own) are not supposed to be “for profit,” so they do not pay taxes. All of this is painful at the family level only beginning with insurance and the huge indecipherable bills that result when you actually need the services. It makes the economy sick as every business thinks constantly about how to offload these costs onto vulnerable gig-workers or by shifting everything possible across the border or replacing humans with robots.

This interwoven system is the leading cause of bankruptcy in most states (for medical debt under $5,000). So who needs democracy when I can’t take my kid to the doctor without risking eviction or having my car towed away?

Pitchfork.

It is ironic that this web of privilege thinks it (we) are protected by our non-profit status and science. Who could quarrel with charitable scientists?  Well, we don’t look charitable and we don’t look scientific. Offensive executive and physician pay levels pulls one fig leaf away. The other fig leaf—science—disappears as it is always used to justify another shinier and more expensive building. What about the low-cost and low-tech science of prevention that makes at least some of those buildings unnecessary? Silence. What about the science supporting investment in education, faith and good stable jobs? Maybe later. What about the science linking democracy and neighborhood stability to health? Sounds woke. Everybody in healthcare knows that science, but we build bigger buildings instead of following it. So the angry people give us a Secretary of Health who doesn’t believe in science either.

The whirlwind is partly our fault. Those of us who do believe in that science and do believe in the non-profit mission should have been far more aggressive in pushing the medical industrial complex to act appropriately. Instead, we prodded gently and waited for a better time.

It’s not too late. Dr. King said it is always the right time to do right. It is crucial that we not be pulled into defending the indefensible. Not everything is worth defending from president Musk who will be losing support pretty quickly on his own. And as you pull apart the data we should notice that some of those most angry are people friends.  This might be a good time to lend some intelligence by helping aim the energy where it can do some good, instead of bad.

For instance. I offer two minor tweaks to non-profit health policy everyone should agree with:

First, hospitals’ non-profit tax status now rests on superficial “community benefit” rules. It should never have been allowed to be superficial. Those rules have little to do with the science of prevention and social determinants because implementation plans have no accountability to local public health (except in Ohio which is a story for another blog).

  • Give the local public health department authority to approve the hospital’s community benefit implementation plan so that it aligns with actual public health science and local government. This has been discussed quietly at the National Academies of Science for years. But religious hospital lobbyists fought it (!?!?!?!) It  would have been better to make the hospitals uncomfortable, Than having the voters angry. Do it now.

Second, hospitals are huge financial enterprises which often make as much money from their investments as from selling expensive medical procedures. It is likely they have about a trillion in their basement, which nobody ever thought possible. But there it is; they are banks that also offer medical services. Legally, their investments are invisible to their non-profit status; they aren’t required to report how much investments they have. They are usually required by their bankers to have between 100-300 “days of cash on hand”. Take your local hospital’s annual revenue and do the arithmetic. Unlike hospitals, your local banks are required by the Federal Reserve to invest some of their corpus in places impacted by their historical racism. Why not hospitals, which have done the same in the past (usually to the identical neighborhoods)?

  • Add transparency to the legal “community benefit” form. And give the Federal Reserve responsibility to oversee non-profit investments instead of the IRS.

Dumb is going to happen. But the chaos breaks open some room to do some good things, too. This is a great time to speak very specifically about how our public goods can be available to everyone no matter how they voted, prayed, worked, worried or shouted. If we use the pitchfork to shovel out the barn, nobody needs it as a weapon.

“American Quarantine” an American Gothic parody created by me with Photoshop. In this together, separately…
byu/rvtherford ingraphic_design

Potbound

Cagne Cochrane

Sometimes a houseplant will get too large for its clay pot.  You don’t notice at first but it slows its growth as the roots circle sideways around and around in a futile strangle. Even in a new a new pot the roots will keep circling and hardly notice the new soil. Not really dead; a withered version of itself that lost the plot.

I’m talking about hospitals here, most of which were created a hundred years ago by faith and community groups who saw that the simple science of their time could benefit their communities by providing healing and justice at large scale. Hospitals were uncomplicated enough for church committees by the dozens to consider starting one with donations, led by pastors and nuns, linens sewn by congregations. Today, these roots circle inside massive brick pots, out-scaling every other local non-profit organization by a quantum; way beyond the capacities of pastors and nuns to keep them on task.

Non profit hospitals are supposed to be kept on mission by a legal tool called “community benefit,” which works about as well as a fig leaf in the Arctic. The idea of “benefit” dates from when “mission” meant giving away urgent care instead of the goal of community-scale well-being that health and social science now make possible. A recent report from the National Academies of Sciences makes the missed opportunity painfully clear (National Academies of Sciences, Engineering, and Medicine. 2023. Population Health Funding and Accountability to Community: Proceedings of a Workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/27258).

Kimberly DiGioia, a program officer at the Patient-Centered Outcomes Research Institute, provided an overview of findings from her research on the effects of Medicaid expansion on community benefit (DiGioia, 2022). About two-thirds of hospitals in the U.S. are nonprofits, spending between 8 and 9 percent of their total operating expenses on community benefits, which seems impressive. But she explained that the vast majority of community benefit spending goes toward charity care, and unreimbursed Medicaid services while a small amount of this money goes to community health improvements. This includes educating its own health professionals, subsidized health services, medical research, and smallest portion, cash and in-kind contributions to community organizations.

The passage of the Affordable Care Act, DiGioia said, raised optimism that hospitals would report more revenue and less uncompensated care and thus spend more on community health. Indeed, the evidence has shown that the more Americans are covered, the more hospitals reported increased Medicaid discharges and decreased uninsured discharges. There was indeed a decline in uncompensated care, but this was offset by an increase in unreimbursed costs associated with caring for Medicaid patients. They charged more for less care and as a result, “community health improvement spending did not increase as expected.”

Pot bound.

Instead of growing into the rich soil of community health science, health system roots just circled the pot. This is a failure of hospital governance and timid government policy, not lack of science or administrative skill. Boards never fire a CEO for bad community health; the government settles for health fairs and a mobile van.

Thousands of highly skilled administrators and staff came to the profession expecting to grow like an oak in deep soil (they don’t mention the pot in school). These are honorable people trapped in doing small things. At a recent medical school reception honoring TC and I, Dough Easterling reminded us of when we traveled across the country in a Winnebago testing the idea that “everything we hope for is already happening.” He quoted us back to ourselves:

“We traveled with the sharp awareness that we are among the privileged class, linked to institutions among the most privileged of all—academic medical centers. It is striking how little is asked of these vast organizations. In most every community the healthcare organizations are pretty much busy with running the hospital. The staff might be kind in the ER and diligent on its wards, but not likely to cross the sidewalk in solidarity with the poor and suffering. There are exceptions in every hospital, but as institutions, the expectations remain low for a reason.” (Road Trip, Stakeholder Health, 2019)

Jim, TC and me in Wilmington NC —our 29th stop 2,600 miles after leaving San Diego. Everything we hope for is happening, but often trapped in small pots.

There are three ways to approach this withering, this tragic failure to fulfill our missional DNA.

One is to ramp up community benefit regulations. Not many hospitals have the internal capacity to know how to do that kind of work, so give local public health authorities power to get intimately involved in deploying hospital funds into serious programs of prevention, social determinants and chronic condition management. Don’t count “loss” on Medicaid and Medicare or training their own medical providers. The political screaming will be deafening as the ones that own the pots resist.

Two is to simply let non-profit hospitals remain inside their acute therapy pot, but give up the pretense that their efforts have much to do with community. Treat them like banks with some, but minimal, expectations of community good. Banks have to invest actual cash in the communities they previously damaged by redlining. Hospitals should do the same in the same communities as well as providing decent access for urgent services.

Third, create a special legal category for mission-driven hospitals. The 21st century work of advancing health at community scale needs a whole new pot. These hospitals would be like Community Health Centers (FQHC’s) that get preferential reimbursement for services that make them sustainable once they are built. Hospitals would need what they once had—preferential and protected access to borrowed capital so they could have modern technology. Treat them like missional utilities with no advertising permitted and community people on their governance Boards. True accountability is needed for meaningful integration with public health and social services, both governmental, private and faith. Restricted pay disparity between highest and lowest staff. Built for mission.

The National Academies report notes that Community Health centers offer much of this logic, but built for primary care, not acute hospital services. But why not? Every one of the major hospital systems have some hospitals they don’t actually want, that won’t ever make much money. Why not flip them to this different model?

We could do so much more with what we have. But our communities have almost given up:

Contrasted with the high enthusiasm when the hospitals were created, “the low expectations of (of hospitals) were striking—maybe for more health fairs, slightly kinder financial assistance policies, or free parking for clergy. We didn’t hear any calls for transformation, hardly any for solidarity. Yet those of us inside the institutions know how much more might be possible.” (Road Trip: Soundings. USA: Stakeholder Press, 2019).

We’ve been circling the pot. We need to break it, point the roots to deep soil and get to work.