National Compliance With Community Input on Nonprofit Hospital Community Benefit Activities

Abstract

Importance: In exchange for tax exemptions valued at $37.4 billion, the Patient Protection and Affordable Care Act (ACA) requires all nonprofit hospitals to conduct a triennial community health needs assessment (CHNA) and develop an implementation strategy (IS). As part of these community benefit (CB) activities, hospitals must solicit and account for input from the community in the form of written comments, which may improve hospital investments in population health. Objective: To examine nonprofit hospital compliance with the community input requirement and the approaches hospitals have used to solicit and account for written comments from the community. Design, setting, and participants: This cross-sectional study used data from CHNAs and ISs completed by nonprofit hospitals between 2018 and 2021. CHNAs and ISs were downloaded from hospital websites in 2022. A 20% stratified random sample was drawn from all 3087 US nonprofit hospitals. Data extraction and content analysis was performed from July 2024 to March 2025, and statistical analysis was performed from March to June 2025. Exposure: ACA community input requirement in CB activities. Main outcomes and measures: Hospitals were considered compliant with the community input requirement if they described the following in their CHNA or IS: (1) how written comments on the most recent CHNA and/or IS were solicited, (2) at least 1 written comment received, and (3) how this information was taken into account in the current CHNA and/or IS. Bivariate analyses using χ2 tests to compare the organizational characteristics of compliant vs noncompliant hospitals. Results: The final study sample included 543 nonprofit hospitals, and 57 hospitals (10.5%) were compliant with the community input requirement. Among compliant hospitals, 27 (47.4%) used paper surveys, 20 (35.1%) used web-based surveys, 13 (22.8%) used in-person surveys at community outreach events, and 2 (3.5%) used telephone-based surveys to solicit community input. None of the characteristics assessed in the bivariate analysis were significantly different between compliant vs noncompliant hospitals. Conclusions and relevance: This cross-sectional study of a nationally representative sample of nonprofit hospitals found low hospital compliance with the Internal Revenue Service community input requirement in CB documents. This finding raises questions about whether the needs and strategies identified and addressed through CB activities reflect community priorities. To ensure that CB activities address community needs as intended under the ACA, policy changes are needed to improve nonprofit hospital compliance, transparency, and accountability.