American Academy of Nursing on Policy
Engaging communities in creating health:
Leveraging community benefit
Susan M. Swider, PhD, PHNA-BC, FAANa,*,
Bobbie Berkowitz, PhD, RN, NEA-BC, FAANa,
Sarah Valentine-Maher, RN, FNP, MSNb, Shannon N. Zenk, PhD, MPH, RN, FAANa,
Betty Bekemeier, PhD, MPH, FAANa
a
Environmental and Public Health Expert Panel
b
Academy Jonas Policy Scholar
Executive Summary
The academy supports sustaining and building on
institutional and regulatory policies to realize the goals
of improved population health and greater health eq-
uity. In 2010, the Patient Protection and Affordable Care
Act (ACA) modified community benefit requirements for
nonprofit hospitals to support hospitals taking a broader
view of community benefits. The law, and its interpre-
tation in final rules of Internal Revenue Service (IRS)
regulations (IRS, 2014), requires nonprofit hospitals to
complete a triennial community health needs assess-
ment (CHNA) and strategic plan to address identified
community health needs. This change in the law invites
possibilities for hospitals to fulfill community benefit
obligations in ways that extend beyond a subsidy for
direct care to address social determinants of health and
emphasize prevention on a population level.
Background
Since 1956, the federal government has linked nonprofit
hospital tax-exempt status to a requirement for provi-
sion of charitable care. After the establishment of
Medicare and Medicaid in 1965, and the subsequent
diminished need for charity care, the requirements for
hospital tax-exempt nonprofit status shifted to empha-
size general community benefits (Folkemer et al., 2011),
while still maintaining a focus on access to direct care
(IRS, 1969). The passage of the Patient Protection and
ACA (Patient Protection and ACA, 2010) has further
decreased the need for charity care in hospitals as
health insurance exchanges and expansion of Medicaid
increased insurance coverage, thus creating an oppor-
tunity for greater investment in population-focused
* Corresponding author: Susan M. Swider, Rush University 600 S. Paulina #1080 Chicago, IL 60612.
E-mail address: Susan_M_Swider@rush.edu (S.M. Swider).
0029-6554/$ - see front matter Ó 2017 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.outlook.2017.08.002
community benefit activities. Recent literature in-
dicates that, although the tax benefit on nonprofit status
for hospitals is large (Rosenbaum, Kindig, Bao, Byrnes, &
O’Laughlin, 2015), some nonprofit hospitals are making
financial investments in their communities equal to or
greater than the financial gains received by maintaining
their tax-exempt status (Coyne et al., 2014; Turner,
Broom, Goldner, & Lee, 2016). However, relatively few
community benefit resources are directed to community
health improvement, as compared with individual sub-
sidies for direct care (IRS, 2015; Singh, Young, Lee, Song,
& Alexander, 2015; Singh, Bakken, Kindig and Young,
2016; Young, Chou, Alexander, Lee, & Raver, 2013). It is,
nonetheless, notable that nonprofit hospitals have re-
ported greater community health assessment and
partnership activity than for-profit hospitals (Song, Lee,
Alexander, & Seiber, 2013) and that nonprofit hospitals
are identifying social determinants of health in CHNAs
(Rosenbaum, Byrnes, Rothenberg, & Gunsalus, 2016).
The ACA community benefits language (Patient
Protection and ACA, 2010), and the related IRS regula-
tions (IRS, 2014) maintain that nonprofit hospitals must
assess and respond to community health needs. How-
ever, there is no ultimate accountability for nonprofit
hospitals to address and improve social determinants of
health in communities. The requirement for CHNA and
strategic planning to address identified community
health needs could result in an expanded form of com-
munity investment. Social determinants of health,
including environmental factors, such as food availabil-
ity, housing, and transportation, have a greatly dispro-
portional impact on population health (Isham,
Zimmerman, Kindig, & Hornseth, 2013; Milstein,
Homer, Briss, Burton, & Pechacek, 2011; Robert Wood
Johnson Foundation, 2014). A 2011 meta-analysis of 50
studies found that social factors, including education,
racial segregation, social support, and poverty, accoun-
ted for more than a third of total deaths in the United
658 Nurs Outlook 65 (2017) 657e660
States in a year (Galea, Tracy, Hoggatt, DiMaggio, &
Karpati, 2011).
To understand the extent to which commitments
to fulfill nonprofit hospital community benefit re-
quirements may serve as a lever to improve population
health, three of the Academy’s Expert Panels (Envi-
ronmental and Public Health, Acute and Critical Care,
and Building Healthcare Systems Excellence) spon-
sored a policy dialog at the October, 2015 “Trans-
forming Health, Driving Policy” conference. This policy
brief incorporates the outcomes of that policy dialog,
and more recent developments, in terms of recom-
mendations to maximize the effectiveness of the
CHNA strategic planning and implementation process
among nonprofit hospitals. Proposed recommenda-
tions share the long-term goal of improving the health
of the public and promoting health equity.
Responses and Policy Options
The new community benefit laws require accountability
by every nonprofit hospital for a CHNA process that
engages community members and gains input from
local public health experts (Patient Protection and ACA,
2010). At the same time, public health department
accreditation through the Public Health Accreditation
Board (PHAB) has advanced the measurement of public
health department performance on standards designed
to assure improvement and protection of the public
across communities and states. Among the domains
within the accreditation process is one that stresses the
importance of public health department engagement
with the broader community in community health
assessment and the development of corresponding ac-
tions to improve public health (PHAB, 2013). This
concurrence of PHAB accreditation requirements with
nonprofit hospital community benefit requirements
opens possibilities for shared accountability for com-
munity health and health equity as well as a leveraging
of resources and expertise (Laymon, Shah, Leep,
Elligers, & Kumar, 2015; Sampson, Gearin, & Boe, 2015;
Stoto & Ryan Smith, 2015). In addition, opportunities
exist to build multisectoral health partnerships (Robert
Wood Johnson Foundation, 2017) that create synergy
around existing community development policy, such
as Community Reinvestment Act regulations that sup-
port more equitable provision of financial lending
(Board of Governors of the Federal Reserve System,
2014). Effectively addressing critical health conditions
facing the community requires a population-based
approach that incorporates social determinants of
health. Hospital collaboration with public health de-
partments and other key community stakeholders may
increase the resources focused on this approach and
advance a paradigmatic shift to population health.
The 2016 national elections brought leaders to the
executive and legislative branches with an agenda of
repealing and replacing the ACA. However, it is not
expected that community benefit provisions of the
ACA will be directly challenged. A more likely threat to
the potential for community benefit to address social
determinants of health is the indirect effect of broad
losses in health insurance coverage, which would pull
from those community benefit resources used for
community health improvement to cover increases in
uncompensated care.
The American Academy of Nursing’s Position
Leveraging the most recent nonprofit hospital commu-
nity benefit requirements under the ACA (Patient
Protection and ACA, 2010) to engage health systems,
public health departments, and community stakeholders
in assessment, planning, and action for community
health improvement is a policy issue of great interest to
the academy. The academy’s strategic plan includes a
goal to build relationships and create collaborations with
other organizations for a bigger impact on the societal
determinants of health (American Academy of Nursing,
2017; goal 3.4). Specifically, the academy recognizes the
potential of community benefit reform to expand the
focus of, and redirect the resources freed by, a decreased
need for charity care toward supporting nonprofit
health care delivery systems and other community
stakeholders to collaborate to address upstream social
determinants of health. Accordingly, the academy
supports sustaining and advancing policies that leverage
community benefit to improve population health and
promote health equity through an upstream social de-
terminants of health approach that includes:

Collaborative approaches to CHNAs and planning
that will assure sharing of data across community
health and public health systems;

Leveraging policy, ideas, and resources across systems
to build capacity and take action to respond to identi-
fied community health improvement needs; and

Promoting measures in CHNAs, which capture
prevention activities.
Recommendations
1. Add the voice of nursing leadership in addressing
congressional leaders and the executive branch to
support legislation that would result in maintenance
of or increases in health insurance coverage, thus
allowing for existing resources to be used for com-
munity health improvement via community benefit.
2. Raise awareness among health care activists and
political actors of the potential for community
benefit investments to address social determinants
of health and improve population health long term.
3. Advocate to the IRS community benefit reforms that
provide a stimulus to channel resources to those
interventions that address underlying community
 Nurs Outlook 65 (2017) 657e660
health needs, emphasize prevention, and promote
health equity.
4. Advocate to congress and the IRS complementary
legislation and regulation to further incentivize
nonprofit hospital system investment in improve-
ment of upstream social determinants of health and
prevention and to expand IRS regulations to address
measurement of outcomes of community health
improvement initiatives.
5. Sustain community health improvement activities
through current nonprofit hospital community benefit
approaches by encouraging the IRS to expand their
definition of community health improvement to more
explicitly include community-building activities.
6. Develop partnerships with the IRS and the American
Hospital Association to collaborate on approaches to
CHNA, planning, implementation, and ongoing
measurement that share data and resources across
health systems, incentivize collaboration with pub-
lic health departments and community members,
and stimulate creative and responsive multisectoral
health partnerships.
7. Advocate to the Centers for Disease Control and
Prevention (CDC), the IRS, and congress, support for
development of systems of measurement and
assessment that are sensitive to upstream social de-
terminants of health and capture prevention activities.
8. Collaborate with the CDC, American Hospital Asso-
ciation, and American Public Health Association to
support development of evidence-based recom-
mendations for best practices in community benefit.
Such practices might include mechanisms to pro-
mote healthy environments (e.g., access to healthy
foods, parks, and walkable communities) and
address such things as environmental exposures,
firearm safety, violence, and school health policies.
Acknowledgments
The authors gratefully acknowledge the Academy’s
Expert Panels on Acute and Critical Care and Building
Healthcare Systems Excellence in supporting this pol-
icy brief. Thank you to Academy staff Matthew J. Wil-
liams, JD, MA, who contributed to the research, review,
and writing.
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