The Impact of the Individual Mandate and Internal Revenue Service Form 990 Schedule H on Community Benefits From Nonprofit Hospitals

摘要

In response to a growing concern that nonprofit hospitals are not providing sufficient benefit to their communities in return for their tax-exempt status, the Internal Revenue Service (IRS) now requires nonprofit hospitals to formally document the extent of their community contributions. While the IRS is increasing financial scrutiny of nonprofit hospitals, many provisions in the recently passed historical health reform legislation will also have a significant impact on the provision of uncompensated care and other community benefits. We argue that health reform does not render the nonprofit organizational form obsolete. Rather, health reform should strengthen the nonprofit hospitals’ ability to fulfill their missions by better targeting subsidies for uncompensated care and potentially increasing subsidized health services provision, many of which affect the public's health. INTERNAL REVENUE CODE § 501(c)(3) exempts nonprofit hospitals from federal income taxes. Since 1969 the community benefit standard 1 has been the criteria by which the deservedness of tax exemption has been determined. 2 There is, however, a long-standing debate in both the health policy and economics literatures on whether there is a substantial difference between the actions of for-profit and nonprofit hospitals, with empirical evidence supporting both schools of thought. 3 The inconclusive nature of this research helped spur political and legal action regarding community benefit provision by nonprofit hospitals. 4 In response to this growing concern that nonprofit hospitals are providing insufficient benefits to their communities in return for their tax-exempt status, the Internal Revenue Service (IRS) has revised Form 990 requiring nonprofit hospitals to submit additional detailed financial documentation regarding their community benefit expenditures on Schedule H beginning with 2009 filings. Simultaneously with tax reform, many provisions in the recently passed health reform legislation 5 will also significantly impact hospitals and their provision of community benefit activities. Sufficient provision of these services has important implications for the public's health. Former US Surgeon General David Satcher has argued that health reform and, specifically, the reduction in the number of uninsured, is “critical to our achieving the overarching goal of eliminating disparities in health.” 6 (p15) Regina Benjamin, the current US Surgeon General, states that “eliminating health disparities should certainly be at the top of our national health agenda.” 7 Approximately 31% of direct medical costs for minority populations from 2003 to 2006 were excess costs resulting from health inequities. 8 We explored the potential ramifications of the Patient Protection and Affordable Care Act (PPACA) and the Health Care Education Affordability Reconciliation Act of 2010 (HCEARA) on the level, measurement, and potential change in the composition of hospital community benefits, with regard to the new IRS regulations. We considered whether these legislative changes may further blur the distinction between for-profit and nonprofit hospital behavior and performance and explored the potential public health consequences of eliminating the tax-exempt status of nonprofit hospitals. We used data from Maryland, a state that implemented legislation similar to the recent IRS regulations in 2001, to guide our discussion and evaluate potential effects under these new legislative acts.