New prescriptions? : nonprofit hospital and health system charitable spending on housing as a social determinant of health

Abstract

There is an emerging consensus that socioeconomic, environmental, and structural factors--known as the social determinants of health (SDOH)--are stronger drivers of health outcomes than genetics or clinical care. In particular, health researchers have elevated housing stability, quality, and affordability as critical SDOH. As focus in public health shifts towards addressing SDOH, attention has turned to the role of hospitals--particularly those with nonprofit status--in improving local housing conditions. To maintain federal tax exemption, nonprofit hospitals and health systems must annually report charitable practices, known as "community benefits," to the Internal Revenue Service (IRS). Recent changes in IRS reporting requirements, coinciding with federal and state healthcare overhauls, encourage hospitals to make local charitable investments to address SDOH, including housing.

Following the regulatory changes and increased recognition of the SDOH, this thesis has two primary aims. First, utilizing processed IRS Form 990 Schedule H annual hospital filings from 2010-2017, I conduct a descriptive analysis to assess geographic and temporal variations in charitable practices across the United States. Second, relying on demographic data summarized at the ZIP Code level, I employ regression techniques to analyze whether the socioeconomic characteristics of an institution's immediate vicinity explain variations in charitable spending on housing and other SDOH activities. I do not find evidence of widespread shifts in community benefit practices to address SDOH. These expenses were minimal and declined relative to other charitable practices from 2010-2017.

Results indicate that local characteristics do explain differences in charitable spending: institutions located in communities with higher poverty and less affordable housing options are more likely to report spending on housing and other SDOH activities. However, stronger unobserved factors are likely driving variations in this spending. These findings suggest limitations of the current community benefits standard for increasing charitable expenditures on housing and other SDOH activities.