Hospitals' Obligations to Address Social Determinants of Health

Abstract

Federal health care reform has expanded medical insurance to millions of people, altering the role that hospitals play in improving community health. However, current federal and state community benefit policy is an ineffective tool for ensuring that hospitals address the social determinants of health afflicting their communities. Policy shifts and other incentives that promote improved population health outcomes can encourage health care organizations to do the same. Hospitals' Responsiveness to Community Needs In the early 19th century, hospitals emerged as welfare institutions, or as branches of cities' almshouses. 1 The municipal almshouse served as a haven for its elderly, unemployed, ill, disabled, delinquent, minors, and incompetent. In the words of Charles Rosenberg, the internal composition of the almshouse "inevitably reflected the diversity of misfortunes afflicting its clients." 1 Physicians became widely engaged to care for clientele at almshouses, where staff positions were sought after as valuable learning and teaching opportunities. Thus, at no point when the hospital first emerged, was "public medicine" detached from medical careers or "distinguishable from the more pervasive problem of dependency." 1 However, beginning in the early 20th century, the welfare hospital for the "rootless and dependent" 1 gradually transformed into a market institution, potentially profitable and powered by patient payments. 1,2 Simultaneously, physicians became increasingly employed by national medical networks and academic institutions whose clientele were less marked by dependency. 2 As a result, market forces in today's medical system may be opposed to the charitable interests of hospitals' past. Nevertheless, nongovernmental nonprofit hospitals retain remnants of their historical mission-a "charitable purpose." 3 In 2019, the American Hospital Association reported that 56% of community hospitals in the United States are organized as nongovernment nonprofit organizations, and, government hospitals included, nearly 80% of community hospitals enjoy tax-exempt status. 4 In return, they are exempt from billions in state and federal tax liability (an estimated $24.6 billion in 2011 5). Courts typically describe the indirect subsidy as a quid pro quo that charitable hospitals receive for alleviating a substantial government burden through the care they provide.

Integrating social determinants of health screening and referral during routine emergency department care: evaluation of reach and implementation challenges

“…This work falls in contrast to healthcare systems rapidly adopting screenings of more limited “social needs” (e.g., for housing, food, transportation), which has resulted in discussions about the nature and content of social needs screening instruments and strategies [ 7 ]. However, one common theme of this work in research and practice settings is that all efforts should be underscored by the importance of developing and implementing social needs screening in a way that is linked to substantive and actionable processes and services to meet patient needs after screening [ 8 – 10 ].…”

The Mental Health of Refugees during a Pandemic: Striving toward Social Justice through Social Determinants of Health and Human Rights

“…Similarly, Boston College School of Social Work and the nonprofit Bhutanese Society of Western Massachusetts have produced videos in Nepali to teach Bhutanese refugees about COVID-19, recognizing that many individuals in the Bhutanese population are illiterate in their (Subedi et al 2015) which assisted Nepali communities in Massachusetts to better recognize depression and improve mental health literacy (Gurung et al 2020). San Diego's City Heights Wellness Center provided similar community education by joining local hospitals to offer multilingual cooking classes tailored to the unique needs of the culturally diverse community to combat diabetes and obesity (Sullivan 2019). Community education, specifically using peer-led community health workshops, is a culturally responsive way of promoting community health and social capital in Bhutanese refugee communities (Im and Rosenberg 2016).…”

“…One example is the federal Accountable Health Communities Model (AHCM) which seeks to reduce clinical spending by addressing social determinants. This prioritizes clinical screenings for unmet social needs and connects different community services to ensure the availability and responsiveness of resettled Bhutanese refugees' needs, which are often unrecognized without established culturally sensitive clinical screenings (Sullivan 2019). Public health and nonprofit agencies, healthcare clinics, and legal services should address community-based issues that expose resettled Bhutanese refugees to mental illness by screening for unmet social needs and providing direct connections to community services and resources.…”

Integrating social determinants of health screening and referral during routine emergency department care: Evaluation of reach and implementation challenges

“…This work falls in contrast to healthcare systems rapidly adopting SDOH interventions to screen for more limited "social needs" (e.g., housing, food, transportation), which has resulted in increased discussion about the nature and content of SDOH screening instruments and in organizations serving as examples of implementation strategies (LaForge et al, 2018). However, one common theme of this work in research and practice settings is that it is underscored by the importance of developing and implementing social needs screening in a way that is linked to substantive and actionable processes and services to meet patient needs Sullivan, 2019).…”