Community Benefit and Tax-Exemption Levels at Non-Profit Hospitals Across U.S. States.

Objective: To assess the association between state policies and sociodemographic characteristics and state mean fair share spending at non-profit hospitals. Fair share spending is a hospital's charity care and community investment less the estimated value of their tax-exempt status.

Background: Hospitals with non-profit status in the United States are exempt from paying taxes. In return, they are expected to provide community benefits by subsidizing medical care for those who cannot pay and investing in the health and social needs of their community.

Methods: We used a multivariable linear regression model to determine the association of state-level sociodemographics and policies with state-level mean fair share spending in 2019. Fair share spending data was obtained from the Lown Institute.

Results: We found no association between the percentage of people living in poverty, in rural areas, or U.S. region and fair share spending. Similarly, there was no association found for state minimum community benefit and reporting requirements. The state percentage of racial/ethnic minorities was associated with higher mean fair share spending [+$1.48 million for every 10% increase (95% CI: 0.01 to 2.96 million)]. Medicaid expansion status was associated with a 6.9-million-dollar decrease (95% CI: -10.4 to -3.3 million).

Conclusions: State-level community benefit policies have been ineffective at raising community benefit spending to levels comparable to the value of non-profit hospital tax-exempt status.