In the US, we live in a world of limited public resources and yet massive investment in healthcare services. Healthcare spending accounts for almost 1/5th of our country’s entire GDP. When compared to other peer nations, that huge expense significantly limits how much we can spend on social services. Now, there are 2 important programs that allow medical systems to pay for social services. One is old and one is new.
The old program is called Community Benefit. It requires non-profit hospitals, which make up almost 8 out of 10 hospitals in the country, justify their tax-exempt status by sharing the benefits of that status with the communities they serve. The new program is a Medicaid Waiver Demonstration or an opportunity for states to apply for money to meet the health needs of their population in innovative ways that include supporting community-based social services.
Sadly, both programs may result in hospitals keeping the money! And more than supremely selfish, it seems deeply problematic, inequitable, and yes, oppressive. I’ll explain.
Historically, only 15% of Community Benefit funds actually make it back to the community. Most are spent in-house, to reimburse charitable patient care. Additionally, some states are considering using their Medicaid Waivers to build social services inside hospitals, instead of supporting existing community-based programs.
Hospital systems will probably cite a myriad of reasons to build their own suite of social services rather than rely on the community. Some of those reasons may even sound credible. For example, some healthcare systems will likely point to a lack of community capacity to handle the volume of need this funding will generate. Because if we know anything, it is that if you pay hospitals to do something, they are going to get really good at it, and here that means potentially identifying more individuals who need a service than there are services to provide them.
But it has to be recognized that “lack of community capacity” doesn’t happen in a vacuum. It occurs as a direct result of the resource scarcity engineered by systems siphoning funds away from neighborhoods and public spaces back into conglomerate enterprises, like hospitals and large medical systems.
Similarly, concerns regarding scale when large systems must interface with a diverse network of community-based social service providers, highlight the dysfunction of the system, not of the smaller players, as may be assumed. The onus for adaptability must always lie with the more resourced-partner, which in this case is the hospital. That means when certain referrals are difficult or meet a dead-end, hospitals will need to provide resources to help community-based organizations figure it out. Note that here the hospital is providing the money, staff, or training, but not driving the actual process by which communities determine how they want to be served.
This is the transformation. This is the re-design.
Payment reform does not simply challenge the conceptual ways we pay for care, it challenges the very notion of relationship between providers, care systems, and the patients, communities, and neighborhoods they serve. That relationship has been historically strained by competing financial priorities, exploitation of people and communities of color, and the commodification of disease to the extent that it bankrupts people and devalues holistic notions of wellness.
The solution then, is not to further strain this already charged relationship by usurping the role of community members and community-based organizations in serving their own needs. But, to admit the ways in which our instinctual preference to reinforce our walls, tears theirs down. To acknowledge the ways our desire to have more power in the shaping people’s lives, even if for the better, may minimize an individual’s power to shape their own life. And to confront the ways medicine historically and currently contributes to gross wealth and racial inequity in this country, through exorbitant costs of care and limited workforce diversity.
At their best, programs like Community Benefit and Medicaid Waivers are a foremost way to redistribute wealth in the United States through the healthcare system. That is a powerful imperative in these times of great inequity and those of us who understand that, must hold our field accountable for proceeding with humility and most of all integrity, when distributing these vital funds.