Montana is one of the most recent states to consider imposing new rules or increasing oversight of nonprofit hospitals amid questions about whether they pay their fair share. Dr. Vikas Saini, president of the national healthcare think tank Lown Institute, said that both at a state and local level, people in California are exploring whether to monitor hospital community benefits and enforce new standards. Last year, Oregon initiated a minimum amount that nonprofit hospitals must spend on community benefits. And Massachusetts updated its community benefits guidelines in recent years, pushing hospitals to give more detailed assessments of how the spending lines up with identified health needs.

Regardless of tax status, medical centers in markets with high medical debt do provide more charity care, according to an analysis by KHN and the Urban Institute, a Washington think tank. That’s important, said Dr. Vikas Saini, president of the Lown Institute, a nonprofit that grades hospitals on their quality and community benefits. But he asked: “Is a hospital truly serving its community if it’s pushing so many into debt?” More

In recent years, more people, like Keenan and Saini, have questioned whether nonprofit hospitals are contributing enough to their communities to deserve the major tax breaks they get while becoming some of the largest businesses in town. "The hospitals are sort of the pillars of communities, but people are starting to ask these questions," Saini says. More