Where we grow up matters immensely when it comes to health, so it would make sense that living near a world-class medical facility should be a big advantage. But that’s not always true, according to researchers with Ohio University and UMass Amherst. In The Conversation, political scientist Dr. Daniel Skinner and sociologist Dr. Jonathan Wynn share findings from their new book with Dr. Berkeley Franz, “The City and the Hospital.”
In the book, the authors explore the relationship between three nonprofit hospitals and their surrounding communities – The Cleveland Clinic, Hartford Hospital, and the University of Colorado Hospital. What they found reflects the importance of community investment and how weak regulatory standards can result in hospitals falling short of their commitment to their neighboring communities.
Better health near the hospital?
The authors used Census data and more than 200 interviews with residents, community leaders, local businesses, and hospital administrators to unpack the complex relationship between each of the three hospitals and those who live closest to them. More specifically, the authors were interested in exploring why health outcomes remain poor despite close proximity to high-quality medical care – what is referred to by the authors as the “paradox of medically overserved communities.” Studying census tracts around each of the three hospitals, they found that residents were disproportionately more racially and ethnically diverse, had lower incomes, and were generally in worse health when compared to the broader city population.
Looking at chronic health conditions, including heart disease, diabetes, and mental illness, researchers found that these residents fared worse than the city average 64% of the time and worse than national averages 80% of the time. One big reason behind these disparities is that residents aren’t accessing these services as much as you’d expect. In interviews, residents said they found these hospitals “intimidating” and were worried about the high cost of care, leading them to seek treatment elsewhere.
“In all three communities, people told us they avoided their local, prominent hospitals because of fears of the financial burden a visit would yield. Many local residents said they saw less celebrated hospitals that were farther from home as safer options in terms of what they expected to pay.”
Dr. Skinner and Dr. Wynn, The Conversation
The need for inclusivity
This research highlights examples of segregation that are common in urban hospital markets across the U.S. The Lown Institute has found that many large urban hospitals tend to serve patients from further away, more often from whiter and higher-income areas, while not serving as many patients from low-income communities of color close by. (You can see our ranking of the most inclusive hospitals in the country on our website.)
To combat hospital segregation and lack of community investment, healthcare experts and hospital leaders have advised facilities to embrace strategies such as inclusive hiring, tracking health outcomes across a variety of demographic backgrounds, and bringing community members into the fold when it comes to decision-making. This research also shows hospitals seeking to be more inclusive must also take a hard look at their prices and financial assistance policies.
Improving community health
There are ways that hospitals can improve community health beyond welcoming local residents into the hospital. Hospitals can engage in programs that benefit the broader community, like health fairs, diabetes clinics, school-based health services, mobile health vans, food pantries, and many, many more.
However, the hospitals featured in “The City and the Hospital” could be doing more. In The Conversation, Skinner and Wynn cite the 2023 Lown Index grades on community benefit for the hospital, which were average: Hartford Hospital earned a B grade, and the University of Colorado Hospital and the Cleveland Clinic both earned a C. None of them made it into the top 1,000 in the community benefit ranking.
These three hospitals are not the only nonprofit hospitals failing to meet the needs of their community. Originally touted as an opportunity to increase nonprofit hospital spending on community health and enhance hospital accountability, community benefit has yet to close disparities such as those identified by the authors. Broadly defined categories of community benefit with no minimum spending requirements leads to wide variations in spending across the country.
Most recent results from the Lown Institute Hospitals Index revealed that 77% of hospitals spent less on charity care and community investment than the estimated value of their tax breaks – what we call a “Fair Share” deficit. The issue has gained national media attention in recent years, taking the form of multipart podcasts examining the implications of hospital property tax exemption on local communities and a Senate Health, Education, Labor, and Pensions (HELP) Committee report criticizing hospitals’ lackluster investment in financial assistance programs.
To paint a better picture of the state of community benefit spending nationwide, the Lown Institute has launched a two-year project to assess the Fair Share Spending of hospitals in 20 states, with full results available in 2025.