Apr 12, 2019

Allison Neswood previously served as CCLP's Deputy Director of Strategic Priorities. She is an expert in public health insurance plans (Medicaid and CHP+), Aid to the Needy Disabled, immigrant access to services and health equity.

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Communities will benefit from making nonprofit hospitals more accountable

by | Apr 12, 2019

Colorado’s nonprofit hospitals receive federal, state and local tax exemptions amounting to hundreds of millions of dollars. They receive these massive financial benefits on the premise that they are investing in services that improve health outcomes in the communities they serve.

But are nonprofit hospitals meeting that expectation?

House Bill 1320, which CCLP helped to develop, aims to ensure that Coloradans have access to the information we need to answer that question for every nonprofit hospital in Colorado. Sponsored by Rep. Chris Kennedy and Rep. Susan Lontine and assigned to the House Health and Insurance Committee, the bill is structured to accomplish several goals.

First, the bill is designed to increase the transparency of hospital investments in community health. It will do so by requiring all nonprofit hospitals to submit annual reports to the Colorado Department of Health Care Policy and Financing (HCPF) regarding their community benefit activities. The reports will be submitted through an online report form, will be accessible by the public, and will include each hospital’s most recent Community Health Needs Assessment (CHNA) and community benefit implementation plan as well as information about the community benefit activities hospitals invested in over the previous year.

Second, the bill is designed to better incentivize investments in activities that actually improve health outcomes. Several aspects of the bill contribute to this goal. Transparency itself is one important contributor as research suggests that increasing the transparency of community benefit spending at the state level is the most effective way of increasing overall hospital investments in community health. The bill will also require nonprofit hospitals to report the value of their tax exemptions so we can see whether their community benefit investments are comparable with the financial benefits they receive through our tax system.

In addition, the bill limits what hospitals can count as community benefit for state reporting purposes using a clear definition of community benefit activities. The bill defines community benefit activities as un-reimbursed hospital investments that address community health needs that are identified in partnership with the community and local public health departments. It also defines three categories of community benefit, including: 1) charity care; 2) programs designed to change individual health behaviors or risk; and 3) programs designed to address the social determinants of health (SDOH) – those resources like housing, nutritious food, transportation and income that impact health outcomes.

Robust hospital investments in those areas are likely to benefit community health and, as a result, reduce underlying health care costs. Ensuring access to health care services will help to address disparate access to care. According to one study, eliminating health care disparities for minorities from 2003 to 2006 would have reduced direct medical expenditures by $229.4 billion and indirect costs associated with premature deaths by $1 trillion. In addition, overwhelming evidence suggests that social, economic and environmental factors are more significant predictors of health than access to care. One study found that 40 percent of the factors contributing to length and quality of life are social and economic. These are followed by health behaviors (30 percent), clinical care (20 percent), and the physical environment (10 percent)

Third, the bill is structured to allow apples-to-apples comparisons between hospitals in the state. The bill requires nonprofit hospitals to report about their community benefit activities in a uniform format. It also requires them to list their community benefit activities in the definitional categories, provide the cash value invested in each activity, and assess the effectiveness of each activity in achieving short and long-term community health goals. The ability to compare hospitals in the state will allow Colorado to highlight and learn from hospitals that are making meaningful and effective investments in improving community health. This will also allow us to put more effective pressure on nonprofit hospitals that aren’t doing their fair share.

While it does not require their participation, the bill allows for-profit hospitals to report regarding their community benefit activities as well. Some for-profit hospitals make meaningful contributions in the community benefit space and encouraging them to publicize the information in the same format as Colorado’s nonprofit hospitals will allow Colorado to learn from those activities and to put additional pressure on nonprofits.

Finally, the bill institutionalizes a process for regular community, administrative and legislative review of nonprofit hospitals’ reported activities. The bill creates a Hospital Community Accountability Board (Community Board) in each of the seven Regional Accountable Entity (RAE) regions. Each nonprofit hospital must submit their community benefit activities report to the Community Board in their region and the Community Board is charged with reviewing those reports and making recommendations. In addition, HCPF is required to report on all the community benefit activity reports submitted from across the state to the General Assembly each year, with an eye toward making policy recommendations that could improve outcomes in the hospital community benefit space.

The legislation builds on and fills gaps in federal law. As a condition of their tax-exempt status, federal law requires nonprofit hospitals to complete Community Health Needs Assessments (CHNA) once every three years. In addition, federal law requires tax-exempt hospitals to complete an implementation strategy that outlines how they will go about addressing needs identified in the CHNA. Federal law also requires nonprofit hospitals to describe the community benefits they provide each year on Schedule H of the Form 990, which most nonprofit hospitals must file with the IRS each year.

This bill is designed to strengthen the local oversight of CHNAs and community benefit implementation strategies. In addition, the bill will address several gaps with the Form 990 reporting. In doing so, the bill will help to ensure we know what types of write-offs and spending hospitals are classifying as community benefit. It will help us know how much money hospitals are investing in different types of community benefits and how that compares to the benefit they derive from their tax-exempt status.  And by making that information available and accessible, it will help Coloradans to ensure our nonprofit hospitals are meeting their community benefit obligations and investing in better health for Colorado communities.

-By Allison Neswood

Recent articles

CCLP’s 2024 legislative wrap-up, part 2

CCLP's 2024 legislative wrap-up focused on expanding access to justice, removing administrative burden, supporting progressive tax and wage policies, preserving affordable communities, and reducing health care costs. Part 2/2.

CCLP’s 2024 legislative wrap-up, part 1

CCLP's 2024 legislative wrap-up focused on expanding access to justice, removing administrative burden, supporting progressive tax and wage policies, preserving affordable communities, and reducing health care costs.


To maintain health and well-being, people of all ages need access to quality health care that improves outcomes and reduces costs for the community. Health First Colorado, the state's Medicaid program, is public health insurance for low-income Coloradans who qualify. The program is funded jointly by a federal-state partnership and is administered by the Colorado Department of Health Care Policy & Financing.

Benefits of the program include behavioral health, dental services, emergency care, family planning services, hospitalization, laboratory services, maternity care, newborn care, outpatient care, prescription drugs, preventive and wellness services, primary care and rehabilitative services.

In tandem with the Affordable Care Act, Colorado expanded Medicaid eligibility in 2013 - providing hundreds of thousands of adults with incomes less than 133% FPL with health insurance for the first time increasing the health and economic well-being of these Coloradans. Most of the money for newly eligible Medicaid clients has been covered by the federal government, which will gradually decrease its contribution to 90% by 2020.

Other populations eligible for Medicaid include children, who qualify with income up to 142% FPL, pregnant women with household income under 195% FPL, and adults with dependent children with household income under 68% FPL.

Some analyses indicate that Colorado's investment in Medicaid will pay off in the long run by reducing spending on programs for the uninsured.


Hunger, though often invisible, affects everyone. It impacts people's physical, mental and emotional health and can be a culprit of obesity, depression, acute and chronic illnesses and other preventable medical conditions. Hunger also hinders education and productivity, not only stunting a child's overall well-being and academic achievement, but consuming an adult's ability to be a focused, industrious member of society. Even those who have never worried about having enough food experience the ripple effects of hunger, which seeps into our communities and erodes our state's economy.

Community resources like the Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, exist to ensure that families and individuals can purchase groceries, with the average benefit being about $1.40 per meal, per person.

Funding for SNAP comes from the USDA, but the administrative costs are split between local, state, and federal governments. Yet, the lack of investment in a strong, effective SNAP program impedes Colorado's progress in becoming the healthiest state in the nation and providing a better, brighter future for all. Indeed, Colorado ranks 44th in the nation for access to SNAP and lost out on more than $261 million in grocery sales due to a large access gap in SNAP enrollment.

See the Food Assistance (SNAP) Benefit Calculator to get an estimate of your eligibility for food benefits.


Every child deserves the nutritional resources needed to get a healthy start on life both inside and outside the mother's womb. In particular, good nutrition and health care is critical for establishing a strong foundation that could affect a child's future physical and mental health, academic achievement and economic productivity. Likewise, the inability to access good nutrition and health care endangers the very integrity of that foundation.

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides federal grants to states for supplemental foods, health care referrals, and nutrition information for low-income pregnant, breastfeeding and non-breastfeeding postpartum women and to infants and children up to age five who are found to be at nutritional risk.

Research has shown that WIC has played an important role in improving birth outcomes and containing health care costs, resulting in longer pregnancies, fewer infant deaths, a greater likelihood of receiving prenatal care, improved infant-feeding practices, and immunization rates

Financial Security:
Colorado Works

In building a foundation for self-sufficiency, some Colorado families need some extra tools to ensure they can weather challenging financial circumstances and obtain basic resources to help them and their communities reach their potential.

Colorado Works is Colorado's Temporary Assistance for Needy Families (TANF) program and provides public assistance to families in need. The Colorado Works program is designed to assist participants in becoming self-sufficient by strengthening the economic and social stability of families. The program provides monthly cash assistance and support services to eligible Colorado families.

The program is primarily funded by a federal block grant to the state. Counties also contribute about 20% of the cost.


Child care is a must for working families. Along with ensuring that parents can work or obtain job skills training to improve their families' economic security, studies show that quality child care improves children's academic performance, career development and health outcomes.

Yet despite these proven benefits, low-income families often struggle with the cost of child care. Colorado ranks among the top 10 most expensive states in the country for center-based child care. For families with an infant, full-time enrollment at a child care center cost an average of $15,140 a year-or about three-quarters of the total income of a family of three living at the Federal Poverty Level (FPL).

The Colorado Child Care Assistance Program (CCCAP) provides child care assistance to parents who are working, searching for employment or participating in training, and parents who are enrolled in the Colorado Works Program and need child care services to support their efforts toward self-sufficiency. Most of the money for CCCAP comes from the federal Child Care and Development Fund. Each county can set their own income eligibility limit as long as it is at or above 165% of the federal poverty level and does not exceed 85% of area median income.

Unfortunately, while the need is growing, only an estimated one-quarter of all eligible children in the state are served by CCCAP. Low reimbursement rates have also resulted in fewer providers willing to accept CCCAP subsidies.