Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health – CMS definition
Failing to address health equity is a risky prospect: In 2018 alone, the economic burden of racial and ethnic health inequities in the U.S. was estimated to be upwards of $421 billion. As federal regulations now require hospitals to assess, report on and address health disparities among their patients, health equity is top of mind for hospital and health system leaders. Implications for direct patient care aside, nonprofit hospitals must also consider what health equity means in the community health needs assessment (CHNA) process.
There are certainly plenty of hospitals that regard the CHNA as a cumbersome regulatory requirement – a box to be checked to avoid tax penalties. However, highly effective organizations recognize the value these assessments bring, particularly for their ability to highlight inequities or disparities in the community.
While addressing health equity in the CHNA is not stated as a direct requirement, the IRS provides some guidance to help hospitals weave equity into the process. First, a hospital may not define the community it serves in a way that excludes medically underserved, low-income or minority patients living in the service area. The hospital must also solicit and consider input received from these populations (or organizations that represent their interests) in the process of identifying and prioritizing needs and available community resources. Finally, the manner in which input was received from these groups and incorporated into the assessment must be documented in the final CHNA report.
Still, if the term “health equity” does not appear in current IRS guidelines for CHNA compliance… then why worry about it? The answer is fairly straightforward: Aside from the moral obligation that many of us feel, there are important business and strategic reasons to address equity issues in your CHNA.
In recent years, nonprofit hospitals have come under federal scrutiny because of alleged gaps between the tax exemption they receive and the monetary value of their annual community benefit spending. A 2023 letter to the IRS penned by a bipartisan group of U.S. senators expressed alarm about “vague” IRS community benefit rules, noting: “These practices – along with lax federal oversight – have allowed some nonprofit hospitals to avoid providing essential care in the community for those who need it most.”
While some critics want to see charity care enshrined as the only measure of community benefit, the law is clear that community building activities and community health improvement services are valid ways that nonprofit hospitals can “earn” their tax exemption. Health equity is about looking for disparities across the whole community and offering help to “those who need it most.” Integrating health equity into the CHNA process demonstrates a good faith effort to address inequities in the community beyond the hospital walls, and positions the hospital as a good community citizen.
In addition, CMS and other regulatory bodies are increasingly weaving health equity requirements into payment models like TEAM and AHEAD, paving the way for payments to eventually incentivize hospitals for their health equity efforts – or penalize them for failing to address disparities. This means that addressing health equity in the broader community has the potential to be a morally, strategically, and financially sound decision.
Health Equity Inputs & Outputs
Integrating health equity into your organization’s CHNA can be done in a variety of different ways.
In terms of structuring or developing the CHNA, some hospitals use a framework specifically focused on health equity, such as Healthy People 2030. Health equity considerations can also be incorporated into the primary data collection process. For example, surveys can be offered in multiple languages spoken in the community, and focus groups can be structured around vulnerable populations, such as recent immigrants/refugees, the unhoused population, or community members with disabilities. A health equity lens can also be integrated into the secondary data collection process, by breaking down health and SDOH data by race, ethnicity, age group, sex/gender, or geographic area to learn more about differences between groups of people.
Likewise, there are various options for building health equity into your final, public-facing documents. Some hospitals will specifically select health equity as a stated priority area. For instance, based on community research, your priorities might be:
- Healthcare Access & Quality
- Maternal & Infant Health
- Health Equity
In that case, you would then need to develop specific initiatives to address each priority – including health equity – in the written implementation strategy.
Conversely, some hospitals might not select health equity as an explicitly stated priority, but rather choose to address it within their other priorities. Take Maternal & Infant Health, for example: Within that priority area, a hospital might decide to focus its strategic efforts/activities on reducing maternal mortality in Black mothers due to a disparity in the community that was identified through the CHNA process.
Connecting your CHNA and implementation strategies with your broader health equity goals can strengthen your organizational commitment to reducing disparities for your patients and the community at large. In fact, the CMS Framework for Health Equity includes several considerations that you may be able to directly align with your CHNA priorities. These include the need to build organizational and workforce capacity to reduce health disparities, advance health literacy and access to culturally and linguistically appropriate services, and increase accessibility to healthcare services and coverage for all.
Conclusion
Integrating health equity into your CHNA work demonstrates a commitment to staying ahead of the curve and, most importantly, a commitment to improving the health of every member of your community.
The CHNA process can help your organization better identify the most critical community health needs, more effectively identify actions outside of traditional clinical care to improve community health and wellness, and begin to unravel some of the underlying social and systemic structures that create health inequities.
