HCS 457 Week 4 Public Health and the Health Care System Example

Two Systems, One County: How a Health Department and Two Nonprofit Hospitals Divided the Work of Community Health After Medicaid Expansion

[Student Name]

University of Phoenix

HCS/457: Public and Community Health

Week 4 Assignment

[Instructor Name]

[Date]

The county, the hospitals and the partnership are composites written for a model paper; research findings come from the sources listed.

Public health and medical care grew up as separate systems in the United States. In the composite county described here, the health department employs 140 people, runs immunization, tuberculosis and sexual health clinics, inspects restaurants and wells, tracks disease and leads emergency preparedness. Two nonprofit hospitals, one of 350 beds and one of 120, employ more than 5,000 people and treat illness. For decades the two sides met mainly in emergencies. This paper examines how public health and the health care system relate in the county, what linked them more closely after 2010 and what tensions remain.

Two Different Systems

Public health's mission is to protect and improve the health of the whole population, mostly through prevention, surveillance, policy and education. Its funding comes from government budgets and grants, and its success is measured in things that did not happen, such as outbreaks prevented. The health care system's mission is to diagnose and treat individuals. It is funded mainly by insurance payments for services delivered, which rewards volume and procedures (Shi & Singh, 2022). The difference in funding explains much of the difference in behavior: hospitals are paid when people are sick, while health departments are funded, often thinly, to keep them well.

A Rule That Pushed Hospitals Toward Public Health

The Affordable Care Act added a requirement that every tax-exempt hospital conduct a community health needs assessment at least once every three years, gather input from people who represent the community, public health experts among them, publish what it finds and then write a strategy explaining how it will respond to each need (Internal Revenue Service, 2024). The rule turned community health from an optional activity into a compliance obligation for nonprofit hospitals, and it gave health departments a formal seat at the table.

What Hospitals Actually Spend

Nonprofit hospitals are exempt from most taxes in exchange for providing community benefit. Young et al. (2013) examined the community benefit reports of tax-exempt hospitals nationally for fiscal year 2009 and found that they spent an average of 7.5% of operating expenses on community benefits. More than 85% of that went to charity care and other patient care services, such as losses on Medicaid patients. Only about 5% of community benefit spending went to community health improvement activities that hospitals carried out themselves, the kind of prevention work that public health departments do every day. The finding showed that most hospital community benefit is really medical care, and that the needs assessment rule would matter only if hospitals changed where they spent.

Medicaid Expansion Changed the Division of Labor

The county's state expanded Medicaid in 2014. Within two years, the share of adults without insurance in the county fell by nearly half, and many people who had used the health department's clinics for basic care could see primary care providers instead. The health department closed its adult primary care clinic and redirected staff to disease investigation and community programs. Expansion affected more than medical visits. Himmelstein (2019) compared expansion states with states that declined to expand and found that among low-income adults without children, very low food security fell from 17.6% to 15.9% in expansion states while it rose slightly in nonexpansion states. Coverage freed household money for food, an effect on a social determinant that public health cares about.

Building a Joint Assessment

In the county, the health department and both hospitals decided to conduct one joint needs assessment rather than three separate ones. They pooled survey data, hospital discharge data and vital statistics, held community listening sessions in each neighborhood and chose three shared priorities: hypertension control, access to behavioral health care and youth tobacco and vaping prevention. Each partner took a lead role suited to its strengths. The hospitals funded community health workers and blood pressure kiosks; the health department ran school-based prevention and tracked progress; all three shared a public dashboard.

Why the Partnership Works When It Does

Each side brings something the other lacks. Hospitals have money, clinical staff and data on patients who reach care. The health department has population data, legal authority, community relationships and experience in prevention. Together they can reach people before and after the hospital door.

How the Work Is Paid For

Money shapes the division of labor as much as mission does. The joint plan's first-year budget of about $1.4 million came mostly from the two hospitals' community benefit funds, with the health department contributing staff time and a state chronic disease grant. Community health workers are paid by the larger hospital but supervised jointly, and the health department's epidemiologist maintains the dashboard. Writing these arrangements into a three-year memorandum of understanding protected the plan from being cut in a single bad budget year and made each partner's contribution visible to the public, which the community benefit reporting rules encourage.

Tensions That Remain

The partnership still has friction. Hospital priorities can tilt toward services that also bring in patients, such as screenings that lead to procedures. Data sharing is slowed by privacy rules and incompatible systems. The health department's budget depends on grants that end, while hospital commitments depend on margins that shrink in bad years. And no one partner is accountable if the dashboard's numbers do not move.

What Each System Should Do Next

The hospitals should move a larger share of community benefit into community health improvement tied to the joint priorities and report results, not only dollars. The health department should keep leading measurement and convening, and should seek stable funding for the work hospitals cannot do. Both should give residents a formal voice in setting and reviewing priorities.

Conclusion

Public health and the health care system in the county started as separate worlds with different missions and money. A federal rule, Medicaid expansion and a joint assessment brought them closer, dividing the work according to each one's strengths. The relationship is still unfinished, but it shows that community health improves most when the two systems plan together.

References

Himmelstein, G. (2019). Effect of the Affordable Care Act's Medicaid expansions on food security, 2010-2016. American Journal of Public Health, 109(9), 1243-1248. https://doi.org/10.2105/AJPH.2019.305168

Internal Revenue Service. (2024). Community health needs assessment for charitable hospital organizations: Section 501(r)(3). https://www.irs.gov/charities-non-profits/community-health-needs-assessment-for-charitable-hospital-organizations-section-501r3

Shi, L., & Singh, D. A. (2022). Delivering health care in America: A systems approach (8th ed.). Jones & Bartlett Learning.

Young, G. J., Chou, C.-H., Alexander, J., Lee, S.-Y. D., & Raver, E. (2013). Provision of community benefits by tax-exempt U.S. hospitals. New England Journal of Medicine, 368(16), 1519-1527. https://doi.org/10.1056/NEJMsa1210239