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Background: the main aim of the study is to find if the National Health Insurance Scheme (NHIS) in Ghana is achieving universal health coverage (UHC) or not. The study gives the trajectories of health policies in Ghana and their implications on long term health financing. NHIS in Ghana was implemented in 2004, with the aim of increasing subscribers’ access to health care services and reduce financial barriers to health care. On equity access to healthcare, it addresses two core concerns: (1) enrolling particular groups (persons exempted from annual premium payments) and (2) achieving UHC for all citizens and persons with legal residence. It utilizes a multifactor approach to the conceptualization of UHC. The research question: Is Ghana’s NHIS on course to deliver or achieve universal health coverage? Methods: we used qualitative methods. In doing so, the study engaged participants in in-depth interviews, focus group discussions and direct observations of participants in their natural settings, like hospitals, clinics, offices and homes, with purposive and snowball techniques. This data triangulation approach aims to increase the reliability and validity of findings. Results: the empirical evidence shows NHIS performed relatively well in enrolling more exempt groups (particular groups) than enrolling all persons in Ghana (UHC). The biggest challenge for the implementation of NHIS from the perspectives of health insurance officials is inadequate funding. The health insurance beneficiaries complained of delays during registrations and renewals. They also complained of poor attitude of some health insurance officials and health workers at facilities. Conclusions: both health insurance officials and beneficiaries emphasized the need for increased public education and for implementers to adopt a friendly attitude towards clients. To move towards achieving UHC, there is a need to redesign the policy, to move it from current voluntary contributions, to adopt a broad tax-based approach to cover all citizens and persons with legal residence in Ghana. Also, to adopt a flexible premium payment system (specifically ‘payments by installation’ or ‘part payments’) and widen the scope of exempt groups as a way of enrolling more into the NHIS.

US nonprofit hospitals are required by law to have a charity care policy, but hospitals have significant discretion in determining specific eligibility criteria. Using a novel national database, this analysis revealed that nonprofit hospitals have chosen widely varying charity care eligibility guidelines. Among hospitals that offered free care, income limits ranged from 41 percent to 600 percent of the federal poverty guideline. Many hospitals considered assets when determining eligibility for charity care, and a significant minority also had residency requirements and restrictions for insured patients. Hospitals generally allowed charity care in cases of hardship, with a median cutoff of a given hospital bill being 20 percent of the patient's income. Hospitals in counties with lower levels of poverty and uninsurance had more generous eligibility policies. The wide variation in requirements for hospital financial assistance poses barriers to equitable access to care.

There is a seemingly intractable disagreement about whether nonprofit hospitals can be meaningfully differentiated from their for-profit counterparts and are therefore still deserving of exemption from federal income tax. Nonprofit, tax-exempt hospitals are intended to be organized and operated for charitable purposes. What this means and requires has evolved from providing relief for the sick and poor to promoting community health and more. At the same time, these institutions have evolved into complex, highly regulated business organizations, some of which struggle to differentiate themselves from their for-profit competitors. The history of American hospitals from almshouses to today’s complex health care systems includes, and is better understood in the context of, the stories of how women’s hospital auxiliary organizations built, supported, and evolved with hospitals.While acknowledging the enduring debate regarding exemption, this article attempts to address the question of how to fill the charitable gap if exempt hospitals were to lose or voluntarily relinquish their preferred tax status. The article recommends preserving the ability to address community and individual health needs through charitable hospital auxiliaries. Auxiliaries are uniquely situated in an increasingly commercial healthcare market, due both to their history and community connections, to hold and direct the use of charitable assets, to accept tax-deductible charitable contributions, and to address unmet community needs.

For nonprofit hospitals to maintain their tax-exempt status, the Affordable Care Act requires them to conduct a community health needs assessment, in which they evaluate the health needs of the community they serve, and to create an implementation strategy, in which they propose ways to address these needs. We explored the extent to which nonprofit urban hospitals identified equity among the health needs of their communities and proposed health equity strategies to address this need. We conducted a content analysis of publicly available community health needs assessments and implementation strategies from 179 hospitals in twenty-eight US cities in the period August-December 2016. All of the needs assessments included at least one implicit health equity term (such as disparities, disadvantage, poor, or minorities), while 65 percent included at least one explicit health equity term (equity, health equity, inequity, or health inequity). Thirty-five percent of implementation strategies included one or more explicit health equity terms, but only 9 percent included an explicit activity to promote health equity. While needs assessment reporting requirements have the potential to encourage urban nonprofit hospitals to address health inequities in their communities, hospitals need incentives and additional capacity to invest in strategies that address the underlying structural social and economic conditions that cause health inequities.

Parks and greenspaces provide well-documented benefits for physical, mental, and social health. Nonprofit hospitals, required to conduct Community Health Needs Assessments (CHNAs) and invest in social determinants of health, could therefore advance health and health equity by supporting park access and quality. We reviewed CHNAs from 51 large nonprofit hospitals in U.S. cities ranking in the lower half of the 2024 Trust for Public Land ParkScore Index. We analyzed how parks and greenspaces were addressed in CHNAs and conducted interviews and focus groups with 29 representatives from hospitals, park agencies, and community organizations. Mental health, access to care, and chronic disease were the most frequently identified community priorities in CHNAs. Although 56.9% of CHNAs included data on greenspaces and 54.9% identified parks as a community need, many CHNAs gave limited attention to parks – largely due to limited familiarity, capacity constraints, and competing priorities rather than opposition. Qualitative findings revealed 4 key themes: (1) CHNAs often included community input but lacked resources and coordination to address built environment needs; (2) parks were widely recognized as vital to mental health and social connection but constrained by inequitable access, safety concerns, and underinvestment; (3) existing collaborations between hospitals, parks, and community groups demonstrated promise yet faced capacity barriers; and (4) historical and ongoing structural racism shaped inequities in park access and investment. Our findings reveal an under tapped opportunity for hospitals to integrate parks and greenspaces into CHNAs, strengthen partnerships with park agencies, and direct community benefit investments toward parks to improve community health outcomes. Doing so could help align hospital community benefit spending with upstream drivers of health. We conclude with recommendations for hospitals, park agencies, and community organizations to collaborate in advancing park equity and health equity.

Significant debate persists about the obligations of nonprofit hospitals toward low-income patients. Many issues pertaining to this subject were discussed during the rulemaking process following the passage of the Affordable Care Act of 2010, which set forth rules for hospital billing and collection. In public comments, hospitals, debt collectors, and patient advocates debated what constituted “reasonable efforts” to determine whether a patient qualified for hospital financial assistance before resorting to extraordinary collection actions including lawsuits, wage garnishments, and adverse credit reporting. This study analyzes public comments to the proposed Internal Revenue Service rule on section 501(r)(6). After an initial review of the data, 5 commonly mentioned issues were identified. Respondents were organized into commenter types, and the opinion of each respondent to each issue was coded by 2 separate reviewers. Discrepancies between reviewer determinations were resolved by consensus during follow-up discussions. This analysis revealed a set of common concerns: whether reporting delinquent medical debt to credit bureaus and selling debt to third party buyers should be considered extraordinary collection actions; whether hospitals should be able to use presumptive eligibility to rule patients either eligible or ineligible for financial assistance; and whether hospitals should be held legally liable for the actions of third-party debt collectors. Hospitals and debt collection agencies were allied on most issues, particularly in their shared belief that reporting debt to credit bureaus and selling debt to third parties should not be tightly regulated. Patient advocacy organizations and hospitals had divergent opinions on most issues. The alliance of hospitals and debt collectors in advocating for fewer regulations around collections is part of a history of hospital lobbying to maintain tax-exemption with fewer charity care mandates. This alignment helps explain why third-party debt collection agencies, and aggressive collection tactics, have become commonplace in hospital billing.

Background Not-for-profit hospitals are facing an uncertain financial future, especially following the COVID-19 pandemic. Nevertheless, they are legally obligated to provide free and discounted health care services to communities. This study investigates the hospital, community, and state regulatory factors and whether these factors are associated with family income eligibility levels for free and discounted care. Methods Data were sourced from Internal Revenue Service Form 990, several data files from the Centers for Medicare and Medicaid, demographic and community factors from the Census Bureau, supplemental files from The Hilltop Institute, Community Benefit Insight, and Kaiser Family Foundation. The study employs multilevel mixed-effects linear and ordered logit regressions to estimate the association between the hospital, community, state policies, and the hospital’s family income eligibility limit for free and discounted care. Results A plurality of hospitals (49.96%) offered a medium level of family income eligibility limit (160–200% of the federal poverty level (FPL)) for free care. In comparison, about 53% (52.94%) offered a low level (0–300 of FPL) eligibility limit for discounted care. Holding all else equal, hospitals designated as critical access, safety net, those in rural areas or located in disadvantaged areas were associated with an increased probability of offering low eligibility limits for free and discounted care. Hospitals in a joint venture, located in highly concentrated markets or states with minimum community benefits requirements, were associated with an increased probability of offering high eligibility limits. Conclusion State and community factors appear to be associated with the eligibility level for free and discounted care. Hospitals serving low-income or rural communities seem to offer the least relief. The federal and state policymakers might need to consider relief to these hospitals with a requirement for them to provide a specific set of minimum community benefits.

The 2017 law known as the Tax Cuts and Jobs Act (TCJA) enacted a tax on private, non-profit college and university endowments for the first time. Institutions with at least 500 tuition-paying students and endowments of $500,000 or greater per student now have to pay a 1.4% tax on their endowments. But like all taxpayers, colleges and universities may be tax averse or seek reductions in their tax burdens. That is, colleges and universities may try to avoid the tax through taking action to ensure they do not meet the threshold. Such actions include increasing the size of their student bodies, increasing student aid to ensure a small number of tuition-paying students, and spending down their endowments. Colleges may also attempt to offset taxed revenue by increasing other revenue streams. Examples of such behavior include increasing revenue from auxiliary services, admitting more “ full-pay” students who do not need financial aid, reducing financial aid for tuition-paying students (perhaps even while increasing the number of students who receive enough aid to become non-tuition paying), and admitting fewer low-income students. All of this would be economically rational behavior, but it could produce negative effects for higher-education stakeholder groups, such as students and their families. In this Article, we assess the ramifications of the TCJA’s endowment tax for college and university revenue-seeking behavior. We use a national-level dataset and a quasi-experimental statistical model known as the “Synthetic Control Method,” which is underutilized in legal research, to examine institutional behaviors in the wake of the TCJA’s passage. We find that individual institutions—such as Northwestern University, Duke University and Vassar College, among others—may have changed their admissions, enrollment and revenue-generating behaviors to reduce their overall tax burden, offset losses in revenue or avoid the tax. We suspect that this is evidence of firm behavior to game the endowment tax imposed by the TCJA.

This article examines five different Medical-Legal Partnerships (MLPs) associated with Yale Law School in New Haven, Connecticut to illustrate how MLP addresses the social determinants of poor health. These MLPs address varied and distinct health and legal needs of unique patient populations, including: 1) children; 2) immigrants; 3) formerly incarcerated individuals; 4) patients with cancer in palliative care; and 5) veterans. The article charts a research agenda to create the evidence base for quality and evaluation metrics, capacity building, sustainability, and best practices; it also focuses specifically on a research agenda that identifies the value of the lawyers in MLP. Such a focus on the “L” has been lacking and is overdue.

Legislative changes and a recent court ruling allow private schools in England and Wales to determine how to provide the public benefits required to justify their charitable status. We investigate how private school headteachers and other informed stakeholders perceive their public benefit objectives and obligations. We find that schools interpret public beneficiaries widely to include one or more of state school pupils, local communities, other charities, and general society through raising socially responsible adults. Private schools pursue their own goals through public benefit provision, and balance the advantages of public benefit activities against the costs. The schools are not constrained by the ‘more than tokenistic’ minimum set by the regulator. The findings highlight the difficulties faced by governments who seek to pursue redistributive educational policies through charitable law.