The federal health law’s efforts to get nonprofit hospitals toprovide more community-wide benefits in exchange for theirlucrative tax status has gotten off to a slow start, new researchsuggests. And some experts predict that a recent repeal of a keyprovision of the law could further strain the effort.

The increased emphasis on community-wide benefits was mandated bythe Affordable Care Act. The health law required hospitals thatmeet federal tax standards to be nonprofits to perform a communityhealth needs assessment (CHNA) every three years, followed byimplementing a strategy to deal with issues confronting the community, such aspreventing violence or lowering the rates of diabetes.

A studyreleased Monday in the journal Health Affairs shows spending inthese areas has remained relatively stagnant.

The research showed average spending by tax-exempt hospitals oncommunity benefits in 2010 was 7.6 percent of total operating costsand bumped to 8.1 percent by 2014. But the bulk of that spendinggoes toward unreimbursed patient care, such as charity care. TheACA was trying to spur more spending on broader communityinitiatives, which have remained below 1 percent of operating costsat the hospitals.

“This is not easy for hospitals to do,” said Gary Young, thestudy’s lead author and director of the Center for Health Policyand Healthcare Research at Northeastern University in Boston. “Bytradition, by the nature of their resources, hospitals have notbeen oriented to prevention, they’ve been oriented totreatment.”

New efforts by the Republican-led Congress may complicate theeffort. The repeal last month of the ACA’s penalties for mostpeople who don’t have health insurance has some experts questioninghow some of these hospitals will be able to spend more on communitybenefits. The Congressional Budget Office has estimated thatbecause of that change about 13 million people would give up theircoverage by 2027, which could drive up costs for hospitals becausethere would be more uninsured patients.

“Anything that destabilizes the system and takes money out ofthe hospitals’ revenue stream is going to negatively impact them,”said Gregory Tung, assistant professor at the University ofColorado’s School of Public Health. “It’s tough for hospitals to benavigating that uncertainty.”

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Kaiser Health News is a nonprofit news servicecovering health issues. It is an editorially independent program ofthe Kaiser Family Foundation that is not affiliated with KaiserPermanente.

Jill Horwitz, professor of law at UCLA who specializes in healthissues, said hospitals have trouble planning community efforts whenthey are unsure of their finances.

“It’s a very difficult context in which to operate a stablesystem,” Horwitz said. “One day to the next, it’s hard to know whatthe rules are, what the reimbursement is going to be and what kindof insurance your patients will have.”

More than half of the hospitals in the United States areprivate, nonprofit organizations that are tax-exempt.

Lawrence Massa, president & CEO of the Minnesota HospitalAssociation, said the repeal of the ACA’s individual mandatepenalties will change hospitals’ calculations.

“We certainly expect to see our uninsured rate go up as a resultof repealing the individual mandate,” he said, “so that’s going tohave an opposite type of effect of where we thought the trend wasgoing to be because we changed the rules in the middle of thegame.”

But it’s too early to tell how hospitals will respond, accordingto Massa. Many are still grappling with the new requirements.

The ACA was enacted in 2010, but the provision requiringcommunity-based action did not come into effect until the end ofMarch 2012, and enrollment in ACA marketplace plans didn’t beginuntil 2014. Hospitals began early investments for assembling theneeds assessments in 2011 and 2012, Massa said.

“In the later years, they’ll be using that data and comparingand reporting to the IRS how they’ve changed their communitybenefits spending as a result of those community health needsassessments,” he said. “If everything stayed the way it was, Ithink we would know by 2020 whether this had the kind of impactthat was anticipated.”

Young and his research colleagues acknowledged in their studythat “certainly, more time is needed” to assess the full impact ofthe law’s requirements on spending for community benefits.

Nonetheless, Young said, many hospitals lack the means toprovide greater preventive care in the community.

They don’t have the necessary infrastructure, “the personnel orthe knowledge to develop those strategies,” he said. “They don’thave the resources to necessarily invest in those areas.”

Horwitz agreed. “If we’re going to require this high level ofspending on community benefits and paying for patients who can’tafford care, something else has to give,” she said.

Kaiser Health News is a nonprofit news servicecovering health issues. It is an editorially independent program ofthe Kaiser Family Foundation that is not affiliated with KaiserPermanente.