BUSI 511 Week 2 Discussion Board Forum 2 Example

Discussion Board Forum 2: Beliefs, Values and the History of U.S. Health Care

BUSI 511 Healthcare Administration, Discussion Board Forum 2

Thread by [Student Name]

The clinic, its board, its patients and the classmates are composites; the textbook, Scripture and the peer-reviewed sources cited are real.

The board of the clinic where I volunteer met last Tuesday in a church fellowship hall to decide whether to open a second site. The clinic serves about 1,900 uninsured working adults a year in a state whose lawmakers turned down the Medicaid expansion, most of them cooks, roofers, home aides and cashiers whose jobs offer no coverage and whose incomes are too high for the state's narrow Medicaid rules but too low for Marketplace subsidies to make sense. A retired surgeon on the board argued that the waiting list proves the need and that the church should answer it. A younger member, a social worker, argued the opposite: every patient the clinic absorbs is one fewer reason for the legislature to act, and the church's money might do more good funding advocacy for coverage. Both are serious people, and both are partly right.

Shi and Singh (2019) frame this tension as a contrast between market justice and social justice. Under market justice, health care is distributed like other goods, according to individuals' willingness and ability to pay, and the obligations of the community are limited. Under social justice, the community bears a collective responsibility to make sure everyone receives basic care, usually through government. The authors explain that American health care has historically leaned toward market justice while adding social justice programs for particular groups, such as Medicare for older adults and Medicaid for some low-income people. The free clinic sits in the gap that mix leaves open. It is a social justice response delivered through private charity, carrying on a tradition the textbook's history traces back to almshouses, charitable dispensaries and voluntary hospitals that cared for the poor long before government programs existed.

Research complicates both board members' views. Darnell and O'Brien (2022) surveyed 156 free and charitable clinics late in 2014 and found that clinics in Medicaid expansion states were significantly more likely to report negative effects on fundraising, staffing, volunteer hours and patient numbers and to make major operational changes, such as adding billing or new services. When public coverage arrives, donors and volunteers move on, which supports the social worker's point that charity and policy are linked. But in states without expansion, the clinics keep carrying the load. Bundy (2024) studied safety net clinics in South Carolina, also a nonexpansion state, and found that patients called "clients" felt they could not complain about delays or poor treatment because the care came from volunteers, so they deferred care and rationed or shared medications rather than appear ungrateful. The clinic absorbs need, and its patients' silence keeps that need invisible to the state. That finding supports the social worker's warning while showing why simply closing or shrinking the clinic would harm the people who rely on it.

Scripture offers a frame that refuses the false choice. The law of Moses told Israel's farmers not to reap their fields to the edges or gather the gleanings, but to leave them for the poor and the sojourner (English Standard Version Bible, 2001/2016, Leviticus 19:9-10). The provision was personal, since each farmer chose to leave the edges, and it was also structural, because it was written into the nation's law rather than left to mood or generosity. A church can leave the edges of its field for the uninsured and still ask why the law no longer requires anyone else to do the same. I recommended that the board open the second site and, at the same time, give patients a confidential way to report problems and a seat on the board, and dedicate part of its budget to reporting its waiting list and patient stories to state lawmakers. Service and advocacy together honor both kinds of justice.

Reply to Alicia

Alicia, your thread described the nonprofit hospital in your city that sends aggressive bills to low-income patients while holding a tax exemption worth millions, and you asked whether such hospitals still earn the exemption that Shi and Singh (2019) trace back to their origins as charitable institutions. National data suggest your example is not an outlier. Zare and Anderson (2024) worked through five years of the tax returns nonprofit hospitals file, 2017 to 2021. Across 17 kinds of community benefit, the typical hospital devoted 8.8% of its expenses, yet free and discounted care for patients who could not pay took up just 1.8%, against tax breaks equal to roughly 5.2% of expenses. For 24% of hospitals, the exemption outweighed every community benefit dollar put together, and for 81% it outweighed charity care alone. In other words, for most nonprofit hospitals the free care that justified the exemption historically is now smaller than the public subsidy itself. The rest of the community benefit total is made up largely of Medicaid shortfalls, training programs and research, which have value but are not the same as caring for the patient in your example who received a collection letter instead of a financial assistance application. When a hospital counts the gap between its costs and Medicaid payments as a gift to the community, it is counting a business decision to accept Medicaid as charity, and that accounting choice deserves scrutiny from boards and regulators.

State rules have not closed that gap. Oddleifson et al. (2025) examined "fair share" spending, a measure that subtracts the estimated value of a hospital's tax exemption from its charity care and community investment, and found no association between state minimum community benefit requirements or reporting rules and how much hospitals actually gave back. States with larger minority populations had somewhat higher fair share spending, but Medicaid expansion was linked to lower spending, likely because fewer patients needed charity care once they had coverage. That last finding cuts both ways. Expansion reduces the need for charity, yet it also lowers the bar hospitals must clear, and the exemption stays the same size either way. The market justice and social justice tension you described appears here in institutional form: hospitals that behave like businesses in their billing while claiming the tax status of charities. A practical step for your hospital's community would be to ask the board to publish its charity care policy in plain language, report charity care as a share of the tax exemption's value each year and pause collection actions until financial assistance eligibility has been checked. Would your hospital's finance office be willing to calculate that ratio and share it publicly, even if the first year's figure is unflattering?

Reply to Ben

Ben, your thread argued that church-affiliated hospitals carry a mission that shows up in how they treat patients who cannot pay, and you described the Methodist hospital where you work as an example. The evidence supports your claim, at least on spending. Zare and Gabow (2023) compared 2,644 nonprofit general hospitals and found that Catholic hospitals spent 7.5% of total expenses on community benefits and other church-affiliated hospitals 9.4%, compared with 6.09% for nonprofits without church ties. Charity care followed the same pattern: 5.2% of expenses for other church-affiliated hospitals and 3.9% for Catholic hospitals, against 2.4% for hospitals with no church affiliation. Those differences held after the authors controlled for other hospital characteristics, which suggests that ownership with a religious mission makes a measurable difference.

Faith-based health work also extends beyond hospital walls. Johnston et al. (2018) describe a statewide initiative in which a university team, Kansas United Methodist congregations and a Methodist philanthropy worked together to build the capacity of lay-led health ministry teams, drawing on systematic review evidence that faith-based health programs can improve health outcomes. Shi and Singh (2019) note that religious organizations were among the earliest providers of hospital care in the United States, and congregational health ministries carry that tradition into communities where hospitals are distant or expensive. A practical question for your hospital is whether its community benefit dollars reach the congregations around it. Hospitals could fund parish health teams, train volunteers to help members apply for coverage or financial assistance and host blood pressure and diabetes screenings in churches where trust already exists. Your own hospital's Form 990 would show where it falls on these measures, since Schedule H reports charity care and community benefit by category. Spending more than secular peers is a good start, but the measure that matters to patients is whether the money reaches the people who need it. One caution belongs alongside the good news. Emmady and Emmady (2025) argue that free clinics last longest when they rest on volunteers' unconditional service and minimal paperwork rather than on shifting government grants and eligibility rules, and the same lesson may apply to church-supported health ministry: programs tied to a single grant cycle tend to disappear when the grant does. A hospital that wants its faith partners to endure should fund them steadily, train their leaders and measure results that matter to the congregation, such as members who gained coverage, screenings completed and follow-up visits kept. Johnston et al. (2018) emphasize building lay capacity for that reason, since trained members remain in the congregation long after a program's funding period ends. Does your hospital's community health needs assessment include local congregations as partners, or only as places to post flyers?

References

Bundy, H. (2024). "Don't fuss at our staff": A moral economy of volunteerism in South Carolina safety net clinics. Social Science & Medicine, 347, 116706. https://doi.org/10.1016/j.socscimed.2024.116706

Darnell, J. S., & O'Brien, L. (2022). Location, location, location: The Affordable Care Act's impact on free clinics depends on what state they're in. Journal of Health Care for the Poor and Underserved, 33(2), 887-901. https://doi.org/10.1353/hpu.2022.0070

Emmady, J. V., & Emmady, P. (2025). Free clinics in the United States: Challenges, models, and a sustainable alternative approach. North Carolina Medical Journal, 86(4). https://doi.org/10.18043/001c.154156

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Johnston, J. A., Konda, K., & Ablah, E. (2018). Building capacity among laity: A faith-based health ministry initiative. Journal of Religion and Health, 57(4), 1276-1284. https://doi.org/10.1007/s10943-017-0445-6

Oddleifson, D. A., Dong, H., & Wadhera, R. K. (2025). Community benefit and tax-exemption levels at non-profit hospitals across US states. Medical Care, 63(3), 222-226. https://doi.org/10.1097/MLR.0000000000002064

Shi, L., & Singh, D. A. (2019). Essentials of the U.S. health care system (5th ed.). Jones & Bartlett Learning.

Zare, H., & Anderson, G. (2024). Beyond the bottom line: Assessing charity care, community benefits, and tax exemptions in nonprofit hospitals. Journal of Healthcare Management, 69(6), 439-454. https://doi.org/10.1097/JHM-D-24-00080

Zare, H., & Gabow, P. (2023). Influence of not-for-profit hospital ownership type on community benefit and charity care. Journal of Community Health, 48(2), 199-209. https://doi.org/10.1007/s10900-022-01159-4