Chapter four: ‘Looking outside their walls’: Exploring community health in chicago hospitals

The 2010 Patient Protection and Affordable Care Act requires not-for-profit hospitals in the United States to conduct a community health needs assessment (CHNA) every three years. Hospitals are also required to develop an implementation plan addressing the needs observed in the CHNA, or provide reasons for not addressing these identified needs. The extent to which CHNAs account for the structural and social determinants of health is open to investigation, particularly when doing so may call on hospitals to go beyond a narrow focus on individual behaviours as the source of preventable morbidity and premature mortality. Our work examines CHNA reports from hospitals in Chicago, Illinois. Our analysis contrasts the first wave of reports (published in the 2012-2013 period) with a second wave of reports (published in the 2015-2016 period). Our results reveal considerable differences in how hospitals met their CHNA requirements, with only a small number of hospitals offering historically deep and community-driven reports in the first wave of CHNA. Important differences also existed in how hospitals conceptualised causality of health inequities in their service areas-in the first wave of reports, most hospitals focused on individual behaviours rather than the root causes of poor health in Chicago, including economic inequality, racism/discrimination, and other aspects of structural violence. By the second wave of the reports a more collaborative approach was taken and a substantially different message emerged, with more hospitals adopting the language of the structural determinants of health. We argue that CHNA reports-which are created at the link between public and private health systems-are an important vehicle through which to understand health inequities in the United States.