New Orleans      No matter what the Supreme Court decides this summer, there is little question that to secure more health care protection for lower income families, particularly in the resister-states that continue to refuse to expand Medicaid under the Affordable Care Act, we are going to have to push so-called nonprofit, tax exempt hospitals to finally carry their full share of the burden.  Talking to Mark Rukavina of the Boston-based Community Health Advisors on Wade’s World on KABF/FM , it became obvious that the kind of close reading he has done of the Act offers some additional handles for on-the-ground organizers and organizations to do so.

In our interview,  we talked about two “soft” spots of vulnerability that concern me in the enforcement of new standards for nonprofit hospitals that are now going into effect, five years after passage of the Affordable Care Act.  One is the ability of the hospitals themselves, who are not always the best actors in this play, to make their own determination of what they believe constitutes the test for charity care as required by their facility.  The other is whether or not the IRS has the capability to enforce the standards regardless, since they are the pointed end of this stick.

On the first point, Rukavina had several things to say.  He acknowledged that there were only a “handful” of states that had set clear limits like the 200% of poverty standard in Illinois and Massachusetts.  On the other hand, he usefully pointed out that though the hospitals were being left with final discretion the language of the regulations made it clear that they were going to have to seek input from the community in making their determination, including everything from any comments on a website or letters of complaint from patients, and even, it seems, from advocates and local organizations.  As we had been moving to get all of our ducks in a row before sending a letter asking for a meeting with the heads of the hospitals, from Rukavina’s remarks on the radio, it seemed they would have little choice but to meet with us – and many others – seriously or refuse to do so at their peril.

On the second point Rukavina was perhaps more hopeful than I have been, but he was very realistic.  He conceded that this would be a big job for the IRS and that the information some of the hospitals were providing on their 990, Schedule H filings were sketchy and contradictory.  He also thought it unlikely that the IRS would be as forceful in denying a hospital the tax exemption without recognizing the serious impact of doing so in many communities.  At the same time channeling his former experiences as an organizer and advocate, he was expansive in his conviction of what local organizations invested in the issue might be able to do to secure compliance.

Another huge handle in holding the hospitals feet to the fire emerged in our conversation.  No matter what the standard the hospital sets, no matter what the determination of what they believe a patient’s ability to pay might be, at the end of the day there are now provisions that will allow a patient to appeal the decision of the hospital, once they get the notice between 90 and 120 days after their billing, if they are dissatisfied.  Obviously, this is a huge opportunity for Local 100’s Citizen Wealth Center and many other nonprofits, agencies, community organizations and others, as Rukavina acknowledged, to stand up and step into that gap and provide the beleaguered family with forceful and effective representation, that would stall or stop the ability of the hospital to implement extraordinary collection practices like the garnishments and court actions that have become common practice for so many nonprofits.  They could try to resist such appeals, but once again, it would be at their peril.

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Bucky Halker: “Casey Jones, the Union Scab” by Joe Hill