Environmental Health Investments: A Minimal Part of Nonprofit Hospital Community-Building Expenses

Context: Environmental impacts on human health are an urgent concern, requiring greater focus and action from health care organizations. Nonprofit hospitals can address community needs through investing in environmental improvement (EI) projects aimed at reducing harm to the community from environmental hazards. These expenditures provide a useful model for understanding how hospitals can respond to environmental influences on health, but national patterns of EI expenditures are under-researched. Objective: To assess nationwide trends in nonprofit hospital EI spending from 2010 to 2021. Design: Observational study using Internal Revenue Service tax data. Setting: US nonprofit hospitals. Main Outcome(s) and Measure(s): We assessed associations between reported EI spending and hospital organization and community characteristics (hospital revenue (quintiles); bed size (<50, 50-199, 200-399, 400 +); participation in group reporting (yes/no); teaching affiliation (yes/no); rurality status; geographic region (Northeast, Midwest, West, and South), and county poverty (quartile). Results: There were 36 093 nonprofit hospital-years included in our analysis. 10.4% of hospitals reported EI spending. EI spending was positively associated with higher revenue and being in the Midwest region and negatively associated with area poverty. The years 2020 and 2021 were significantly associated with a lower likelihood of spending relative to 2010. 40% of hospitals included utilized group reporting. Only 6% of independently reporting hospitals reported EI spending. Among hospital organizations with any reported community-building expenses, the percentage of their total operating budget dedicated to EI averaged 0.002% each year (0%-1.52%). Conclusions: Though EI investments are small relative to community-building spending, the characteristics of hospitals reporting these investments provide insight into EI trends over time and which hospitals are conducting these efforts. Future research should consider the specific gaps to stimulating EI, what environmental needs hospitals are equipped to fill, and their relevance to broader environmental health policies and initiatives.