Benefit Expenditures Research Articles

Rural nonprofit hospital community benefit and financial assistance spending: A call for greater reporting transparency.

US nonprofit hospitals must provide community benefits including financial assistance to be tax-exempt. Rural residents particularly benefit from financial assistance because they have higher medical debt on average. The Internal Revenue Service allows nonprofit hospitals that are members of health systems to report expenditures for their entire system (group returns) rather than for individual hospitals. Our study examined how (if at all) rural nonprofit hospitals filing group returns are different than those filing individual returns. We used 2021 data extracted from Community Benefit Insight and the American Hospital Association for 100 rural nonprofit hospitals in Wisconsin and Minnesota. We conducted bivariate analyses examining differences in mean total community benefit spending and mean financial assistance spending as a percentage of total operating expenses for hospitals filing individual versus group returns. We conducted multivariable regression models examining the association of filing group returns and individual returns with community benefit spending and financial assistance spending. Bivariate analysis revealed significant differences between group return hospitals and individual return hospitals in spending on community benefits (5.81%vs. 9.49%, respectively) and on financial assistance (0.36% vs. 0.71% respectively). Multivariable regression demonstrated filing group returns is significantly negatively associated with community benefit expenditures (β = -2.90, p < 0.05) and financial assistance expenditures (β = -0.31, p < 0.01). In our sample, filing group returns was associated with less spending on community benefits and financial assistance. To understand this finding, researchers need data on individual hospital spending to increase transparency and accountability.

Analysis of Indirect Costs of Absence Associated with Mental Disorders on the Basis of Social Security Data (2012-2023).

Mental and behavioral disorders significantly impair psychophysical functioning, leading to challenges in daily activities. The increasing recognition of the importance of mental health in global development goals has resulted in its inclusion in the United Nations' Sustainable Development Goals. The burden of mental disorders has grown worldwide due to demographic changes, with substantial economic and social impacts. This study aimed to examine the indirect costs of mental disorders in Poland by analyzing the expenditures by the Social Insurance Institution (ZUS) on work incapacity benefits and disability pensions from 2012 to 2023. The goal was to identify trends, dependencies, and the economic impact of policy changes. Data were collected from ZUS reports on annual expenditures for work incapacity benefits and disability pensions. Advanced statistical methods, including linear regression and Pearson correlation, were employed to analyze trends and relationships. Student's t-tests assessed the statistical significance of the observed trends. The expenditures on benefits for work incapacity due to mental disorders increased significantly over the past decade, particularly from 2020 to 2023, partly due to the COVID-19 pandemic. Short-term absenteeism due to mental disorders accounted for 10.5% of the total sick leave days. A strong positive correlation was found between years and benefit expenditures. Conversely, the disability pension expenditures exhibited a downward trend, potentially reflecting improvements in public health or policy changes. The significant increase in expenditures on benefits related to mental disorders may reflect greater awareness, improved diagnostics, and the impact of the COVID-19 pandemic. In contrast, the decline in disability pension expenditures could suggest improved mental health or effective policy measures. However, it is important to emphasize that the presented data are not the only factor influencing this situation. Multiple variables, including societal, economic, and healthcare system changes, contribute to these trends. Therefore, further research is necessary to fully understand the underlying causes and to guide effective policy development. Regular monitoring and continued investment in mental health are essential to managing indirect costs such as absenteeism and presenteeism efficiently.

Trends in severity of work-related traumatic injury and musculoskeletal disorder, Ontario 2004-2017.

Traumatic injury surveillance can be enhanced by describing injury severity trends. This study reports trends in work-related injury severity for males and females over the period 2004-2017 in Ontario, Canada. A weighted measure of workers' compensation benefit expenditures was used to define injury severity, obtained from the linkage of workers' compensation claims to emergency department (ED) records where the main injury or illness was attributed to work. Denominator counts were obtained from Statistics Canada's Labor Force Survey. Trends in the annual incidence of injury, classified as low, moderate, or high severity, were examined using regression modeling, stratified by age and sex. Over a 14-year observation period, there were 1,636,866 ED records included in the analyses. Overall, 57.6% of occupational injury records were classified as low severity, 29.5% as moderate severity, and 12.8% as high severity conditions. There was an increase in the incidence of high severity injuries among females (annual percent change (APC): 1.52%; 95% CI: 0.77, 2.28), while the incidence of low and moderate severity injuries generally declined for males and females. Among females, injuries attributed to animate mechanical forces and assault increased as causes of low, moderate, and high severity injuries. The incidence of concussion increased for both males (APC: 10.51%; 95% CI: 8.18, 12.88) and females (APC: 16.37%; 95% CI: 13.37, 19.45). The incidence of severe work-related injuries increased among females in Ontario between 2004 and 2017. The methods applied in this surveillance study of traumatic injury severity are plausibly generalizable to applications in other jurisdictions.

Savings in social expenditures for work incapacity in patients with inflammatory bowel disease depend on access to innovative therapies in Poland.

Inflammatory bowel diseases (IBD) are an increasing burden for societies. We examined Polish Social Insurance Institution (ZUS) work incapacity expenditures for people with IBD compared with the general population. Aggregate data were obtained on ZUS expenditures between 2012 and 2021 in Polish zlotys (PLN). Annual work incapacity benefit expenditures were analyzed and IBD benefit expenditures were examined relative to innovative IBD drug utilization in individual provinces. Between 2012 and 2021, annual ZUS expenditures per person increased, while expenditures per IBD patient decreased. Proportionally, absenteeism was the largest ZUS expenditure in the general population, while disability pensions were the largest in the IBD population. ZUS expenditures due to absenteeism in the general population increased by PLN 282 per person; those due to disability pensions decreased by PLN 85. Disability pension spending due to Crohn's disease (CD) and ulcerative colitis (UC) decreased by PLN 371 and PLN 284, respectively, while absenteeism spending per person with CD and UC decreased (PLN 58 and PLN 35, respectively). Nationwide in 2021, 8.5% of people with CD and 1.9% of those with UC received innovative drugs. The percentage of people receiving innovative drugs and ZUS expenditure per person were inversely related in 9/16 provinces for CD and 5/16 for UC. Polish state spending on work incapacity benefits increased in the general population but decreased in people with IBD between 2012 and 2021. Use of innovative drugs was associated with reduced spending per person with IBD in some provinces.

Geographic variation in inpatient medical expenditure among older adults aged 75 years and above in Japan: a three-level multilevel analysis of nationwide data.

In Japan, a country at the forefront of population ageing, significant geographic variation has been observed in inpatient medical expenditures for older adults aged 75 and above (IMEP75), both at the small- and large-area levels. However, our understanding of how different levels of administrative (geographic) units contribute to the overall geographic disparities remains incomplete. Thus, this study aimed to assess the degree to which geographic variation in IMEP75 can be attributed to municipality-, secondary medical area (SMA)-, and prefecture-level characteristics, and identify key factors associated with IMEP75. Using nationwide aggregate health insurance claims data of municipalities for the period of April 2018 to March 2019, we conducted a multilevel linear regression analysis with three levels: municipalities, SMA, and prefectures. The contribution of municipality-, SMA-, and prefecture-level correlates to the overall geographic variation in IMEP75 was evaluated using the proportional change in variance across six constructed models. The effects of individual factors on IMEP75 in the multilevel models were assessed by estimating beta coefficients with their 95% confidence intervals. We analysed data of 1,888 municipalities, 344 SMAs, and 47 prefectures. The availability of healthcare resources at the SMA-level and broader regions to which prefectures belonged together explained 57.3% of the overall geographic variance in IMEP75, whereas the effects of factors influencing healthcare demands at the municipality-level were relatively minor, contributing an additional explanatory power of 2.5%. Factors related to long-term and end-of-life care needs and provision such as the proportion of older adults certified as needing long-term care, long-term care benefit expenditure per recipient, and the availability of hospital beds for psychiatric and chronic care and end-of-life care support at home were associated with IMEP75. To ameliorate the geographic variation in IMEP75 in Japan, the reallocation of healthcare resources across SMAs should be considered, and drivers of broader regional disparities need to be further explored. Moreover, healthcare systems for older adults must integrate an infrastructure of efficient long-term care and end-of-life care delivery outside hospitals to alleviate the burden on inpatient care.

Understanding the dynamic of government expenditures for disability and other social benefits: evidence from a Lotka–Volterra model for the Netherlands

Understanding the dynamic of government expenditures for disability and other social benefits: evidence from a Lotka–Volterra model for the Netherlands

Transformation to E-Public Procurement in the United Arab Emirates in the Light of Uncitral Model Law

Purpose: This research investigates the transformation of the e-public procurement system in the United Arab Emirates in light of the UNICETRAL Law Model. &#x0D; &#x0D; Theoretical framework: The current research consists of an introduction and the definition of public procurement and e-public procurement in addition to the e-tender system in UAE at the Federal and local levels and how it is consistent with the UNICETRAL Law Model.&#x0D; &#x0D; Design/Methodology/Approach: It should be noted that a descriptive/analytical approach has been adopted in this study, clarifying the concept of public procurement and then addressing the mechanism of electronic systems used in the UAE.&#x0D; &#x0D; Findings of the paper: The UAE has six electronic systems for public procurement that helped to reduce public spending, simplify the process and procedures, save time, and maximize the benefits of public expenditure.&#x0D; &#x0D; Research, Practical &amp; Social implications: We suggest using AI in public procurement systems to reduce the dealing with human resources to make the tender less corrupted and not to abuse the public procurement employee power.&#x0D; &#x0D; Originality/Value: We propose to create electronic systems for public procurement in the Emirates that do not have electronic systems for public procurement, in addition to continually introducing technical support to the employees to avoid mistakes and to enhance effectiveness and efficiency.

Hospital Community Benefit Reporting: How Group Reporting Practices Limit Accountability.

To identify the prevalence of group reporting of hospital community benefit efforts to the Internal Revenue Service (IRS) and understand hospital and community characteristics associated with this practice. The study was based on data collected from publicly available community benefit reports from 2010 to 2019, as well as secondary data from the 2020 American Hospital Association (AHA) Annual Survey. The sample was drawn from the entire nonprofit US hospital population reporting community benefit activities. The analytic plan employed descriptive statistics and bivariate analysis. The United States. All data are self-reported by US hospitals, either through the publication of community benefit reports (IRS Form 990 Schedule H) or a response to the AHA Annual Survey. Analyzed variables include whether a hospital reported its community benefit expenditures individually or as a group member; community benefit spending as a percentage of hospital operating expenses; and whether the hospital was part of a multihospital system, with consideration of hospital and community characteristics. Between 2010 and 2019, more than 40% of hospitals participated in group reporting, with most doing so consistently. System membership and hospital size were significantly and positively tied to group reporting, with state community benefit policy tied to the lower prevalence of group reporting. The high prevalence of group reporting limits accountability to communities and restricts an accurate assessment of community benefit expenditures, counter to policy intentions. Stakeholders should consider what modifications to reporting rules could be made to promote transparency and to ensure that the effects of community benefit policies align with intentions.

Redistributive Effects of Fiscal Policy across the Income Groups in the Urban-Rural Areas of Pakistan

There exist a large number of studies related to the estimates of government budgetary redistributive effects and its related problems with regard to different countries of the world.1 Studies of the impacts of government expenditures and taxes in Pakistan have been conducted within the framework of either incidence of taxes or the impact of expenditures across the income groups. The studies carried out by Azfar (1972); Jeetun (1978); Alauddin and Raza (1981) Malik and Saqib (1985, 1989) cover different aspects of taxation—tax incidence, progressivity or regressivity of the tax system across the income groups/individuals and regions. These studies did not discuss the expenditure side of the budget. Shirazi (1996) analysed the impact of government transfer programmes (Zakat and Ushr) across the income deciles. Ghaus (1989) studied the incidence of provincial and municipal government service-related expenditure benefits in Karachi metropolitan and therefore, the scope of her study was limited to one city only. Despite the existence of a rich bibliography on the subject of government redistrbutive budgetary effects and its related problems, no study is available which covers the overall redistributive impacts of government budgetary policy in Pakistan. This study explores the impacts of government expenditures and taxes on the distribution of income across various income groups along with net fiscal impacts in the urban-rural areas of Pakistan. The rest of our study is organised as follows. In the following section, Part II, we describe the methodology and data set. In Part III, the results of the study are presented. The Part IV concludes the paper.

Estimating the financial benefits of employers’ occupational health and safety expenditures

While employer expenditures on occupational health and safety (OHS) in high income countries can be substantial, the financial benefits of these expenditures are not well described. The objective of this study is to apply a transparent methodology to estimate the financial return to employers from OHS expenditures in the Canadian province of Ontario. There were three phases in the study workplan: establishing an accurate estimate of the average direct cost of disabling work injury or illness; identifying employers in the construction, transportation and manufacturing sectors with a low incidence of work-related injury and illness; and the application of a set of plausible assumptions to estimate the financial benefits of OHS expenditures in this sample of employers with strong OHS performance. Financial benefits combined estimates of the tangible financial benefits arising from averted disabling work-related injury and illness and intangible financial benefits associated with improved employee retention and morale, improved production quality and strengthened corporate reputation. Applying these plausible assumptions, the average return on OHS expenditures was 1.24 for 289 manufacturing employers, 2.14 for 56 transportation employers and 1.34 for 88 construction employers. There was variation around these average return on investment values; 138 employers (32% of the sample) had an estimated return on investment less than 1.0, and 295 employers (68% of the sample) had a return on investment estimate greater than 1.0. The estimates of average financial return among large Ontario employers in three important economic sectors, while moderate, are positive, in the range of 1.24 to 2.14. These estimates are consistent with the range of estimates available from research in this field over the past decade.

Association between non-profit hospital community benefit spending and health outcomes.

To determine if greater non-profit hospital spending for community benefits is associated with better health outcomes in the county where they are located. Community benefit data from IRS Form 990/Schedule H was linked to health outcome data from Area Health Resource Files, Map the Meal Gap, and Medicare claims from the Center for Medicare and Medicaid Services at the county level. Counties with at least one non-profit hospital in the United States from 2015 to 2019 (N=5469 across the 5 years) were included. We ran multiple regressions on community benefit expenditures linked with the number of health professionals, food insecurity, and adherence to diabetes and hypertension medication for each county. The three outcomes were chosen based on prior studies of community benefit and a recent survey sent to 12 health care executives across four regions of the U.S. Data on community benefit expenditures and health outcomes were aggregated at the county level. Average hospital community benefit spending in 2019 was $63.6 million per county ($255 per capita). Multivariable regression results did not demonstrate significant associations of total community benefit spending with food insecurity or medication adherence for diabetes. Statistically significant associations with the number of health professionals per 1000 (coefficient, 12.10; SE, 0.32; p < 0.001) and medication adherence for hypertension (marginal effect, 0.27; SE, 0.09; p=0.003) were identified, but both would require very large increases in community benefit spending to meaningfully improve outcomes. Despite varying levels of non-profit hospital community benefit investment across counties, higher community benefit expenditures are not associated with an improvement in the selected health outcomes at the county level. Hospitals can use this information to reassess community benefit strategies, while federal, state, and local governments can use these findings to redefine the measures of community benefit they use to monitor and grant tax exemption.

IMPACT OF FISCAL DISCIPLINE ON PLATEAU STATE GOVERNMENT EXPENDITURE

The main objective of the public sector as part of the macro-economy is the provision of necessary government services to the public in order to achieve macro-economic stabilisation. Fiscal discipline is the application of fiscal rules to achieve deficit reduction and long-term fiscal consolidation. The aim of the study was to examine the impact of fiscal discipline on Plateau state government expenditure and to determine, given the existence of fiscal discipline, if a significant relationship exists between state government expenditure and the following demographic and economic variables: disposable income, population density, inter-governmental revenue, retirement benefit expenditure, and capital expenditure. State government expenditure, if properly deployed, should lead to expansion of public goods and services and the attainment of economic growth and development. The study made use of secondary data which were collected from Plateau State Ministry of Finance and the National Population Commission Jos. The data were analysed using the linear ordinary least square regression analysis. The result shows that state government expenditure has a significant positive relationship with disposable income, intergovernmental revenue and retirement benefit expenditure, a significant negative relationship with population density and capital expenditure. It was concluded that (i) state government expenditure is not geared towards the expansion of public goods and services that will enhance growth and development (ii) economies of scale in the production and provision of government services is yet to be attained and (iii) state government expenditure is incurred in order to implement possible fiscal discipline mechanisms of balanced-budget or deficit reduction. The study recommends that fiscal discipline mechanisms should be implemented only to the extent that the decision does not constrain expenditure on public goods and services that may result in growth and development

The principle of good governance: national and european judicial practice

The article reveals the content of the principle of good governance based on the analysis of the Constitution and laws of Ukraine, international treaties, decisions of the Constitutional Court of Ukraine, as well as decisions of the European Court of Human Rights and the Supreme Court.The author analyzes the decisions of the European Court of Human Rights, which formulates the principle of good governance in its modern sense, and on the basis of this analysis determines its content and features. It has been established that the rulings of the European Court of Human Rights have established a consistent practice of understanding the principle of good governance, which includes five main components, a detailed analysis of each of which is based on specific examples. It was found that the principle of good governance is characterized by the dynamics of its development, which is manifested in the constant expansion of the content of this principle. It is argued that the permanent development of the principle of good governance has led to the formation of a new component of this principle - proportionality.The national case law in cases arising from public law disputes is described and the approach of courts to the application of the principle of good governance is clarified. It is substantiated that there is a well-established case law in social disputes, according to which one of the manifestations of the principle of good governance is that in the absence of an effective mechanism for guaranteeing social benefits provided by law, in full or no statutory expenditures for such benefits. should make it impossible to protect the property rights of a person guaranteed by Article 41 of the Constitution of Ukraine. Other aspects of the application of the principle of good governance in judicial practice have been clarified and analyzed. Based on the analysis, a conclusion is drawn about the importance of the principle of good governance in Euro-pean and national case law.

The political economy of academic publishing: On the commodification of a public good.

This paper provides an institutional and empirical analysis of the highly concentrated market of academic publishing, characterized by over proportionally high profit margins for publishing companies. The availability of latest research findings is an important issue for researchers, universities and politicians alike. Open access (OA) publication provides a promising but also costly solution to overcome this problem. However, in this paper we argue that OA publication costs are an important, but by far not the only way for academic publishers to gain access to public funding. In contrast, our study provides a comprehensive overview of the channels through which public expenditure benefits big academic publishing companies. Furthermore, we offer the results of an explorative case study, where we estimate the annual financial flows of public expenditures in Austria for the field of social sciences. In all, these expenditures add up to about 66.55 to 103.2 million € a year, which amounts to a fourth of total public funding for this field. Against this background, we contribute to the debate whether and to what extent public subsidies are justified for economically successful companies.

State‐level social safety nets for families coping with job loss

AbstractCritics of the modern American welfare state allege that safety net benefits discourage work by providing sufficient resources to replace earned income. Yet, research in social policy has long depicted the US safety net as parsimonious and inadequate relative to its European counterparts, even when considering benefits from programs that reward favorable work histories. Other theories predict variability across states and regional clustering even amid low overall spending. Moreover, the recent COVID‐19 outbreak has exposed the insufficiency and lack of resilience of the major US safety nets in the face of unprecedented unemployment. This study examines the benefit expenditures on three safety net programs available to American families with recently unemployed breadwinners—Temporary Assistance for Needy Families, Supplemental Nutrition Assistance Program, and Unemployment Insurance—as a proportion of median annual income for a given state‐year between 1997 and 2017. We examine the overall spending as well as variability and clustering across states. We find that the average benefit expenditure comprises only 42% of median income, and while there is substantial variability around this average, only one state is above 78%. We also find that spending levels appear to be regionally clustered. We conclude that safety nets for the recently unemployed and their families are weak relative to earned income and that the extent of this weakness varies by state, with some regional patterning.

Editor's Letter

AbstractThis letter from the editor provides a brief summary of the articles contained in this issue and invites readers to respond and submit their own articles.

Enhancing Pension Adequacy While Reducing the Fiscal Budget and Creating Essential Capital for Domestic Investments and Growth: Analysing the Risks and Outcomes in the Case of Greece

Many countries around the world are resorting to mandatory funded components in their multi-pillar pension systems with the purpose of catering for the financial pressure from ageing. This paper aims at analysing the possible replacement rates for such a scheme, by choosing different assumptions and setting the best combined area for the expected result. Then, an approach for analysing the potential for the implementation of such a scheme in Greece is presented along with the actuarially projected expected benefit expenditure and respective accrued capital. A result of the introduction of such a component is expected to be the elevated replacement rate at retirement with a concurrent alleviation of the fiscal burden for the state. The projected scale of savings will also provide domestic financing for investments generating growth.

Comparison of progression of care-need levels among long-term care recipients with and without advanced care management in a rural municipality of Japan: A population-based observational study

BackgroundLittle is known about the association between advanced care management and patient outcomes in home settings. In 2009, the Japanese government introduced a financial incentive scheme for advanced care management by long-term care agencies with at least one advanced care manager. However, it remains unclear whether advanced care management in rural areas is associated with improved outcomes for recipients. ObjectiveTo compare the progression of care-need levels among long-term care recipients in home settings with and without advanced care management. DesignA population-based observational study. SettingA rural municipality in Japan. ParticipantsRecipients of long-term care (n = 2005). MethodsWe used individual-level secondary data provided from a rural municipal government that was collected as part of the Survey of Long-Term Care Benefit Expenditures and medical care claim records between April 2012 and March 2017. We linked these two databases using unique identifiers. The inclusion criteria for study subjects were that they: (1) were aged ≥65 years; (2) were newly certified as care-need level 1, 2, or 3; and (3) used long-term care insurance services in home settings from April 2012 through March 2017. We excluded individuals using long-term care insurance services for less than six months. Ultimately, we selected 1722 propensity-matched recipients with and without advanced care management, and then conducted Kaplan–Meier survival analyses and a log-rank test. The outcome measure was progression of care-need levels. ResultsThe proportions of five-year cumulative progression-free survival in the groups with and without advanced care management were 50.3% and 42.2% for recipients of care-need level 1 (p < .01), 34.3% and 32.3% for recipients of care-need level 2 (p < .01), and 22.3% and 24.5% for recipients of care-need level 3 (p > .05), respectively. The progression-free period lasted a median of 12 (interquartile range, 10–24) months for recipients of care-need level 1, 14 (interquartile range, 11–28) months for recipients of care-need level 2, and 12 (interquartile range, 10–24) months for recipients of care-need level 3. ConclusionsLong-term care recipients with advanced care management in home settings had a higher probability of progression of care-need levels in a rural municipality of Japan. This finding suggests that the governmental policy of providing financial incentive for advanced care management may not be effective in improving the outcome of long-term care recipients in a rural municipality of Japan.

Shifts in Community Benefits Spending Among Nonprofit Hospitals in Nebraska and 10 Proximate States, 2012 and 2015.

Federal and state policy makers have debated the evolving concept of community benefit and the extent to which nonprofit hospitals are providing benefits to the community in exchange for the tax benefits they receive. This study compares community benefits spending by nonprofit hospitals in Nebraska and other selected states in both 2012 and 2015. Expenditures are also examined by rural, regional, and urban hospitals within Nebraska. Community benefit expenditure data were taken from Community Benefit Insight and consolidated into the categories of direct patient care, community health improvement initiatives, and health professions education and research. When community benefit expenditures were compared across 11 states, Nebraska had the highest percentage of expenditures for community health improvement initiatives in both 2012 and 2015. Although community benefit expenditures for the 44 nonprofit hospitals within Nebraska increased from 2012 to 2015, they remained flat as a share of total hospital expenditures. In 2015, 63% of community benefit expenditures were allocated to direct patient care, which represented a 7.3% decrease from 2012. This decline led to greater spending on community health improvement initiatives (3.1%) and health professions education and research (4.2%). Rural, regional, and urban hospitals spent more proportionately on community health improvement initiatives in 2015 than in 2012. The shift in community benefit expenditures from direct patient care to community health improvement initiatives and health professions education and research suggests that hospitals are investing in programs with broader community-wide benefits. Nebraska allocates a significantly larger share of its community benefits spending to community health improvement activities than other Great Plains and Midwestern states. Nebraska is in the process of implementing Medicaid expansion, which may shift future community benefits spending decisions.

Association of State Medicaid Expansion With Hospital Community Benefit Spending

Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities. To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion. This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019. State Medicaid expansion between 2011 and 2017. Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending. Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P < .001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P = .04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P = .049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P =.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P = .14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P = .70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P = .06). In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.