Tax-exempt Hospitals Research Articles

Provision of Social Care Services by US Hospitals.

Despite growing interest in identifying patients' social needs, little is known about hospitals' provision of services to address them. We identify social care services offered by US hospitals and determine whether hospital spending or state policies toward community benefits are associated with the provision of these services by tax-exempt hospitals. National secondary data about hospitals were collected from the American Hospital Association Annual Survey, with additional Internal Revenue Service (IRS) Form 990 data on community benefits spending from CommunityBenefitInsight.org and state-level community benefits policies from HilltopInstitute.org. Descriptive statistics for types of social care services and hospital characteristics were calculated, with bivariate chi-square and t-tests comparing for-profit and tax-exempt hospitals. Multivariable Poisson regression was used to estimate associations between hospital characteristics and types of services offered and among tax-exempt hospitals to estimate associations between social care services and community benefits spending and policies. Multivariable logistic regressions modeled associations between community benefits spending/policies and each type of social care services. Private US hospitals offered an average of 5.7 types of social care services in 2018. Tax-exempt hospitals offered about 36% more social care services than for-profit hospitals. Larger number of beds, health system affiliation, and having community partnerships are associated with more social care services, whereas rural hospitals and those managed under contract offered fewer social care services. Among tax-exempt hospitals, greater community benefits spending is associated with offering more total (incidence rate ratio [IRR] = 1.10, p < 0.01) and patient-focused social care services (IRR = 1.16, p < 0.01). Hospitals in states with minimum community benefits spending requirements offered significantly fewer social care services. Although tax-exempt status and increased community benefits spending were associated with increased social care services provision, the observation that certain hospital characteristics and state minimum community benefits spending requirements were associated with fewer social care services suggests opportunities for policy reform to increase social care services implementation.

Comparison of US Hospital Charity Care Policies Before vs After Onset of the COVID-19 Pandemic

Tax-exempt hospitals are required to provide charity care to maintain their tax-exempt status; charity care policies must be published online with clear eligibility criteria. Prior research has shown wide variability in charity care policy content; it is unknown how hospitals change their charity care policies over time. To examine changes to tax-exempt hospital charity care policies before vs after the COVID-19 pandemic. This cohort study used downloaded charity care policies from a geographically representative sample of 170 tax-exempt hospitals from December 1 to 31, 2019, and December 1 to 31, 2021, and categorized the policy changes made as more restrictive, more generous, indeterminate, minimal, or not updated. Onset of the COVID-19 pandemic. The primary outcome was charity care policy content changes from 2019 to 2021. Also examined were the effects of hospital ownership type, state Medicaid expansion status, and hospital consolidation on policy changes. In this sample of 170 hospitals, 151 published documents available for comparison. Among these hospitals, 127 (84.1%) updated their charity care policies and 77 (51.0%) made substantial changes, with 242 distinct policy changes to categories such as income eligibility cutoffs, asset limitations, and service exclusions. Although the majority of hospitals expanded charity care (47 [31.1%]), a sizable minority restricted charity care (12 [7.9%]). Medicaid expansion during the study period and hospital consolidations were not associated with expansion of charity care; the largest merger in this sample led to reduced charity care at all 4 hospitals involved. Tax-exempt hospitals appear to have updated their policies with mostly positive changes during and after the onset of the COVID-19 pandemic; however, some hospitals restricted charity care in 2021 documents. Unpublicized or vague eligibility criteria may limit patients' understanding of charity care policies and conceal the full extent of charity care policy changes over time. Policy makers should consider requiring greater transparency and simplification for hospital charity care policies to ensure adequate access to care for uninsured and underinsured patients.

Characteristics of US hospitals using extraordinary collections actions against patients for unpaid medical bills: a cross-sectional study

ObjectiveThis study aims to characterise and evaluate the largest 100 hospitals in the USA that have adopted aggressive collection tactics to pursue patients with unpaid medical bills, such as lawsuits,...

Community Benefit: Policies, Practices, and Opportunities at the Half-Century Mark.

In the 50 years since the expansion of the legal definition of charity for tax-exempt hospitals, there have been periodic regulatory actions at the municipal, state, and federal level to quantify charitable contributions and justify the deferral of tax revenues. The movement toward risk-based reimbursement in the last decade creates an incentive for a shift in hospital leadership understanding and approach to community benefit programs and services. The historical interpretation of community benefit as an issue of compliance with legal obligations is being questioned by forward-thinking hospital leaders, in recognition that more strategic resource allocation offers the potential to reduce financial risk associated with preventable emergency department and inpatient utilization. Recent actions in the policy arena to strengthen community benefit practices, as well as policies in related areas such as homelessness and behavioral health, challenge hospitals to strengthen their focus on prevention. At the same time, increased availability of data on health care costs, mapping of health care utilization patterns, and parallel overlays of hospital location, jurisdictional boundaries, and the social determinants of health offer significant potential for informed public dialogue at the regional level that builds an ethic of shared ownership for health across sectors. Local public health agencies can play an important role by establishing baselines, goals, and objectives in communities where health inequities are concentrated within county and municipal jurisdictional boundaries to align and focus the assets of health, community development, and business sector stakeholders.

Association of Nonprofit Hospitals’ Charitable Activities With Unreimbursed Medicaid Care After Medicaid Expansion

In the United States, nonprofit hospitals receive tax-exempt status with the expectation that they provide a high level of benefit to local communities. Prior work has shown that Medicaid expansion reduced hospital spending on uncompensated care. To measure the association of tax-exempt hospital spending with community benefit and changes in uncompensated care after Medicaid expansion. This cohort study was performed using a difference-in-differences analysis (ie, a pre-post treatment-control design) to estimate changes in reported charitable categories associated with Medicaid expansion. Data from Internal Revenue Service form 990, Schedule H, tax filings for 2253 tax-exempt hospitals in the United States from 2012 to 2016 were used. Data were analyzed from June to November 2019. The proportion of the hospital's tax filing that spanned the period after Medicaid expansion. Hospital-reported spending on uncompensated care, unreimbursed Medicaid expenses, and other community benefit spending categories. Across 2253 hospitals, mean (SD) uncompensated care costs between 2012 and 2016 were $4.20 million ($8.80 million) and unreimbursed Medicaid expenses were $7.60 million ($18.62 million). Compared with tax-exempt hospitals in states that did not expand Medicaid, those in states that did expand Medicaid reported mean reductions in their provision of uncompensated care of $1.11 million (95% CI, $0.35 million to $1.87 million; P < .001), representing a mean change of -2% (95% CI, -6% to 2%; P < .001). These reductions have been offset by mean reported increases in the provision of unreimbursed Medicaid expenses of $1.63 million (95% CI, $0.31 million to $2.94 million; P = .02), representing a mean increase of 2% (95% CI, 1% to 4%; P = .01). Tax-exempt hospitals in states that expanded Medicaid reported no statistically significant mean increase in spending on other community benefit activities. In this study, large decreases in uncompensated care among tax-exempt hospitals associated with Medicaid expansion were not accompanied by increases in other reportable categories of community health benefit spending. Instead, they were accompanied by increased spending on unreimbursed Medicaid expenses.

Charity Care Characteristics and Expenditures Among US Tax-Exempt Hospitals in 2016

Objectives. To examine content of financial assistance polices (FAPs) among US tax-exempt hospitals and determine whether restrictive policies were associated with reduced charity care spending.Methods. Using hospital tax filings with the Internal Revenue Service in 2016 and FAPs obtained from hospital Web sites, we examined characteristics of FAPs and associated expenditures for charity care in a representative sample of 170 tax-exempt hospitals. We identified common eligibility requirements and used them to define restrictiveness of FAPs.Results. FAPs were characterized by various ways to exclude patients, a patchwork of coverage for typical health care services, and wide-ranging discounts. FAP expenditures were lowest among restrictive hospitals in states that expanded Medicaid as part of the Affordable Care Act and highest among nonrestrictive hospitals in nonexpansion states. FAP expenses did not differ by hospital restrictiveness alone.Conclusions. Standardizing common eligibility requirements among FAPs carries potential benefits with regard to optimizing charity care for community benefit and achieving at least some level of equity; however, further policy efforts must account for additional restrictions, charges, and exclusions to be effective.

Advancing Public Health Through Tax-Exempt Hospitals: Nonprofits’ Revenue Streams and Provision of Collective Goods

Nonprofit organizations play an essential role in the provision of collective goods. Focusing on a unique subsector in the United States, this study examines the extent to which nonprofit hospitals’ provision of community benefits is related to their revenue streams. Building on existing theories, we postulate that as the proportion of a certain revenue source (i.e., government grants, private contributions, and program fees) increases, its corresponding benefits also increase. Using data from the Internal Revenue Service (IRS) 990 filed by tax-exempt hospitals nationwide, we performed panel data analysis with year and id fixed effects using robust standard errors. The findings show that the proportion of private donations is positively associated with community benefits, whereas that of program income is negatively related to community benefits. Overall, nonprofits’ decision to serve disadvantaged groups and larger communities is associated with their income sources. The study raises implications that are pertinent to nonprofit management, public administration, and health administration.

Community Benefit Spending Among North Carolina's Tax-Exempt Hospitals After Performing Community Health Needs Assessments.

As of March 23, 2012, the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct Community Health Needs Assessment (CHNA) every 3 years to incentivize hospitals to provide programs responsive to the health needs of their communities. To examine the distribution and variation in community benefit spending among North Carolina's tax-exempt hospitals 2 years after completing their first IRS-mandated CHNA. Cross-sectional study using secondary analysis of published community benefit reports. Community benefit was categorized on the basis of North Carolina Hospital Association's community benefit reporting guidelines. Multiple regression analysis using generalized linear model was used to examine the variation in community benefit spending among study hospitals considering differences in hospital-level and community characteristics. Fifty-three private, nonprofit hospitals across North Carolina. Dollar expenditures as a percentage of operating expenses of the 2 categories of community benefit spending: patient care financial assistance and community health programs. Study hospitals' aggregate community benefit spending was $2.6 billion, 85% of which was in the form of patient care financial assistance, with only 0.7% of total spending allocated to community-building activities such as affordable housing, economic development, and environmental improvements. On average, the study hospitals' community benefit spending was equivalent to 14.6% of operating expenses. Hospitals with 300 or more beds provided significantly higher investments in community health programs as a percentage of their operating expenses than hospitals with 101 to 299 beds (P = .03) or hospitals with 100 or fewer beds (P = .04). Access to care was not associated with patient care financial assistance (P = .81) or community health programs expenditures (P = .94). The study hospitals direct most of their community benefit expenditures to patient care financial assistance (individual welfare) rather than population health improvement initiatives, with virtually no investments in community-building activities that address socioeconomic determinants of health.

Did Performing Community Health Needs Assessments Increase Community Health Program Spending by North Carolina's Tax-Exempt Hospitals?

As of March 23, 2012, the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every 3 years. This study assessed whether the IRS CHNA mandate incentivized North Carolina's tax-exempt hospitals to increase investments in community health programs. The authors gathered the 2012-2016 community benefit reports of 53 North Carolina private, nonprofit hospitals from the North Carolina Hospital Association. Community benefit spending data from the year of the first CHNA were compared to that 2 years later using paired t tests among matched subjects. No significant increases were found in hospitals' community health programs spending (P = 0.6920) or in providing patient care financial assistance (charity or discounted care) (P = 0.0934). In fact, aggregate community health programs spending effectively decreased by 4%, from $393.3 million to $377.5 million. Among all community benefit items, only the unreimbursed cost for treating Medicare patients increased significantly (P = 0.0297). The proportion of spending on community health programs relative to patient care financial assistance decreased significantly (P = 0.0338). Performing CHNAs did not incentivize North Carolina's tax-exempt hospitals to progressively invest in community health programs. The hospitals continue to spend heavily on patient care financial assistance and little on disease prevention and community health improvement activities. These findings suggest that tax-exempt hospitals continue to function as a safety net for the poor and the uninsured rather than as active partners in population health management initiatives. At present, performing CHNAs may be more a demonstration of compliance than a tool to improve population health.

Determinants of Community-Related Expenses of US Tax-Exempt Hospitals, 2013.

Tax-exempt hospitals in the United States are required to report community benefit expenses on their federal tax forms. Two categories of expenses critical to the public health mission of hospitals are the "community health improvement" and "community-building" expense categories. The community health improvement expenses formally qualify as a community benefit, whereas community-building expenses do not. Increasing both types of spending would be consistent with the growing evidence on the effects of social determinants on population health. To identify characteristics associated with the level of community health improvement and community-building expenses reported by tax-exempt hospitals. The general acute care hospital is the unit of analysis. We utilize secondary data for all US general acute care hospitals that filed their own Internal Revenue Service Form 990 Schedule H for 2013 (n = 1508). We apply linear regression analysis to an explanatory model with 8 independent variables. The primary dependent variables are percentage of operating expenses devoted to community health improvement and to community building. The independent variables include 4 hospital-level measures, 3 county-level measures, and a measure of state requirements for community benefit. The level of community health improvement expenses is positively associated with bed size, system membership, profit margin, and urban location. In states where tax-exempt hospitals are required to demonstrate community benefit to the state, there is lower community health improvement spending. Teaching hospitals also demonstrate lower community health improvement spending. Results for community-building expenses mirror those for community health improvement except that teaching hospital status and per capita income lose significance and hospital competition gains significance in the negative direction. Leaders among tax-exempt hospitals in community-related spending are hospitals that are larger, more profitable, members of systems, and located in urban areas and in states that do not have community benefit requirements.

Community Benefit Spending By Tax-Exempt Hospitals Changed Little After ACA.

Provisions of the Affordable Care Act (ACA) encouraged tax-exempt hospitals to invest broadly in community health benefits. Four years after the ACA's enactment, hospitals had increased their average spending for all community benefits by 0.5 percentage point, from 7.6 percent of their operating expenses in 2010 to 8.1 percent in 2014.

Tax-Exempt Hospitals' Investments in Community Health and Local Public Health Spending: Patterns and Relationships.

To investigate whether tax-exempt hospitals' investments in community health are associated with patterns of governmental public health spending focusing specifically on the relationship between hospitals' community benefit expenditures and the spending patterns of local health departments (LHDs). We combined data on tax-exempt hospitals' community benefit spending with data on spending by the corresponding LHD that served the county in which a hospital was located. Data were available for 2years, 2009 and 2013. Generalized linear regressions were estimated with indicators of hospital community benefit spending as the dependent variable and LHD spending as the key independent variable. Hospital community benefit spending was unrelated to how much local public health agencies spent, per capita, on public health in their communities. Patterns of local public health spending do not appear to impact the investments of tax-exempt hospitals in community health activities. Opportunities may, however, exist for a more active engagement between the public and private sector to ensure that the expenditures of all stakeholders involved in community health improvement efforts complement one another.

Increased Public Accountability for Hospital Nonprofit Status: Potential Impacts on Residency Positions.

The Institute of Medicine recently called for greater graduate medical education (GME) accountability for meeting the workforce needs of the nation. The Affordable Care Act expanded community health needs assessment (CHNA) requirements for nonprofit and tax-exempt hospitals to include community assessment, intervention, and evaluation every 3 years but did not specify details about workforce. Texas receives relatively little federal GME funding but has used Medicaid waivers to support GME expansion. The objective of this article was to examine Texas CHNAs and regional health partnership (RHP) plans to determine to what extent they identify community workforce need or include targeted GME changes or expansion since the enactment of the Affordable Care Act and the revised Internal Revenue Service requirements for CHNAs. Texas hospitals (n = 61) received federal GME dollars during the study period. Most of these hospitals completed a CHNA; nearly all hospitals receiving federal GME dollars but not mandated to complete a CHNA participated in similar state-based RHP plans. The 20 RHPs included assessments and intervention proposals under a 1115 Medicaid waiver. Every CHNA and RHP was reviewed for any mention of GME-related needs or interventions. The latest available CHNAs and RHPs were reviewed in 2015. All CHNA and RHP plans were dated 2011 to 2015. Of the 38 hospital CHNAs, 26 identified a workforce need in primary care, 34 in mental health, and 17 in subspecialty care. A total of 36 CHNAs included implementation plans, of which 3 planned to address the primary care workforce need through an increase in GME funding, 1 planned to do so for psychiatry training, and 1 for subspecialty training. Of the 20 RHPs, 18 identified workforce needs in primary care, 20 in mental health, and 15 in subspecialty training. Five RHPs proposed to increase GME funding for primary care, 3 for psychiatry, and 1 for subspecialty care. Hospital CHNAs and other regional health assessments could be potentially strategic mechanisms to assess community needs as well as GME accountability in light of community needs and to guide GME expansion more strategically. Internal Revenue Service guidance regarding CHNAs could include workforce needs assessment and intervention requirements. Preference for future Medicaid or Medicare GME funding expansion could potentially favor states that use CHNAs or RHPs to identify workforce needs and track outcomes of related interventions.

Exploring the Link Between Completion of Accreditation Prerequisites and Local Health Departments' Decision to Collaborate With Tax-Exempt Hospitals Around the Community Health Assessment.

Community health assessments (CHAs) are a core function of local health departments (LHDs). Recently, completing a CHA has become a prerequisite for LHDs seeking accreditation by the Public Health Accreditation Board (PHAB). Similarly, under the Affordable Care Act, nonprofit hospitals are required to conduct periodic community health needs assessments (CHNAs). Opportunities thus exist for LHDs and hospitals to jointly complete CHAs/CHNAs. This study examined existing LHD-hospital collaborations around CHAs/CHNAs, focusing specifically on the relationship between LHDs' level of engagement with PHAB accreditation activities and their collaboration with hospitals around CHAs/CHNAs. Data came from the 2013 NACCHO (National Association of County & City Health Officials) Profile Study and the Area Health Resource File. Complete data were available for 1332 LHDs that participated in the 2013 NACCHO Profile Study. Logistic regression explored the relationship between LHDs' completion of accreditation prerequisites, in particular completion of a CHA, community health improvement plan, and strategic plan, and their involvement in collaborations with tax-exempt hospitals around CHAs/CHNAs. LHDs that collaborated with tax-exempt hospitals on CHAs/CHNAs were larger, more likely to be locally governed, and more likely to have a local board of health. Bivariate analysis showed that CHA/CHNA-related collaboration with hospitals was significantly correlated (P < .01) with an LHD's completion of accreditation prerequisites. In multivariate regression analysis, completion of all 3 PHAB accreditation prerequisites significantly increased the odds of LHDs collaborating with hospitals when controlling for other LHD and community-level characteristics. PHAB accreditation prerequisites together with IRS requirements for hospitals foster potential for collaboration around CHAs/CHNAs. Joint completion of CHAs/CHNAs not only allows partners to complete the assessment more efficiently but has also been shown to produce higher-quality assessments, thus building a strong foundation for continued collaboration to improve community health.

The Progress of US Hospitals in Addressing Community Health Needs

To identify how US tax-exempt hospitals are progressing in regard to community health needs assessment (CHNA) implementation following the Patient Protection and Affordable Care Act. We analyzed data on more than 1500 tax-exempt hospitals in 2013 to assess patterns in CHNA implementation and to determine whether a hospital's institutional and community characteristics are associated with greater progress. Our findings show wide variation among hospitals in CHNA implementation. Hospitals operating as part of a health system as well as hospitals participating in a Medicare accountable care organization showed greater progress in CHNA implementation whereas hospitals serving a greater proportion of uninsured showed less progress. We also found that hospitals reporting the highest level of CHNA implementation progress spent more on community health improvement. Hospitals widely embraced the regulations to perform a CHNA. Less is known about how hospitals are moving forward to improve population health through the implementation of programs to meet identified community needs.

Hospital Community Benefit in the Context of the Larger Public Health System: A State-Level Analysis of Hospital and Governmental Public Health Spending Across the United States.

Achieving meaningful population health improvements has become a priority for communities across the United States, yet funding to sustain multisector initiatives is frequently not available. One potential source of funding for population health initiatives is the community benefit expenditures that are required of nonprofit hospitals to maintain their tax-exempt status. In this article, we explore the importance of nonprofit hospitals' community benefit dollars as a funding source for population health. Hospitals' community benefit expenditures were obtained from their 2009 IRS (Internal Revenue Service) Form 990 Schedule H and complemented with data on state and local public health spending from the Association of State and Territorial Health Officials and the National Association of County & City Health Officials. Key measures included indicators of hospitals' community health spending and governmental public health spending, all aggregated to the state level. Univariate and bivariate statistics were used to describe how much hospitals spent on programs and activities for the community at large and to understand the relationship between hospitals' spending and the expenditures of state and local health departments. Tax-exempt hospitals spent a median of $130 per capita on community benefit activities, of which almost $11 went toward community health improvement and community-building activities. In comparison, median state and local health department spending amounted to $82 and $48 per capita, respectively. Hospitals' spending thus contributed an additional 9% to the resources available for population health to state and local health departments. Spending, however, varied widely by state and was unrelated to governmental public health spending. Moreover, adding hospitals' spending to the financial resources available to governmental public health agencies did not reduce existing inequalities in population health funding across states. Hospitals' community health investments represent an important source for public health activities, yet inequalities in the availability of funding across communities remain.

Describing Total Population Health: A Review and Critique of Existing Units.

Total population health is a key tenet of health care reform efforts, evident in initiatives such as the National Quality Strategy, shifts toward population-based payments, and community benefit requirements for tax-exempt hospitals. Representing total population health in a way that guides best practices and establishes shared accountability for geographic communities, however, remains a challenge in part because of differences in how stakeholders define populations. To better understand the landscape of potential denominators for population health, this study examined a selection of relevant geographic units. The approach included a comprehensive review of health services and public health research literature as well as recent pertinent health policy documents. Units were characterized based on whether they: exhibit "breadth" of coverage across the whole US population; are "accurate" or grounded in health care utilization patterns; are "actionable" with mechanisms for implementing funding and regulation; and promote "synergism" or effective coordination of public health and health care activities. Although other key components of a total population health unit may exist and no single identified unit possesses all of the aforementioned features, several promising candidates were identified. Specifically, healthcare coalitions link health care and public health domains to care for a geographic community, but their connection to utilization is not empiric and limited funding exists at the coalition level. Although Accountable Care Organizations do not uniformly incorporate public health or facilitate coordination across all payers or providers, they represent an effective mechanism to increase collaboration within health care systems and represent a potential building block to influence total population health.

Tax-Exempt Hospitals and Community Health Under the Affordable Care Act: Identifying and Addressing Unmet Legal Needs as Social Determinants of Health.

This article reviews recently promulgated Internal Revenue Service regulations for nonprofit hospitals seeking tax exemption and a new estimate of national hospital community benefit spending, and analyzes how they point to the value of hospitals working with community partners to address the social determinants of health. It then explains how unmet legal needs function as health determinants, and suggests how hospitals' participation in medical-legal partnerships can address those needs. This article was published on December 7, 2015, at www.publichealthreports.org

A Review of Tools to Assist Hospitals in Meeting Community Health Assessment and Implementation Strategy Requirements

Recent changes in U.S. national policies and regulations have created an opportunity for meaningful collaborations to take place between health systems, public health departments, and social service organizations. For medical systems, and particularly tax-exempt hospitals, new requirements include community health assessments (CHAs) and implementation strategies to address identified health needs. Individuals and groups responsible for meeting the new CHA and implementation strategy requirements may be unsure about the best ways to achieve specific aspects of the CHA process. In this report, we provide an in-depth review and rating of tools developed by public health and community experts that cover the steps necessary to meet the new requirements. A team of three community and public health experts and the authors developed a rating sheet based on a well-known community health improvement process model and on the steps in the new requirements to identify and systematically rate nine comprehensive tools. The ratings and recommendations provide a guide for hospitals in choosing tools that will best assist them in meeting the new requirements.

The Value Of The Nonprofit Hospital Tax Exemption Was $24.6 Billion In 2011.

The federal government encourages public support for charitable activities by allowing people to deduct donations to tax-exempt organizations on their income tax returns. Tax-exempt hospitals are major beneficiaries of this policy because it encourages donations to the hospitals while shielding them from federal and state tax liability. In exchange, these hospitals must engage in community benefit activities, such as providing care to indigent patients and participating in Medicaid. The congressional Joint Committee on Taxation estimated the value of the nonprofit hospital tax exemption at $12.6 billion in 2002--a number that included forgone taxes, public contributions, and the value of tax-exempt bond financing. In this article we estimate that the size of the exemption reached $24.6 billion in 2011. The Affordable Care Act (ACA) brings a new focus on community benefit activities by requiring tax-exempt hospitals to engage in communitywide planning efforts to improve community health. The magnitude of the tax exemption, coupled with ACA reforms, underscores the public's interest not only in community benefit spending generally but also in the extent to which nonprofit hospitals allocate funds for community benefit expenditures that improve the overall health of their communities.