40 Years Essential

In 1981, five hospitals came together with one common mission: to create a unique voice for hospitals that provide safety net care. Four decades, three names, and 300 members later, America’s Essential Hospitals remains the nation’s foremost champion for hospitals with a mission to care for underrepresented people and create access to care in underserved communities. This is their story.

The opportunity to get people together who share a common set of issues, and more importantly, a common vision about what health care can and should be in this country is a real opportunity for renewal because the day-to-day work of running a safety net hospital can be challenging.
Kate Walsh, CEO, Boston Medical Center


Larry Gage, Esq., served as deputy assistant secretary for health legislation for the U.S. Department of Health, Education, and Welfare — which later split into the departments of Health and Human Services (HHS) and Education — under President Jimmy Carter. In this role, Gage traveled the country cultivating support for legislative proposals among different groups, including state hospital associations, and built relationships with public hospital administrators. He heard their needs — unique in their communities but similar to each other — and became more and more convinced they needed a different type of organization to tell their story.

Summer 1980

During Gage’s final year in the Carter administration, he invites six public hospital leaders to the office of Rep. Charles Rangel (D-NY)—a fateful meeting that planted the seeds of a new association.

Rangel knew the group “needed a different pair of eyes to look at the different set of problems that public hospitals had. Their commitment was just as strong as any health provider’s, but their resources were not there,” he says.

Five of those leaders leave Rangel’s office having decided to start a new organization: the National Association of Public Hospitals (NAPH):

  • Robert (Bob) Johnson, CEO of DC General Hospital;
  • Richard (Dick) Durbin, from Harris County (Texas) Hospital District;
  • Sue Brown, from the College of Medicine and Dentistry of New Jersey;
  • John Sbarbaro, MD, MPH, from Denver General Hospital; and
  • David Rosenbloom, PhD, former commissioner of health and hospitals for the city of Boston and a founding association member as then-head of Boston City Hospital.

“They paid $5,000 each in dues and I wished them well,” Gage says. Ten years later, Bob Johnson recalled the payment saying, “The bottom line, of course, is that it turned out to be one of the best investments any of us ever made.”

That fall, Ronald Reagan wins the presidency in a landslide that also took the Senate, and Gage is out of a job—but not for long.

Invitation to the February 1981 "Lame Duck Ball," where Gage announced the formation of NAPH

January 19, 1981

Gage hosts the Lame Duck Ball to celebrate the creation of a “brash, presumptuous new hospital association,” as founding member Bob Johnson called it. Gage becomes the founder and first president of NAPH.

President Reagan confers with Vice President Bush in 1981.

1980 and 1981

The Omnibus Reconciliation Acts create disproportionate share hospital (DSH) payments.

In the Omnibus Reconciliation Act of 1981, Congress gives states greater flexibility in designing Medicaid reimbursement systems, thus breaking the link between Medicare and Medicaid payment methodology. Under this legislation, the Boren Amendment gives states the flexibility to adopt alternative reimbursement methodologies and requires states to pay providers amounts that were “reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated facilities.” Initially targeting nursing homes in 1980, the 1981 amendment expands to hospitals. These payments become known as disproportionate share hospital (DSH) payments, a vital advocacy issue for America’s Essential Hospitals.


The association hosts its first annual meeting, in Denver.

The association announces its involvement in the Redbud lawsuit on the steps of Alameda Health System’s Highland Hospital in Oakland, Calif. (Photo courtesy of Rebecca Stanck.)

September 3, 1982

America’s Essential Hospitals successfully inserts the DSH provision into Medicare as part of the Tax Equity and Fiscal Responsibility Act of 1982.

But with no regulations to carry out the law, it is an empty achievement. America’s Essential Hospitals joins other hospital associations in a lawsuit filed by Redbud Memorial Hospital, a small California hospital district that sought a Medicare DSH adjustment because it serves a large number of low-income Medicare patients. A federal district court judge in San Francisco not only orders relief for Redbud but also orders the HHS secretary to create nationwide regulations. After a series of appeals, the U.S. Supreme Court reverses the lower court’s decision on the nationwide regulations but upholds Redbud’s right to payment.

Larry Gage (right) and Ed Foley (left), then–association board chair and CEO of the Los Angeles County Harbor UCLA Medical Center, present Rep. Pete Stark with the association’s inaugural leadership award, a silver bed pan, in 1987, in recognition of his advocacy on behalf of essential hospitals.


On Capitol Hill, America’s Essential Hospitals works with supporters, such as Rangel and Rep. Pete Stark (D-CA), to legislate Medicare DSH.

To get around the lack of regulatory support, Stark begins writing much more specific language for Medicare DSH, including payment methodology and formulas, that is included in the next budget reconciliation bill.


October 1987

The National Public Health and Hospital Institute (NPHHI) opens as the association’s research arm.

Since then, Institute researchers continue to study a wide variety of issues that affect the health of marginalized and underserved people. This research gives members a crucial repository of evidence-based studies of the issues readily affecting their patients and their hospitals. Often included in the research are examples of innovative solutions, best practices, and new ideas that can be shared and implemented across the membership and within the larger industry. In addition to informing members’ everyday decision-making, the Institute informs care and public policy for many leaders and professionals nationwide.

Whenever you go to Washington or your state capital, you go with facts. You can’t argue facts, concrete research.
King Hillier, MS, Vice President, Public Policy and Government Relations, Harris Health System
Volume 1, Issue 1 of The Safety Net

June 1987

The association publishes its inaugural issue of The Safety Net, a quarterly news magazine dedicated to sharing information of interest to essential hospitals.

Topics range from current health care challenges to legislative updates to recent association and member work. The new communications vehicle demonstrates the growth of the association, which has reached 55 members representing more than 75 hospitals. Years later, the association continues to communicate actively with members, now leveraging email newsletters and social media to share news.


NPHHI works with the Council of Teaching Hospitals (COTH) to survey large, urban public and teaching hospitals—members of NAPH and COTH—about AIDS care nationally. Institute staff conduct the survey to uncover the facts of the disease and its treatment and to address related medical, social, and economic questions.

The survey’s results, published in the Journal of the American Medical Association in 1989, finds that the nation’s public and teaching hospitals—and association members in particular—were bearing a disproportionate share of the burden of AIDS care. This association research supports member initiatives, including Harris Health System’s Thomas Street Health Center, the nation’s first freestanding facility dedicated to outpatient HIV/AIDS care, which opened in 1989. The association continues to be a leading force in public health research.

1994 Fellows Program class at the White House


America’s Essential Hospitals establishes its Fellows Program to help membership develop and inspire their high-potential staff.

The program brings colleagues together to study the current major financing and delivery challenges essential hospitals face and to develop those necessary management and public-facing skills. Many past fellows say the program’s greatest benefit is the access it provides to a network of peers. Hundreds of past fellows have gone on to serve as CEOs and other senior-level positions, and many past fellows also have since become association board members and chairs.

I was fortunate to be nominated by my organization to participate in the Fellows Program in 2018. I went through that yearlong endeavor, met some great colleagues from around the country, shared best practices [and] challenges that we're all being faced with and was able to establish a network of key resources from around the country. So, I believe the Fellows Program is one of the hallmarks of [America's Essential Hospitals], and it's one of the things that I'm most proud of.
Parveen Chand, MHA, COO, Indiana University Health Academic Health Center – Adult Hospitals


In a decade of growth for NAPH, the association moves into its first dedicated office in Washington, D.C., and begins building its internal staff and infrastructure. NAPH also begins laying the groundwork to make essential hospitals’ issues a legislative and regulatory priority.

Burch, second from right, with Dave Carvalho of Cook County Health System; Bill Walker, MD, of Contra Costa Health Services; Pat Terrell of Cook County Health System; and Dan McLaughlin of Hennepin County Medical Center. (Photo courtesy of Christine Burch)

January 1990

Chris Burch, a longtime Senate staff member and former Washington representative for association member the New York City Health and Hospitals Corporation (now NYC Health + Hospitals), signs on as executive director.

She remembers those early days as worthwhile but challenging. “All of us did a little bit of everything,’’ Burch says. “I signed the checks and I lobbied on the Hill. We didn’t have a surplus or a healthy bottom line.”

Tom Traylor, right, then vice president for federal, state, and local programs at Boston Medical Center, presents King Hillier, King Hillier, then vice president of government relations at Harris Health System, with a Safety Net Award in 1998. (Photo courtesy of Tom Traylor)


America’s Essential Hospitals creates the Safety Net Awards, presented to hospitals for operating innovative programs that successfully meet the health needs of their surrounding communities.

Awards are initially granted in three categories: development, patient care management, and community service. In 2012, the awards are renamed the Gage Awards in honor of retiring association founder Larry Gage. The categories also change to reflect current industry events. Categories in 2021 include population health and quality, in addition to a temporary category honoring members’ response to the COVID-19 pandemic. Learn more about the Gage Awards program at https://vital2021.org/gage-awards/.


Congress enacts the 340B Drug Pricing Program, which requires pharmaceutical manufacturers to offer discounts on prescription drugs to specific hospitals, including DSH hospitals.

In a House of Representatives legislative report, lawmakers explain that “In giving these ‘covered entities’ access to price reductions the Committee intends to enable these entities to stretch scarce Federal resources as far as possible, reaching more eligible patients and providing more comprehensive services.” Burch calls the 340B program “one of the few federal programs that really gives a direct benefit to the members.”


Growing member interest in and engagement with the 340B program inspires the creation of the Public Hospital Pharmacy Coalition.

The coalition grew out of NAPH and eventually broke off to become Safety Net Hospitals for Pharmaceutical Access, renamed 340B Health in 2015. America’s Essential Hospitals continues to work with 340B Health to protect and extend access to this benefit for members.

In the early years, educational and networking opportunities were smaller and geared more toward networking within the membership and on Capitol Hill. Here, 1995 association board chair James W. Wright Jr., meets with Secretary of the U.S. Department of Health and Human Services Donna Shalala. In a blow to the entire membership, Wright was killed in a plane crash later that year.

April 10, 1996

Reflecting the changing hospital market, the association adds “and Health Systems” to its name, becoming the National Association of Public Hospitals and Health Systems.

NAPH Executive Director Chris Burch attends the HIPAA bill signing on the White House lawn. (Photo courtesy of Christine Burch)

August 21, 1996

President Clinton signs the Health Insurance Portability and Accessibility Act, which protects data privacy and the ability to transfer health insurance.

The association's fledgling Internet presence in December 1996 includes this website (source: archive.org).

December 1996

By the end of 1996, 15 years after its founding by five public hospitals in four states and the District of Columbia, the association’s membership has grown to more than 140 hospitals and health systems and stretches from coast to coast.

Larry Gage meets with President Clinton.

August 5, 1997

President Clinton signs the Balanced Budget Act (BBA), which posed legislative challenges for essential hospitals.

The BBA breaks the longstanding link between Medicaid and welfare eligibility, which adds to the difficulty of obtaining coverage and threatens access to care. The BBA also places a five-year bar on Medicaid coverage for newly arrived legal immigrants and cuts state DSH payments for fiscal years (FYs) 1998 through 2002. The DSH cuts are gradual, starting small in the early years and then getting much steeper.

Larry Gage (middle) and Chris Burch (right) meet with Leon Panetta, President Clinton’s chief of staff.


America’s Essential Hospitals advocacy contributes to the creation of the State Children’s Health Insurance Program, which insures children in families that cannot afford private insurance but have too much income to qualify for Medicaid.


The early 2000s are marked by a series of regulatory threats to the safety net, prompting the association to launch its largest advocacy campaign yet. Later on, the Affordable Care Act poses new opportunities — and new challenges.


Working closely with the Secretary of Health and Human Services, America’s Essential Hospitals develops the Healthy Communities Access Program, which offers grants to coalitions of providers within communities to strengthen the connections among them.

The money could be used for a variety of initiatives toward this goal, including building common registration systems and electronic health record (EHR) systems. Several association members earn grants and began to invest in the infrastructure to create better community networks and more continuous care. NAPH and the National Association of Community Health Centers form the Healthy Communities Access Coalition, a nonprofit organization to support and advocate for these grantees. Although the Bush administration opposes the program and eventually convinces Congress to stop funding it, the infrastructure remains.

This little program really was doing a lot of good. It put in place in a lot of communities an infrastructure through which community health centers and public hospitals and other types of safety net providers could work together, setting up a framework to collaborate that endures today.
Barbara Eyman, JD, Washington Counsel, America’s Essential Hospitals


America’s Essential Hospitals successfully lobbies for a provision in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 that postpones steep DSH cuts in 2001 and 2002.

Instead, DSH payments in these years could rise according to the consumer price index. BIPA also raises the hospital-specific DSH cap for public hospitals from 100 to 175 percent of Medicaid spending for two years. This crucial advocacy win recognizes in law that essential hospitals truly deserve this funding for the work they do.


The DSH cuts postponed in the BIPA of 2000 ultimately create the first DSH cliff in 2003, when BBA cuts would ultimately be imposed.

However, the association’s successful lobbying quickly tempers these cuts, as Congress gives all states a 16 percent increase over 2003 DSH levels for FY 2004 in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Wright Lassiter III, head of Alameda Health System, is pictured on the cover of the March 17, 2008, edition of Modern Healthcare during the Save Our Safety Net Campaign. Alameda served as lead plaintiff for the association’s lawsuit.

January 2007

The association launches the Save Our Health Safety Net campaign in response to threats to Medicaid funding mechanisms during the George W. Bush administration.

The Centers for Medicare & Medicaid Services (CMS) begins questioning and ultimately denying long-standing state funding arrangements, such as intergovernmental transfers and upper payment limits.

The agency eventually enacts a series of proposed rules restricting crucial Medicaid funding that had been in place for years, including provider taxes and payments for governmental providers, graduate medical education, and outpatient services. NAPH is alarmed not only at the potentially devastating effects these rules could have on essential hospitals, but also that the administration had usurped Congress in attempting to rewrite so drastically rules that had existed with Congress’ approval for years. The association responds with the most comprehensive advocacy campaign it had ever undertaken, which included working on both sides of the aisle with Reps. Eliot Engel (D-NY) and Sue Myrick (R-NC). The association also integrates media, litigation, and member mobilization into its strategy.

The level of intensity of that campaign was unprecedented in the association’s history.
Barbara Eyman, JD, Washington Counsel, America’s Essential Hospitals


The Save Our Health Safety Net campaign culminates in a major legal win for America’s Essential Hospitals and its members.

The organization secures repeated moratoria on these proposed rules, one of which was tucked into the U.S. Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007. The bill provides funding for the Iraq war, and President Bush quickly signs it into law the day after it passed through Congress. However, earlier that day, before the bill is signed, CMS issues a final rule to one of the proposals under moratorium in the law. The proposal would have allowed the agency to limit Medicaid payments to governmental hospitals. “We filed suit,” Eyman says, “… there’s good precedent that when a law is signed … it’s effective at 12:01 am on the day that it’s signed. The final rule was a violation of the moratoria in the law.” NAPH wins the litigation and the proposed rules stay just proposals.

December 2007

When the Great Recession begins, more and more jobs are lost, and states begin cutting rates, benefits, and payments, so NAPH begins advocating for help for hospitals, which are shouldering increased volumes of uninsured patients.


With support from Kaiser Permanente’s Community Benefit Fund, the association partners with the National Patient Safety Foundation to deliver the Patient Safety Initiative at America’s Public Hospitals.

This multiple-year program provides education, resources, and communication strategies that promote safer health care to association members. Kaiser Permanente also offers scholarships to association members and staff to attend Institute for Healthcare Improvement training programs. In 2010, Kaiser’s Community Benefit Fund goes on to provide crucial backing for the association as it prepares to cultivate new ground in its work with essential hospitals. Today, Kaiser’s Community Benefit Fund supports scholarships for training opportunities for members of America’s Essential Hospitals.

February 17, 2009

The American Recovery and Reinvestment Act includes two association priorities: getting a temporary increase in the federal medical assistance percentage (FMAP), which is used to determine the federal government’s matching percentage for Medicaid funding, and a temporary 2.5 percent increase in DSH allotments to states.

Spring 2009

As House and Senate committees begin marking up health reform legislation, which would become the Patient Protection and Affordable Care Act (ACA), America’s Essential Hospitals advocates for three reform priorities: support expanded coverage, protect DSH, and proactively develop funding to coordinate care for low-income patients.

While other advocates join the association in advocating for universal coverage, the organization is alone in its fight for DSH, which had become a target for savings to finance expanded coverage. The funding pool remains a target when policymakers look for ways to expand coverage.

America’s Essential Hospitals was one of the leading voices pushing to expand coverage. I don’t think health reform would have happened without America ‘s Essential Hospitals having been in the forefront of these efforts for years. [We’ve] always said that everyone has to have access to health care, that that is a right, not a privilege.
Bruce Siegel, President and CEO, America’s Essential Hospitals

Fall 2009

When the Senate proposes a health reform bill with $50 billion in cuts to Medicaid and Medicare DSH (based on an argument that expanded coverage lessened the need for DSH), NAPH fights back by bringing in members to advocate, engaging media, talking to legislators, and filing four separate amendments to reduce the DSH cuts.

December 24, 2009

The Senate gets its 60 Democratic votes—one from every Democratic senator—and passes the bill, with nearly $50 billion in DSH cuts.

The vote is met with mixed emotions. While the bill is a landmark step for health care reform and the vision of universal coverage, its steep price for essential hospitals temper elation over the progress it makes toward reducing the number of uninsured. But before any of this can play out, the House and Senate still have to come together to negotiate a final bill—and they are starting from distant corners.


The rollercoaster of a decade begin with a years-long fight over the Affordable Care Act and ends with a global pandemic that lays bare the cracks in the American health care system. Through it all, America’s Essential Hospitals continues to fight for its members, their patients, and their communities.

January 19, 2010

Partisanship clouds final negotiations for the ACA, as Republican Scott Brown wins the Massachusetts special election to replace Sen. Ted Kennedy, who died in August, bringing the Senate to 59 Democratic votes. But a reconciliation bill, which requires only 51 votes to pass the Senate, provides new hope.

Meanwhile, NAPH works with legislators in the Hispanic, Black, and Progressive caucuses to create pressure for smaller DSH cuts, an effort that generates a letter from 100 House Democrats to Speaker Nancy Pelosi (D-CA). It works: Pelosi comes back from the bargaining table with reduced cuts. For NAPH, it is mostly a win.

March 2010

President Barack Obama signs the ACA March 23. When the dust settles, more Americans gain coverage and DSH escapes a $50 billion hit. But there is little time to soak it in—the ACA remains under fire for the foreseeable future.

Bruce Siegel, MD, MPH, president and CEO of America's Essential Hospitals

October 2010

Executive Director Chris Burch retires, and the association hires Bruce Siegel, MD, MPH, as its first CEO.

Siegel brings extensive experience in health care management, policy, and public health to the association. He previously served as president and CEO of two member systems: Tampa General Healthcare (now Tampa General Hospital) and the New York City Health and Hospitals Corporation (now NYC Health + Hospitals). He also served as New Jersey’s commissioner of health.

July 1, 2011

Association founder Larry Gage retires after leading NAPH for 30 years. With his retirement, Siegel becomes president and CEO.

December 2011

The Institute wins a contract to form a hospital engagement network, the Essential Hospital Engagement Network (EHEN), through the Partnership for Patients (PfP), a CMS initiative to reduce medical errors and adverse events and improve care quality.

Twenty-two member hospitals across 10 states work through the Institute’s Transformation Center to meet the PfP’s goals to reduce preventable hospital-acquired conditions and readmissions. The EHEN provides distance learning, site visits, coaching calls, and comprehensive data reports for participating hospitals, as well as a Leadership for Safety program for C-suite executives and clinical managers. The EHEN achieves outstanding results over the three years of its federal contract, averting more than 4,000 harmful events and saving more than $40 million in associated costs.

Harm can be reduced, absolutely. And the work that we’ve done here shows that it can be accomplished. With the culture right and the tools and the commitment right, you can do it.
David Engler, PhD, former director, Essential Hospitals Institute
Protestors gather outside the U.S. Supreme Court building in Washington, D.C., as the Court announces its decision on the Affordable Care Act. (Photo courtesy of La Dawna Howard)

June 28, 2012

NAPH staff huddle in a conference room to watch as the U.S. Supreme Court rules on the ACA’s constitutionality.

The association has been consistently involved in the legal battle, working in partnership with the other national hospital associations to file a series of amicus briefs in support of the ACA at the appeals court and Supreme Court levels.

The Court rules on a number of things, including whether the individual mandate—the requirement to obtain health insurance—is constitutional and whether Congress can require states to choose between complying with the ACA’s mandatory Medicaid expansion or losing all Medicaid funding.

While the Court upholds the ACA for the most part, it severely threatens the promise of expanded health care coverage by rendering optional the expansion of Medicaid to include people living at or below 138 percent of the federal poverty level. The Court, citing the coercion doctrine, allows states to opt out of that expansion without losing their current Medicaid funding.

NAPH responds with support for the individual mandate, tempered by deep concern for the fate of the Medicaid expansion, noting, “…in the 26 states that participated in the federal lawsuit, more than 27 million people have no insurance, and many who would have been eligible for Medicaid in 2014 might no longer have that option. We hope states choose to do the right thing. But we cannot base federal policy on hope alone. [We] urge Congress to avert a potentially disastrous outcome for vulnerable populations by immediately re-evaluating safety net funding in light of this decision.”

Association Senior Vice President of Policy and Advocacy Beth Feldpush, DrPH, works with members, policymakers, and other industry leaders on crucial essential hospital legislative and regulatory issues.


As policymakers on Capitol Hill begin discussing block grants and per capita caps, association leaders develop 10 entitlement reform principles to shape their advocacy message, focused on topics such as guaranteed access to Medicaid and Medicare, as well as all necessary services, for eligible individuals; preserving the long-term viability of essential hospitals; and ensuring all relevant stakeholders are at the table during reform discussions.

Association staff and leaders discuss potential new names at a rebranding meeting.

June 2013

As governance structure changes for many public hospitals, and private, nonprofit hospitals sharing a community-focused mission also join the association, the association faces an identity crisis: Government ownership no longer is a defining characteristic of membership, and the association’s name didn’t reflect that.

Through branding research and interviews with members, the association identifies five defining member characteristics. Essential hospitals share a mission to serve the underserved; train the next generation of caregivers; provide high-acuity care; work beyond their walls to improve community health; and coordinate care across the health care spectrum.

With that, NAPH becomes America’s Essential Hospitals, and the National Public Health and Hospital Institute becomes the Essential Hospitals Institute.

This whole package of services is something that no one else in the community provides. If our members were not there, there would be this tremendous void in some of these areas where there would be this incredible unmet need. Filling that need makes our members essential. And once we came to that, it just made sense.
Beth Feldpush, DrPH, senior vice president of policy and advocacy

December 2013

In a major victory won by aggressive association advocacy, Congress votes to forgo scheduled cuts to Medicaid DSH payments in fiscal years 2014 and 2015 of $500 million and $600 million, respectively. The cuts are part of more than $18 billion in Medicaid DSH cuts mandated by the ACA. The immediate relief is welcome news for association members but accompanied by increases in DSH cuts in later years—a pattern that was to become all too familiar.

April 2014

Association advocacy further delays Medicaid DSH cuts when Obama signs a bill that temporarily patches the flawed Medicare sustainable growth rate (SGR) and pushes the FY 2016 DSH cuts back a year.

The new law includes another association priority: codifying in law the definition of an essential hospital in a requirement that the Medicaid and CHIP Payment and Access Commission (MACPAC) annually report on the state of Medicaid DSH, data that likely would support arguments against cuts.

In 2019, the association adds a new programming track to the Medicaid Summit, focused on Medicaid financing.

September 2014

America’s Essential Hospitals holds its first annual Medicaid Summit, a one-day convening for members to learn about Medicaid policy and share best practices.

While the summit initially focuses on Medicaid waivers and the Delivery System Reform Incentive Program, programming expands to cover other aspects of Medicaid policy and financing of interest to association members.

Spring 2015

America’s Essential Hospitals launches its biennial Government Relations Academy, a yearlong program to help members advocate more effectively for their hospitals and patients. Nearly 60 participants have graduated from the program’s three classes.

People react to the King v. Burwell decision outside the Supreme Court.

June 25, 2015

In a 6-3 decision, the U.S. Supreme Court rules in King v. Burwell that the federal government may legally provide tax-credit subsidies to people who buy health insurance through federally facilitated ACA marketplaces.

At issue in the case was language in the ACA that created individual eligibility for subsidies in marketplaces “established by the State…” The lawsuit’s plaintiffs, who lived in states using federally run marketplaces, argued that Congress intended this wording to encourage states to set up their own marketplaces and that it precludes subsidies in federally run marketplaces. But the Obama administration disputes this claim, arguing that the sentence must be read in the context of the full law. The decision protects subsidies for an estimated 6 million Americans in 34 states.

As many as 6 million people stood at risk of losing coverage if the court ruled against premium subsidies. With its decision, the court keeps coverage within reach for individuals and families who otherwise have few affordable options to pay for care they need.
America's Essential Hospitals, statement on King v. Burwell decision

August 28, 2015

HRSA publishes proposed 340B Drug Pricing omnibus guidance, known colloquially as mega-guidance, which would dramatically narrow eligibility for 340B drugs. America’s Essential Hospitals launches a regulatory advocacy campaign, including a congressional roundtable for lawmakers about the harm this guidance would cause patients.

May 2016

Extensive advocacy by America’s Essential Hospitals leads to a longer than first proposed transition to the end of Medicaid managed care pass-through payments and the establishment of permissible “directed payments.”

In a final rule, CMS acknowledges the important role of safety net support through managed care by allowing up to 10 years for phasing out pass-through payments and creating an accountable and transparent process for states to provide support through directed payments.

July 27–29, 2016

America’s Essential Hospitals hosts its first Essential Women’s Leadership Academy. This leadership development program, held every two years, supports female leaders at essential hospitals through mentorship, coaching, leadership training, and peer support, with the aim of reducing the gender gap in health care administration. To date, nearly 70 women have participated in the program or served as a program mentor.

November 2016

Essential Hospitals Institute, with support from the Robert Wood Johnson Foundation, publishes a road map to help hospitals navigate the process for building programs that improve the health of a community.

The findings reflect expert interviews, hospital surveys, and a summit that convened nearly 30 participants from the association’s membership and other stakeholders. Case studies are featured on essentialcommunities.org. Later work includes learning networks to continue convening population health leaders at essential hospitals, as well as diversity and inclusion officers.

An important aspect of this work was to understand how hospitals and community partners can collaborate to promote a culture of health and act in meaningful ways to improve health in the community. This work must reach beyond the hospital walls, which makes community partnerships vital to success.
Kalpana Ramiah, Vice President of Innovation and Director, Essential Hospitals Institute

December 13, 2016

President Obama signs the 21st Century Cures Act. Notably, this law includes risk adjustment in the Hospital Readmissions Reduction Program to lessen the likelihood the program penalizes hospitals for factors outside their control—a key advocacy goal of America’s Essential Hospitals.

January 2017

The Trump administration withdraws proposed 340B “mega-guidance” from Office of Management and Budget review. This guidance would have limited 340B program eligibility for essential hospitals.

America's Essential Hospitals conducts an extensive media and advertising campaign in response to the threat to Medicaid in repeal and replace proposals.

March 2017

Affordable Care Act repeal efforts kick off when House Republican leaders introduce the American Health Care Act, which would eliminate a requirement that private health plans provide a minimum essential benefits package and cap the federal contribution to Medicaid while also cutting the program. Congressional leaders ultimately withdraw the bill and reintroduce it in April and again in May, this time with an amendment that would establish a high-risk pool. It passes the House.

June 2017

America’s Essential Hospitals continues pressure in Washington as Senate leaders introduce their version of the repeal and replace bill, the Better Care Reconciliation Act, which includes draconian cuts to Medicaid and caps that would have gutted the program over time. The following month, Senate Republicans pull that bill and replace it with the Health Care Freedom Act, which opponents defeat in a dramatic late-night, 51-49 vote July 27, ending the repeal and replace effort.

An interactive map at EssentialCommunities.org helps site visitors pinpoint member programs focused on social determinants of health.

October 2017

Essential Hospitals Institute launches Essential Communities, a website to help hospitals evaluate their community’s greatest needs to determine where best to direct population health efforts.

The website includes a resource library covering topics such as multisector partnerships, program implementation, and structural racism; a map of community programs at essential hospitals; video spotlights; and a pledge for CEOs to improve population health.

November 2017

America’s Essential Hospitals, the American Hospital Association, and the Association of American Medical Colleges sue HHS in the U.S. District Court for the District of Columbia to prevent a nearly 30 percent payment cut for essential hospitals’ purchases of outpatient drugs under the 340B program. The court rules in December that the lawsuit is premature, but it does not rule on the merits of the case, so the groups refile the lawsuit when the cuts begin.

February 2018

In yet another budget deal, Congress delays for two years cuts to Medicaid DSH funding. This comes on the heels of extensive advocacy by America’s Essential Hospitals, including digital advertising, social media, a congressional dear colleague letter with 220 signatures, and a dedicated campaign website.

March 15, 2018

Amid growing scrutiny of the 340B Drug Pricing Program, association President and CEO Bruce Siegel, MD, MPH, testifies before the Senate Health, Education, Labor, and Pensions Committee at a hearing titled “Perspectives on the 340B Drug Pricing Program.”

Remember that 340B grew from an urgent need for action when drug prices surged as manufacturers reacted to Medicaid's Rebate program. We are no less at-risk now than we were then. Skyrocketing drug costs threaten our hospitals and patients, and the 340B Program is still our best defense against high drug prices.
Bruce Siegel, MD, MPH, prepared statement, “Perspectives on the 340B Drug Pricing Program”
The State Action page on the America's Essential Hospitals website

Summer 2018

America’s Essential Hospitals expands its public policy focus to include analysis of state policies of interest to essential hospitals. This work focuses on comparative analyses and summaries of emerging state trends but doesn’t include lobbying at the state level. Content includes website articles, policy briefs, data-driven policy snapshots, and a standing state policy session at VITAL, our annual conference.

July 2018

Institute research, supported by the Patient-Centered Outcomes Research Institute, culminates in a road map to integrate person-centered care and evidence-based research into hospital care for low-income and other marginalized people, who often are underrepresented in care improvement activities due to the multiple chronic conditions and limiting socioeconomic circumstances they face.

August 2018

The Institute launches a two-year research project to give hospitals tools to build patient trust. This project culminates in a guide for essential hospitals that identified five dimensions of trust, as identified in surveys of patients and caregivers at essential hospitals, and strategies to build trust.

September 11, 2018

America’s Essential Hospitals joins several hospital association partners in suing the federal government over its years-long delay of regulations that would require pricing transparency for drug manufacturers and penalties for overcharging covered entities in the 340B program.

The suit leads HRSA, which administers 340B, to publish a final rule on ceiling price transparency and begin enforcing it Jan. 1, 2019. The agency also launches a website April 1, 2019, to report manufacturer ceiling prices and gives regulators the power to impose civil monetary penalties (CMPs) for ceiling price violations.

The Cost of Care Conversation Resources page on the America's Essential Hospitals website

November 2018

As conversations about surprise billing begin to dominate Capitol Hill, America’s Essential Hospitals works with the Robert Wood Johnson Foundation to disseminate tools for health care providers to talk about the cost of care with their patients.

March 2019

With support from the Kresge Foundation, the Institute publishes a toolkit for hospitals seeking to hire population health executives, reflecting a commitment to helping association members institutionalize their focus on community needs. Later that year, the Institute publishes another Kresge Foundation–supported report on the The State of Climate Resilience and Climate Mitigation Efforts at Essential Hospitals.

America’s Essential Hospitals and association colleagues host a standing room–only briefing on Capitol Hill to inform members of Congress and congressional staff about the harm the MFAR would cause to the Medicaid program.

November 18, 2019

CMS proposes the Medicaid Fiscal Accountability Regulation (MFAR), which would establish highly restrictive new rules on supplemental payments to Medicaid providers and burdensome new reporting requirements. The association mounts a months-long advocacy campaign against the rule, including a Capitol Hill briefing in February 2020 featuring speakers from the American Health Care Association, Missouri Hospital Association, Children’s Hospital Association, and Safety Net Hospital Alliance of Florida.

January 30, 2020

The World Health Organization identifies COVID-19, a disease caused by the novel coronavirus SARS-CoV-2, as a public health emergency of international concern. The United States quickly follows suit, with HHS Secretary Alex Azar declaring a public health emergency the next day. UW Medicine, in Seattle, becomes the first association member to treat diagnosed COVID-19 patients.

Members and staff at a Capitol Hill reception for spring 2020 Policy Assembly, the association’s last in-person event before the COVID-19 pandemic.

March 11, 2020

The World Health Organization declares COVID-19 a global pandemic, the same day America’s Essential Hospitals wrapped up its biannual Policy Assembly. The association quickly responds by educating and disseminating late-breaking information to members through a COVID-19 resource center, a weekly COVID-19 newsletter, research briefs, and webinars.

March 27, 2020

President Trump signs the Coronavirus Aid, Relief, and Economic Security (CARES) Act, a $2.2 trillion economic relief bill. The bill authorizes the $175 billion Provider Relief Fund to support providers incurring health care–related expenses and lost revenue related to COVID-19 response efforts. The CARES Act also eliminates $8 billion in scheduled Medicaid DSH cuts—for the first time, without imposing higher cuts in later years—and temporarily increases Medicare reimbursements, marking two major advocacy wins for essential hospitals.

Spring and Summer 2020

After extensive advocacy by America’s Essential Hospitals for better targeting of CARES Act funding (initial distribution formulas provided underwhelming support), HHS targets a total of $15 billion from the Provider Relief Fund toward hospitals with a safety net role, a vital funding stream for essential hospitals responding to the COVID-19 pandemic.

Summer 2020

America’s Essential Hospitals begins monitoring troubling actions by six drug manufacturers related to the 340B program. Eli Lilly, AstraZeneca, and Novo Nordisk stop providing 340B discounted drugs to covered entities’ contract pharmacies.

Sanofi, Novartis, and United Therapeutics ask covered entities for contract pharmacy claims data on 340B drugs, and manufacturers penalize covered entities for failing to comply with the burdensome new reporting requests, including by halting shipments of 340B-priced drugs to their contract pharmacies. After extensive advocacy by America’s Essential Hospitals, more than 250 House members sign a bipartisan letter to HHS Secretary Azar expressing concerns with drug manufacturer actions to undermine the 340B program.

July 22, 2020

Continuing a legacy of advocacy for marginalized groups, America’s Essential Hospitals launches a three-pronged initiative to combat the urgent public health threat of structural racism.

The association develops a strategy centered on:

  • identifying and fostering the adoption of groundbreaking and transformative health system approaches to combat structural racism;
  • building partnerships on social justice with other national organizations while clarifying and enhancing the association’s own policy principles on equity; and
  • advancing ongoing work to ensure diversity in its board and other governance bodies.

As an early step in this initiative, the association publishes a research brief on the role of essential hospitals in combating structural racism.

Our hospitals have long confronted and worked to overcome these pervasive social determinants of health. This initiative is about looking upstream to understand what actions we can take to confront the structural racism and social injustices at the root of so many of these problems.
Bruce Siegel, MD, MPH

August 2020

Amid the COVID-19 pandemic, the association holds its first virtual annual conference, including six days of educational programming.

December 21, 2020

America’s Essential Hospitals successfully advocates for the elimination of $4 billion in DSH funding cuts and a two-year delay of further reductions. This victory comes as part of a consolidated appropriations bill that also includes additional funding for the Provider Relief Fund, a suspension of the Medicare sequester cut, and the ability for public hospitals to claim COVID-19 employer tax credits.

December 27, 2020

A year-end spending package includes the No Surprises Act, which includes provisions to protect patients from surprise medical bills. Under this legislation, out-of-network facilities and providers would be prohibited from billing patients for more than the in-network cost-sharing amount, with some exceptions. The legislative package includes provisions the association sought in lieu of more onerous original proposals.


Looking toward the future, America’s Essential Hospitals — now more than 300 members strong — continues to fight for equitable, high-quality health care for all people and all communities.

January 15, 2021

CMS officially withdraws MFAR, which had remained on the administration’s unified agenda even after Administrator Seema Verma announced in a September 2020 tweet her intention to withdraw the proposed rule.

Department of Homeland Security Secretary Alejandro Mayorkas announces that the government will no longer defend the 2019 public charge rule from court challenges, effectively reversing the Trump-era policy.

March 9, 2021

After strident opposition by America’s Essential Hospitals and other advocacy groups, the Biden administration reverses a September 2018 Trump administration change to immigration rules regarding public charge determinations.

The action rolls back the previous administration’s decision to include, for the first time, non-emergency Medicaid and other non-cash support among the criteria for defining a public charge. Those changes had a chilling effect on access to care, as immigrants, afraid to lose their legal immigration status, chose not to enroll in Medicaid or delayed needed care.

April 2021

After extensive work with CMS, the agency updates hospital star ratings to reflect a new methodology, including the use of peer grouping and other changes called for by America’s Essential Hospitals. From the first publication of CMS’ hospital star ratings in 2016, the association has pushed the agency to examine the data behind the ratings. However, more work is needed, and the association will continue to urge CMS to produce a rating that is an accurate assessment of quality at essential hospitals and useful to consumers.

May 17, 2021

In a crucial victory for essential hospitals, HRSA directs six drug manufacturers—Eli Lilly, AstraZeneca, Novo Nordisk, Sanofi, Novartis, and United Therapeutics—to immediately begin offering 340B pricing to covered entities on covered outpatient drugs dispensed through contract pharmacies. The agency rules that failure to comply could result in civil monetary penalties. Litigation against HRSA’s policy brought by several manufacturers is ongoing.

Now, four decades into its journey from modest beginnings to a force in Washington, America’s Essential Hospitals continues the fight for hospitals and health systems that care for people who have nowhere else to turn. From funding to operations to public and population health, America’s Essential Hospitals is committed to advancing the work of its members, sharing their accomplishments, and advocating for their needs. We are — and always have been — essential.

Happy Anniversary America's Essential Hospitals

A 40th anniversary message from your essential hospital friends.