Over the past decade, reforms to the U.S. health care system have sought to reduce spending on health care expenditures, while improving quality of care and population health. At the same time, increased attention to the social determinants of health has fostered a deeper discussion on the social responsibility of health care systems in furthering health equity at a population and community level. As the U.S. health care system attempts to meet the societal demands of delivering value and striving towards health equity, important questions arise—to what extent is health equity shaped by local government decisions on public budgets, hospital administrator decisions on community benefits spending, or individual decisions between clinicians and patients around low-value care? This dissertation provides a novel contribution on these questions with three studies that explicitly test hypotheses on these related issues. The first study used claims data from Medicare, the nation’s largest health plan, and government finance data to examine the relationship between local government spending on social programs and the use of primary care, emergency department, and inpatient services among low-income older adults. We found that higher spending on welfare, public transit, housing, and other social services was associated with greater primary care use. We also found that higher spending on housing and public transit were associated with lower preventable hospitalizations, specifically from acute conditions. The second study used data from non-profit hospital tax returns and Medicare claims to examine the relationship between hospital community benefits spending and the use of primary care and emergency department (ED) services among older adults living in the same zip code as a non-profit hospital. This study did not find evidence that variation in community benefit spending over time was associated with differences in primary care or ED visits. The third study used claims data from a single health care system to examine variation in the provision of low-value services by race and ethnicity. We observed that Asian, Black, and Latino older adults were less likely to receive low-value care in general, but were more likely to receive a low-value prescription.

Taken together, the findings from this dissertation clarify the relationships between health care organizations and their local communities. Moreover, this work highlights important systems and policy-level opportunities for improving equity, population health, and health care value.