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Policy Options In Community Development For Promoting Long-Term Health Equity

Just Economy Conference – May 14, 2021

 

Social determinants of health (SDOH) have become an increasing area of focus to improve population health equity and reduce total costs of care, made all the more relevant by the COVID-19 pandemic. Even before the pandemic, the majority of disparities in morbidity and mortality in the U.S. were driven by risk factors with social influences, with one study estimating that approximately 60% of ill health was driven by social, environmental and behavioral factors. These factors are especially salient in childhood, when experiences and exposures can alter long-term developmental trajectories. Community development is one of the most important areas of policy for addressing these upstream drivers of health inequities, but has received relatively little attention in health policy debates. Join us for an overview of the evidence for community development’s role in promoting long-term health equity for children and families and a discussion of potential policy options for advancing this role to achieve gains in long-term health equity at scale in the United States.

Speakers:

  • Nathaniel Counts, SVP, Behavioral Health Innovation, Mental Health America
  • Shadi Houshyar, Senior Associate, Center for the Study of Social Policy
  • Vinu Ilakkuvan, Founder and Principal Consultant, PoP Health
  • Karen Kali, Senior Program Manager, NCRC
  • Kendra Smith, Vice President, Community Health, Bon Secours Mercy Health

Transcript

NCRC video transcripts are produced by a third-party transcription service and may contain errors. They are lightly edited for style and clarity.

Kali 00:01 

Good afternoon, everyone. Thank you so much for joining us today. This Friday afternoon on the very last day very last session of the 2021 just economy conference, we saved the best for last today. And today’s session is, Policy options and community development for promoting long-term health equity. The session today is sort of about moving away from the narrative of one’s healthy 100% about personal choices about personal behaviors, even clinical care. This that’s a narrative that’s certainly been predominant for such a long time, but it’s basically ingrained in our thinking about population health and our own health. The reality though, is that the built environment plays a much more significant role than we originally thought. local culture plays a significant role. conditions in our neighborhoods play a significant role. Our hours of codes are a determinant of health risks and life expectancy and have that meeting mostly because our housing and our communities are so segregated. When people live just a few blocks away from each other. There’s such a discrepancy or can be such a discrepancy and health risk factors in life expectancy, even when you’re controlling for demographic variables like gender, and age, for example, there just aren’t genetic differences, right? We can’t explain those differences in health risk factors or life expectancy by genetics alone. It’s a difference in resources, a difference in environments and local culture, and other social conditions. And I think that many of us probably feel that the COVID pandemic unfortunately illustrated this very well to well as the pandemic disproportionately affects black communities and other communities of color, LGBTQ plus communities. The conclusions that I think a lot of researchers and practitioners have come to you is that residential segregation, structural racism, social determinants of health are the driving factors in the spread of infections and communities of color. And so what I think this awareness provides for us, is the knowledge that there is an opportunity possibly within our communities to influence our social conditions, to influence our built environment and ultimately improve our population health. We know that we that if we create communities of lasting value, if we invest in things like affordable housing, if we improve food access, if we maintain Jobs and Communities, if we reduce poverty, we can also improve our health. So I, you know, in order to make that happen, we need to make health equity happen, we need policy action. And that’s why I’m so thrilled today that we have this expert panel coming together today at the intersection of community development and health, to better illustrate the argument and to identify specific policies and actions that can offer concrete steps forward for our communities. So we’re joined today by Nathaniel Counts, who’s the senior vice president of behavioral health, innovation, and mental health America. We’re joined by Shadi Houshyar, our senior associate at the Center for the Study of social policy. We’re also joined by Vinu Ilakkuvan founder and principal consultant at pop health. And lastly, we’re joined by Kendra Smith, Vice President of community health advanced the core Mercyhealth. Please be sure to check out their bios and connect with them via the conference platform if you are so interested. We’re going to go ahead and kick off the presentations with Shadi. If you have any questions for her or for any of our other presenters, please be sure to post them in the chat. We will Over the last 1015 minutes or so for live q&a. And with that, let’s begin. 

Houshyar 04:02 

Great. Thank you, Karen. I’m just gonna wait for the slides to come up.  

Kali 04:07 

Yeah, that’s me. Great. 

Houshyar 04:14 

Hi, everyone. It’s good to be here with you this afternoon. Again, my name is Shadi who share and I am the Center for the Study of social policy. We are a national nonprofit based in DC. And our mission is to achieve a racially, economically and socially just society where all children and families can thrive. I’m going to spend a little time today framing our discussion, talking a bit about the impacts of the pandemic on children and families, its disproportionate toll on communities of color, and then highlight some opportunities to promote health equity in the American rescue plan. And two ways to really advance racial equity through anti-racist policies, strategies and tools. Next slide. So racism and white supremacy as Karen sort of started to talk about really often deny black people and other communities of color most protections, and the pandemic is really no different. It brought into a much sharper focus that deep-rooted and persistent structural and systemic inequities in our systems and institutions, widening existing disparities, we saw higher rates of death and communities of color, many core and working-class people of color were forced to return to unsafe work conditions and more likely to make up the essential workforce. Black and Latinx caregivers were more vulnerable to the virus because of higher underlying rates of chronic conditions. And we’re now seeing inadequate access to not only vaccines but more broadly health care and treatment, and again, widening of already existing health disparities, and poor health for black Latin x and Native communities and others that have faced historical and systemic racism. Next slide. So the pandemic has really worn on our physical and mental health. We know families are worried about where their next meal will come from about losing their homes about job loss and money. Many parents have felt over the past year or longer really the strain of caring for children, at the same time their aging parents for many. For those in the service industry, they’ve had to make difficult choices about their health versus their jobs. Children really saw changes in their routines, their friendships, the loss of safe outdoor places, holiday traditions, and the challenges of virtual learning. We saw changes to healthcare delivery changes in clinic hours shifts to virtual health visits. And school closures also meant that many children didn’t have access to health, behavioral health and meal programs that are offered in schools. But this picture really wouldn’t be complete if we didn’t sort of recognize the incredible resilience that children, families and communities really showed during the pandemic. And we’ve all seen examples of this resilience in our everyday lives and ourselves, our families, our communities and colleagues and neighbors. Next slide. Even as we begin to emerge from the depths of the pandemic, it’s really important to recognize the toll it has taken on the physical and emotional well-being of parents and children. Parents have recorded concerns for their children’s social and emotional health. younger children exhibiting signs of distress and hospitals seeing an increase in mental health emergency room visits for younger children. Parents are putting experiencing mental health challenges. Nearly half of us adults say that the pandemic has affected our mental health. And for many families and parents pandemic-related stressors are contributing to declines in mental health. And they’re only compounded by concerns around lack of coverage, cost of care and barriers to need to care for themselves and for their children. Next slide. So a number of comprehensive relief packages have passed in response, at least in part to these urgent and very real needs of children, families and communities, including the family first Coronavirus response Act, the cares Act and the consolidated Appropriations Act. And each of these included a number of key provisions relevant for family maternal and child health, including an increased f map or federal Medicaid assistance percentage rate for Medicaid, required paid sick leave and leave for medical leave paid medical leave for certain businesses and flexibility in reimbursements for telemedicine. The latest of the COVID response bills American rescue plan included a massive infusion of infant investments on a wide range of policies, including a number of provisions that expanded eligibility for programs and that provided substantial funding increases for programs that are serving children and families including an expansion of the child tax credit and etc. A third direct economic impact payment for families 40 billion and childcare funding, and expansion of snap and many more. And while we won’t be able to walk through all of these in detail, I did want to provide a visual of the range of AARP provisions that can advance equity and are important for family and maternal and child health, everything from incentives for states to adopt Medicaid expansion to Medicaid coverage for COVID-19 vaccines and treatment for the uninsured, to tax credits to purchase health insurance for families who are at or below 133% of the federal poverty level. And one provision that I wanted to call to your attention is a state option to provide extended postpartum coverage for one year after birth, which we believe is critical for advancing racial and health equity. And this is because good health care reduces risk associated with pregnancy and birth. And we know that women are more likely to die of pregnancy-related conditions in the weeks following birth than doing either pregnancy or delivery. And in particular, black women are three to four times more likely to die of pregnancy-related causes than white women. So extending Medicaid through at least 12 months, post-birth really ensures access to services and essential for the well-being of mothers, as well as the health of their infants. Next slide. So as we think about opportunities to advance racial and health equity during the pandemic and beyond, it’s really critical to be thinking about what it means to develop anti-racist policy, what does that look like? And so we suggest the anti-racist policy needs to have one of four characteristics. The first and one of the most critical is that it needs to be anti-racist, it needs to recognize and dismantle historic and justices. So too often policymakers ignore the role racism has played in shaping policies and fail to acknowledge the disparate impact of policy. And so design policy to meet the needs of all families. We have to recognize how policies are historically disadvantaging families of color, undo and redress the harms caused by racist policy. The second principle is that policy needs to be explicitly designed to meet the needs of families of color. policies that are colorblind on their face, have all too frequently not actually been colorblind at all, but rather designed to benefit white children and families and exclude or harm children and families of color. For example, looking at income supports racist stereotypes have been used to exclude immigrant families from benefits and others designed to limit access for black families. So anti-racist policy centers, children and families of color to ensure that they benefit directly from the policy. The last two policy principles are really intimately connected. So to support the whole family, anti-racist policy recognizes the children grew up as a part of families and therefore supports the whole family. So in the past, public policy has too often been siloed. And policies intended to support children have been designed without a recognition of the larger struggles of their families. And so in the end, they haven’t really adequately supported families or children, policies have even actively undermined families in the name of protecting children. And we see this with the child welfare system, right, which disproportionately threatens and ultimately separates many children of color from their loved ones. So anti-racist policy has to be designed to support and strengthen the whole family so that families can thrive together. And anti-racist policy also serves all families in need. So again, in the past policies that artificially segment our separate families and attempt to draw these lines between those who are deserving, and those who are undeserving have consistently upheld white supremacy by labeling children and families of color as undeserving and leaving them without access to services and supports, or with access to services, of course, that do not work for them, or even sometimes actively do them harm. So narrowly targeting policies according to income and other characteristics has really resulted in what we have, which is a social safety net with gaping holes, which are designed to let families of color fall through. So broad-based programs are often necessary to ensure that children of color and their families are not carved out or excluded from programs. Next slide. So I won’t go through too much detail here, but I wanted to share with you cssp is anti-racist early childhood policy platform, which includes 10 policy recommendations. And I think as you look across this, you can see that the songs are not typically once you associate with early childhood. But these recommendations were informed by the policy principles I just laid out. And we had this in mind as we decide which policies to include and the details. So as an example, we included reparations for families of children descended from, say, people, as well as indigenous families, and also a recommendation for permanent legal status for immigrant families. And as we’re thinking about this broader set of policies, we thought About the full range of supports that children families need in their communities, and in details, how these policies should be designed to work for children and families of color. So for example, we included home visiting programs, but really reimagined and brought to scale so that these programs are truly accessible to and meet the needs of all families who want them. We also included a healthy housing guarantee, high quality, affordable and culturally responsive childcare and early learning for all affordable access to health care for all because health care for all was really critical to everyone ensuring that we have access to affordable health, high-quality health insurance, and we know that children are more likely to be insured if their parents are sure. And we also recognize the importance of diversifying the healthcare workforce, empowering community health workers, and providing culturally and linguistically responsive care. Next slide. So in addition to the principles for anti-racist policymaking, we’ve also outlined strategies that can guide systems and administrators, policymakers, advocates, and others, who share a commitment to advancing anti-racist early childhood systems. And while these strategies were developed with early childhood systems in mind, they really can be used to guide any child and family serving system. And I’ll just highlight a few for you. So our first strategy is to establish a commitment to advancing anti-racist policy and practice so that all children and families can thrive. Again, it’s important to take that step back to question the underlying assumptions, shaping our systems and the policies they implement. And the key here is really sharing this commitment with other stakeholders. And this is a place where we need to be critical with ourselves about who those stakeholders are, and ensure that families are at the table and at the center of the work. Our second strategy is to implement approaches that help to identify and dismantle racist policies and practices. So systems have to start working around unpacking how they’re organized, how racism impacts systemic, systemic, and institutional beliefs and policies and practices, and really work to actively dismantle entrenched harms. And they can use approaches which we’ll talk about a few today, like race equity impact assessments, and by making commitments to anti-racist frameworks and trainings on systemic racism on implicit bias on cultural humility. The third one is a big one, and it’s to share power with families. So barriers that are rooted in structural racism and biases that influence attitudes and behaviors and policies and practices of our systems prevent many families of color from being true partners and leaders in their children’s healthy development. So to ensure that policies are effective that they work for children, families and communities, they have to be authentic partners in that policy development, the program designed the implementation, and they have to have the supports needed to engage. So strategies for creating space for family voices include partnering with and investing in parent and community-based organizations to support their ideas and priorities. The fourth strategy is to implement family-centered policies to better meet the needs of children and families. So again, too often, services and supports are difficult or have been difficult for families to access. And historically, we had intentionally created barriers to deter and exclude children and families of color from services. So designing policy around families so that the supports and services are easy to access for all families, and especially children and families of color is important. And one really simple Family Center strategy is to allow families to sign up for and providing services in places where they spend time like childcare centers, libraries, schools, and pediatricians offices. Next slide. Sorry, seventh strategy is it’s to sort of ensure that community health workers, pure advocates, parameters, and others with lived experience and expertise in supporting families as a net navigate systems are a valued and growing part of our workforce. And we know that community health workers and others in similar roles are really trusted members of the community. They have expertise in supporting families, and they can help them navigate health and other supportive services. And we need to think about how we can scale these models to ensure that they’re adequately, workers are adequately compensated. And they’re empowered to reflect and recognize the importance that they serve in our systems. And the last one I’ll highlight is how to the importance of collecting meaningful data to understand how policy is impacting children and families of color. So often, the people most likely to be shortchanged, are not adequately captured or represented in our data are often the most marginalized. So it’s important to invest in those opportunities to improve how our data is disaggregated how we integrate Community voices into our design in our research design, how do we develop sources of high-quality survey data that really sort of captured dimensions of intersectionality, right of gender, race, ethnicity, health, looking at how our data is, is able to impact communities that we’re serving. So measuring improvements using baseline data to see if programs are actually working and having a positive impact on communities of color. Next slide. And I think I’ve said this several times. But before we can begin to really address inequities, we have to take that time to understand and to unpack those historical root causes of our present day inequities and why systems function the way they do, and how systems were, in fact designed to function exactly as they do. And this will really help us effectively identify strategies for moving forward. We also have to work with policymakers and system leaders to understand disparities and to look at policy strategies that can actively address disparities for children and families of color. And that data is a big part of this right, you have to be looking at your data to understand service needs and gaps for families to see where barriers exist, and disparities show up. And there are a number of strategies as we talked about earlier that can help you advance equity in your own work, including waste equity, impact assessments, continuous quality improvement, and taking steps to institutionalize change. So I’ll walk through these with you quickly. Next slide. So you may be already using these by race equity Impact Assessments really provide that systematic look at how a proposed action or decision is likely to affect different racial and ethnic groups. They can help us really look at the actual and the anticipated effects of our proposed policies or practices or programs and plans and budgetary decisions. And they can help us surface unintended consequences of our ideas and proposals. So when doing a race equity impact assessments, we’re going to ask critical questions like are all racial and ethnic groups that are affected by the policy practice or decision at the table? How will the proposed policy or practices decision affect each group? And how does it address systemic racism? Next slide. So continuous quality improvement, or CQ II is really about that commitment to learning and intentional improvement, and it can advance equity. It’s really critical that we’re focusing on experiences of families, and really constantly evaluating the methods and processes that we’re using to achieve our desired results. And CQ, I can help us do that. It does require that we have data systems that are designed to capture and produce reliable quality, actionable data, that’s both looking at our processes that we put in place and the outcomes that we’re achieving. And there’s some key questions to ask as you’re building out your data systems. So how do we gather data and information? Who are we gathering our data and information from whose voices do we value here? And what do we know about who’s not being served? Well? Why are the programs and strategies we’ve put in place not working for some, and to continuously be asking these questions about who’s not being served? Well, how can we better serve families and what services and support in the system are we failing to provide? Next slide. Advancing equity also requires a long-term commitment, intentionality, and focus on institutional change. And it requires us to think about the ways in which we’re ensuring that all our principles, our policies, and our practices are grounded in equity, that when possible, we’re incorporating processes and tools and guides to help our decision making and that we’re aligning our existing and ongoing efforts with those of other systems, partners and programs. And this work also really requires that meaningful accountability structure to hold ourselves accountable to communities of color, to our commitment to equity, and to dismantling systemic racism. So that’s all I have. I’m happy to answer any questions to share any resources that I referenced here that may be of interest to you. And I’m going to go ahead and pass it over to Kendra.  

Smith 23:15 

Thank you so much, Shadi, such great information. My name is Kendra Smith. I’m the Vice President of community health, advanced core Mercyhealth. We are one of the largest nonprofit healthcare systems in the country, serving seven states in our footprint. You know, the opportunity for a community health team in a hospital is really great. Our team gets to kind of divide our time between thinking about the infrastructure of community and the places that we serve, whether that is where our patients are coming from where our employees live, or those that live in the communities around us. And then we also get to spend A great amount of time thinking about our patients, our populations, how we deliver the best care possible to those that interest us with that service. And one of the really important interplays that that happen in our space is this interplay between policy and implementation, and how do we not just deliver the status quo not just kind of keep doing business as usual. But as we see, the continued emergence of the conversation around social determinants of health, as we see the emergence of conversation around health equity, around structural racism, all of these things that have ever played together for so long, that are just now kind of really coming into the forefront, you know, how do we really embrace that not just as a healthcare system, but generally for all of us as practitioners or policymakers in this work. And so one of the biggest pieces of this for us as bonsor, for mercy health is ensuring that our ties to community collaboration, our commitment to community engagement, remains strong, it’s always been at the forefront. But now we are really having enhanced conversations around things like structural racism, and not just what that looks like maybe in the healthcare setting, but what that looks like in a community setting, how our communities function, how our communities are resourced, and what does that mean, and really acknowledging the fact that there are organizations, there are individuals, there are movements in our communities that have really worked to address this, far before any of this was really on a prime pedestal on a prime spotlight, and respecting that work, that institutional expertise, that everyday experience, and asking how we can support that through our policy work, and our implementation and investments. So I think is, as we all in this space, think about best practices and community collaboration, I think it’s important to understand that, that all partners have value, but that not all partners are going to be expert experts in the same way that we are. So as we continue to have conversations, for example, around structural racism, you know, as a hospital system, it is part of our value proposition, it is part of our mission, to serve all that come to us, we are a Catholic healthcare system, rooted in compassion, rooted in dignity, in providing the best care that we can. But as, as topic experts, that may not be our space. And so while we want to lend our expertise and support, realizing that our job in that role may be to support others that are leading that movement, and so really trying to find this, this ground, where sometimes we lead, sometimes we support. And sometimes we follow and implement and being open to that as organizations being open to that as funders being open to that as as anchor institutions to say, this is really going to take all of us to figure this out. One of the spaces where we are really committed to advancing the work is around policy. And so as a healthcare organization, you know, obviously health care policy is at the top of our list, we are always thinking about accessible health care, we are always thinking about affordable health care. We are always thinking about especially in this time of COVID. How do we pivot quickly, we, you know, we saw telehealth, we saw what had to happen with reimbursement policy around CMS and how they were able to quickly pivot the reimbursement structure for telehealth because we couldn’t get our patients to us. And so health care policy, obviously is always at the forefront of what we do. But what we know is that community development, community-based practice, economic development has its own sets of policies that also can supplement the work that we’re doing as a healthcare system as we look to address health outside of our four walls. And so we spend a lot of time also thinking about affordable housing policy. And so if you were to look at our policy agenda, in that space, we are supporting the affordable housing credit Improvement Act. And so making sure that our communities have access to low-income housing tax credits that make sense that build quality housing in areas that need it. We’re consistently thinking about home dollars. We’re consistently thinking about new innovations. There’s a new policy that many healthcare systems have tied down to the healthcare-oriented housing proposal. And what this does is in a QA p for a tax credit process improves the basis opportunities for developments that have health care or health and well being related interventions included in whether it’s site design, whether it’s service delivery, in that space, and so thinking about how do we really help provide safe, affordable quality housing in communities of choice, that not only impact health care, but also the daily well being of those around us, looking at things like land, use zoning. So when we think about the environmental impacts when we think about conflicting land uses, when we think about zoning regulations, that impact density, you know, those are all things that as a hospital system maybe aren’t inherently at the top of the list, but absolutely impact what we do. And so that’s where we have to be a supporter, you know, we may not be on the front lines, but we are impacted. And so how do we lend our expertise? How do we lend our time? How do we lend our resources to those opportunities? When we think about things like economic development, you know, knowing that right now, CRA modernization is on the table, and how does that impact not just our workforce, our wages, our relationships with banks around investment, really, there are so many economic opportunities that come from those policies, again, not a direct correlation to delivering health care, but a huge, huge, huge part of health and well being. And so for organizations, whether it’s a community-based organization, nonprofit, whether it is a health or hospital system or organization, whether you are a housing organization, wherever you may fall, in that spectrum, there is an opportunity to really cross-sector support policy that really goes to the well-being instabilities of our neighborhoods. And so while we do oftentimes have to think about what is important to our sectors, there’s also now this movement that we are seeing of these cross-sector partners of these cross-sector Coalition’s in Consortium’s that are really saying, we are going to take our lived experience our lived experience with barriers, with successes, with the things that our constituents our patients, or clients are telling us or not working in, we’re going to turn that into a policy agenda that benefits all. And so I think one of one of the most important things that I want to leave with you today is if a partner maybe doesn’t seem, you know, that doesn’t seem like that’s our partner, that doesn’t seem like that’s our space. Sometimes that may be true, but oftentimes, it’s not there, there is a value add to so many cross-sector partnerships that we are still discovering that are still emerging. And really, as community members in the same geography, there’s always a natural collection. And so as we’re building our policy agendas, as we’re building our partnerships, as we’re building our investment strategies, really taking time to say, all of these really large problems that we’re facing structural racism, social determinants of health, health, inequity, working towards justice, you know, how do we really advocate for not just ourselves, but our partners in the work? And so you’re going to hear from a couple more of our speakers this afternoon about some very specifics in that space. But consider that umbrella. Consider as you’re hearing all the great information today, who in your community, have you not reached out to yet who in your community is a partner and you’re and you’re still trying to figure out where to go, but what are the opportunities there. And know that it can be policy, it can be a program, it can be investment, but all of that has the impact to make really long-lasting change. And so from there, I’m going to turn it over to Vinu, to talk a little bit more about current policies around communities that are emerging. 

Ilakkuvan 32:23 

Thank you so much Kendra. And give me just a moment to see if I am able to pull up my slides having some technical issues. So I will see if someone else can hold them up. And in the meantime, to take it from where Kendra just left off. Exactly. Like Kendra was talking about there, you know, health systems, folks in community development and public health really across sectors. There, it has been a real movement towards thinking about multi-sector efforts to work in ways that are rooted in the community to address upstream determinants of health. So exactly what Karen was talking about at the beginning of this panel, I think, you know, thinking about housing, thinking about wages, thinking about the environment, the policies and systems, all of those things. So thank you. So as we think about all of those things, I wanted to take a moment to share some policy recommendations around fostering effective community-based, multi-sector collaboration to address these upstream determinants. So on the next slide, you’ll See some of the essential elements that are needed to to foster this kind of community-based, multi-sector collaboration that’s really focused truly upstream, you know, in the ways that we are talking about. So these essential elements that you see on the screen are community ownership, which you, you know, heard earlier in this panel as well, thinking about, you know, sharing power with families very much falls into this category, thinking about community ownership, thinking about sound evidence-based strategy, thinking about partnership, infrastructure, thinking about flexible, coordinated financing, and thinking about data collection and sharing. So I’m going to walk through each of these categories, and talk through some specific policies really across federal, state and local levels that can support these elements when it comes to multisector community health improvement efforts. So on the next slide, we’ll dive a bit into community ownership. So first, local governments can revise and strengthen their public participation laws, many of which haven’t been updated in decades, really, these could be revised to implement and support more meaningful civic engagement, more meaningful participation. Just as one example, more and more local governments are experimenting with participatory budgeting, which is a process that allows community members to directly decide how to spend all or part of a local budget. And that kind of participatory process, when it is designed well and designed to be inclusive, really increases transparency, shares power and puts power in the hands of those who historically have had less access or control over budgeting decisions. The next piece that I wanted to talk about is around you know, government agencies really at all levels can engage in participatory action research, things like community-based participatory research, community-based systems dynamics modeling, these approaches can really help assess community needs and concerns and potential policy solutions. Next, local governments can build accountability to communities into their work. So some of accountable some of the accountable communities for health, which I’ll talk about a little bit later have done this via you know, shared community health assessments that are paired with community health improvement plans that really hold all actors, health system actors and others and the government really accountable to what the community has put forth as its means. And then the last piece here is obviously one of the most fundamental ways community members influence government at all levels is through voting. So legislation to address those structural barriers to make voting more widespread to make it more equitable, are an important piece of the puzzle here. I next I thinking about what sound evidence-based strategy in these multi-sector efforts looks like first, governments can invest in require incentivize actions that promote systems change to address these upstream determinants everything from allowing and encouraging broader use of Medicaid 115 waiver authority to address upstream determinants to direct investments in affordable housing, like we were talking about earlier in this panel. On next policies can also be structured to incentivize or even require evidence-based approaches to collective impact that include those foundational elements of collective impact, you know, common agenda, backbone, support, continuous communication, mutually reinforcing activities, shared measurement, and I’ll touch on a couple of those soon. Third, we have established you know, high-level, inter-agency planning groups that coordinate funding and programming across agencies to pursue goals is really important state-level children’s cabinets are a prime example of this. And then in addition, you know, the federal government should consider establishing evidence-based registries that are multi-agency cutting across outcomes that are looking at practices and programs and policies that address risk and protective factors that are common across issues and sectors. And lastly, agencies can make funding contingent on the use of evidence-based practices, evidence-informed innovation and regular evaluation. OMB in particular could strengthen its targets for utilizing evidence-based policymaking at the federal level. I’m building on the 2018, evidence-based policymaking act. Next we have in terms of partnership infrastructure. First government should invest in partnership development and maintenance. This is something that takes significant staff and resources. And that comes with a price tag. And it’s important for funders, government and others, other funders to actually invest in that infrastructure their next government can invest in capacity building around collective impact via technical assistance, learning collaboratives and approaches, similar to those third agencies can invest in and require backbone support. You know, these partnerships really need dedicated staff performing key functions for the sustained operation of the collective impact initiative. So that backbone support is really key. And lastly, at the same time, we also want to see policies that incentivize and support broad stewardship, stewardship, with leadership really distributed across many groups and individuals, which allows for more room for innovation builds genuine commitment, and can also help enhance equity and community voice as has come up with this point. Next, I want to talk about flexible and coordinated financing and funding. So first, we know that there is a you know what we call a wrong pocket problem where oftentimes, the agency or entity bearing the costs of an initiative, like community health improvement efforts, is not the same one that’s reaping the benefits. So because of that wrong pocket issue, governments really need to be forecasting and accounting for savings to other sectors and agencies. And this is true across, you know, a range of budgeting processes, budget analysis activities, like cost neutrality, determinations, waivers, determining waivers, and at the federal level CBO scoring. Next, you know, when we talk about braiding funding, we’re talking about coordinating multiple streams of funding. And funders at all levels of government can facilitate that kind of braiding of funding. And the federal government in particular has a lot of tools at their disposal in terms of streamlining application processes, creating single announcements for aligned programs, using proposal requirements and preferences to encourage breeding, there’s a lot they can do to help with this. And over time, also, we’d like to see, you know, federal government work towards eliminating the need for that kind of intense breeding and actually building towards universal applications for communities to access multiple funding streams. A third, we want to see, you know, more, we need more capital to do this work, communities need more capital to do this work and sustain it and scale it. And when it comes to that kind of capital financing, there’s a major role here for CDFIs for community development, to you know, leverage the Community Reinvestment Act to have parallels to that CRA in to encourage health systems to invest in similar ways that we ask things to invest in communities. And there’s a lot of legislation that can advance those types of strategies, as well as advanced outcomes-based financing models. So thinking about Pay for Success, thinking about the social impact partnerships to pay for results, sepra, partner performance partnership pilots, these sorts of federal policies can advance that. And lastly, this kind of braiding of funds requires, again, that infrastructure, so having a designated financial intermediary, Maryland has something called local management boards that use this kind of model where they have these boards as a financial intermediary, bringing in multiple streams of funding and then putting them out into the community and targeted ways to support children and families. So that kind of model can be very useful. On the next slide, we’ll go into data collection and sharing so at first, you know, data that’s being gathered at taxpayers expense, must be publicly available, accessible in an equitable way, and analyzed at you know, a community level that makes it actually actionable and useful. Next, it’s also important to establish common measures, the well being and the nation has a measurement framework that offers a helpful starting point. And on top of that, government can also play a key role in establishing standards for structuring and exchanging data around data interoperability. We also need more convincing incentives to share data and sometimes even perhaps participation mandates with data sharing. So exploring those policies would be useful. A third, a lot of data sharing is inhibited by both perceived and actual legal and regulatory concerns, for example, related to HIPAA and FERPA. So finding ways to minimize those barriers while keeping protections in place, sometimes that might involve issuing additional guidance around the kind of data sharing that is acceptable. And doing that would really help move some of this data sharing forward. And then lastly, government should directly engage in and require those funds to engage in and require rigorous evaluation. So with that, this is just kind of the recap of the key categories we talked about. And then on the next slide, I wanted to touch very briefly on a couple of key opportunities that address really all of these five elements that we’re talking about. So one is accountable communities for health. These are multisector partnerships, addressing upstream social determinants at the community level, and the federal government could use its resources and authorities to scale this model. Further, it really holds a lot of promise in enhancing community voice and equity, while effectively addressing these upstream determinants. Next, there are a couple of pieces of legislation that were very recently introduced the social determinants accelerator act, and the link to address social needs act. And these both in different ways empower states and communities. to more effectively address social determinants. They address some of these key elements we’ve talked about in terms of data sharing technical assistance around breeding and blending of funds, thinking about rigorous evaluation and outcomes tracking. So these types of efforts if they are passed, and tested and scaled, really hold a lot of promise. On the next slide, you’ll see all of this is really about finding ways to move upstream, address those upstream determinants, and allow us to achieve equity at all levels. The next slide I have on resources, these are all linked. And these are where a number of the policy recommendations are explained in further detail here. And these slides will be available to you later. So with that I will, you know, again, just say these are all important pieces of strengthening community-based multi-sector efforts that are going to help improve health and well-being and equity. And with that, I will hand it over to Nathaniel. 

Counts 46:40 

Well, some president everything all of these, I feel like it’s the answer to every meeting I’ve been to for like the past five years, which is summarized these past three presentations. So I would I guess building on everything I just wanted to talk about, um, I guess, bring together a couple themes, and then some additional kind of policy thoughts to finish us off. Um, one major theme that I hope came through across all these talks is that there’s really two sets of major determinants related to what life course health equity, there’s this sort of like local control and community power aspect, which I think Henry really spoke to a lot. And then also equally important, that I think sometimes get locked out of these conversations are the macro level determinants, like, you know, housing subsidies and food access at the national level that are just as critically important and need to be addressed. And I think one way to kind of engage people towards addressing these is improving the amount of accountability to both local community stakeholders and to the broader national policy environment. So I think what really animates This is not every company is mercy bonds, the quarters, I think if if every company kind of shared this dedication towards investing community health and learning how to both lead when necessary, and step back, and then share resources. This would be a very different panel. But I think there’s a need for across all these from policies and investing community increased accountability to the local stakeholders, and really brings us home for me was Urban Institute did a report opportunity zones, I think about a year ago, where they found that a huge percentage of opportunity’s own funds just went to, you know, developing high rise luxury condos, and areas that were targeted, which has gone horrifying. And then some of the reports on the community benefits side and health care have found that some horrifying percentage actually went directly into executive compensation and quite a lot of it ends up not going to communities. Um, but this is all built on a landscape where we have tons and tons of different policies doing community gauged needs assessment. So, you know, hospitals do needs assessments and headstart, student needs assessments and public health needs assessments, and all of them create opportunities to engage with the community. Figure out what your committee members care about, and how do we plan around that, but they’re not, they don’t hit the kind of coherence you would hope, where you have community LED, and community accountable investments. And so I think in the future of policy, there’s a real opportunity to leverage the resources that are already in communities. And I think binu really got this a lot too. To have community members engaged in planning of where the resources go, and then only allowing resources to be only get the kind of federal subsidies for these programs, if they align with the community goals, then having community members evaluate it. So I think it’s going to be critical to move away from this paradigm where you say like, here’s an underserved area, you have free rein to invest in however you want, or here identify some health needs and invest in everyone, but actually saying, like, no, this has to fit into a plan developed by the community in order to get credit. And so it’s freeing the resources really do build towards community power and long-term health equity. Um, the other big portion of that, too, is this kind of like intergenerational piece. I think we’re getting better and better of being accountable to adults in the system, like workers, for example, employees, community partners, but it’s, I think children have really been in the kind of like, intergenerational dimension has really been left behind. And I think, to Shawn’s point, those conditions are really shaped by these kind of national level policies, like what the, you know, the kind of community that children have access to, and grow up. And, um, and I think we’re going to need to move towards this framework for accountability for corporations where these kind of like ESG metrics and sustainability focus not just on governance and climate change, and you know, supply chain sustainability, but thinking about intergenerational health and well being as well, because I think right now we get have this kind of opportunity, where companies if they hire diverse staff get full credit, but if they use their political influence to undermine long term health equity, nobody really knows about them, they’re not held accountable in any meaningful way. And I think, interestingly, the current administration has been increasingly putting rules on who like who they’ll buy from. So they’ll do procurement with only companies that meet certain governance standards, or only certain new standards about emissions. But nothing really has been put in place about standards around the way that they engage with communities in the way that Kendra was talking about to elevate community power and the way that they wield their political influence on the national stage, either advanced or undermine health equity. So I think that’s going to be one of the major next frontier is holding stakeholders accountable for both local and national conditions with an intergenerational well-being and health equity lens. The last really quick point I want to touch on is thinking beyond the community development realm. So there’s unfortunately no way within Treasury commune development is one piece in the rest of the economic system is, you know, broadly worried about risks to the financial markets and your economic health. But missing from all of that, is this kind of like the health and well-being of the people that make up the economy? Like there’s this idea that like, oh, productivity slowed down and like things aren’t quite going the way we want? Maybe it’s technology isn’t being as productive. But nobody stopped to wonder like, is it? The people are sicker? And you know, we’ve seen rising rates of mental health and substance use an obesity that has no place right now, I think in the current discussions about the economic health of our nation. And so I think one other key frontier is going to be mainstreaming long-term, intergenerational health, equity, and well-being into the way that we assess our nation’s economy and financial risks. And so be looking forward to working with everyone as part of the session on these things in the future. And with that, I’ll turn it over for a little bit of q&a.  

Kali 52:41 

Hi, everyone, thank you so much. We have about five minutes left of our session. So I do want to make sure that we get  a couple questions. And if anyone in the audience has a question, please be sure to put it in the chat and we will get to it as best as we can. Okay, no, I just wanted to comment on what you said there about, you know, holding our stakeholders accountable when you talk about sort of the community, the process of the Community Health Needs Assessment, you know, community process, right, it’s supposed to be an opportunity to engage with the community to, you know, gather their inputs and thoughts to create that sort of three-year plan. That’s interesting to me about, you know, sort of the guidance coming from, you know, under the Affordable Care Act, or even the IRS who sort of, you know, holds that nonprofit status of a hospital or health system is that there’s no there is no actual guidance in terms of the quality right, of a Community Health Needs Assessment. How does that hold us back? Well, if they firstly does that hold us back in terms of, you know, the impact that we could have right further down the line with improving health outcomes. And what’s Is there a path forward on that? That’s one question. And we’ll Why go ahead and ask that. We have just a couple minutes left to you, Nathaniel, but also to anyone else who’d be interested.  

Counts 54:03 

Yeah, I don’t know who’s the audience everybody Don’t yell at me. But there was that paper in Health Affairs a few weeks ago about who does charity care, and they found for-profit hospitals do more charity care, the nonprofit hospitals. So you’re like, Oh, my God, like and that’s the whole thing is like, what why do they How do they own their nonprofit status. So I think there’s I absolutely need to be held accountable for something and there’s a lack of guidance, I feel it was necessary to make get it over the finish line, the first go-round, but now, you know, the healthcare systems, you know, some of them aren’t hitting their q1 revenue targets, but they’re doing, they’re gonna be just fine. And I think I think it’s gonna be critical to hold them accountable to the committee members, because we’re certainly rich enough in needs assessments to figure out what communities need. 

Smith 54:45 

Now really say, as an urban planner, that is now in charge of creating Community Health Needs Assessment, it is a little bit shocking, how much free-range, you haven’t been creating a CH and a, but I think, you know, there really is an opportunity as we want to be able to measure impact, both within a unique system, but also these larger scales, if we really want to have these upstream investments and be able to impact health and well being there is going to have to be some common threads, I think we’ll see systems continue to have their own aspects. And really, you know, whether that is their social determinants cross-cutting, whether that’s, you know, their outreach methods, or engagement methods, everybody will look different and have some expertise that rises. But if we really want to have change, I think we do need to start implementing some common measurable threads that then start to create that evidence base for the change that we’ve all kind of talked about here today.  

Kali 55:38 

Excellent, thank you so much. Just a couple more minutes left, I’m curious what folks think about or, you know, sort of general thoughts that folks may have on the American rescue plan? Is it? Is it just right, is it? You know, not far enough? And any sort of thoughts on the impact that it? It may have? 

Houshyar 56:04 

So I can say a little bit, um, I think, I think it really is a significant infusion of funding. And so in that way, I feel like it’s like it’s a historical sort of investment in families and communities. We talked about the Medicaid postpartum Medicaid expansion, there’s funding in there for food security, rental assistance, home visiting tax credits, public health workforce, mobile crisis. So like the really the range of sort of supports that we’d like to see, one thing I will say is that on many of these provisions, it really does come down to implementation. So for example, the postpartum coverage is a state option, the Medicaid expansion is a state option. And we know that states that have not expanded are likely not going to take up this option. And I’ll point out on Medicaid expansion, that most of the states that have not done it are in the south, where a large number of people of color lab and also fall into that coverage gap. So I think implementation is a concern, and where it’s an option, it certainly could have gone further. Another example is the child tax credit. With immigrant children who lack social security numbers, they’re not eligible for the child tax credit, and to access that families need to be connected to tax code. So there are sort of limitations in that sense, both in terms of implementation and also how far we were willing to go and some provisions. But in terms of a broader view, it really was a historical infusion of funding for families and communities. 

Ilakkuvan 57:30 

And I think one that did, in many ways get at some of these upstream determinants that we’re talking about more so than a number of federal policy efforts have in the past. So I think it is encouraging to see movement in that direction, though, to Saudis points, certainly, in terms of implementation in terms of sort of scalable and sustainable long-term capacity building around these things. You know, I think we have a ways to go, but I’m glad to see things moving at least. 

Kali 58:01 

Nice. Thank you. So what we’re gonna take a question that we have from an audience member, then I’m going to ask our panelists to just provide some brief closing remarks. So one question comes from someone in the research field, what data is missing? Or what? Or in what format that you can work with related to this work? What data do you need? The most that would help you, I guess, get the furthest? 

Smith 58:30 

You know, I think for me, I always say the most valuable data is that data that’s connected by collected by our community-based organizations and whether that’s their, you know, participation data, their outreach data, but how do you create put that in a way you know, then you talked about accessible data, public data, you know, making sure we can get to it? How do I Get somebody that data from a local CDC in my town, you know if they live in another state, but would probably also be helpful, like, how do we codify that hyperlocal hyper community collected data to supplement all of the other, you know, publicly available data that we all know and use every day would just be a dream scenario for me to be able to have someone figure out and teach us all how to do that. 

Ilakkuvan 59:19 

And relatedly at a community level, I feel like the data that communities need to do this work effectively. A lot of it comes to that to that piece around data sharing and data integration, and how do you take data that the hospital has that the social services agencies have that the state health department has, and start bringing them together in ways that allow it to be actionable. And there’s a lot that goes into that, but I think that’s a key data need. 

Counts 59:50 

And on the national stage, I might, I would say, to more data around corporate political influence, and its effects on health equity, just example, a paper just came out like a couple months ago about where they fired the CDC to get all the contacts between a well-known beverage manufacturer and the CDC, and there was a lot and in a world where we have, you know, massive cardiovascular and metabolic issues around equity lines, because of the differences in distribution of these beverages. One might wonder why they need a lot of contact with the CDC, for example, but there’s only uncovered through a FOIA request. It’s not available elsewhere. 

Kali 1:00:26 

Excellent. Well, as we wrap up, do we have any sort of final closing remarks or our panelists? 

Smith 1:00:35 

Thanks for having a policy conversation. I think so many times we get focused on the programs. And then immediate social need that right now that we don’t give ourselves a lot of time to talk about policy. And it’s great to see so many dedicated, great folks, I know, both in the audience on the panel, and even folks, we aren’t connecting to today doing that work. And that hopefully, that is enough to drive it forward and elevate it. So thank you, Karen, for having all of us. 

Ilakkuvan 1:01:02 

I agree. I agree with all of that Kendra. And I would add to what Nathaniel was starting to say I think as we think about policy solutions, and as we think about moving upstream, I think thinking about those kind of even broader issues of kind of commercial and corporate determinants of health of political determinants of health and political processes and how those work. That is really a key part of the puzzle. And I hope we can, you know, continue to have these concrete policy conversations that go that far upstream, because those are the things that are really driving the downstream health of health and well-being that we see in communities. 

Houshyar 1:01:42 

I think I just quickly would say, you know, as we think about advancing health equity, really working to advance racial equity, and that requires that we take an anti-racist approach, which is really an active process. 

Counts 1:01:56 

And I guess my last thought would be building on that. The AMA just came out with its strategic plan for equity. And it’s incredible. And I think that should be like the, you know, new for, for all organizations, to strive to go far beyond. 

Kali 1:02:11 

Excellent. Thank you all so much. I’m so sorry. We don’t have more time for questions. Because there’s a whole list that I have for all of you because you’re all such excellent experts in this field. And we’re so thankful that you were able to join us today for this session. I want to thank you in the audience for being here with us today on a Friday afternoon. This is as I said, the last session of our conference. Thank you from all of us in NCRC for tuning in over the past two weeks. If you do still have any questions or want to connect with any of the speakers, feel free to pop into the socio platform to reach out again, thank you, speakers and everyone have a wonderful weekend. Thank you. Thank you. Thank you. 

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Redlining and Neighborhood Health

Before the pandemic devastated minority communities, banks and government officials starved them of capital.

Lower-income and minority neighborhoods that were intentionally cut off from lending and investment decades ago today suffer not only from reduced wealth and greater poverty, but from lower life expectancy and higher prevalence of chronic diseases that are risk factors for poor outcomes from COVID-19, a new study shows.

The new study, from the National Community Reinvestment Coalition (NCRC) with researchers from the University of Wisconsin–Milwaukee Joseph J. Zilber School of Public Health and the University of Richmond’s Digital Scholarship Lab, compared 1930’s maps of government-sanctioned lending discrimination zones with current census and public health data.

Table of Content

  • Executive Summary
  • Introduction
  • Redlining, the HOLC Maps and Segregation
  • Segregation, Public Health and COVID-19
  • Methods
  • Results
  • Discussion
  • Conclusion and Policy Recommendations
  • Citations
  • Appendix

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