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Community Development and Population Health
As the discussion about how to modify the social determinants of population health at the community level continues, it is clear that the field needs to have clear definitions of what needs to change, clear understandings of the expectations for change, and a clear idea of where the investments will come from to make those changes. In this session, three speakers provided their perspectives on these issues as they relate to the role that community development can play in population health.1 The first presenter was Raphael Bostic, the Judith and John Bedrosian Chair in Governance and the Public Enterprise at the Sol Price School of Public Policy at the University of Southern California, who offered an overview of the history of community development’s tie to population health and described some opportunities for leveraging
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1The Community Reinvestment Act defines community development as investments by banks in affordable housing and community services directed at low- or moderate-income individuals. Revitalization and stabilization activities should address communities, including those designated as “distressed or underserved nonmetropolitan middle-income geographies” by relevant federal agencies based on factors that include poverty rates, unemployment, population loss, population size, density, and dispersion (http://www.fdic.gov/regulations/laws/rules/2000-6500.html#fdic2000part345.11 [accessed July 11, 2014]).
existing federal resources to accelerate progress. Donald Hinkle-Brown, president and chief executive officer of The Reinvestment Fund (TRF), and Nancy Andrews, president and chief executive officer of the Low Income Investment Fund, then discussed some of the lessons that their organizations have learned from the programs they administer. These presentations were followed by a discussion moderated by José Montero, a member of the workshop planning committee and director of the New Hampshire Division of Public Health Services.
HISTORY, DIMENSIONS, AND OPPORTUNITIES
Raphael Bostic said that an important consideration for being successful and effective in the space of community development and population health will be generating an evidence base concerning what works and does not work. A solid body of evidence will be key for making the kind of sound policy decisions that can provide a consistent level of funding for initiatives in this area. For example, he said, funding for programs that prevent homelessness has not been subject to budget cuts precisely because there is a broad understanding about the value of these programs. Bostic also commented that while policies and rules have to change in order to enable success in this area, there must also be a bottom-up effort to identify what policies and rules need to be changed and how they need to be changed. He recognized the potential of groups such as the Roundtable to create a place where all the different stakeholders can have a voice, to ensure that information flows among all the necessary parties, and to create a common conception of the problems that need to be addressed. Another factor that plays a major role in whether a program will get funded, he said, is the type of governance structure. As examples, Bostic pointed to San Francisco, where the boundaries of the city and county are aligned and thus savings from county investments in city programs are all realized internally, and Los Angeles, where savings generated from a city program will accrue to the county, which is a much larger geographic entity. This latter type of governance structure discourages the city from designing programs.
Although the scale of change that needs to occur is large, Bostic said that he is optimistic that proactive behavior to create new partnerships will lead to progress on the social determinants of health and result in better population health. “I think there are signs and examples of this all over the country,” he said, “but we need to be particularly sensitive to the fact that it takes proactive action. You have to plan, you have to anticipate, and you have to design.” The programs highlighted in the workshop did not happen suddenly, he noted; they evolved over time.
Community development and population health have a long history,
and in the United States that history started in the 1890s, when cities began clearing and upgrading slums as a public health initiative. The National Housing Act of 1949, which was the federal government’s first foray into housing policy, provided $1 billion in loans to acquire slums and blighted areas for public and private development, and it also funded public housing. What was even more important, Bostic said, was that the act marked the appearance of a divergence in housing and urban policy and health policy—a divide that the nation still struggles with today. Nonetheless, despite this divide, he said, progress has occurred in a number of areas, such as the relatively rapid reduction in the incidence of childhood lead poisoning that resulted from federal regulatory actions and funding.
What is needed for more rapid and extensive progress, Bostic said, is a reset in the way that people think about community development and population health—a reset that he believes is happening. One reason for this change in how people think is that the largest effects coming out of the biggest demonstration projects in the housing and urban development area have been health benefits. For example, the Moving to Opportunity program, in which low-income families were given vouchers that enabled them to move out of areas with concentrated poverty, produced marked improvements in stress-related outcomes, depression, obesity, and diabetes. “That was a wake-up call,” Bostic said. “When the demonstration started, health was not even on the radar screen.”
Another factor driving this reset, he said, has been the growing recognition that social and economic factors can drive population health outcomes. Budget pressures are also pushing this reset, he added, because housing and urban policy programs and population health programs are having to broaden their funding base and to better leverage existing resources. Bostic listed a number of federal agencies that fund programs that are not purposefully linked to health outcomes but that could be. These agencies include the U.S. Department of Housing and Urban Development (HUD), which spends about $30 billion on housing and community development; the U.S. Department of Justice, which funds community-based violence and substance abuse prevention programs; the U.S. Department of Transportation and the Environmental Protection Agency, both of which provide sustainable community and neighborhood grants; and the U.S. Treasury Department, which offers such programs as the Community Reinvestment Act. There are also various education-oriented programs funded by multiple agencies that could be tied into population health initiatives.
The bottom line, Bostic said, is that there is money available that can be leveraged in effective ways in order to make positive change—with “effective” being the key. He said that to be effective, the field will need
to take a decidedly multi-sectoral and multidisciplinary approach based on a common language and a common understanding of goals and possible outcomes. Partnerships will need to link organizations from varied sectors, including those that have not been part of the discussion up to now. As an example, Bostic cited the recent decision by the CVS pharmacy chain to stop selling all tobacco products in all of its stores. “That should make all of us step back and think about who else out there is thinking about these issues and that we should be engaging and talking with,” he said. “If this company is willing to take those sorts of steps, that would suggest that there are other resources that are available to be leveraged in this way.”
Bostic closed his remarks by saying that it is important for the field to develop a vision. “We need to have some clarity on where it is we are trying to get to, what are the outcomes we want to achieve, what are the processes, and what are the metrics,” he said. “That vision will allow us to build a narrative, and that narrative is what you use to build allies and partners that allow you to make change.”
LESSON FROM THE REINVESTMENT FUND
TRF is a community development financial institution (CDFI) that is based in Philadelphia and that primarily serves the mid-Atlantic region.2 It has deployed $1.3 billion in cumulative investments and currently manages $709.0 million in funds with more than 850 investors. Donald Hinkle-Brown explained that, as a CDFI, TRF serves as the last mile of the credit chain of the financial industry, reaching those who are otherwise disconnected from that industry. “We work at the nexus of organized people and organized communities,” he said. “We organize money to deliver it to those communities, we organize capacity in those communities, and we organize data and use that in our work. We’re very committed to the interplay of smart data advising smart subsidy decisions and smart capital allocation decisions.”
TRF finances a variety of projects and activities that are germane to population health, including food access, health care, education, and housing, in order to build healthy communities in underinvested places. As examples of its activities, Hinkle-Brown listed several targeted funds that it manages, including the Baltimore Integration Partnership, the New Jersey Food Access Initiative, and the Pennsylvania Fresh Food Financing Initiative. He noted that TRF has worked hard to make sure that the
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2CDFIs use federal resources in order to serve low-income people and communities that do not have access to affordable financial services and products. See http://www.cdfifund.gov (accessed July 22, 2014).
new farm bill includes a food access program at the U.S. Department of Agriculture, and it even has a policy solutions team that uses analytics to advise the fund and its clients on where to invest money for the biggest impact. TRF, for example, conducted the data-driven analysis that quantified the nature of the food desert concept, which holds that lower-income individuals travel farther for their groceries than do their middle-income peers.
The goal of these analyses is not to develop strategy itself, but rather, as Hinkle-Brown explained, “to give communities or the local HUD office the framework from which to more efficiently develop a strategy that makes sense in their geography.” From this work, TRF has developed PolicyMap.com, a national website that displays about 8,000 data layers of public policy–related information and that is now being used in a number of colleges and universities. “What we’re really interested in,” he said, “is reaching the next generation of decision makers and making them [comfortable] with the idea that easily used and easily manipulated analytics can help them make a smart decision.”
In its real estate development work, TRF Development Partners makes its housing investments based on three tenets, Hinkle-Brown said. The first is to use the mapping data to examine an area and identify nodes of strength and weakness in marketplace activity. This allows the partners to invest in weak areas that are adjacent to strong neighborhoods, such as the area between Johns Hopkins Medical Center and Penn Station in Baltimore. TRF is taking the same approach in Jersey City, New Jersey; Camden, New Jersey; and Wilmington, Delaware. “That is a more efficient use of subsidy,” he said, “because if you go to a place totally insulated from the marketplace, it is hugely expensive to build enough activity to then create its own marketplace.”
Hinkle-Brown noted that there is a great deal of activity in the housing arena today that goes beyond providing a safe, high-quality space to live. Housing organizations are now using spatial analyses of human and health care services of various kinds to do such things as match supply and demand. Transit-oriented development that increases livability, walkability, and access to fresh food is important not only for quality of life issues, but also for health issues. Hinkle-Brown commented, too, on how the availability of data from an increasing number of sources is influencing decisions that may ultimately affect health. To further enable that trend, PolicyMap is making an effort this year—2014—to greatly increase the amount of health-relevant data that it makes available.
There is movement within both the community development world and the public health world that Hinkle-Brown believes could be fruitful. The community development world, he said, is becoming less focused on deals and more concerned with the longitudinal effects of its work.
The primary outcomes it is interested in are related to affordable housing, but those working in community development are now beginning to view health benefits—which were once just unintentional byproducts—as being a purposeful part of an investment program. “We’re becoming much more focused on the broader impacts of our work, and we’re beginning to study those impacts in interesting ways,” he said. At the same time, the public health practice community is moving from a reactive position to a proactive approach in how it thinks about the social determinants of health, and it is now showing a willingness to move beyond broad macroeconomic correlations to a granular level that can produce specific, actionable interventions, which is where community development works best.
Access to fresh and healthy foods has been an increasingly important aspect of TRF’s work, and since 2004 TRF has financed 130 healthy food projects across the mid-Atlantic region, totaling more than $180 million. This was an economic development and equity initiative, not one driven by health considerations, and the overall health effects of having supermarkets in previously underserved rural and urban areas are still not completely clear. While the data so far indicate that these supermarkets have not had an impact on obesity, there still may be an opportunity to change behavior that will ultimately benefit health. Hinkle-Brown said that TRF has partnered with the CDFI Fund and the Opportunity Finance Network to train other CDFIs to launch food access programs. In closing, he noted that TRF is working to develop a national methodology to assess community health disparities, just as it did for disparities in food access, with the goal of creating a roadmap for those people who work at the intersection of community development activities and the social determinants of health.
COMMUNITY DEVELOPMENT STRATEGIES FOR IMPROVING POPULATION HEALTH
The primary mission of the Low Income Investment Fund, as Nancy Andrews explained, is to alleviate poverty by breaking down large chunks of capital provided by the fund’s primary investors on Wall Street into smaller, neighborhood project–sized pieces. For example, the Fund recently closed on a $25 million loan from a large investment bank that it will break down into loans ranging from $500,000 to $2 million. Individually these loans are too small for a major investment bank, but they are the right sizes for community-based projects. And, because the Low Income Investment Fund is a CDFI, it can operate on a break-even basis rather than a for-profit basis. Over the approximately 30 years of its existence, the fund has deployed about $1.5 billion dollars and has served 1.7 mil-
lion people in 31 states around the nation. Andrews said that by the fund’s calculations, this $1.5 billion investment has generated about $31 billion in social return. Equally important, the fund has achieved this return with a loss rate of 0.68 percent, a track record that creates a level of comfort among its Wall Street and philanthropic partners.
Andrews said that over the past approximately 2 years, she has become “personally passionate about the intersection between health and community development. If you had asked me 2 years ago what our work has to do with health,” she said, “I would have said we fund health clinics, and I wouldn’t have really had the concept of going upstream and thinking about the social determinants and what causes people to get sick.” Today, the Low Income Investment Fund is using a framework of “healthy communities” as an umbrella for all of its programs and as the way in which it wants to measure the value of its programs going forward. Andrews said that what has been happening in practice is that the places where the fund has been working and investing money are the same places where public health agencies are working. “What’s happening now is we are getting to know potential partners who are working in some of the very same places,” she said. As a result of this change in focus, the Low Income Investment Fund is taking a more holistic approach that involves not only building affordable housing in a neighborhood but also building and supporting high-performing schools, health clinics, and recreational facilities with access to public transit.
Andrews stressed that the Low Income Investment Fund is just one piece of the puzzle in terms of the integrated approach that is necessary to address poverty and population at a scale that will transform communities. Together with David Erickson, a colleague at the Federal Reserve Bank of San Francisco, Andrews has compiled ideas that work in a book titled Investing in What Works for America’s Communities (available free at www.whatworksforamerica.org). One of the big ideas that came through in the book is what she calls the quarterback—an entity that is accountable for actually accomplishing positive outcomes. “This is not just about outputs, not just about creating access to services, but literally being accountable for creating outcomes,” Andrews said. An analogous position in the technology world would be the lead systems integrator, the person who oversees the development of the modules that form the basis of large computer programs and models. Without a lead systems integrator, the modules are not likely to be well harmonized.
As an example of the types of programs that the fund invests in and some of the surprising impacts that they can have, Andrews described the Booth Memorial Child Development Center in Oakland, California, which serves 63 low-income children. The fund made an $80,000 grant that the center leveraged with another $78,000 from other sources to replace its
20-year-old carpet with child-friendly flooring and to install toddler-level hand-washing sinks and new changing tables that the toddlers could get on themselves so that the teachers would not have to lift them. Not unexpectedly, the children started washing their hands more; what was surprising, however, was that because of the removal of the old carpet, there was a sudden drop in asthma attacks among the children and teachers at the center, which resulted in fewer emergency room visits, less lost work time for parents, and fewer disability claims. The attendance rate at the center also increased by 15 to 20 percent, which improved the financial viability of the center.
Andrews also described recent research on the health benefits of transportation services. In Charlotte, North Carolina, people using the city’s new light rail system were found to experience a 6.7-pound weight loss, compared with a control group. Although the Low Income Investment Fund got involved with transit-oriented development (TOD) because of the better access to jobs and amenities that TOD provided, it turns out that TOD has important health outcomes as well. One example of how the Low Income Investment Fund has put ideas into action is that it has led a capital program for TOD in the San Francisco Bay area. The program started with $10 million seed investment by the Bay Area Metropolitan Transportation Commission. “When you manage to convince the transportation agency to invest in affordable housing and other social amenities, that’s pretty good silo busting,” Andrews said, adding that the fund is developing a partnership with two community development groups, Living Cities and the Enterprise Community Partners, together with the National Resources Defense Council, an environmental organization, to replicate this idea in multiple locations around the United States. “We hope we’re making a compelling case for those in the health industry to begin to come together around these kinds of models,” she said.
Looking to the future, Andrews said that one thing that her community is not good at yet—and which it hopes the health sector can help with—is determining how to get the evidence needed to make the case for joint investments even more compelling. She also wants to take the idea of the quarterback for healthy communities and begin to design programs around that idea to show how it works. “We do believe that this will open the opportunity for collaboration between our two sectors,” she said in closing. Toward that end, Citibank’s foundation recently provided the Low Income Investment Fund with $3.25 million to make grants to lead integrators at 13 organizations in 12 cities around the nation.3
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3See http://partnersinprogressproject.org (accessed July 11, 2014).
In opening the short discussion period, José Montero said it would be useful for those like him who are in the health sector to have a better understanding of how other sectors are investing in areas that affect population health. He also said that he thought the health sector would benefit from learning how to measure the large social impact of its programs using the tools and analytic methodologies that the community development sector has developed.
The panelists answered questions about why Wall Street banks would bother investing in these projects, given that they could probably get a larger return on their capital by loaning their money to straight commercial projects. Andrews explained that these banks are motivated by the Community Reinvestment Act, a federal law passed in the 1970s that requires that banks reinvest in the low-income communities from which they take deposits. Banks receive grades on how well they are doing, and they want to receive “satisfactory” to “outstanding” ratings.4
Part of the discussion related to the concept of quarterbacks for healthy communities and the sources of funding to promote these types of organizations. Andrews emphasized that quarterbacks are critical pieces for integrating different sectors and forming partnerships. She mentioned examples of groups that have been funded by banks and philanthropic organizations that may not have health as their primary goal but that end up with positive health outcomes. Other funding streams include tax credits and block grants.
In response to a question from Catherine Baase of Dow Chemical Company on how the community development sites are chosen, Hinkle-Brown explained that the sites must provide a healthy return on investment. Isham asked how much financial capital is needed to maximize health benefits for the whole nation. Hinkle-Brown responded that the calculation was overwhelming and probably infinite, and Bostic replied that currently we do not have enough capital to realize those outcomes. Andrews offered a different perspective, saying that she did not view the availability of private capital as a constraint because the savings can be continually reinvested.
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4Performance evaluations are conducted by four federal agencies: the Office of the Comptroller of the Currency, the Office of Thrift Supervision, the Federal Deposit Insurance Corporation, and the Federal Reserve Board. Financial institutions that do not receive satisfactory evaluations are prevented from opening additional branches, participating in mergers, or otherwise expanding their services (http://www.ncrc.org/programs-a-servicesmainmenu-109/policy-and-legislation-mainmenu-110/the-community-reinvestment-actmainmenu-80/a-brief-description-of-cra-mainmenu-136 [accessed July 11, 2014]).
