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6 Policies to Support Community Solutions
Pages 335-382

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From page 335...
... They can provide important opportunities or constitute barriers to promoting health equity. The policy context shapes the levers that are available to communities to address change.
From page 336...
... . Communities -- and the federal and state agencies that support them in their efforts to address health disparities -- have multiple examples to follow in expanding their focus beyond health care and social services and examining opportunities in economic development, land use and housing, education, and criminal justice, areas which have not traditionally been the focus of health improvement efforts.
From page 337...
... In this chapter, specific policies in six areas are discussed for their high relevance to community-based solutions that advance health equity: taxation and income inequality, housing and urban planning, education, civil rights, health, and criminal justice policy. TAXATION AND INCOME INEQUALITY As discussed in Chapter 3, income has been identified as one of many drivers of population health and health inequity over the life course, along with factors that are closely related to income such as education, occupation, and place of residence (Adler and Rehkopf, 2008; Chow et al., 2006; Cutler and Lleras-Muney, 2006)
From page 338...
... Thus, across all three measures examined by the CBO, income inequality has grown substantially. These analyses also demonstrate the important role of government transfers and tax policy, as well as general economic conditions, in shaping income inequality.
From page 339...
... The largest of these programs is Medicaid, which is discussed later in the chapter. The second largest program by expenditures is the earned income tax credit (EITC)
From page 340...
... . Because the EITC targets low- and middle-income workers, its expansion ­ reduces income inequality and improves health equity.
From page 341...
... Roughly $42 billion is put toward numerous forms of means-tested housing assistance, such as vouchers to low-income families, subsidized rent in public housing projects, privately owned subsidized housing, and support for the construction of low-income housing. Two-thirds of federal subsidy recipients are either low-income elderly or people with disabilities.
From page 342...
... At the same time, research findings on the impacts of housing policy on health equity are mixed. A recent review (Collinson et al., 2015)
From page 343...
... . One dimension of urban planning that can greatly influence health equity relates to so-called greening policies and programs.
From page 344...
... . Local communities and governments across the country have started to integrate processes and policies to advance health equity within the urban planning and land use context.
From page 345...
... • Collaborate with public health agencies and others to ensure a broad consideration of unintended conse quences for health and well-being, including whether the benefits and burdens will be equitably distributed.4 • Highlight the co-benefits of -- or shared "wins" that could be achieved by -- considering health equity in the devel opment of comprehensive plans5 (e.g., improving public transit in transit-poor areas supports physical activity, promotes health equity, and creates more sustainable communities)
From page 346...
... The East Harlem Neighborhood Plan Steering Committee was formed and convened local stakeholders in a community engage ment process to create the East Harlem Neighborhood Plan. The goals of the neighborhood plan encompassed community organizing, political activism, social planning, and capacity building efforts targeted at multiple determinants of health in the context of New York City's increasing income inequality: • Collect and organize community concerns and ideas in order to influence city agencies' planning processes and rezoning efforts.
From page 347...
... New federal legislation, the Every Student Succeeds Act (ESSA) ,6 makes an important contribution to any effort to promote communitybased strategies for reducing health inequities by recognizing the need for schools to improve educational achievement and to embrace and support "whole child" strategies.
From page 348...
... Creating examples of needs assessments that effectively incorporate health and wellness will be of real value over the next 3 to 5 years as school districts work with community stakeholders in crafting these plans. Finally, one of the most important components of ESSA pertains to its state and local accountability provisions.
From page 349...
... The Healthy Students, Promising Futures tool kit states The community health needs assessments (CHNAs) that nonprofit hos pitals are required to undertake include consultations with community members and public health experts, which can help launch productive partnerships between hospitals and schools.
From page 350...
... Recommendation 6-3: To support schools in collecting data on student and community health, tax-exempt hospitals and health systems and state and local public health agencies should: • Make schools aware of existing health needs assess ments to help them leverage current data collection and analyses.8 • Assist schools and school districts in identifying and accessing data on key health indicators that should inform school needs assessments and any related school improvement plans. Furthermore, ED could consider leveraging the needs assessment mandate of ESSA and require that schools and school systems collect such information on student and community health.
From page 351...
... Voluntary compliance with and enforcement of equal justice laws and policies can be preferable to court action as a means to achieve equal justice goals, including health equity. A comprehensive civil rights approach to ensuring health equity relies on planning, data collection and analysis, media, negotiation, policy advocacy, and coalition building -- all as part of a larger problem-solving strategy (Rodriguez et al., 2014)
From page 352...
... . The Americans with Disabilities Act affords similar protections against discrimination based on ability.11 The National Environmental Policy Act also provides protections that can be used to buttress equal justice laws.12 In addition, the President's Executive Order 12898 on environmental justice and health requires federal agencies to address the effects of programs, policies, and activities on minority and low-income populations.13 Some states such as California have parallel laws that will become increasingly important to promote health equity, 9 42 U.S.C.
From page 353...
... Section 11135 was recently amended to strengthen compliance and enforcement. See, e.g., California Equal Justice Amendments Strengthen Law under 11135, http://www.city projectca.org/blog/archives/43834; and John Auyong et al., Opportunities for Environmental Justice in California Agency by Agency (Public Law Research Institute U.C.
From page 354...
... These and other examples demonstrate that environmental and civil rights laws can be used together, with the strengths in one body of policy and law shoring up challenges in the other. A Planning Process The following planning process is a policy and legal tool from the domain of civil rights and environmental justice -- designed for use by federal, state, and local agencies and their grantees -- that can be adapted to support community-based solutions to promote health equity.
From page 355...
... An implementation plan through monitoring, compliance, and enforcement helps promote health equity and avoids unjustified discriminatory impacts regardless of intent, as well as intentional discrimination and implicit bias (DOT, 2012a; The City Project, 2016b)
From page 356...
... Good intentions and vague commitments to "equity" or "local parks and urban greening" alone can exacerbate rather than alleviate disparities. Discriminatory Impacts and Data Analysis An important starting point for promoting health equity is the analysis of disparities that bear more heavily on one group of people than another.
From page 357...
... 1, 2012) ; FTA, Environmental Justice Policy Guidance for Federal Transit Administration Recipients, Circular (FTA C 4703.1)
From page 358...
... University of Texas at Austin in 2016 recognized the value of diversity in ways that support communitybased solutions to promote health equity. Valuing diversity promotes cross-racial understanding, ending stereotypes, preparing for an increasingly diverse society and workforce, and cultivating leaders with legitimacy in the eyes of the public.
From page 359...
... . WE ACT, a community example featured in Chapter 5, organized a coalition with 41 partners nationwide to address climate justice and health using the framework under Title VI of the 1964 Civil Rights Act (Environmental Justice Leadership Forum on Climate Change, 2016a,b)
From page 360...
... Congress passed the Medicare Act in 1965, which provided funding for medical services, as part of the War on Poverty. Medicare funding, coupled with the Title VI prohibition against discrimination by recipients of federal funding, resulted in improved outcomes in health equity and health outcomes for people of color and non-Hispanic white people.
From page 361...
... Using Civil Rights Law The following guidance can help civil rights attorneys, public health professionals, community groups, public agencies, recipients of public funding, foundations, and other stakeholders promote community-based solutions to promote health equity using civil rights tools and reinforce a culture of health (Rodriguez et al., 2014) : • Communities and other stakeholders can work together on com pliance and equity plans for programs or activities by recipients of public funding that use the civil rights framework by describ ing what is to be done, analyzing the impact on all communities, analyzing alternatives, including full and fair participation by diverse communities, and promoting health equity.
From page 362...
... Conclusion 6-2: The committee concludes that using civil rights approaches in devising and implementing community solutions to promote health equity can guard against unjustified and unnecessary discriminatory impacts, as well as against intentional discrimination in programs that affect health. For example, those implementing com munity solutions can employ methods and data in ways that include full and fair participation by diverse communities.
From page 363...
... Although communities individually may have little influence over state and federal policy change, they can leverage existing policies to their advantage. Thus, communities can actively promote health insurance enrollment activities and help increase the number of individuals with health insurance in their communities, leading to greater financial well-being.
From page 364...
... Nonetheless, federal reporting forms and instructions have caused some confusion related to community benefit, investments in improving the social determinants of health, and CHNAs. As health insurance coverage has expanded, the level of uncompensated care provided by hospitals has declined, leaving hospitals to consider other areas and ways to invest community benefit dollars.
From page 365...
... This work should include meaningful participation by members of low-income and minority populations in the community. In addition to leveraging federal tax provisions around community health benefit in order to improve the social determinants of health and health equity, work by the Institute for Healthcare Improvement has shown that hospitals effectively tackle health equity not only in the community but also within their own institutions (Wyatt et al., 2016)
From page 366...
... . At issue is that the pursuit of the Triple Aim could perpetuate and even worsen disparities unless the concept is expanded to incorporate a health equity focus.
From page 367...
... That committee has stated that reducing disparities in access, quality, and outcomes is one of four policy goals in accounting for social risk factors (NASEM, 2016a,b,c,e) , and its reports suggest that reforms to value-based payment programs that compensate providers fairly and increase fairness and accuracy in 35 Better care, better population health, and lower cost are often described as the Triple Aim (Berwick et al., 2008)
From page 368...
... These policies have long-term implications for education completion, employment, and income -- all of which in turn affect health. Because the justice-involved population is disproportionately people of color and disproportionately comprises other vulnerable populations such as persons with mental illness, criminal justice policies have important implications for health equity.
From page 369...
... . As a result, federal drug policies that sanction crack more than powder cocaine have exacerbated a widescale racial inequity that characterizes criminal justice sanctions for drug use and possession.
From page 370...
... . Since 2007, the Justice Reinvestment Initiative -- a public–private partnership that includes the DOJ Bureau of Justice Assistance -- has also supported efforts in 33 states, all of which "aim to improve public safety and control taxpayer costs by prioritizing prison space for serious and repeat offenders and investing some of the savings in alternatives to incarceration for low-level offenders that are effective at reducing recidivism" (The Pew Charitable Trusts, 2016)
From page 371...
... . Beyond the far-reaching effects of a criminal record, criminal justice policies can play a role in health equity by influencing the odds of victimization (e.g., through gun policies)
From page 372...
... CONCLUDING OBSERVATIONS Chapter 4 discussed the importance of communities and the fact that they not only are the locus for change, they also possess agency and can draw on their own power and assets to help effect change. However, as acknowledged in that chapter, it can be difficult for communities to promote health equity on their own.
From page 373...
... http://www.changelabsolutions.org/sites/default/files/ Preserving_Affordable_Housing-POLICY-TOOLKIT_FINAL_20150401.pdf (accessed October 24, 2016)
From page 374...
... 2015. Health insurance coverage: Early release of estimates from the National Health Interview Survey, January–March 2015.
From page 375...
... 2012a. Environmental justice policy guidance for Federal Transit Administration recipients (FTA c 4703.1)
From page 376...
... http:// www.iea.org/publications/freepublications/publication/capturing-the-multiple benefits-of-energy-efficiency.html (accessed October 20, 2016)
From page 377...
... 2015. Health insurance coverage of nonelderly 0-64.
From page 378...
... 2016. The earned income tax credit from the economics of means tested transfer programs in the United States, volume one.
From page 379...
... 2014b. San Gabriel mountains best practice environmental justice frame work for parks, health, and conservation values.
From page 380...
... 2016d. US EPA EJSCREEN park access and health disparities civil rights and environmental justice best practice.
From page 381...
... 2016. Achieving health equity: A guide for health care organizations.


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