Health / Nonprofit Sector

Reflections from NFF Staff on Health Equity

October 14, 2020

There’s been a lot of recent focus on defunding the police because of inherent, institutionalized racist practices. There is another structure whose funding flows must be examined: the healthcare system. Based on our experience working in healthcare over the past several years, NFF is adding its voice to those speaking out against racist practices in healthcare funding, with a focus on racism at the organizational level.

There is now widespread recognition that social determinants of health (SDOH) – access to healthy foods, strong mental health, viable transportation options, etc. – all contribute to our physical health, and can in fact help prevent health problems. Healthcare has increasingly focused on addressing SDOH to help reduce healthcare costs and improve patient outcomes. The genesis of our consulting work in healthcare was to facilitate working relationships between community-based organizations (CBOs), which have long addressed SDOH, and the healthcare system. Our aim was to increase access to resources – financial and otherwise – for CBOs so that they could deliver their vital piece in the continuum of care with healthcare institutions. However, after observing how healthcare systems perpetuate racist practices – such as centering the work of white-led organizations, prioritizing short-term profits over longer-term health outcomes, and expecting CBOs to conform to their way of doing things – we’re left questioning whether partnerships between CBOs and healthcare can offer a viable path forward to health equity. If CBOs don’t have equitable access to resources, then neither do the people they serve. 

Here are three observations from our work at the intersection of healthcare and CBOs.

1) Innovating in a racist system that is white-led means that white-led CBOs – or white-led networks of CBOs – get the most traction and funding to do the work.

Those with relationships already in place are the ones with the most access to resources. As one example, NFF’s Healthy Outcomes Initiative explored how partnership and integration between community-based human services organizations and health systems could propel large-scale improvements in the health of America’s communities. Over the course of this multi-year initiative, we observed how organizations that were white-led, well connected, and had the largest budget size made the most progress toward partnerships with health systems.   

We’ve learned from experience that the status quo reinforces racist practices. In another of NFF’s projects – Advancing Resilience and Community Health (ARCH) – we’re exploring what it takes for networks of CBOs to come together and partner with healthcare. One of the criteria for participating in this initiative was the presence of a strong relationship with a healthcare partner that was likely to result in a contract. After a nationwide call for participants, those networks that succeeded in the selection process were all led by white men. Granted, those networks are deeply rooted in their communities and supply critically needed services, but by using this criterion NFF perpetuated racist standards that underlie many of these partnerships. As part of our commitment to diversity, equity, and inclusion, we are changing our approach to work in the healthcare space to identify CBOs that are overlooked by the traditional funding system. 

2) The burden is on CBOs to figure out how to rename or contort their services to fall within the constructs used by healthcare systems to justify funding.

“There is a government program in Los Angeles designed to help organizations that are doing grassroots social services get better connected to government funding streams. One organization offers story circles where moms can come together to share stories and talk to strengthen resiliency. They were given guidance that if they renamed their story circles as ‘group therapy’ then they could better qualify for government funding. In other words, the organization would need to take the extra time to rename their services using systemic jargon in order for it to be considered clinically billable rather than being able to use words that describe the service in a way that's relatable and meaningful for participants.” Annie Chang, NFF’s Los Angeles office

One of the networks participating in ARCH has pivoted its work to focus on mobilizing a partnership between healthcare payors and a cohort of Federally Qualified Health Centers. Although the organization is deeply concerned about care delivered outside the walls of a clinic, the most viable path to partnership seems to be optimizing services already billable through Medicaid.

“The network members, as part of their missions, do significant amounts of outreach and engagement that support access to the healthcare system, but getting funding for these services from healthcare partners has not yet panned out. It’s the Medicaid billable services that appeal to healthcare partners rather than finding new ways to fund more upstream food, housing, or other services that address social determinants of health.” Deirdre Flynn, NFF’s New York office

Much of our work at NFF has focused on helping prepare CBOs or networks of CBOs for contracts with healthcare partners, but if those contracts are primarily landing with white-led organizations that are already more financially resourced, or if those contracts focus on short-terms savings to the health system rather than long-term improvements in community health, contracts will continue to perpetuate an inequitable distribution of wealth in the nonprofit sector among CBOs and the communities they serve.  Building on the success of any partnership and using the savings to re-invest in the community is a critical part of creating health equity. Partnerships need to be approached as a catalyst for building a better system where health and wealth is created in tandem, step by step, rather than financial savings as an end in and of itself.

3) Progress toward health equity will be driven by efforts that center racial equity and organizations led by and serving people of color.

We are in the early stages of a place-based project with HealthierHere to strengthen the financial capacity of community-based and tribal organizations that are part of a multi-sector coalition working to improve health outcomes and reduce health disparities in King County, WA. Partners are collaborating on several strategies, including testing innovations to strengthen linkages in clinical and community care and the development of a community information exchange to address the critical need for a shared data system for service providers.  

“We can learn a lot because we are coming into an ecosystem where this coalition of organizations is really centering equity. They’re governed by a 27-member board comprised of leaders from a range of sectors, and which intentionally includes community members and tribal representatives.” Alex Chan, NFF’s Oakland office

With the ARCH project, some of the most direct progress toward better health outcomes has had nothing to do with partnerships between CBO networks and healthcare, but rather deep engagement with other CBOs and local stakeholders.

“The healthcare system is what we orient around and is where all of the dollars go. But there are other community-led systems out there that are better at meeting people’s needs.  One of our clients responded to the COVID crisis by working with its network partners to find temporary shelter for people experiencing homelessness and at risk when ‘anchor’ institutions failed to step up. It seems to me like the anchor in this community is those CBOs that rolled their sleeves up and responded with innovation and dignity to provide critical services to those in need.” Deirdre Flynn, NFF’s New York office

As we approach our own work at the intersection of social determinants of health and healthcare, there’s a tension between managing as best as possible within existing systems versus helping to create new systems that can do a better job achieving health equity. We are working to do both, to improve existing systems while also building knowledge and expertise so that we can contribute to reimagined ways of delivering healthcare. We are also reassessing our own work to identify and root out racist practices. 

To ensure that we are helping to advance racial equity, rather than contributing to inequity, here are some questions we are now asking ourselves when we get involved in new work:

  • Is racial equity a primary goal in how the project is designed?  How do we know and how will we hold ourselves accountable? 
  • Are we trying to fix something that’s broken, or build something new? 
  • Who does the work benefit, and who might it harm?  
  • Who have we engaged to inform our work and approach?  
  • Whose needs are we meeting? Those of large healthcare systems, those of community-based organizations, or those of the community members whose health is most at stake?  

There is great potential in partnerships between healthcare institutions and community-based organizations that could translate into better health outcomes and stronger bottom lines for everyone involved. But it's no longer enough to invite CBOs and the communities they represent to the table where healthcare still holds all the cards. There needs to be a shift toward equitable decision-making among healthcare institutions and those who are most closely connected to the needs of their communities, especially in communities that have been experiencing disparate health outcomes for generations. We will make this a priority in our work going forward, and hope to see others doing so as well. 

Click here to learn more about our commitment to advancing equity – both in how we work and the work we do.