Fostering Healthy Neighborhoods

RESEARCH BRIEF Alignment across the community development, health and financial well-being sectors.

A PROJECT AND REPORT LED BY Build Healthy Places Network Prosperity Now Financial Health Network

Table of Contents

3 Overview 7 Key Findings 13 Conclusion 14 Appendix A – Examples of Existing Work 18 Appendix B – Public Health and Healthcare Sectors Overview 24 Appendix C – Community Development Sector Overview 27 Appendix D – Financial Well-being Sector Overview 30 Appendix E – Interviews 30 Appendix F – Focus Groups 32 Appendix G – List of Resources

Support for this report was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.

Research and writing contributor Paul DeManche 2 FOSTERING HEALTHY NEIGHBORHOODS | 3

Overview

Substantial evidence links financial well-being and health. As income and wealth increase or decrease, so does health. Individuals and families with more wealth and higher incomes are better able to access the material and physical conditions that facilitate good health and are less likely to suffer from the mental and physical effects of financial stress caused by income volatility, insufficient savings, and unmanageable debt.

The physical, social, and economic conditions FIGURE 1. FRAMEWORK FOR in our neighborhoods have a significant impact NEIGHBORHOODS THAT SUPPORT on both our health and financial well-being HEALTH AND FINANCIAL because they shape the opportunities we have WELLBEING and the choices that are available to us. To define a neighborhood that supports health and financial well-being(see Figure 1), which we call a Healthy Neighborhood, we Stable, affordable, Quality community adapted a definition used by the New York and safe housing institutions City Office of Financial Empowerment’s Collaborative for Neighborhood Financial Health1 to include the following characteristics that are available to all residents: Affordable, high A safe and quality goods supportive built and services environment » Stable, affordable, and safe housing

» Quality community institutions

» A safe and supportive built environment Neighborhood that High quality public supports health and Social capital, » Social capital, networks, and support education financial wellbeing networks, and support » Opportunities to build assets

» Quality jobs and income supports Affordable, high » Affordable, high-quality financial services quality financial Opportunities that meet the needs of residents services that to build assets meet the needs » Affordable, high-quality goods and of residents services, including healthcare Quality jobs and » High-quality public education. income supports

These conditions have a profound impact on how long and how well residents live— and on the future health and well-being of their children. For instance, research

1 How Neighborhoods Help New Yorkers Get Ahead: Findings from the Collaborative for Neighborhood Financial Health. (2017). New York, NY: New York City Department of Consumer Affairs. https://www1.nyc.gov/assets/dca/downloads/pdf/partners/Report-HowNeighborhoodsHelpNYersGetAhead.pdf (accessed August 2019). 4

shows that children living in high-poverty, FIGURE 2. STAKEHOLDER MAP under-resourced neighborhoods have lower test scores and lower earnings COMMUNITY FINANCIAL in adulthood.2 HEALTH DEVELOPMENT WELLBEING Low-income communities and communities of color have historically County and State Community Depository Financial and systematically been excluded from Health & Human Development Institutions—Banks accessing these kinds of amenities and Services Agencies Corporations and Credit Unions opportunities (“access” being determined Integrated Community Municipal/State both by proximity and a range of factors Delivery Systems Development Offices of Financial Financial Institutions Empowerment that either inhibit or allow them to benefit Hospitals from that proximity). The result is that, Community Based Non-profit service when it comes to health outcomes, low- Pharmacies Organizations providers income people and people of color are less Managed Care Public Housing Long-term Asset well off. Therefore, creating the conditions Organizations Agencies Management that foster healthy neighborhoods as Community defined above is necessary to ensure that Municipal Community Insurance for non- Health Centers Development Agencies health purposes all people can thrive. Public Health Investor/Finance Tax Preparation Departments Services To create these conditions (i.e., to foster Affordable Housing healthy neighborhoods) the community Developers (Nonprofit Financial Technology development, public health, healthcare, and for profit) Legal Services and financial well-being sectors (see Providers Figure 2) must better align their work (see the appendix for descriptions of Insurance each sector). These sectors have been Lenders working to address different components of healthy neighborhoods in the same Employers places and often with the same people for decades, yet often without joining forces and leveraging each other’s efforts. By aligning their work, these sectors can more effectively build neighborhoods that support health and financial well-being. HEALTHY COMMUNITIES

*Many entities work in more than one sector. For instance, Community Development Corporations integrate financial capability and asset building work into neighborhood revitalization efforts.

2 Chetty, R. and Hendren, N. (2017). The Impacts of Neighborhoods on Intergenerational Mobility I: Childhood Exposure Effects. Cambridge, MA: National Bureau of Economic Research. https://www.nber.org/papers/w23001.pdf (accessed August 2019). FOSTERING HEALTHY NEIGHBORHOODS | 5

The financial well-being sector, through policies, programs, and services that help people plan, save, borrow, spend, earn, own, and protect their financial resources, helps to build wealth for low-income individuals and households (see Figure 3). In collaboration with community development, public health, and healthcare, these interventions can improve neighborhood conditions by increasing access for low-income communities and communities of color to affordable housing, asset-building opportunities, income supports, and high-quality financial services.

FIGURE 3. CATEGORIES OF FINANCIAL WELLBEING POLICY AND PRACTICE

PLAN SPEND Î Have appropriate insurance Î Spend less than income Î Plan ahead for expenses Î Pay bills on time and in full

BORROW OWN Î Have a sustainable debt load Î Own a home, business, investment and/or other assets that build wealth. Î Have a prime credit score Î Have affordable financing, incentives and supports to purchase and maintain assets. EARN Î Have quality jobs and access to public benefits PROTECT and tax credits. Î Have insurance to protect income or asset loss. Î Have affordable and reliable transportation, child care, and other supports to be able to work. Î Have consumer protections that safeguard against discriminatory and predatory practices.

SAVE Î Have sufficient liquid savings Î Have sufficient long-term savings

With support from the Robert Wood Johnson Foundation, the Build Healthy Places Network (a program of the Public Health Institute), Prosperity Now, and the Financial Health Network partnered to explore how to foster alignment across the community development, public health, healthcare, and financial well-being sectors. This brief presents key findings and recommendations from our research. 6 FOSTERING HEALTHY NEIGHBORHOODS | 7

Key Findings

We conducted focus groups, interviews, and an exhaustive scan of the published and online resources and materials at the intersection of this work (see the appendix for a list of resources, interviews, and focus groups).

Our Research Identified: (see below) to facilitate access for their (see Alliance for Health Equity and Get patients to a wide range of services Healthy San Mateo County examples in Examples of existing alignment across and programs that can improve health the appendix). the sectors. There are bright spots where and financial well-being (see DotHouse community development, public health, Health example in the appendix). Municipal agencies are integrating financial healthcare, and financial well-being work coaching and savings programs into their has aligned in ways that can build healthy services to improve access to affordable neighborhoods. A Community Quarterback is housing (see Ready to Rent and Cities for an entity that coordinates local Financial Empowerment Fund examples Opportunities for increased collaboration interventions by articulating a in the appendix). and integration. While alignment is unifying vision and then marshalling occurring, it is still underdeveloped. the financial resources and managing Public housing authorities are Our research identified five priority a diverse coalition of partners to partnering with financial well-being opportunities to increase alignment. achieve that vision. A community organizations to provide savings and asset-building services to their residents Challenges to integration across sectors. quarterback­ may function as an organizer and navigator toward and in the neighborhoods in which Even when there is acknowledgment they operate (see Tacoma Housing of connected aims and a desire to the shared goal of a cross-sector initiative in many ways, which Authority and Compass Working collaborate, building effective collaboration Capital examples in the appendix). is complex. Our research highlights four could include articulating the goal primary challenges to effective alignment. itself, estab­lishing shared metrics, bringing together knowledgeable Opportunities for Ways to foster alignment. There are allies and financial resources, and key supports, systems changes, and facilitating the work of an initiatives Increased Collaboration institutions that would help to foster many community partners. In and Integration alignment across these sectors this model, the quarterback knits together the diverse abilities of The intersection of the sectors is formerly­ siloed sectors, creating nascent and there are opportunities Examples of Existing a powerful integrated initiative. for increasing alignment.

Alignment Across Sectors Expand and replicate cross-sector We found several examples where work Community Development Corporations partnerships that build healthy across the sectors is already aligned to and Community-Based Organizations neighborhoods. As the examples above build healthy neighborhoods. are using financial capability and asset- highlight, there are bright spots, yet building strategies as part of their work this work is still not widely practiced. Healthcare systems, acting in their to revitalize low-income neighborhoods Successful models of cross-sector capacity as anchor institutions, are through economic development, workforce alignment with demonstrated impact investing in comprehensive community development, and affordable housing on neighborhood conditions can and development efforts that address various strategies (see Stronger Together should be expanded and replicated in social determinants of health within low- Partnership example in the appendix). more places. We provide suggestions, income neighborhoods, including access below, for what supports and systems to employment, income supports, savings, Public health departments, in collaboration changes are needed to achieve this. housing, and healthy food (see LISC- with community organizations and other ProMedica example in the appendix). public sector agencies, are advocating Better connect effective cross-sector for policies that address financial and work at the individual- or family-level Federally Qualified Health Centers health inequities by improving economic to neighborhood revitalization efforts. (FQHCs) in low-income neighborhoods opportunities and access to affordable The research uncovered examples of are acting as community quarterbacks housing in low-income neighborhoods cross-sector alignment that impact the 8

individuals and families they touch, but do not directly address neighborhood conditions per se. Examples include financial well-being organizations that are providing tax preparation assistance at pediatricians’ offices to help families with children boost their incomes (see StreetCred example in the appendix); government agencies that have layered financial education and coaching onto their services and programs (see $tand By Me example in the appendix); and banks and credit unions partnering with healthcare organizations to provide safe and low-cost financial products to patients and clients (see Allegacy Federal Credit Union/Wake Forest Baptist Health and CareSource/ Fifth Third Bank examples in the appendix). These types of interventions can be expanded, replicated, and integrated into neighborhood revitalization work, digital divide—is a challenge, and at least community development and public health for example, by targeting the expansion initially, engaging technological solutions organizations focus on neighborhood- of low-cost financial products to banking must be done in conjunction with high- level change, while healthcare and deserts through partnerships with local touch approaches able to engender trust financial well-being organizations focus community development corporations. and ensure technology doesn’t exacerbate on individual-level change, making aligned existing inequities. outcomes difficult to articulate, work Expand and replicate efforts to build toward, and measure. neighborhood wealth. Community land Create a shared policy agenda. trusts and worker-owned cooperatives A number of policy issues have cross- Different goals and incentives. Actors offer wealth-building opportunities for sector implications. For example: wages within and across the sectors have 3 low-income communities. In Cleveland, and benefits; short-term and long- different goals and their work is shaped by Ohio, the Evergreen Cooperative term savings; affordable housing and different incentives. For example, public Initiative leverages hospital procurement homeownership; community development health organizations use their expertise dollars to start and grow worker-owned incentives; healthcare; government and experience primarily to focus on cooperative enterprises as a way to program and court fines and fees; and improving population health (e.g., reducing increase employment and wealth-building consumer protections, among others. In rates of diabetes), whereas financial opportunities in the neighborhoods each sector, there are policy collaboratives well-being organizations primarily focus 4 it serves. In Richmond, Virginia, Bon operating at local, state, and national on improving financial well-being (e.g., Secours Health System and Virginia levels (for example, the Alliance for increasing credit scores). While improved Credit Union have each made financial Health Equity, which is described in the financial well-being can lead to improved contributions to the Maggie Walker appendix). Expanding these collaboratives health, it can be challenging to get Community Land Trust (MWCLT), which strategically to include stakeholders from individuals and organizations to establish is creating permanently affordable all sectors and to work toward cross- and work towards goals that are outside homeownership housing in a rapidly their areas of expertise, even if they are 5 sector policy goals can enhance alignment. gentrifying neighborhood in Richmond. serving the same population.

Expand cross-sector integration with Challenges to Integration Data collection and measurement. Tools for technology. The integration of community Across Sectors collecting and sharing data and measuring development, public health, healthcare, the impact of cross-sector work are and financial well-being work can In order to advance cross-sector lacking. Each sector collects its own data benefit from new technological systems alignment, there are a few major using different tools and at varying levels and tools that make referrals, client challenges that need to be addressed. of sophistication. One challenge is the tracking and outcome reporting across time, money, and expertise needed to partners and programs more efficient and Different terminology and units of design and implement systems to measure seamless. However, deploying technology focus. When it comes to defining the influence of cross-sector work on effectively requires a deep understanding outcomes and impact, organizations residents’ health and financial well-being. of the risks and challenges faced by with different terminology and units of Another challenge is the sensitivity and underserved populations. Disparities focus (i.e., neighborhood vs. individual) privacy requirements associated with in technology access—the so-called can struggle to align. For example, health information. For good reason,

3 Holmes, T. E. (2016, October 21). In the World of Community Wealth-Building, Ownership Has Its Privileges. Shelterforce. https://shelterforce.org/2016/10/21/in-the-world-of- community-wealth-building-ownership-has-its-privileges/ (accessed August 2019). 4 Wright, W., Hexter, K., and Downer, N. (2016). Cleveland’s Greater University Circle Initiative: An Anchor-Based Strategy for Change. Washington, D.C.: The Democracy Collaborative. https://democracycollaborative.org/sites/clone.community-wealth.org/files/downloads/ClevelandGreaterUniversityCircle-web.pdf (accessed August 2019). 5 Green, J., and Hanna, T. M. (2018). Community Control of Land and Housing. Washington, D.C.: The Democracy Collaborative. https://democracycollaborative.org/community-control- of-land-and-housing (accessed August 2019). FOSTERING HEALTHY NEIGHBORHOODS | 9

privacy laws inhibit data sharing between Establish more funding and financing neighborhood-level social and economic healthcare providers and non-healthcare streams for cross-sector work focused issues is needed—both to build a organizations. However, these rules on building healthy neighborhoods. As common understanding of the challenges prevent community development and mentioned, cross-sector work may communities face and to establish a financial well-being organizations from take a long time to show measurable baseline against which program and policy accessing data they could use to develop impact. Flexible and patient funding impact can be measured across sectors. policies and programs, and measure and financing that is invested in cross- outcomes. These barriers limit the ability sector collaboratives, rather than System Changes of organizations to work together to design individual organizations or agencies, Align incentives across the sectors through and deliver the investments, programs, can facilitate new innovations, scaling policy changes. In the same way that the and services that would be most beneficial of what works, and further testing of ACA has shifted healthcare incentives in the neighborhoods with the most need. promising efforts. These funding and toward social determinants of health, financing streams can and should include thereby opening new opportunities Mismatched timing and funding horizons. grants, loans, and equity investments. for collaboration with the community The impact of cross-sector work can The Healthy Futures Fund, created by development sector, policy changes in take years—even decades—to become LISC, Morgan Stanley, and The Kresge other areas could similarly facilitate measurable. These long timeframes Foundation, is one example of the kind greater alignment across sectors. are often at odds with funder/investor of tool that can serve as a model.6 For example, eliminating asset limits expectations and needs. For example, from public benefit programs would private health insurance companies, Create data collection and measurement remove disincentives to increasing investors, and affordable housing tools that can capture the impact of savings among program beneficiaries developers focus on innovation efforts cross-sector work on neighborhood and increase opportunities for cross- that demonstrate short-term cost saving conditions. More and better data on sector collaboration between the outcomes and impact (e.g., interventions with homeless populations and seniors). Yet research shows that reducing childhood poverty would have the greatest impact over the long term, even though that impact takes a generation to realize. Ways to Foster Alignment In order to take advantage of the opportunities for, and address the challenges to effective cross-sector alignment, our research identified supports and system changes that are needed, and key institutions through which alignment can be advanced.

Supports Build relationships, knowledge, and shared outcomes across the sectors. Broadly speaking, leaders across these sectors do not know about each other or the goals they share. One of the first steps to fostering greater alignment is to build knowledge and relationships across sectors. Build relationships through convenings and fellowship opportunities for current and future leaders in each sector. Build shared knowledge through trainings and curating and disseminating the existing evidence base that highlights shared aims, outlines the “business case” for alignment and collaboration, and promotes successful models. Build shared outcomes by sharing local data on key metrics related to social determinants of health with community- based organizations and other local stakeholders in order to standardize what metrics are being tracked.

6 “Healthy Futures Fund,” LISC, accessed September 2019, http://www.healthyfuturesfund.org/. 10

community development organizations Anchor Network,9 have made important how funds, initiatives, and other resources that help families access benefits and strides towards embracing an anchor stemming from their CRA obligations can the financial well-being providers mission through hiring, procurement, and be put towards supporting cross-sector who help families build savings. More investment policies and practices with a initiatives focused on building healthy research is needed to understand where focus on low-income neighborhoods. neighborhoods. Additionally, the three policy changes could align incentives agencies that administer the CRA—the within and across the three sectors. Trusted community-based organizations. A Federal Reserve, the Federal Deposit trusted community organization can bring Insurance Corporation (FDIC), and the Explore ways to facilitate data sharing together groups that do not have a history Office of the Comptroller of the Currency across sectors to inform neighborhood of working closely together. The community (OCC)—can administer and enforce the law revitalization. Given the challenges quarterback model (see sidebar, page 7) in ways that provide the flexibility banks mentioned, further strides toward has demonstrated success aligning work need to be more innovative in supporting data sharing across the sectors, while across sectors. Attention to advancing cross-sector initiatives and provide protecting individuals’ privacy, is equity and addressing structural barriers clarity to banks that these investments needed in order for practitioners and to racial and health inequities is key. are qualified CRA investments. researchers to evaluate the impact of cross-sector interventions on health Financial institutions and Community and financial well-being and inform Reinvestment Act (CRA) regulators. how and where to focus neighborhood The CRA is a powerful tool for interventions and improvement efforts. directing investment into low-income neighborhoods. While much depends on Key Institutions for Advancing whether CRA modernization occurs and Cross-Sector Alignment what changes it brings, banks can explore Credit unions. Credit unions’ success is correlated with—and therefore they are incentivized to support—the health and well-being of their members. They provide access to services in low-income communities and banking deserts and can forge partnerships with health organizations to deliver programs and services in low-income neighborhoods. For example, Allegacy Federal Credit Union’s partnership with Wake Forest Baptist Health to create WellQ™7, which is described in the appendix.

Employers. Employers rely on a financially healthy workforce.8 Research shows that financial stress can reduce productivity, increase absences and healthcare claims, and lead to higher turnover. Employers have important levers such as living wages, availability of benefits to contractors and part time staff, and healthy working environments to improve employee financial well-being.

Anchor institutions. Anchor institutions (such as universities, hospitals, and community-based organizations) are well positioned—often as large employers, purchasers, and landowners in communities—to serve as catalysts for cross-sector alignment by initiating new partnerships in the places where they are situated and by helping to scale up promising collaborations. Healthcare organizations, for example, including those that are part of the Healthcare

7 “Welcome to WellQ™,” wellQ, accessed September 2019, https://yourwellq.com/. 8 Kohli, S. and Levy, R. (May 2017) Employee Financial Health: How Companies Can Invest in Workplace Wellness. Center for Financial Services Innovation. https://s3.amazonaws.com/ cfsi-innovation-files/wp-content/uploads/2017/05/26183930/2017-Employee-FinHealth.pdf (accessed August 2019). 9 About the Healthcare Anchor Network,” Healthcare Anchor Network, accessed August 2019, https://www.healthcareanchor.network/about.html. HEALTH AND WEALTH | 11 12 FOSTERING HEALTHY NEIGHBORHOODS | 13

Conclusion

Existing bright spots—like the LISC-ProMedica example— illuminate approaches for cross-sector collaboration that do create conditions for healthy communities. However, such examples are few and nascent, and the financial well-being sector is still largely isolated from the health sector despite the clear health value of its work. There is work yet to be done to build understanding across sectors, articulate common aims, and address the barriers to collaboration. This brief highlights findings salient to the financial well-being sector, yet applicable across the community development, healthcare, and public health sectors as well. Particularly, the framework for a healthy community as defined can provide a foundation for collaborative efforts. 14

APPENDIX A Examples of Existing Work

Examples of alignment Compass Working Capital and partnering with other neighborhood In Boston, MA, Compass Working Capital, organizations to provide additional across community a nonprofit financial services organization, resources. Recognizing that factors such development, public partners with public housing agencies and as housing, finances, and legal issues multifamily property owners to improve have an impact on health, they screen health, healthcare, and or launch the HUD Family Self-Sufficiency patients to identify these needs as a part financial well-being (FSS) program. The Compass model for of the intake process. Case managers the FSS program supports residents to then develop a care plan for patients, that directly impact build assets and financial know-how which can include financial coaching, by combining one-on-one financial enrollment in federal and state benefits, neighborhood conditions: coaching that supports and encourages connection to housing programs, and participants to increase their earnings free legal and tax preparation assistance. Alliance for Health Equity and achieve other individually identified In addition, DotHouse Health provides In Chicago and Cook County, IL, the financial goals, with the program’s escrow on-site access to WIC, a food pantry, a Illinois Public Health Institute, hospitals, account that captures, and saves for the youth center, senior services, a swimming 12 health departments, and community residents, any rent increase that result pool, a gym, and a farmer’s market. organizations have come together to from increased earnings. Graduates form the Alliance for Health Equity, of the Compass program typically use Get Healthy San Mateo County one of the largest hospital-community the savings from their escrow accounts In San Mateo County, CA, community- partnerships in the U.S. The goal of the to pursue an education, buy a vehicle, based organizations, county agencies, alliance is to develop and implement purchase a home, pay down debt, open cities, schools, and hospitals are working collective strategies for improving secured credit cards, or establish together to advance policy changes community health and advancing health emergency savings. Outcomes of the that will build healthy and equitable equity in the region. Alliance members partnership include increased earnings, communities. This collaborative effort, work together to conduct tri-annual increased credit scores, and reduced debt called Get Healthy San Mateo County Community Health Needs Assessments in collections for participants. Expansion, (GHSMC), is facilitated by the county (CHNAs), which help set shared priorities or replication, of the Compass FSS model health department, San Mateo County for partners to work towards; to track can be challenging for housing authorities Health. In their current five-year strategic relevant legislation and coordinate policy that lack financial capability expertise on plan, GHSMC has identified housing, advocacy activities; to build their capacity staff. Therefore, two major ingredients are neighborhoods, schools, and the economy through training and peer learning; and to generally needed: (1) housing authorities as key priority areas. Healthy Economy advance housing/health partnerships.10 who are willing and able to complete objectives include ensuring that people required HUD paperwork and manage have the ability to increase household Cities for Financial Empowerment Fund escrow accounts, and (2) a Financial Well- income and build financial security, and The Cities for Financial Empowerment being service provider to provide financial have access to high-quality education Fund (CFE Fund) provides funding and education, and coaching or counseling. and well-paying job opportunities. The technical assistance to mayors across opportunities for action towards these the U.S. to help them embed financial DotHouse Health objectives include supporting efforts to empowerment into city services in order to In the Dorchester neighborhood of advance living and/or minimum wage improve their effectiveness. For example, Boston, MA, DotHouse Health, a policies and increasing access to fair and in Lansing, MI, financial counseling was federally qualified health center (FQHC), affordable financial services for low-income integrated into a prisoner reentry program, provides comprehensive health and families and people of color. GHSMC works which improved client financial outcomes wellness services to the community. to achieve their objectives by developing as well as reduced the amount of time it DotHouse Health serves as a Community evidence-based policy tools, engaging in took clients to move from transitional to Quarterback (see sidebar, page 7) by city and community planning processes, permanent housing.11 To date, the CFE Fund connecting people to a range of financial providing funding opportunities for place- has worked with approximately 80 cities. capability, housing, and legal services, based health equity efforts, creating

10 “Purpose, Vision, Values,” Alliance for Health Equity, accessed August 2019, https://allhealthequity.org/purpose-vision-values/. 11 CFE Coalition City Expert Topics: Reentry Integration Strategies. (2018). Cities for Financial Empowerment Fund. http://cfefund.org/wp-content/uploads/2018/10/CFE_Reentry_ Integration_Strategies-10181_KB.pdf (accessed August 2019). 12 “Social Services Case Management,” DotHouse Health, accessed August 2019, http://www.dothousehealth.org/services/case_management.html FOSTERING HEALTHY NEIGHBORHOODS | 15

toolkits and publications to disseminate Financial Opportunity Center (FOC) eligibility requirements) are key financial research and best practices, building the provides coaching/counseling to support barriers preventing eligibility for affordable capacity of local organizations through the financial health of clients. Additionally, housing.” The program provides financial technical assistance, and conducting it is co-located with ProMedica’s not-for- counseling assistance to families and public education and engagement.13 profit grocery store—which enables job helps them apply for affordable housing training opportunities and access to fresh through HPD’s Housing Connect website. LISC-ProMedica food—with over 65,000 customer visits in During the pilot phase in 2015, there were In the UpTown neighborhood of Toledo, year one. The initiative has brought 120 325 program participants and a total of OH, ProMedica, an integrated health new jobs to the neighborhood and has 141 positive financial outcomes achieved, system, and Local Initiatives Support increased incomes, credit scores, and which included increasing or establishing Corporation (LISC), a national CDFI, are wealth. Results among those who have credit scores, reducing debt, increasing partnering to improve health outcomes received financial counseling include: 27% savings, and accessing affordable checking by increasing neighborhood resident realized an increase in net income; 17% and savings accounts. Since the launch of access to employment opportunities, improved credit scores by an average of 39 Ready to Rent in 2017, the program has affordable and healthy food, medical care, points; and 18% increased their overall net served over 500 clients, most of whom income supports, and savings. In 2017, worth.14 Additionally, ProMedica reports make less than $20,000 per year.15 ProMedica made a 10-year, $50-million that the initiative is beginning to yield commitment to create a new place-based, promising results on health utilization Stronger Together Partnership health-focused community development and cost. The Fifth Avenue Committee, Inc. (FAC) model in the neighborhood. This initiative, is a community development corporation called the ProMedica Ebeid Neighborhood Ready to Rent working in South Brooklyn, NY. FAC’s Promise, was created to improve health In New York City, the Department of comprehensive community development and well-being by addressing the social Housing Preservation and Development strategy includes building and preserving determinants of health in the UpTown (HPD), the Department of Consumer affordable housing; providing job neighborhood, where more than half of Affairs (DCA) Office of Financial training, placement, and counseling residents live in poverty and 30 percent Empowerment (OFE), and Ariva, a services; providing adult education and are unemployed. Through the initiative Bronx-based financial well-being literacy classes; grassroots community and in collaboration with community provider, created Ready to Rent: Financial organizing and policy advocacy; and partners, UpTown residents have access Counseling for Affordable Housing, in offering benefits access assistance and to job-training opportunities, a healthy and response to a study by the DCA that found financial and legal counseling services. affordable grocery store, a health clinic, “poor credit, a lack of savings and difficulty The Stronger Together Partnership is support from community health workers, navigating affordable housing applications a collaboration between FAC, Brooklyn and a financial opportunity center. In (including the complexity of accurately Workforce Innovations, Red Hook partnership with LISC, the ProMedica calculating household income to meet Initiative, and Southwest Brooklyn

13 Strategies for Building Healthy, Equitable Communities. Get Healthy San Mateo County 2015-2020. (2015). Health Policy and Planning Division, San Mateo County Health System. https:// www.gethealthysmc.org/sites/main/files/file-attachments/get_healthy_smc_strategic_plan_2015-2020_final.pdf?1485905434 (accessed August 2019). 14 Results from July 1, 2017 from program inception to June 30, 2019. (Source: ProMedica, email to authors, July 11, 2019) 15 Salas, L. “Financial Counseling Helping New Yorkers Unlock Affordable Housing.” Prosperity Now (blog). May 7, 2018. https://prosperitynow.org/blog/financial-counseling-helping- new-yorkers-unlock-affordable-housing (accessed August 2019). 16

Industrial Development Corporation sector-based job training programs. The of having shared goals that the CSA to improve education and employment initial results of the program indicate program reinforced.18 THA anticipates outcomes for public housing residents that for just $144 per participant, the the program will, in the short-term, help living in poverty in the Red Hook and remedial training program can raise the improve students’ academic performance Gowanus neighborhoods, many of potential lifetime earnings of a person who and behavior, connect families to whom are unemployed and do not have enters the program without a high school mainstream banking services, build a high school diploma. The partners diploma by approximately $340,000.1617 savings for students. In the long-term, share intake, referral, and data tracking THA hopes the program will improve high systems to help residents access job Tacoma Housing Authority school graduation rates, enrollment in training, adult education, college access, In Tacoma, WA, the Tacoma Housing postsecondary education, and completion financial literacy, income supports, and Authority (THA) administers a Children’s of degree or certification programs. job placement services. As part of the Savings Account program for elementary, effort, FAC implemented a central data middle, and high school students who live hub where program data from all four in the Salishan neighborhood and attend a Examples of alignment Stronger Together partner organizations Tacoma Public School. THA partners with across community is uploaded, which has streamlined the the local school district and homeowners’ referral process and allowed staff to spend associations to recruit participants; a local development, public more time serving clients. Over its first bank to provide funding and accounts for health, healthcare, and three and a half years, the partnership students; and two organizations to provide helped 289 residents secure employment. financial education for adults and the financial well-being Additionally, the partnership piloted a students in the program. In an interim remedial education program to help evaluation of the program, conducted by that directly impact residents gain the skills needed to qualify the Urban Institute, program partners individuals and families, for Brooklyn Workforce Innovations’ highlighted the importance and value but do not directly impact neighborhood conditions:

CareSource and Fifth Third Bank CareSource, one of the largest Medicaid managed care plans, has established a partnership with Fifth Third Bank to facilitate access to safe and affordable financial services for its members. CareSource members are eligible for Fifth Third Express Banking, which has no monthly service charge, minimum balance, or overdraft fees. The partnership fits with CareSource’s mission to improve its members’ health and well-being, as they acknowledge that “financial health is an important part of well-being.”19

$tand By Me $tand By Me ($BM) is a statewide program in Delaware that offers one-on-one financial coaching and free VITA tax preparation through partnerships with employers, social service systems, and housing, education, and healthcare providers. The $BM model integrates financial well-being services into existing programs in order to improve outcomes across the areas those programs focus on, such as education and housing. The $BM program works with a number of partners: the Department of Social Services to embed financial coaching into TANF,

16 Smart Organizations, Strong Neighborhoods: Measurable, Scalable Impact. (n.d.). New York, NY: Change Capital Fund. https://changecapitalfund.org/wp-content/uploads/2015/09/ CCF_Report_FIN_031918.pdf (accessed August 2019). 17 “Fifth Avenue Committee,” Change Capital Fund, accessed August 2019, https://changecapitalfund.org/grantee/fifth-avenue-committee/ 19 “Fifth Third Express Banking®,” Fifth Third Bank, accessed August 2019, https://www.53.com/content/fifth-third/en/mkg/lp-express-banking.html. 18 Galvez, M., Gilbert, B., Oneto, A., and DuBois, N. (2017). Tacoma Housing Authority’s Children’s Savings Account Program Evaluation Interim Report. Urban Institute for the Tacoma Housing Authority. https://www.tacomahousing.net/sites/default/files/ui_deliverable_tha_csa_interim_report_final_november_2017.pdf (accessed August 2019) FOSTERING HEALTHY NEIGHBORHOODS | 17

SNAP, and other public benefits programs; StreetCred WellQ - Allegacy Federal Credit Union the Department of Housing to build a In Boston, MA, a coalition of nonprofits, and Wake Forest Baptist Health pipeline of financially ready homebuyers; businesses, and community organizations In 2018, Allegacy Federal Credit the Department of Transportation to help is working with the region’s largest safety- Union and Wake Forest Baptist Health build the financial capacity of disadvantaged net hospital to help families increase their created WellQ™, a credit union service business enterprises and minority-owned earnings and improve their children’s health organization (CUSO). WellQ provides businesses; the Department of Education outcomes by accessing the Earned Income members (individuals or families who to help increase the number of high-school Tax Credit (EITC) and public benefits. Boston join for an annual fee) with access to a students attending college; Head Start Medical Center created a new organization, bundle of health and financial services, and other childcare centers to provide StreetCred, in partnership with the Boston including a clinic, pharmacy, physical and financial coaching to staff and families; and Tax Help Coalition, to address the root financial wellness classes, and financial Christiana Care, one of the largest hospital causes of poor child health outcomes by products. One of the financial products, providers in Delaware, to provide financial increasing access to the EITC. StreetCred the AllHealth Wellness Savings account, coaching to all employees of the hospital. began its work with families waiting to see rewards members for physical fitness or Since 2011, $BM has helped more than a pediatrician by helping them prepare volunteer activities. The account offers 110,000 Delawareans—more than 5% of their taxes. StreetCred chose pediatrician higher interest rates based on how often the population. The program has improved offices for their quality as both a trusted members either exercise or volunteer at and convenient space for families. From credit scores on average by 64 points, helped the YMCA of Northwest North Carolina or 2016 to 2019, StreetCred has returned individuals save more than $3.3 million, the UNC Greensboro Leonard J. Kaplan over $5.3 million to about 2700 families. and reduced personal debt by $19.6 million. Center for Wellness. The purpose of (Source: StreetCred, interview with authors) Additionally, $BM has seen improvements WellQ™ is to “bridge the gap between StreetCred has since expanded to other in children’s educational outcomes— physical and financial health and to offer health services locations in eight states children in Head Start whose parents consumers co-located health and financial received $BM services outperformed their and plans to add additional services to help families establish savings accounts, advisors to facilitate information sharing, peers. (Source: Mary Dupont, interview collaboration and improved outcomes.”20 with authors, December 3, 2018) have paid employment opportunities, and engage in financial coaching.

20 Hyland, C. G., and Revere, C. J. (2018). Health and Financial Well-being: Two Good Things that Go Better Together, The Case for Credit Union and Health Care Collaboration (p. 16). The National Credit Union Foundation. https://www.ncuf.coop/media.acux/e9aea8e4-5e41-4671-b802-721073609884 (accessed August 2019). 18

APPENDIX B disease centered around “germ theory” that preventing illness and premature (individual-level risk factors and behaviors); death requires going beyond focusing on back to a more holistic understanding of single risk factors or health conditions Public Health prevention and socioeconomic influences and understanding social determinants on health. In the late 80s and 90s, several of health affecting their patients. The and Healthcare seminal reports on dramatic racial and Patient Protection and Affordable Care ethnic disparities emerged, and in 2000, Act of 2010 (ACA) and underlying Triple Sectors Overview the Minority Health and Health Disparities Aim—a framework which emphasizes the Research and Education Act—the first simultaneous goals of improved patient federal legislation focusing on reduction health outcomes, reduced healthcare In the United States, the actors involved in of health disparities—was signed into law. costs, and improved population health— addressing health and well-being are vast. has institutionalized imperatives to In a broad sense, all community actors Now, one of public health’s main goals address these social determinants can play a role in shaping the physical, is to achieve health equity, eliminate through payment reform and innovation mental, and social dimensions of health, disparities, and improve the health of programs, changes to Medicaid and including schools, spiritual leaders, all groups..3 After years of documenting Medicare, and new requirements for community centers, employers, financial health disparities based on race, ethnicity, nonprofit hospitals. A number of these service providers, and others. For the gender, education, and socioeconomic imperatives encourage closer alignment, purposes of this paper, this section will status, researchers, policy makers collaboration, and partnership between discuss public health and healthcare— and advocates in public health are now public health, healthcare systems, and two sectors with an interest in health shifting their focus from educating community partners to improve the health outcomes (e.g., life expectancy, diabetes, individuals on health-promoting of populations (see Emerging Models and etc.) and an increasing focus on well-being behaviors to addressing the underlying Practices, below). and the social determinants of health. causes of those disparities, known as the social determinants of health.4 Public health is an academic discipline Major Stakeholders and accredited field within the health Healthcare, one of the largest economic While not a comprehensive list, this sector that works to prevent disease and drivers in the U.S., is comprised of section highlights the major actors in both promote the health of whole populations organizations and people focused on the public health and healthcare sectors. through educational programs, policies health and well-being including hospitals, Both public health and healthcare operate and regulations, services, research, healthcare systems, and other healthcare on multiple levels and sometimes straddle and advocacy, and typically involving facilities, health insurers, purchasers of disciplines, ranging from local actors environmental scientists, health educators, healthcare services, and others. Some are who interact directly with populations; to medical professionals, and others. Public based in the public sector; others operate those that provide supporting services health does not usually include provision in the private sector as either for-profit or and organizing infrastructure; to 1 of medical or healthcare services to not-for- profit entities.5 These entities make organizations shaping national influencing individuals; it generally involves initiatives up what is known collectively as the health agendas, policy, and funding sources. to promote healthy lifestyles, improve care delivery system, with the general goal access to health care, control infectious of providing high quality, cost-effective Medical Providers diseases, and reduce environmental medical services to maintain and restore Health care providers include individuals hazards, violence, substance abuse, and health. However, the word “system” belies who provide preventive, curative, injury across populations. Public health the fact that the healthcare delivery system promotional, or rehabilitative health organizations are largely funded by is fragmented, oriented toward treatment care services in a systematic way to government; in 2017, federal, state, and of disease rather than prevention, and people, families, or communities. local governments invested $88.9 billion neither structured nor incentivized to Medical providers represent doctors, in public health programs nationwide.2 address health and well-being holistically. nurses, surgeons, physical therapists, psychiatrists, etc. These providers Over the past two centuries, public In light of multi-trillion-dollar healthcare exist within all branches of health care, health has undergone several paradigm spending and persistent health outcomes including medicine, surgery, dentistry, shifts, from a wider population-oriented that are inequitably distributed across midwifery, pharmacy, psychology, perspective focused on improving socioeconomic categories and lagging nursing, and allied health professions. neighborhood conditions and poverty; in international comparisons, the to a more narrow view of health and healthcare sector has begun to recognize

1 Health services provision varies; some local health departments operate as safety net care providers. Services can include mental health hospitals and outpatient clinics, substance abuse treatment programs, maternal and child health services, and clinics for the homeless. 2 “National Health Expenditure Data, Historical,” U.S. Centers for Medicare and Medicaid Services, accessed August 2019, https://www.cms.gov/Research-Statistics-Data-and- Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. 3 This goal is outlined in Healthy People 2020. Released in 2010 by the U.S. Department of Health and Human Services (HHS), Healthy People 2020 serves as a broad framework for national, state, regional, and local public health initiatives. Since the first Healthy People framework (released in 1990 for the year 2000), HHS has released successive frameworks every ten years to identify emerging public health priorities and align health-promotion resources, strategies, and research. 4 Cohen, A., Grogan, C., and Horwitt, J. (October 1, 2017). The Many Roads toward Achieving Health Equity. Journal of Health Politics, Policy and Law, 42(5), 739-748. https://read. dukeupress.edu/jhppl/article/42/5/739/131410/The-Many-Roads-toward-Achieving-Health-Equity (accessed August 2019). 5 Institute of Medicine. (2003). The Future of the Public’s Health in the 21st Century. (pp. 212-267). Washington, DC: The National Academies Press. https://doi.org/10.17226/10548. FOSTERING HEALTHY NEIGHBORHOODS | 19

A number of other organizations—public or part of a network, defined as a group maintenance organizations—HMOs), which and private—may serve a direct health of hospitals, physicians, other providers, contract with health care providers and service provision role (for example, insurers, and others that work together to medical facilities to provide care for their Walgreens, drop-in clinics, community coordinate and deliver a broad spectrum members. The contractual arrangements health workers, community development of services to their community (e.g., that health plans have with the providers in corporations or affordable housing Kaiser Permanente). their network vary based on how they are managers that provide services to their paid (e.g., on a per service basis or through residents, faith-based organizations, Public health departments/districts a single flat rate), what incentives they home care, social services, mental health (local and state) have (e.g., bonus payments for providing agencies, etc.). Local health departments (county, certain screenings), and how much risk combined city-county, or multicounty) are they assume (e.g., being responsible for Safety net providers6 agencies operated by local government the cost of certain tests or treatments if Safety net providers include public hospitals with oversight and direction from a local a patient gets sick). The details of these (more recently termed “essential” hospitals), board of health, and which provide public contractual relationships influence the community health centers/federally health services throughout a defined level of motivation/incentive that health qualified health centers (FQHCs), community geographic area. State health agencies plans, providers, or hospitals have for or teaching hospitals, school-based health have responsibility for identifying and keeping patients healthy and addressing centers, and local health departments. meeting the health needs of the state’s social determinants of health (SDOH). Safety net providers care for low-income citizens and can be free standing or people, the uninsured, and others who units of multipurpose health and human Health associations/Institutes/Schools face economic and social hardships. As service agencies. Generally, public health of Public Health part of their unique role and mission, core departments have three main functions: These organizations teach, convene, build safety net providers offer a combination of (1) assessment of community conditions, capacity, and share best practices and comprehensive medical or “wraparound” health needs, and their determinants; ideas among constituents. As learning services (e.g., language interpretation, (2) policy development, which includes institutions, they represent fertile ground transportation, outreach, and nutrition and advocacy, prioritization, and plans to to make connections between health, social support services) specifically targeted address health needs; and (3) assurance wealth, and other social determinants. to the needs of vulnerable populations, that high quality services are available, A few key organizations include the who make up a majority of patients/ which includes resource management, American Public Health Association, people receiving safety net services. program implementation and evaluation, the American Hospital Association, the Safety net providers receive funds from and public education.7 National Association of City and County national, state, and local governments. Health Officials (NACCHO), Association Payers of State and Territorial Health Officials Hospitals Payers are institutions that pay providers (ASTHO), the Catholic Health Association, Hospitals are health care institutions for healthcare services, including the National Network of Public Health that have an organized medical and insurance carriers, private employers, Institutes, and the Council on Education other professional staff that deliver the government, and also individuals. The for Public Health. various health services (e.g., emergency majority of healthcare in the U.S. is paid services, surgery, specialized services) for by two entities: employers and the Health policy advocates 24 hours a day, 7 days a week. In 2018, government. The Centers for Medicare Policies shape the social and physical there were 5,534 registered hospitals in & Medicaid Services (CMS) is the single conditions reflected in social determinants the U.S. Those facilities can be divided largest payer for healthcare in the United of health. Thus, policy advocates—who into a variety of categories depending on States, covering 33% of Americans can be part of any organization and size, location, demographics, finances, in 2016 through two main programs: at any level—play an essential part in and affiliation. An important distinction Medicare and Medicaid. Sixty percent of ensuring policies are fair and promote is for-profit vs. nonprofit, as nonprofit Americans get their healthcare from their health equity. Health policy advocates’ hospitals are subject to certain rules employer. Under employer-paid plans, roles can range from policy analysis, to under the ACA, including community employees may be required to contribute technical assistance, to larger national benefit regulations (demonstration of part of the cost of insurance, while the campaigns, and more. One example unreimbursed expenditures benefiting employer is responsible for choosing the of a policy advocacy organization is the local community in support of tax- insurance carrier and negotiating plans Community Catalyst, a non-profit advocacy exempt status), while for-profit hospitals and premiums. organization working to build the consumer are not. Nonprofit hospitals make up and community leadership that is required over half of all hospitals. Hospitals may Health Plans to transform the American health system. exist independently (e.g., Marin General Most insurers (including government) Community Catalyst works in 40 states Hospital), as part of a system defined as organize the delivery of care through and helps organizations achieve wide- two or more hospitals owned, leased, health plans (also known as managed reaching reforms in areas like Medicaid sponsored, or contract managed by a care organizations—MCOs—or health central organization (e.g., Dignity Health),

6 Institute of Medicine (US) Committee on the Changing Market, Managed Care, and the Future Viability of Safety Net Providers; Ein Lewin M, Altman S, editors. America’s Health Care Safety Net: Intact but Endangered. Washington (DC): National Academies Press (US); 2000. 2, The Core Safety Net and the Safety Net System. Available from: https://www.ncbi.nlm.nih. gov/books/NBK224521/ 7 Basic Duties of Local Health Departments. (n.d.). Public Health Association of Nebraska. http://publichealthne.org/phan-sections/public-health-education-section/marketing/core- functions-of-public-health/ (accessed August 2019). 20

policy, prescription drug prices, and improving health care to people who are communities, and 3) lower costs through diversity in the healthcare workforce. geographically isolated, economically or improvement for our health care system. medically vulnerable. HRSA also supports National Health Actors/Federal Agencies the training of health professionals, the Other HHS agencies that influence health A number of federal agencies influence distribution of providers to areas where and its social determinants include the health and well-being. The Centers for they are needed most, and improvements Food and Drug Administration (FDA); the Disease Control and Prevention (CDC) is in health care delivery. Administration on Children and Families; an operating agency of the Department and the Administration for Community of Health and Human Services (HHS) that HHS’s Centers for Medicare and Medicaid Living (ACL). Other federal agencies serves as the nation’s leading public health Services (CMS) administers the Medicare that influence health and its social institution. The CDC’s primary mission is program and works in partnership with determinants include the Environmental to protect public health and safety through state governments to administer Medicaid, Protection Agency (EPA); the Department the control and prevention of diseases, the Children’s Health Insurance Program of Education (DOE); and the Department injury, and disability. The CDC operates (CHIP), and health insurance portability of Agriculture. the Prevention and Public Health Fund, standards. CMS regulates reimbursement established through the Affordable Care for healthcare products and services for Finally, the Internal Revenue Service Act, which currently serves as the primary Medicaid and Medicare. The Center for (IRS) plays a dominant role in enforcing funding source for local initiatives that Medicare & Medicaid Innovation (CMMI many of the laws in the Affordable address social determinants of health. or the Innovation Center) was created by Care Act. Among others, these include the ACA to support the development and enforcing health insurance coverage Another agency operating under HHS testing of innovative payment and service penalties and provisions for individuals is the Health Resources and Services delivery models. The goals of these efforts and employers and evaluating nonprofit Administration (HRSA). It is the primary are to achieve the Triple Aims of 1) better hospitals’ provision of community benefit. federal agency responsible for care for patients, 2) better health for our

8 Easterling, D., Smart, A. and McDuffee, L. “Hospital & Health Conversion Foundations.” Stakeholder Health (blog). March 14, 2016. https://stakeholderhealth.org/conversion- foundation/ (accessed August 2019) FOSTERING HEALTHY NEIGHBORHOODS | 21

Foundations Health: Defined by the World Health Triple Aim as “A simultaneous approach In addition to national foundations Organization as “a state of complete to optimizing health system performance with a health focus (e.g., the Robert physical, mental, and social well- using three dimensions: 1) Improving Wood Johnson Foundation, the Kresge being, and not merely the absence of the patient experience of care (including Foundation, and others), two other types disease or infirmity.” This association quality and satisfaction); 2) Improving the of foundations of interest are hospital of health with overall well-being health of populations; and 3) Reducing the foundations and health conversion highlights the importance of addressing per capita cost of health care. foundations.8 Many hospitals set up a the social determinants of health. Health Care Reform: Generally, the term foundation to raise funds from individuals Population Health: “health care reform” refers to major policy and organizations. These hospital The study of population change that attempts to expand health foundations channel charitable giving to health emphasizes health outcomes care coverage; improve access to health projects aligned with the donors’ interests and the social, physical, and economic care specialists; improve the quality of and the hospital’s strategic priorities, factors that explain how health outcomes health care; decrease health care costs, which might include an expansion of a are distributed across populations, in or other related goals. In the United States, facility, new equipment, patient support contrast to an individual-level focus. the debate regarding health care reform services, or subsidies for medical care. The “population” in population health can be defined from several different includes questions of a right to health care, perspectives, which can result in some access, fairness, sustainability, quality, and Health conversion foundations (also confusion when using the term across funding amounts spent by government. called “health legacy foundations”) are components of the health sector. These The term “health care reform” also usually formed when a nonprofit hospital, health definitions for population include: refers to changes made under the Patient care system, or health plan is either Protection and Affordable Care Act acquired by a for-profit firm or converted » Population served by an individual (see below). to for-profit status. The proceeds from provider or payer—assuring that these transactions are transferred into patients are assigned correctly to a The Patient Protection and Affordable the endowment of a foundation that primary care provider Care Act: The Patient Protection and maintains the general mission of the Affordable Care Act (ACA), passed by entity that was sold (that is, improving or » Population served by the entire delivery Congress in 2010, achieves comprehensive advancing the health of the population system—e.g. primary care patients health care reform through a focus on served by the entity). The most recent increasing the number of Americans census identified 306 conversion » Population of those residing in the covered by health insurance and improving foundations nationally that submitted broader community—e.g. a geographic the quality of health care, while lowering their annual Form 990 to the IRS in 2010. area or a category of persons that share the cost of care, in part through a focus on Together they held a total of $26.2 billion specific attributes, such as a specific prevention and population health. Some in assets. A more recent census is not disease like Type 2 diabetes. of the ACA’s most significant changes available, but at least another 100 have include expanded Medicaid eligibility; been established since 2010. Examples Health Equity: “The attainment of the tax credits to purchase insurance; of health conversion foundations highest level of health for all people.” funding pilots to improve delivery, cost- include the Colorado Health Foundation The Robert Wood Johnson Foundation efficiency, and quality of health care and the California Endowment. defines health equity as follows: “Health services; providing new opportunities to equity means that everyone has a fair and partner with social service providers to Key Terms just opportunity to be as healthy as possible. address social determinants of health; This requires removing obstacles to health and strengthening prevention services. Social Determinants of Health (SDOH): such as poverty, discrimination, and their “The conditions in which people are consequences, including powerlessness Payment reform: The ACA contains born, grow, live, work, and age, including and lack of access to good jobs with fair numerous provisions intended to resolve the health system.” Specific social pay, quality education and housing, safe underlying problems in how health care determinants of health include economic environments, and health care.” is delivered and paid for in the United and housing stability, employment status, States. These provisions focus on three educational attainment, access to health Health Disparities: A difference in the broad areas: testing new delivery models, care, access to healthy foods, exposure incidence, prevalence, mortality, and encouraging the shift from payment based to crime and violence, and environmental burden of diseases and other adverse on quantity of services provided (known conditions. By improving neighborhood health conditions that exist among specific as “fee for service”) toward payment conditions, community development population groups. based on the quality and value (or “value- addresses multiple social determinants based care”), and developing resources 9 of health, thus providing a pathway and Triple Aim: This is a term that has become for system-wide improvement. See means to finance the neighborhood popular recently to describe the goals “Promising Models” for more information, changes required to achieve health equity. of health care reform. The Institute for or visit APHA’s summary on major ACA Healthcare Improvement defines the delivery and payment reform initiatives.

9 Abrams, M. K., Nuzum, R., Zezza, M. A., Ryan, J., Kiszla, J. and Guterman, S. (May 7, 2015). The Affordable Care Act’s Payment and Delivery System Reforms: A Progress Report at Five Years. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2015/may/affordable-care-acts-payment-and-delivery-system-reforms (accessed August 2019) 10 LaPointe, J. “Examining the Role of Financial Risk in Value-Based Care.” Revcycle Intelligence. Risk Management News (blog). July 25, 2016. https://revcycleintelligence.com/news/ examining-the-role-of-financial-risk-in-value-based-care. 22

Risk: In healthcare, risk refers to financial » Health trajectories are particularly and investments across sectors. HiAP loss. One of the goals of value-based care affected during critical or sensitive approaches have been used worldwide. (a model used as part of payment reform) periods, which tend to occur early in life. One example is Richmond, California; the is to transition financial risk away from (Timing) HiAP approach allowed residents to bring taxpayers and healthcare payers and health equity to the forefront and involved instead place the burden on providers to » The broader community environment– agencies across local government, such make smarter decisions about healthcare biologic, physical, and social–strongly as housing, transportation, parks and utilization. This means that within valued- affects the capacity to be healthy recreation, public health, and education. based care, providers are rewarded—or through direct and increasingly well- penalized—for how well they manage understood biological mechanisms. Accountable health initiatives: to reduce healthcare costs and improve (Environment) Accountable health initiatives are patient outcomes.10 For more information an umbrella term for organizational on how risk varies across payment models, » While genetic makeup and personal models with a cross-sector approach see “Emerging Models/Practices”. choice result in both protective and risk to addressing population health factors for disease conditions, these disparities. Accountable health initiatives Medicaid: Medicaid is an assistance differences in health are also derived fundamentally embrace the concept program paid for by federal and state from profound and often inequitable that there is a shared responsibility for funds. It serves low-income people of variation in context able to turn on/off the health of a community or patient every age and is run by state and local genes and limit personal choice. (Equity) population across sectors. By focusing on governments within federal guidelines. the alignment of clinical and community- The services covered and the eligibility The life course model emerged from based organizations, they offer an criteria vary from state to state. For the field of public health, but aspects integrated approach to health, health example, in 2014, the ACA gave states the of the model have been explored in care, and social needs of individuals and option to expand Medicaid to low-income various economic studies (e.g., Raj communities to achieve equity and better adults. At this time, 33 states have taken Chetty’s “Impacts of Neighborhoods population health outcomes, to reach a advantage of this option and 18 have on Intergenerational Mobility”) and higher quality of health care, and to reduce not. In most states, patients do not have community development organizations costs. Some of these models include: any co-payments under Medicaid, but in (e.g., The Unity Council’s “across-the- some states, for some services, a small lifespan” approach to programs). Accountable care organizations co-payment is required. Total Medicaid (ACOs) ACOs differ from accountable spending in 2017 was $595 billion. Toxic stress and epigenetics: The negative health initiatives slightly in that they impacts of poverty, childhood trauma, and hold providers responsible for better Medicare: Medicare is an insurance racism on health and opportunity have management of clinical conditions program. Medical bills are paid from trust been linked to poor health outcomes. in a patient population. This may funds which those covered have paid Until recently, however, the biological involve some community partners, into. It serves people over 65 primarily, mechanism for these changes was not but primarily represent organizations whatever their income, and also serves well known. In lay terms, breakthroughs in of healthcare providers. However, younger disabled people and dialysis epigenetics, or the study of mechanisms the principle of shared responsibility patients. Patients pay part of costs that switch genes on and off, indicate that and coordination holds true. through deductibles for hospital and chronic, repeated, and uncontrollable other costs. Small monthly premiums stress (known as “toxic stress”) of social Accountable care is one of seven are required for non-hospital coverage. disadvantage, socioeconomic inequality, broad categories of innovation models Medicare is a federal program. It is and racial discrimination affect the way testing new payment and service basically the same everywhere in the that genetic “instructions” are read, which delivery models under CMS. ACOs United States and is run by CMS. Medicare can lead to changes in the body’s ability financially encourage providers to spending was 15 percent of total federal to fight disease or stay healthy. While keep a population of patients healthy spending in 2017 ($702 billion) and is epigenetic changes can be reversed, at a lower cost by improving efficiency projected to rise to 18 percent by 2028. they also can be passed down to future and better coordinating care. The generations. As healthcare is incentivized Centers for Medicare and Medicaid Managed Care: See description under to keep patients healthy, addressing the Services initially developed the ACO “Health Plans” in the section on social determinants of health takes on model for the Medicare population, “Major Stakeholders.” increased significance for both the patients but ACOs now frequently provide themselves and their descendants. services for Medicaid programs and private payers as well. Emerging Models Health in all policies (HiAP): Health in All Policies (HiAP) is a collaborative Accountable Health Communities and Practices approach to improving the health of all (AHC): Another CMS innovation Life course model/theory: Life course people by incorporating health, equity, model being tested in a number of theory (LCT) is a conceptual framework and sustainability considerations into communities nationally, the ACHC that helps explain health and disease decision-making across sectors and policy approach will explore whether patterns—particularly health disparities— areas, especially across local and state identifying and addressing Medicare/ across populations and over time. Four key governmental agencies and departments. Medicaid patients’ health-related concepts of the life course model include: The approach recognizes that our social needs (housing, transportation, greatest health challenges—like chronic utilities, social supports, etc.) will » Today’s experiences and exposures illness, climate change, health inequities impact health care costs and reduce influence tomorrow’s health, that is, between populations, and increasing health care utilization. Over a five- experiences and exposures earlier in life health care costs—are highly complex year period, the model will provide influence health later in life. (Timeline) and influenced by policies, programs, support to community organizations FOSTERING HEALTHY NEIGHBORHOODS | 23

to test promising service delivery resource used. Providers then earn Community Benefit, Community Health approaches aimed at linking or lose the difference between the Needs Assessments (CHNAs), Community beneficiaries with community services actual cost of care and the set cost. Health Improvement Plans (CHIPs), that may address these needs. and Community Health Assessments Capitated payment: Providers receive (CHAs): To merit their federal tax- Accountable Communities for a set payment per year for each exempt status, nonprofit hospitals must Health (ACH): An Accountable person or “covered life” for whom report on the community benefits they Community for Health (ACH) is a they provide care, regardless of have provided—previously called charity structured, cross-sectoral alliance whether or not people use health care—that contribute to the health and of healthcare, public health, and services. The healthier patients well-being of surrounding communities. other organizations that plans and are/remain, the more savings Calculated hospital community benefits implements strategies to improve providers reap in the difference typically include unreimbursed care population health and health equity between the initial payment and (free and discounted care to uninsured for all residents in a geographic actual costs. These payments and low-income patients), initiatives area (as compared to CMS AHC can be adjusted based on the to increase access to health care (e.g., model, which aims to assess impact demographic characteristics of a health fairs), medical research done at on Medicare/Medicaid patients). provider’s patient population, such their facilities, and costs associated with The Prevention Institute outlines as age and gender, to account for training for doctors, nurses, and other nine core elements of an ACH: differences in expected costs. health professionals. However, with (1) mission; (2) multi-sectoral improved guidance from the Internal partnership; (3) an integrator Medicaid Waivers: Authority granted Revenue Service (IRS) which regulates organization; (4) a governance by the Secretary of Health and Human this process, many hospitals are beginning structure;( 5) data and indicators Services to allow a state to continue to align and deploy their community to measure progress; (6) an receiving federal Medicaid matching funds benefits to address health needs arising overarching strategic framework; (7) even though it is no longer in compliance from the social determinants of health community member engagement; with certain requirements of the Medicaid including, in some cases, investing with (8) a communications platform; statute. States can use waivers to community development organizations. and (9) sustainable financing. implement home and community-based services programs and managed care, and As part of community benefit, the ACA Payment reform: Various payers have to expand coverage to populations such mandates that nonprofit hospitals conduct been experimenting with payment reform as adults without dependent children who community health needs assessments models as reimbursement shifts from are not otherwise eligible for Medicaid. (CHNAs). CHNAs are completed to fee-for-service, the traditional method of For example, New York state has received alert the hospital to the local needs paying for medical services under which a waiver to use a portion of its state that most urgently require financial doctors and hospitals are paid for each Medicaid funds to pay for the costs of support. Hospitals must publicly report service they provide, toward value-based housing, which would not normally be CHNA findings and community benefit care. Under value-based care agreements, allowed under the Medicaid statutes. expenditures every three years and solicit providers are rewarded for helping patients input from a diverse group of community improve their health, reduce the effects Wellness trusts: A wellness trust is a members, stakeholders, and public health departments. Once a CHNA is complete, a and incidence of chronic disease, and live funding pool raised to support prevention hospital must develop a plan for how it will healthier lives in an evidence-based way. and wellness interventions that improve address the identified health challenges— Payment reform models of interest fall on population health outcomes. Sources of the Community Health Implementation Plan a spectrum of risk that holds providers funding can include public and/or private (CHIP). Through this regular and intensive accountable to providing quality, cost- money. The Massachusetts Prevention look at pressing health challenges, efficient care and keeping their patients and Wellness Trust was established by nonprofit hospitals can better target healthy. Examples include: the Massachusetts legislature in 2012 and became the first state effort to use a partnerships, strategies, and investment of its community benefit resources. However, Pay for performance: Providers wellness trust as a vehicle to make a large there remain unresolved questions over receive incentives for meeting or commitment to population-based health what types of expenditures, especially exceeding quality, and sometimes promotion efforts. related to infrastructure investments, cost, benchmarks. Some systems also are allowable as community benefit. penalize providers who do not meet Growing interest in wellness trusts There is also a wide range CHNA quality established benchmarks. The goal of coincides with the current transformation across hospitals, including the allowable pay-for-performance programs is to of the healthcare system that moves care re-use of CHNAs for multiple hospitals improve the quality of care over time. away from traditional fee-for-service within a larger healthcare system, which payments to value-based, global payment limits their utility in guiding resource Payment Bundling: Providers or for the care of a population of patients. deployment.Similar to a CHNA, public hospitals receive a single payment These new delivery and payment reform health departments must conduct a for all of the care provided for an efforts are better aligned with community- community health assessment (CHA) every episode of illness, or over a set based prevention and wellness efforts. three years as part of their accreditation period of time, rather than per Wellness trusts can supplement limited process. Many public health departments service. For example, a single set public resources for prevention and and hospitals are joining forces to align rate for a pneumonia hospitalization allow for innovative prevention efforts these efforts. Opportunity exists to link (usually, adjusted for age or co- that target upstream drivers of health other organizations to these needs existing illness) instead of payment and wellness, including community assessments, implementation plans, for each night’s stay and every infrastructure such as housing or other and community benefit opportunities medication, doctor visit, and/or needed neighborhood resources. to more fully address SDOH. 24

APPENDIX C participation and fullest possible reliance its focus to respond to the large-scale upon the community initiative,” in the destruction of affordable housing by U.S., community development represents freeway development and other forms of Community more than a process or activity. Rather, urban renewal. EBALDC now owns and it is best viewed as a self-defined sector manages 30 residential developments and Development: involving organizations from multiple commercial spaces serving childcare and fields that share a common focus on health centers, nonprofits, a resident- Sector Overview improving low-income communities. owned market, and popular, locally owned These organizations come from fields restaurants. They have developed and including real estate, city planning, law, preserved 2,200 affordable homes. The community development sector is social work, public policy, public health, a vast, financially savvy, mission-driven affordable housing, and finance, and Affordable Housing Developers industry that tackles poverty in America’s generally identify themselves as being part More narrowly focused on housing, and most under-resourced neighborhoods. of the community development industry. more often regional or national in scope At its root, the community development Some of the key players (described below) than CDCs, are the nonprofit and for-profit sector is an anti-poverty movement. Driven provide leadership in the sector, and work affordable housing developers. Together, by a mix of public and private resources— alongside neighborhood residents and a the 13 largest nonprofit affordable housing federal and state grants and tax incentives combination of city agencies, philanthropic developers in the country own and as well as federally mandated investments organizations, investors, real estate operate over 130,000 rental apartments by for-profit banks—the community developers, and social-service providers. serving low-income residents. In addition, development sector intervenes to address dozens of for-profit developers also many of the social determinants of The sector is not without its limitations. provide affordable and mixed-income health (SDOH) and inequity. Partnering Despite the hundreds of billions housing, with the ten largest companies with one another and using the federal of dollars invested over the years, constructing over 11,000 affordable homes and private capital described below, poverty alleviation has clearly not been in 2016 alone. Both nonprofit and for- these mission-driven and often nimble achieved. In part that is due to a lack profit affordable housing developers rely institutions have been able to incorporate of coordination or alignment in these heavily on Low Income Housing Tax Credit resident voices and provide the housing investments to achieve their maximal (LIHTC) resources and investments from and other neighborhood infrastructure impact. Too often investments are driven CRA-motivated banks to do their work. that responds to community needs. by immediate financial considerations or opportunities that produce one-off Community Development Financial Community development is a multi-billion- transactions. Measurement of impact also Institutions (CDFIs) dollar sector of the American economy remains elusive. Outputs such as units of CDFIs make up a third important that invests in low- and moderate-income housing built or jobs created are tracked category of community development communities through the development without truly examining outcomes (i.e., organizations. At root, CDFIs are non- and financing of affordable housing, whether the apartment or job actually profit banks with the mission to provide schools, grocery stores, health clinics, improved the resident/employee’s life). lending and financial resources to small businesses, job training programs, Further, in some cases, particularly low-income neighborhoods underserved and services to support children, youth, with inadequate planning, gentrification by the for-profit banking sector. and families. The sector has its roots in and subsequent displacement can the urban revitalization efforts of the late undermine the goals of this work. The origins of CDFIs can be traced back to 19th century but expanded as a result of the early 1970s and the mission-focused the War on Poverty programs of the 1960s. loan funds started by religious orders However, community development today is Major Stakeholders of nuns to provide low-interest loans to not the centralized urban renewal of that Broadly, one can break down the major economically disadvantaged residents era, an approach that too often resulted players into three groups: community in their communities. At that same time, in the industrial-scale public housing development corporations (CDCs), the first community development bank projects we associate with the urban core affordable housing developers, and in the country, ShoreBank in Chicago, of many American cities. Those types of community development financial was founded by young, banking activists U.S. Department of Housing and Urban institutions (CDFIs). in 1973 to fight against the growing Development (HUD) efforts fell out of tide of racist lending practices. In 1994, favor in the late ‘70s and were slashed in Community Development Corporations President Bill Clinton, inspired by these the ‘80s. In their place gradually arose a The first community development earlier efforts, championed the creation network of community-based, local and of the Community Development Financial national, largely non-profit organizations corporation (CDC) was founded in 1967 in New York City. CDCs, which are nonprofit Institution Fund (CDFI Fund) within the that responded to the unabated need U.S. Treasury Department to spread the for affordable housing. There are now organizations incorporated to support and promote community development work of CDFIs nationally. The field has thousands of these organizations across grown substantially over the past 20 the country representing communities efforts in struggling neighborhoods, now number over 4,000 across the years with the CDFI Fund now certifying large and small, investing $200 billion over 1,000 CDFIs across the country. annually into low-income neighborhoods. country. They are in almost every urban neighborhood and many smaller cities The CDFI Fund itself has distributed over $2 billion since its inception, and in While the United Nations defined and rural areas as well. As an example, the East Bay Asian Local Development 2017 alone financed over 14,700 small community development in 1955 as “a business and microenterprise loans, process designed to create conditions Corporation (EBALDC) was started in 1975 by community leaders working to serve the nearly 28,000 affordable housing units, of economic and social progress for and served more than 470,000 individuals the whole community with its active Chinatown neighborhood of Oakland, CA. Subsequently, the organization expanded with financial literacy or other training. FOSTERING HEALTHY NEIGHBORHOODS | 25

One of the most important roles for Key Terms Capital. Wealth in the form of money or other CDFIs is to coordinate the complex assets owned by a person or organization or financial transactions required for Affordable Housing. Housing capable of available for a particular purpose such as modern community development. Most being purchased or rented by persons starting a company or investing. community development investments whose income level is categorized as very require the braiding of multiple streams low, low, or moderate within standards Equity. In the finance world, equity means of capital: philanthropic dollars, tax set by HUD or state departments of ownership of a share of an asset. For credits (LIHTC and/or New Market Tax housing/community development (for example, an investor could purchase shares Credits, or NMTCs), CRA-motivated example, below 40%, 80%, or 120% of stock in a company or a real estate investments, and market-rate loans. This of area median income, or AMI). investment trust (REIT) that owns multiple complex approach to obtaining necessary buildings or properties. In the context of resources demands a high level of AMI. Area Median Income (AMI) is the homeownership, equity is the value of financial expertise, which CDFIs provide. household income for the median—or a home or property less any remaining middle—household in a region. Each mortgage payments (debt). This value or National Umbrella Organizations year, HUD calculates the median income equity grows over time as the property The large, nonprofit affordable housing for every metropolitan region in the owner pays off the mortgage and the developers utilize SAHF as a shared country. This measure, which varies market value of the property appreciates. organization advocating for the importance widely nationally, is used to determine Guaranteed Loan. A loan that is of their work at the national and regional eligibility for affordable housing programs. guaranteed partly or fully for the benefit of level. The CDFI industry has a national Assets. Assets are useful or valuable protecting a lender against possible losses. membership body called the Opportunity skills, facilities or tools within a Finance Network (OFN) that provides community that can lead to positive Comprehensive community initiative. support, training, and a national forum change. It is also defined as property These are neighborhood-based efforts that for gathering and guiding the field. At this owned by a person or company, regarded seek improved outcomes for individuals time, CDCs lack a national institution, but as having value and available to meet and families as well as improvements a pair of organizations fills part of that debts, commitments, or legacies. in neighborhood conditions by working gap. The federally funded NeighborWorks comprehensively across sectors. America supports over 240 CDCs that Built Environment. Buildings, roads, meet its rigorous membership criteria, parks, and all other improvements Community Quarterback. A community and the National Alliance of Community constructed by people that form the quarterback is an entity that serves in Economic Development Associations physical character of a community. a coordinating role, managing a diverse (NACEDA) provides a forum for the many coalition of players in order to achieve state and regional CDC associations. 26

community betterment. A community one or more buildings whose design and often, single-family homes; special needs quarterback may function as an organizer orientation facilitate transit use. Equitable housing for the elderly or disabled; and and navigator toward the shared goal of a TOD (eTOD) focuses additionally on supportive housing for homeless families cross-sector initiative in many ways, which housing and services for individuals and and individuals. Fully 30% of the 10 million could include articulating the goal itself, families across the income spectrum. units of affordable housing in the country establishing shared metrics, bringing have been developed through the together knowledgeable allies and financial Transitional Housing. Shelter provided LIHTC program. resources, and facilitating the work of to the homeless for an extended an initiative’s many community partners. period, often as long as 18 months, and New Markets Tax Credit (NMTC) In this model, the quarterback knits generally integrated with other social NMTC is managed by the Treasury together the diverse abilities of formerly services and counseling programs to Department and since 2001 has provided siloed community development sectors, assist in the transition to self-sufficiency nearly $55 billion targeted at job creation creating a powerful integrated initiative. through the acquisition of a stable in low-income neighborhoods ($3.4B in income and permanent housing. 2017 alone). These dollars can be invested Gentrification. The process of renewal and directly in small businesses or into other rebuilding in a deteriorating, disinvested Terms derived from the Build Healthy job-creating community facilities. In recent neighborhood that can be followed by an Places Network Jargon Buster, Institute years community clinics have been seen influx of middle-class or affluent people of Local Government’s Land Use and as important job creators in low-income and displacement of poorer residents. Planning glossary, and the Ball State neighborhoods and, thus, are increasingly University Community and Economic being built using NMTC funding. Inclusionary Zoning. Regulations to diversify Development Glossary of Terms. the range of housing choices constructed Healthy Food Financing Initiative (HFFI) or offered within a development to meet the needs of low- and moderate-income Sources of Funding HFFI has provided hundreds of millions families. Often such regulations require a of dollars through the U.S. Treasury, U.S. Community Reinvestment Act (CRA) minimum percentage of housing for low- Department of Agriculture (USDA), and and moderate-income households in new Passed in 1977, the CRA is often called an U.S. Department of Health & Human housing developments and in conversions “anti-redlining” law because it responded Services (HHS) for grants, loans, and of apartments to condominiums. to decades of discriminatory lending financial assistance to community practices that created disinvestment development organizations to build grocery Neighborhood. A planning area commonly in predominantly African American stores in food deserts and for other efforts identified as such in a community’s neighborhoods in cities across the U.S. that increase the availability of fresh, planning documents, and by the The CRA requires for-profit banks to invest healthy food in low-income neighborhoods. individuals residing and working within the in the low-income neighborhoods where neighborhood. Documentation may include they take deposits. The results of the CRA Innovative Loan and Equity Funds a map prepared for planning purposes have been staggering. In 2016 alone, banks Loan funds provide private investment showing the names and boundaries of made CRA investments totaling over $255 dollars in the form of low-interest loans neighborhoods. Though neighborhoods billion. This is the single greatest driver of for community development efforts. The are not legal designations, they are resources into low-income neighborhoods. innovation is either in the criteria that must among the most commonly recognized be met to gain access to those dollars or and understood land use designations. Community Development Block Grant the source of the funding. For example, (CDBG) the Healthy Futures Fund (HFF) is a $200 NIMBY. An acronym for “Not-In- A grant program administered by HUD on million loan fund developed jointly by a My-Backyard” used to characterize a formula basis for larger “entitlement” national CDFI, the Kresge Foundation, and opponents of development projects, communities and by state agencies for Morgan Stanley, the for-profit investment with the implication that the opposition smaller “non-entitlement” jurisdictions. bank. HFF incentivizes a particular type of is based on personal self-interest as This grant allots money to cities and investment by requiring that its resources opposed to the interests of the larger counties for housing rehabilitation and only go towards the development of community. Local agencies’ alleged community development, including public community clinics that are built in responsiveness to “NIMBY-ism” is one facilities and economic development. conjunction with or adjacent to affordable of the reasons some advocate for state housing. Several hospital systems have laws to preempt local agencies’ authority Low Income Housing Tax Credit (LIHTC) created similar community development over certain kinds of land use decisions. Created as part of the Tax Reform Act of loan funds. Importantly, in each case the 1986 to encourage private investment in funds are derived from a small fraction of Supportive Housing. Housing that affordable housing, LIHTC vouchers are the institutions’ investment portfolio, not combines non-time-limited affordability distributed by the states and amounted claimed as part of required community with wrap-around supportive services for to nearly $9 billion in 2017. Organizations benefit expenditures. For example, Dignity people experiencing homelessness, as allocated tax credits by their state housing Health, one of the largest healthcare well as people with disabilities. finance agencies sell them to corporations systems in the country, created a $140 million loan fund (representing about 2% Transit-oriented Development (TOD). who use them as payment for future taxes, saving money in the process. The of its investment portfolio) that provides Moderate- to higher-density development, financing for community development located within easy walk of a major organizations that sell the vouchers get cash that they can then use for production projects in low-income neighborhoods transit stop, generally with a mix of served by its member hospitals. Another residential, employment, and shopping or preservation of affordable rental housing. Housing can be in the form of large healthcare system, Trinity Health opportunities designed for pedestrians based in Michigan, has a similar loan fund without excluding the auto. TOD can be fully affordable or mixed-income housing and can include multi-family or, less of $75 million, and Kaiser Permanente new construction or redevelopment of announced a $200 million national FOSTERING HEALTHY NEIGHBORHOODS | 27

affordable housing fund in 2018. In each For many in this ecosystem, their work first informal loan was made in this of these cases, the financial resources includes a particular focus on working country, a modern-day focus on consumer are deployed not as grants but as below- with low-income people and people of financial health and well-being—and market rate loans (e.g., 2-4%) that will color who have been denied opportunities in particular, what drives inequitable be paid back, thus allowing these dollars to build wealth, access quality financial outcomes among lower-income people— to be redistributed multiple times. services, and access pathways to achieve has been more recent. The shift began financial health and well-being. with the 1990 publication of Michael A more complex investment tool, and Sherraden’s seminal book Assets and the to date the only one of its type, is the This ecosystem includes financial services Poor, which highlighted the importance Boston-based Healthy Neighborhoods providers such as banks, credit unions of helping low-income households Equity Fund (HNEF). Focused on transit- and community development financial build not just income, but wealth as a oriented development, HNEF makes institutions (CDFIs); payment providers and strategy for helping families escape equity investments into mixed-use and financial technology (fintech) innovators; poverty. Because traditional poverty residential developments in low-income non-profit social service organizations alleviation efforts to date had focused on neighborhoods near transit that are providing financial education and coaching, increasing income, this new framework vulnerable to gentrification. HNEF blends credit and debt management, and savings showed how assets—a home, savings, an government tax credits, philanthropic opportunities in communities; companies education, or a business—is necessary dollars, bank capital, and other private providing similar services to employees to create a financial buffer to weather investor dollars including investments and clients; consumer advocates working emergencies, promote success in the from two area hospitals, Boston Medical to promote and protect fair practices labor market, and help families move up Center and Boston Children’s. Unlike a and prevent unjust ones; researchers the economic ladder. From this, an entire loan fund that provides assured repayment gathering evidence on what’s happening field of practice, policy, research, product with interest using the development as in people’s financial lives and which innovation, and philanthropy has developed collateral, HNEF participants are at-risk solutions work best; regulators setting dedicated to the idea of asset building equity investors in the neighborhood with the rules for consumer and wholesale for low-income households, and in later no guaranteed return. Rather, they earn finance; and policymakers at all levels years, financial health and well-being. revenue from rents —a portion of which intersecting with these stakeholders. are maintained affordable to those making As the field has matured in practice and 30-80% AMI—and from the increasing People’s lives are complex and our understanding of the drivers of wealth value of the property they partly own. The multifaceted, so addressing financial inequality have grown, so too has the focus return is then obtained when the investor health and well-being requires a of the work. Early on, financial education later sells their higher value share of the multi-pronged approach. The work was the key focus area of the work, ownership to either the owners of the of this field aligns with seven broad building on the notion that increasing building or a new investor. This process, in categories of policies and practices knowledge about good financial choices effect, harnesses gentrification to provide that support the needs of individuals, would lead people to make wiser financial a return to investors while preserving families and communities. decisions. The field quickly realized that commercial space and homes for low- education alone was insufficient to address income residents and business owners. » Plan ahead for expenses, have the problems of financial insecurity and insurance against emergencies, and wealth inequality. Next, the field focused be able to make financial decisions on coupling financial education with wealth APPENDIX D and manage resources effectively. creation strategies, and in particular the creation of the Individual Development » Earn sufficient income through Account (IDA) in the 1990s, an incentivized Financial wages, employer benefits, business savings product earmarked for use in earnings, public benefits, tax credits or buying a home, starting a business, or investments to both cover expenses and investing in post-secondary education. Well-being to save. While IDAs were a great success, the Sector Overview » Spend and store money and conduct field also began to realize that for many transactions for goods, services, and households, it was not the appropriate other expenses safely and within their product, or the right time for such a Throughout the report we use the terms means. financial health and financial well-being product. The framework of financial capability developed to denote a fuller interchangeably and as shorthand to » Borrow funds on reasonable terms to range of institutions, products, and describe the focus area of a diverse group smooth short-term consumption and services that needed to be in place to build of organizations and companies building to invest in opportunities and wealth- the financial security outcomes we were financial security, stability, and economic building assets. prosperity through their work. While it looking for: notably, that individuals not only needed both knowledge and skills, cannot be technically defined as a sector, » Save income left over after covering the goal of this broad ecosystem is to expenses and debt payments for now, but also the opportunity to practice them, improve financial health and well-being soon, and later savings needs. by having access to quality products for millions of households. Together and services in their daily lives. With these organizations have a common aim » Own assets—such as a home, business, this financial capability framework as a to ensure everyone in this country can or investments—that help build financial guide, the fields of financial counseling, have the freedom of choice to build their stability and wealth. coaching, credit counseling and debt own financial security, effectively manage management, planning and budgeting, day-to-day financial issues, and build While the consumer financial services and so much more have been honed over long-term financial resilience and wealth. sector has been in operation since the the last decade into a vibrant sector taking 28

in customer feedback and continually by each organization in 2015 and 2016, Through research conducted by CFSI redefining best practice in communities respectively. These terms are defined as and others on the financial lives of across the country. Fields ranging from ensuring people can be in control of their individuals and families, we learned that education to workforce development to day-to-day finances, absorb financial while access to an account is important, health have integrated these practices shocks, meet financial goals (however it is no guarantee of broader outcomes. and products. Ongoing policy work defined), and be financially free to make The outcomes we seek should certainly ensures consumer protections are in choices in life. include access to high-quality and place to prevent predatory practices from affordable products, but also address and flourishing and government programs And so, this field which has gone from support families’ financial resilience in such as the Earned Income Tax Credit financial education to asset building to the face of volatile income and expenses. (EITC) provide supplemental sources financial capability, is referred to in this Instead of just measuring how many of income to those most in need. report as the financial health and well- people have an account, there is a being sector. recognition that we must consider all As this field of practice has grown, the rich of the financial services and programs understanding of both the problem and This choice of terminology also reflects that people need to take control over the ways to address it have continued to the growing consensus from the public, their financial lives—from financial- evolve. Namely, we have begun to name non-profit, and, increasingly, the private planning tools to manage budgets and the drivers of wealth inequality—and in sector that a focus on achieving financial expenses; to access to affordable credit particular the deep divides by race in the health and well-being is a shared, to start businesses, purchase homes U.S.—and the ways our financial services mutually beneficial path forward. Early and invest in higher education; to liquid system has existed to create those divides, efforts by stakeholders to influence savings to weather an emergency; to not erase them. A growing practice around financial services providers to meet the insurance to help deal with unexpected racial wealth inequality and race equity needs of underserved individuals were expenses; retirement accounts for challenges our notions of what are the largely focused on access or “financial long-term savings; and more. most effective solutions and the role inclusion.” The terms “unbanked” and local and federal policy currently plays in “underbanked,” describing nearly a shaping a system that furthers this divide. quarter of the population that either Major Stakeholders had no or limited engagement with Because financial issues affect so many The latest paradigm shift in our field mainstream finance, were used to aspects of life, the major players in has been to further define the outcomes highlight the challenge of financial access this field are diverse and wide-ranging. we are looking for. The definitions for and encourage financial service providers Here we outline the major categories of financial health and financial well-being— to recognize the business opportunity interested and involved stakeholders. distinct but overlapping concepts—were in offering these segments financial created separately by the Financial Health services. It was the Great Recession, Financial Services Providers: Financial Network (then known as the Center for however, that revealed that the challenges services providers include banks, Financial Services Innovation, CFSI) facing unbanked and underbanked credit unions, CDFIs, asset managers, and the Consumer Financial Protection households were bigger and more lenders, and insurance providers. Each Bureau (CFPB), in research published pervasive than previously understood. of these players has different regulatory frameworks and incentives to address the financial health and well-being of their clients and of the communities in which they work. They provide the backbone infrastructure of the financial health and well-being sector—the checking accounts, savings products, lending vehicles, and insurance products that people use day-to-day to manage their financial lives and achieve financial goals.

Non-Profit Service Providers: A range of direct service non-profits provide the services commonly thought of in the financial capability and asset building field of practice. Non-profit organizations serving low-income communities and individuals with a variety of social services, including emergency assistance, savings programs, wealth-building, workforce development and job training, affordable housing and homeownership may all be integrating these services. Some of these organizations also advocate for public policies at the local, state, and national level that address issues of poverty, wealth inequality, financial predation, and power in communities. FOSTERING HEALTHY NEIGHBORHOODS | 29

Tax preparers: Tax time is a significant Regulators: The financial services industry products, save, manage credit, reduce debt, financial event in the lives of low-income has a complex array of regulatory bodies at access available tax credits, and more. people, particularly because of the the state and federal levels, including the proportionately large tax refunds many Federal Reserve Banks, the Federal Deposit Financial Capability: Financial capability families earn because of the EITC and Insurance Corporation (FDIC), the Office is the capacity, based on knowledge, other refundable tax credits. The IRS of the Comptroller of the Currency (OCC), skills, and access, to manage financial runs the Volunteer Income Tax Assistance the Consumer Financial Protection Bureau resources effectively. (VITA) and Tax Counseling for the Elderly (CFPB), and state banking supervisors. Financial Coaching: Financial coaching (TCE) programs to increase access to free, is one-on-one interactions between a volunteer-run, quality tax preparation Benefits and Payroll Providers: Providers coach and participant that empower services. Paid tax preparation—an offering benefits including retirement, participants to set and achieve their unregulated activity—provides a large life insurance, and payroll processing are unique financial goals through behavior share of the services in this industry, a key part of individuals’ daily financial change and skill development. including to low-income communities. lives and a key partner for employers. For example, they may support people saving Financial Counseling: Financial Financial Technology Companies: for retirement in a 401k or making tax-free counseling is one-on-one sessions driven Companies that provide financial services payroll deductions. Increasingly, they are by a counselor to help clients address using technological innovations to increase partnering with large employers and others specific financial matters like managing the user-friendliness of financial services to support employees’ financial health. credit or purchasing a home. and bring financially excluded individuals into the financial system. Key Terms Financial Health: Financial health occurs when people’s day-to-day financial Local and State Government: Local and Asset Building: Asset building refers to systems build long-term resilience and state governments provide services and strategies that increase financial and opportunity. establish policies that affect the ability tangible assets, such as savings, a home, of its citizens to improve their financial and businesses of all kinds. Fin Tech: Fin tech refers to any technology health and well-being. Increasingly, cities used to provide financial products and are implementing Offices of Financial Children Savings Accounts (CSAs): CSAs services to consumers, including online Empowerment—often as an initiative of the are long-term, incentivized accounts, personal finance tools, mobile payment, Treasurer’s Office—to coordinate services established for children as early as birth. and virtual loans and savings products. across city agencies that improve the Accounts are usually seeded with an initial financial lives of residents. This includes deposit and built by contributions from Financial Well-being: Financial well- coordinating a Bank On campaign to family, friends, and the children themselves. being occurs when people have control increase access to banking products with Accounts are augmented by savings over their day-to-day and month-to- low barriers to entry, embedding financial matches and/or other incentives, and the month finances, financial freedom to coaches into other city or state services, or savings are used to purchase an asset— make choices to enjoy life, and capacity to absorb a financial shock; and are expanding access to VITA sites and the EITC. typically to finance postsecondary education. on track to meet financial goals. Credit Bureaus: Credit bureaus collect Community Development Financial Individual Development Accounts (IDAs): data on consumer financial behavior, debt, Institution (CDFI): CDFIs are private IDAs are matched savings accounts that and other information that makes up a financial institutions that are 100% help low-income individuals save money credit score, and provide it to financial dedicated to delivering responsible, to buy a home, start a business, obtain affordable lending to help low-income, institutions. They also sell these data a post-secondary degree, or purchase low-wealth, and other disadvantaged to institutions, including players in the another type of financial asset. healthcare industry, that use it to make people and communities join the business decisions. economic mainstream. Lending Circles: Lending circles consist of 6-12 people that contribute a set Credit Counseling and Debt Management Consumer Protection: Consumer protection amount of money each month, and the Agencies: These organizations, both in refers to policies and practices that protect person who receives the pool of money, the for-profit and nonprofit sector, assist consumers from financial abuse. or “loan,” alternates each month. consumers struggling with debt issues to negotiate with lenders, pay off debt, and Credit Building: Credit building supports Neighborhood Financial Health: repair credit scores. clients with no credit history or a thin Neighborhood financial health refers credit file with beginning to establish a to the neighborhood conditions that Consumer Advocates: Advocates— positive credit record—such as through promote long-term financial resiliency sometimes single organizations and often opening a small dollar installment loan and opportunity for residents and coalitions or networks of organizations— or a secured credit card—and assisting provide resources that residents use strive to represent the consumer voice in clients with low credit scores to improve to spend, save, borrow, and plan for legal and policy matters such as banking them through good credit behaviors (e.g., life. In turn, financial health among industry regulation, payday lending rules, paying credit card bills on time). residents contributes to a strong and housing affordability matters, and in other cohesive neighborhood and local places where consumer financial issues Financial Education: Financial education economy. Neighborhood financial health are being regulated or affected by policy is generally one or more standalone can be measured by the prevalence of decisions at the local, state, and workshops or classes that involve the supportive institutions, actors, and goods federal level. transfer of information, often in a group and services in a community, as well as setting, on a specific set of topics such as residents’ collective financial health. how to budget, use mainstream financial 30

APPENDIX E Kate Sommerfeld, President, Social Alison Donovan, VEIC Determinants of Health, ProMedica, on MC Dyalekt, Brunch & Budget Podcast December 6, 2018 Interviews Ryan Easterly, WITH Foundation Mary Dupont, Director of Financial Empowerment, $tand by Me, Delaware Kendra Edlin, Montana’s Credit Unions Abby Hughes Holsclaw, Senior Director Department of Health and Social Services for Community Development at Asset Funders Network on Statewide, on December 3, 2018 Kimberly Edmonds, Virginia Cooperative February 9, 2018 Lucy Marcil and Michael Hole, Co- Extension-Henrico County George Reuter, Director of Learning and Founders, StreetCred, on December 11, Jeannine Esposito, Self-Help Federal Impact, Compass Working Capital, on 2018 and January 3, 2019 Credit Union December 20, 2018 Michael Mirra, Executive Director and Sakuri Fears, LISC Milwaukee Leigh Philips, President & CEO, and Tim Amy Van, Project Manager, Tacoma Lucas, Director of Research, EARN, on Housing Authority, on December 20, 2018 Donita Fischer, Four Bands June 4, 2019 Community Fund Adam Schickedanz, MD, Research Fellow, Ashley Conners Sherwin, Vice President of University of California, Los Angeles, on Philip Getz, Navicore Solutions External Affairs, and Jesus Gerena, CChief February 14, 2019 Nan Gibson, JPMorgan Chase Executive Officer, Family Independence Initiative, on January 7, 2019 Padmini Parthasarathy, Senior Program Lars Gilberts, University District Officer, Walter & Elise Haas Fund’s Development Association Bill Druliner, [former] Director of Strategic Economic Security program, August 14, Partnerships, GreenPath Financial 2017 and February 8, 2019 Cary Gladstone, Granite United Way Wellness, on August 21, 2017 Sarah Gordon, Financial Health Network Bill Druliner, [former] Director of Strategic (formerly CFSI) APPENDIX F Partnerships, GreenPath Financial, and Michelle Gorsuch, ProMedica Tom Jacobson, Executive Director, Rural Health Systems Dynamics, Inc. and Director of Strategic Focus Groups Partnerships, GreenPath Financial Kate Griffin, Prosperity Now Wellness, on January 4, 2019 Michal Grinstein-Weiss, Washington Health Clinic, Session September 5, 2018 Matt Josephs, Senior Vice President, University in St. Louis at Prosperity Summit in Washington, D.C. Local Initiatives Support Corporation, on Mario Gutierrez, New York Legal February 11, 2019 Assistance Group Kimberly Cutcher, Executive Director, List of Registrants Susan Harlos, Coconino County Local Initiatives Support Corporation Megan Bautista, CASH Campaign Community Services Department Toledo, on December 6, 2018 of Maryland Kadija Hart, Belair-Edison Valeria Moffitt, Director of Financial Denise Belser, National League of Cities Neighborhoods, Inc. Opportunities, Local Initiatives Support Corporation Toledo, on December 6, 2018 Courtnee Biscardi, Urban League Shaheen Hasan, Center for Financial of Broward County Services Innovation (CFSI) Julia Ryan, Vice President, Health Initiatives, Local Initiatives Support Kelvin Boston, Moneywise TV Patricia Hasson, Clarifi Corporation, on December 6, 2018 Candice Cambridge, TD Bank, N.A. Logan Herring, Kingswood Community Center Robert Cashman, President & CEO and Samantha Canton, AHEAD Inc. Charlene Bauer, Senior Vice President, Gail Hillebrand, Consumer Financial Outreach, Advocacy & Chief Development Austin Carrico, Prosperity Now Protection Bureau Officer, Metro Credit Union, on February Annette Case, Asset Funders Network Krista Holub, Intuit Tax and Financial Center 27, 2019 Andrea Caupain Sanderson, Amanda Hunsucker, OnTrack WNC Gigi Hyland, Executive Director, The Byrd Barr Place Financial Education & Counseling National Credit Union Foundation, on Carrie Cook, GreenLight Charlotte August 14, 2018 and December 17, 2018 Adrian Ilchuk, American Center Kris Cooley, Ability360 for Credit Education Nicole R. Perry, Deputy Commissioner for the Office of Financial Empowerment, Melanie Crecy, IRC Anneth Izquierdo, Americorps Public Allies and Nichole Davis, Director of Programs Anna Cunningham, NC Council Tom Jacobson, Rural Dynamics, Inc. for the Office of Financial Empowerment, on Developmental Disabilities New York City Department of Consumer Nicholas Jaegar, Minneapolis Urban Affairs and New York City Office of Financial Laura D’Alessandro, Local Initiatives League Support Corporation Empowerment, on January 4, 2019 Laurie Jensen-Wunder, American Oxiris Barbot, MD, Commissioner, New Anagha Das, Bank of America (former) Cancer Society York City Department of Health and Mental Marvin DeJear, DMACC/Evelyn K. Davis Johannessen, Elaina LSS Financial Hygiene, on March 27, 2019 Center for Working Families Counseling Jennifer Talansky, Managing Director, Santra Denis, Catalyst Miami Don Jonas, PhD, Care Ring Knowledge and Impact, Nonprofit Finance Mathieu Despard, Washington University Fund, on June 3, 2019 Martha Kanter, College Promise Campaign in St. Louis FOSTERING HEALTHY NEIGHBORHOODS | 31

Katrin Sirje Kärk, Rural LISC Michael Roush, National Disability Institute Jeremy Burke, USC Center for Economic and Social Research Rota Knott, Somerset County Local Luella Sanders, United Way of the Plains Management Board, Inc. Michael Bush, Great Place to Work Diane Sandoval,Guadalupe Credit Union Ashley Kohlrus, Allegacy Federal Louis Caditz-Peck, Lending Club Adam Schickedanz, MD, UCLA Credit Union Jimmy Chen, Propel Donald Schwarz, Robert Wood Johnson Andrew Ladd, Communities In Schools/ Foundation Kristin Crellin, SchoolsFirst Federal Charlotte-Mecklenburg Credit Union Gregory C. Scott, Community Action Kate Larose, CVOEO Partnership of Orange County Laura D’Alessandro, LISC Angel Lee, Prosperity Now Anindya Sengupta, Prudential / David Derryck, EARN Meg Lovejoy, Institute on Assets and Social Strategic Initiatives Policy Brandeis University Bill Druliner, GreenPath Kenneth Smith,Grace Mar Services Inc Sangeetha Malaiyandi, Bureau of Tracy Faleide, WEX Health Nashila Somani-Ladha, Commonwealth Consumer Financial Protection Abbie Gilbert, Humana Carter Steger, American Cancer Society Melody Marchese, Belmont Housing Melissa Gopnik, Commonwealth Resources for WNY, Inc. Cancer Action Network Andrea Green, LaGuardia Bea Stotzer, New Capital LLC Wil McCall, Dallas Leadership Foundation Community College Kimberly Tang, Chinese Community Center David McGee, Build Wealth Minnesota Lisa Hasegawa, National CAPACD (former) Kalena Thomhave, The American Prospect Regina McGee, Build Wealth Minnesota David Kilby, FinFit Karan Tucker, Jannus, Inc. Penny McPherson, Wells Fargo Peter Long, Blue Shield of California Elsie Meeks, Lakota Funds Emy Urban, The Aspen Institute Foundation Monica Mitchell, Wells Fargo Lindsey Vaclav, Accounting Aid Society Abigail Marquez, Housing and Community Investment Department, City of Los Angeles Erin Moos, Intuit Financial Freedom Tracy Wiedt, American Cancer Society Tom More, BCU Foundation Katina Williams, United Way of Greater Greg Morishige, Wells Fargo Richmond & Petersburg Rachel Van Noord, BECU Mercedeh Mortazavi, JPMorgan Chase Kenneth Worthey, National Credit Union Kimberly Ostrowski, Prudential Financial Administration Amy Nelson, University of Nevada, Reno Padmini Parthasarathy, California Wellness Foundation (former) VanNhi Nguyen, LISC Houston EMERGE Financial Health Forum Jake Peters, Payperks Cameron Nicholson, YMCA June 6, 2018 at the CFSI’s annual EMERGE Sabra Purifoy, Department of Consumer Erin Offord, Big Thought Financial Health Forum in Los Angeles and Business Affairs, Los Angeles County Becky Pakarinen, Lutheran Social Service Michelle Rhone-Collins, LIFT-LA of Minnesota List of Attendees Padmini Parthasarathy, The California Anne Romatowski, JPMorgan Chase Wellness Foundation (former) Charlene Bauer, Metro Credit Union Kristen Simmons, Experian Health Sonya Passi, FreeFrom Katie Beacham, Fiserv Bea Stotzer, NEW Capital LLC Marjorie (Marne) Piccolomini, CFC- Marcus Berkowitz, Grameen America Andrew Weltman, Union Privilege Cleveland Neighborhood Progress Nathan Bidnet, Charles Schwab Sarah Willis, Metlife Foundation Walkiria Pool, Centro de Apoyo Familiar Francis Poole, Juma Ventures Andrew Posner, Capital Good Fund Michelle PRISM, PRISM Roslyn Quarto, Empowering and Strengthening Ohio’s People Richard Reeve, CCCS of Savannah Kate Reeves, The Financial Clinic Katherine Rios, UnidosUS Jorge Riquelme, Community Housing Works (CHW) Stephen Roll, Washington University in St. Louis Kelly Rome, Prudential Financial Karina Ron, United Way of Miami Dade 32

APPENDIX G List of Resources

Sources Organization(s) Author(s)

100 Million and Counting: A Portrait of Policy Link, USC Program for Environmental Economic Insecurity in the United States & Regional Equity

2016 SCF Chartbook Federal Reserve

A Municipal Policy Blueprint for Prosperity Now Holden Weisman a More Inclusive Path to Prosperity

Home Delinquency Rates Are Lower Among The Center for Social Development, George Emily A. Gallagher, Radhakrishnan Gopalan, ACA Marketplace Households: Evidence From Warren Brown School of Social Work Michal Grinstein-Weiss, Stephen P. Roll, and a Natural Experiment Genevieve Davison

The African American Financial Capability Prosperity Now African American Financial Cat Goughnour and Lillian Singh Initiative: An Implementation Blueprint Capability Initiative

Alliance for Health Equity Alliance for Health Equity

Antipoverty Impact Of Medicaid Growing Health Affairs Naomi Zewde and Christopher Wimer With State Expansions Over Time

ASPPH: Discover Association of Schools and Programs of Public Health

Financial Coaching: An Asset Building Strategy Asset Funders Network Dr. J. Michael Collins

Assets for Independence Program Report U.S. Department of Health and Human Services to Congress: Status at the Conclusion of the Sixteenth Year, Fiscal Year 2015

Better for Employees, Better for Business: Financial Health Network, Morgan Stanley The Case for Employers to Invest in Employee Financial Health

Beyond Health Care: New Directions Robert Wood Johnson Foundation to a Healthier America

Bound: How Race Shapes the Outcomes Prosperity Now Lebaron Sims of American Cities

Building Savings for Success: Early Impacts Urban Institute Gregory B. Mills, Signe-Mary McKernan, from the Assets for Independence Program Caroline Ratcliffe, Sara Edelstein, Mike Randomized Evaluation Pergamit, Breno Braga, Heather Hahn, Sam Elkin

Can Savings Help Overcome Income Instability? The Urban Institute Gregory Mills, Joe Amick

CFE Coalition City Expert Topics: Reentry Cities for Financial Empowerment Fund Integration Strategies

Fifth Avenue Committee (FAC) Change Capital Fund

Cleveland’s Greater University Circle Initiative: The Democracy Collaborative Walter Wright Kathryn W. Hexter Nick Downer An Anchor-Based Strategy for Change

Consumer Debt: A Primer The Aspen Institute FOSTERING HEALTHY NEIGHBORHOODS | 33

Sources Organization(s) Author(s)

Consumer Financial Health Study: Financial Health Network Aliza Gutman, Thea Garon, Jeanne Hogarth, Understanding and Improving Consumer Rachel Schneider Financial Health in America

Consumer Fraud in the United States, 2011: Federal Trade Comission Keith B. Anderson The Third FTC Survey

Coping with Costs Big Data on Expense JPMorgan Chase & Co. Institute Diana Farrell, Fiona Greig Volatility and Medical Payments

County Health Rankings and Roadmaps - Robert Wood Johnson Foundation Policies and Programs That Can Improve Health

County Health Rankings & Roadmaps: Robert Wood Johnson Foundation Unemployment

Data by Issue Prosperity Now Scorecard

Digest of Education Statistics 2016 National Center for Education Statistics, Thomas D. Snyder, Cristobal de Brey, American Institutes for Research Sally A. Dillow

DotHouse Health DotHouse Health

Economic Mobility: Research & Ideas Federal Reserve Bank of St. Louis, the Board on Strengthening Families, Communities of Governors of the Federal Reserve System & the Economy

Effects of a Tax-Time Savings Experiment on Journal of Poverty Mathieu R. Despard, Samuel Taylor, Chunhui Material and Health Care Hardship among Ren, Blair Russell, Michal Grinstein-Weiss, Low-Income Filers Ramesh Raghavan

Employee Financial Health: How Companies Center for Financial Services Innovation (CFSI) Sohrab Kohli, Rob Levy, Can Invest in Workplace Wellness

Enterprise Opportunity 360 Measurement Enterprise Community Partners Report

Evaluation of the Compass Family Self- Abt Associates, Compass Working Capital, U.S. Judy Geyer, Lesley Freiman, Jeffrey Lubell, Sufficiency (FSS) Programs Administered Department of Housing and Urban Development Micah Villarreal in Partnership with Public Housing Agencies in Lynn and Cambridge, Massachusetts

Fifth Third Express Banking Fifth Third Bank

U.S. Financial Health Pulse: 2019 Trends Financial Health Network Beth Brockland, Thea Garon, Andrew Dunn, Eric Report Baseline Survey Results Wilson, Necati Celik

Financial Well-being: The Goal of Financial Consumer Financial Protection Bureau Education

Health and Financial Wellbeing: Two Good The National Credit Union Foundation Christiane Gigi Hyland, Christopher J. Revere Things That Go Better Together

Health Care and Opportunity Zones: The New Localism Ken Gross, Evan Weiss, Bruce Katz The Game Begins

Healthcare Anchor Network Healthcare Anchor Network

Household Financial Stability Center for Household Financial Stability Federal Ray Boshara and Income Volatility Reserve Bank of St. Louis 34

Sources Organization(s) Author(s)

How Neighborhoods Help New Yorkers Get New York City Department of Consumer Affairs Ahead Findings From the Collaborative for Neighborhood Financial Health

In the World of Community Wealth-Building, ShelterForce Tamara E. Holmes Ownership Has Its Privileges

Key Resources to Help Your Organization Adopt Prosperity Now Melissa Grober-Morrow and Improve Financial Capability Services

Labor Force Statistics from the Current United States Department of Labor, Bureau of Population Survey Labor Statistics

Leveraging Innovation to Support the Financial Financial Health Network Josh Sledge, Aliza Gutman, James Schintz, Health of LMI Families with Children Rachel Schneider

National Health Expenditure Data , Historical Centers for Medicare & Medicaid Services

Neighborhood Network Analysis Pre Read The Boston Consulting Group, United Way of Metro Chicago

Neighborhood Poverty and Household The Pew Charitable Trusts Financial Security

New America: Overview New America

Paying for Healthcare in America Wex Inc.

Paying Out-of-Pocket: The Healthcare JPMorgan Chase & Co. Institute Diana Farrell, Fiona Greig Spending of 2 Million US Families

Preparing for Tomorrow by Fixing Today: Center for Financial Services Innovation (CFSI) Karen Andres, Katy Golvala Helping Low- and Moderate-Income Americans Thrive in Retirement

Prosperity Now, 2019 Scorecard Prosperity Now

Prosperity Now, Getting a Head Start Prosperity Now

Race Matters: The Concentration of Payday Center for Responsible Lending Uriah King, Wei Li, Delvin Davis, Keith Ernst Lenders in African-American Neighborhoods in North Carolina

Report on the Economic Well-Being of U.S. Board of Governors of the Federal Households in 2017 Reserve System

Responses to and Repercussions from Income The ASPEN Institute, The Center for Social Stephen Roll, David S. Mitchell, Krista Holub, Volatility in Low- and Moderate-Income Development, George Warren Brown School Sam Bufe, Michal Grinstein-Weiss Households: Results from a National Survey of Social Work, Intuit

Routinizing the Extraordinary Investing in What Works for America’s David Erickson, Ian Galloway, Naomi Cytron Communities

Scaling Financial Coaching: Critical Lessons NeighborWorks America and Citi Foundation and Effective Practices

Scaling Financial Development: Improving The Financial Clinic Rebecca Smith, Mae Watson Grote Outcomes and Influencing Impact and Karina Ron

Smart Organizations, Strong Neighborhoods: Change Capital Fund Measurable, Scalable Impact FOSTERING HEALTHY NEIGHBORHOODS | 35

Sources Organization(s) Author(s)

Strategies for Building Healthy, Get Healthy San Mateo County Equitable Community

Strengthening Santa Fe Through Affordable Homewise Home Ownership

Tacoma Housing Authority’s Children’s Savings Urban Institute for theTacoma Housing Martha Galvez, Brandi Gilbert, Alyse Oneto, Account Program Evaluation Interim Report Authority Nicole DuBois

The Consequences of Gentrification: A Focus Cityscape, U.S. Department of Housing Lei Ding, Jackelyn Hwang. on Residents’ Financial Health in Philadelphia and Urban Development, Office of Policy Development and Research

The Experience of Volatility in Low and The ASPEN Institute, The Center for Social Stephen Roll, David S. Mitchell, Sam Bufe, Moderate-Income Households: Results Development, George Warren Brown School Gracie Lynne, Michal Grinstein-Weiss From a National Survey of Social Work

The Impacts of Neighborhoods on National Bureau of Economic Research Raj Chetty, Nathaniel Hendren Intergenerational Mobility I: Childhood Exposure Effects.

The Movement Takes Off: The State of the Prosperity Now Children's Savings Filed 2017

The Potential of Downpayment Assistance for U.S Department of Housing and Urban Christopher E. Herbert, Winnie Tsen Increasing Homeownership Among Minority Development, Office of Policy Development and and Low-Income Households Research (PD&R)

The Road to Zero Wealth How the Racial Wealth Prosperity Now, Institute for Policy Studies Emanuel Nieves, Chuck Collins, Josh Hoxie Divide is Hollowing Out America’s Middle Class

The Role of Emergency Savings in Family The Pew Charitable Trusts Financial Security: How Do Families Cope with Financial Shocks?

The State of the Nation's Housing 2018 The Joint Center for Housing Studies of Harvard University

Universal Accounts at Birth: Results from The Center for Social Development, George Sondra G. Beverly, Margaret M. Clancy, SEED for Oklahoma Kids Warren Brown School of Social Work Michael Sherraden

Urban Wire, Housing and Housing Finance: Urban Institute Christina Plerhoples Stacy, Brett Theodos, An Innovative Model for Reducing Gaps in Bing Bai Homeownership

Wage Stagnation in Nine Charts Economic Policy Institute Lawrence Mishel, Elise Gould, Josh Bivens

Wealth Matters for Health Equity University of San Francisco, Robert Wood Paula Braveman, Julia Acker, Elaine Arkin, Johnson Foundation Dwayne Proctor, Amy Gillman, Kerry Anne McGeary, Giridhar Mallya wellQ wellQ

What Could We Have Expected from a $10 Federal Reserve Bank of St. Louis Charles Gascon, Daniel Eubanks Minimum Wage in the City of St. Louis?

What Is Health Equity? And What Difference University of California San Francisco, Robert Paula Braveman, Elaine Arkin, Tracy Orleans, Does a Definition Make? Wood Johnson Foundation Dwayne Proctor, Alonzo Plough

What It's Worth - Strengthening the Financial Federal Reserve Bank of San Francisco, Editors: Laura Choi, David Erickson, Future of Families, Communities and the Nation Prosperity Now Kate Griffin, Andrea Levere, Ellen Seidman 36