At the Intersection of Health, Health Care and Policy

Cite this article as: Mariana Arcaya and Xavier de Souza Briggs Despite Obstacles, Considerable Potential Exists For More Robust Federal Policy On Community Development And Health Health Affairs, 30, no.11 (2011):2064-2071

doi: 10.1377/hlthaff.2011.0778

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By Mariana Arcaya and Xavier de Souza Briggs doi: 10.1377/hlthaff.2011.0778 HEALTH AFFAIRS 30, NO. 11 (2011): 2064–2071 ANALYSIS & COMMENTARY ©2011 Project HOPE— The People-to-People Health Foundation, Inc. Despite Obstacles, Considerable Potential Exists For More Robust Federal Policy On Community Development And Health

Mariana Arcaya (marcaya@ hsph.harvard.edu) is a doctoral ABSTRACT The implementation of the Affordable Care Act of 2010 and the candidateintheDepartment Obama administration’s urban policy create an opportunity to link of Society, Human Development, and Health at community development with health in new and powerful ways. The the Harvard School of Public ’ Health, in Boston, administration s policy emphasizes improved access to and quality of care Massachusetts. through coordinated local and regional approaches, expansion of access — Xavier de Souza Briggs is an to healthy food, and the support of environmental health including associate professor of clean air, water, and soil—and healthy homes. New federal programs, sociology and planning at the ’ Massachusetts Institute of such as the Affordable Care Act s Community Transformation Grants, Technology, in Cambridge. seek to prevent death and disability through policy, environmental, programmatic, and infrastructure changes. But fragmented congressional jurisdiction and budget “scoring” rules pose challenges to needed reform. We argue that government agencies need to adopt so-called systems of innovation, or organizational practices and support mechanisms that seek continuously to test new models, refine promising ones, bring to scale those that work best, and restructure or terminate what does not. We also argue that a strong and well-focused policy advocacy coalition is needed to help drive reform focused on the social determinants of health.

he implementation of the Afford- demands coupled with little decision-making able Care Act of 2010 and the im- power or control at work—is linked to poor car- perative to reduce the cost of health diovascular health.2 Low and unstable income care while improving outcomes cre- predicts worse cognitive, physical, and psycho- ate the opportunity to forge closer logical functioning over time, compared to the Tlinks between community development and functioning of people who do not suffer eco- health. Fortunately, the evidence base is now nomic hardship.3 Discrimination is a known risk strong enough to warrant a major focus on shap- factor for unhealthy behavior, psychological dis- ing the social determinants of health through tress, and high blood pressure.4 community development. More proximate social determinants of health, Researchers have established that the social such as living conditions in the home and neigh- and physical environment, not just genetic borhood, can affect exposure to both environ- makeup and individual behavior, influences mental and social risk factors for poor health. health outcomes. It is clear, for example, that For example, both allergens and violence in the structural determinants of health such as socio- home increase the risk of developing childhood economic status have serious health conse- asthma.5 Similarly, material exposures—such as quences.1 Stress—including as a result of high air quality and food access—and psychosocial

2064 Health Affairs November 2011 30:11 Downloaded from content.healthaffairs.org by Health Affairs on November 9, 2011 at MASS GENERAL HOSPITAL exposures—such as social support and fear of large and persistent differences across socioeco- crime—can increase residents’ chances of suffer- nomic and racial or ethnic groups in health, ing mental health problems, becoming obese, income, educational attainment, and other out- engaging in unhealthy behavior, and even comes. That is, both community development dying.6,7 and efforts to address social determinants of In addition, it is clear that social factors influ- health seek to move beyond resolving individ- ence what happens when someone does get sick. ual-level problems and symptoms case by case For example, racial and ethnic minorities have to increasing opportunities for health and well- been shown to receive worse health care than being across the population as a whole. non-Hispanic whites, even after income, age, and health status differences are accounted for.8 Community development can be a useful tool A Framework To Shape Health for effecting change, especially in improving liv- Outcomes ing conditions in homes and neighborhoods. With so many possible interventions, it is impor- There is much that we do not yet know about tant to identify those areas in which community which health-oriented interventions are most development is best—even uniquely—positioned promising for particular populations in particu- to shape positive health outcomes. It will be lar community settings. Equally, we need more necessary to design rigorous, actionable frame- information about the scale of return on invest- works that accommodate organizing principles ment in community development.9,10 But during from both community development and health. the past decade, encouraging evidence has accu- Four Pathways From Social Context To mulated that well-run community-based inter- Health Finn Diderichsen, Timothy Evans, and ventions can effectively serve a number of at-risk Margaret Whitehead offer the foundation for populations, including the frail elderly,11 low- one such framework by categorizing the major income children,12 those in the criminal justice social determinants of health.25 They propose system,13 people with HIV/AIDS,14,15 and the four pathways from social context to health: up- chronically homeless.16,17 stream structural drivers of social position; These are overlapping populations that face health-relevant exposures; vulnerability to expo- multiple risks, and they account for a dispropor- sures; and reactive processes that mitigate or tionate share of costs in the health care and other exacerbate the consequences of poor health. support systems.18 The evidence underscores, Applying this model to childhood lead poison- in particular, the value of supportive housing, ing as an example, community development which includes targeted social services and might intervene along the first pathway by in- care.19 creasing residents’ incomes—through increased Community development should not be earnings, access to subsidies, or both—so that thought of as limited to improving conditions families could afford better-quality food and in poor urban neighborhoods or rural areas, housing. But neighborhood-level intervention or advancing the health and well-being only of per se is typically able to raise incomes only vulnerable populations. The general public also somewhat, since the larger workforce system, stands to gain from the broader benefits of tax code, capital markets, and other factors drive healthier neighborhoods and housing and what incomes. Access is just a part of the equation. has been termed a broader “geography of oppor- An intervention along the second pathway tunity.”20,21 Results can include improved indoor would be requiring lead paint removal from af- air quality; safer and more walkable streets; fordable housing. Such an intervention could greater access to fresh food; mentoring pro- reduce lead exposure for people living in such grams and other efforts that buffer young people housing. from violence; and networks of active and en- Providing education about hand washing (fre- gaged neighbors who press for these priorities quent washing makes it less likely that a child and also provide direct social support for indi- will unintentionally ingest lead in dust) and viduals and families in need. Each is a vital con- child nutrition (proper nutrition can reduce tributor to the health of the public,6 and together the amount of lead that the body absorbs) is they achieve the goals that community develop- an intervention along the third pathway. It could ment has long pursued.22–24 reduce vulnerability to lead poisoning for chil- Community development and evolving efforts dren in homes with lead-based paint. to promote reforms that reflect the social deter- Along the fourth pathway, examples of inter- minants of health share a social movement ori- ventions include improved health care, special entation, and both have social equity as a core education services, and disability insurance. value. More concretely, both seek to tackle the These interventions, although not usually prod- unfair structures of opportunity that produce ucts of community development, could all miti-

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gate the consequences of experiencing lead poi- tandem with our three intervention types, soning. specific solutions emerge, including some with Three Intervention Types To build on this potentially large and wide-ranging impacts. For basic framework of multiple pathways, one example, federal health policy could explicitly needs an “intervention type” dimension to help encourage the promotion of decent, safe, and specify how community development policy and affordable housing as part of improving health. programs can affect each pathway. Three inter- The outlines of what constitutes smart funding vention types are particularly important. The mechanisms are also becoming clear. One first is policy change to create a population-level example of a promising funding model to ad- impact, such as—in this example—regulations dress living conditions through community de- banning the use of lead-based paint. The second velopment is the Community Transformation is funding mechanisms and programming for Grants program authorized under the Afford- place-based activities, such as grant funds for able Care Act. The program is designed to pre- lead abatement in key neighborhoods. The third vent death and disability through policy, envi- is knowledge generation and assessment, such ronmental, programmatic, and infrastructure as a health impact assessment of housing inspec- changes. From the perspective of community tions and code enforcement, both to increase development and health, the program’s essential community engagement and to continuously quality is that it moves beyond the status quo of improve other interventions. treating illness and disease after they emerge to Community development arguably has a role recognizing the role of community context—the to play along all four of the pathways described characteristics and dynamics of the community above. But its most natural targets are the second setting—in shaping health outcomes. The Com- and third—that is, reducing exposure to health monwealth Care Alliance in Massachusetts, a risks and diminishing vulnerability to the risks respected delivery system model, is testing those that people do encounter. Community develop- causal connections, in particular by making ment can be thought of as a tool to address both home- and community-based alternatives to access to positive health-relevant exposures and costly institutional care a central aspect of its freedom from negative ones. These include practice, combined with careful analysis of costs psychosocial health drivers such as chronic and health outcomes. stress and social support and material health Health Impact Assessments The increasing drivers such as food, housing, and education use of health impact assessments in the United (Exhibit 1). Priorities can be set based on ex- States could call public attention to the health pected results (how likely they are and how large consequences of projects and policies that are and sustained they are expected to be) as well as seemingly unrelated to health.26 Such assess- the availability of funding, stakeholders’ sup- ments provide a framework for systematically port, and other resources. examining the potential health effects of gov- When key living conditions are considered in ernment decisions, development plans, or con-

Exhibit 1

Community Development Intervention Points Intervention point Promotes access to Provides freedom from Provision of high-quality, Opportunities for capital accumulation Allergens affordable housing Safer homes, streets, other neighborhood Toxins spaces, and schools (through the nexus Faulty wiring and other with school attendance zones) building-system hazards Housing stability Community organizing and Stronger social support and networks Risks targeted by organizing outreach with wider function efforts, such as violence and Assets targeted by organizing efforts, such as pollution efficient public transportation, grocery Chronic stressors, such as poor stores with fresh food, and playgrounds bus service Predatory marketing Local economic develop- Higher and more secure income Job strain ment, including employment Job control Food deserts and workforce development Improved local goods and services through retail upgrading

SOURCE Authors’ analysis.

2066 Health Affairs November 2011 30:11 Downloaded from content.healthaffairs.org by Health Affairs on November 9, 2011 at MASS GENERAL HOSPITAL terns of residential development on the sub- Community urban fringe of a city affects both access to jobs for city dwellers and traffic congestion for sub- development is about urbanites.28 boosting the vitality During his 2008 campaign for the presidency, signaled his intention to take a of communities of all more regional view of community development, broadly defined. For example, in an address to kinds. the nation’s mayors, he said, “We need to pro- mote strong cities as the backbone of regional growth. And yet,Washington remains trapped in an earlier era, wedded to an outdated ‘urban’ agenda that focuses exclusively on the problems in our cities and ignores our growing metro struction projects before they are implemented areas—an agenda that confuses antipoverty so that health benefits may be maximized and policy with a metropolitan strategy, and ends risks reduced. up hurting both.”24(p3) Although the use of health impact assessments Soon after taking office, President Obama es- is more common abroad, and assessment meth- tablished the first White House Office of Urban ods are still under development,27 they constitute Affairs.29 He noted, “About 80 percent of Amer- important knowledge-building tools. For exam- icans live in urban areas, and the economic ple, they can help communities quantify the health and social vitality of our urban commun- health benefits of building additional affordable ities are critically important to the prosperity housing or the health risks inherent in planned and quality of life for Americans.” The new office state transportation projects, while providing was charged with developing “comprehensive for community input into development proc- urban policy,” coordinating the actions of dispa- esses. By highlighting these connections, health rate agencies and programs to address the vital- impact assessments could build knowledge that ity of places, and working closely with the Office improves decision making and engages the of Management and Budget “to ensure that public. federal government dollars targeted to urban areas are effectively spent on the highest-impact programs.”29(p8139) Obama signed another execu- The Obama Administration’s tive order in June 2011, establishing a rural ‘Place-Based’ Policy counterpart to this agency.30 The Obama administration has made strides to- In August 2009 the heads of the Office of Man- ward establishing a new federal “place-based” agement and Budget, Domestic Policy Council, policy. Community development is inherently Office of Urban Affairs, and National Economic place-based. As noted above, community develop- Council jointly issued the first-ever budget guid- ment is often taken to mean efforts to revitalize ance to federal agency heads on “developing ef- or otherwise upgrade socially and economically fective place-based policies.”31 They argued for a distressed urban neighborhoods and rural more integrated approach to places as a way to areas—places with high rates of poverty and job- reform federal programs and achieve better re- lessness, and often high rates of crime, environ- sults with the taxpayers’ money. “Place-based mental hazards, and sickness. In terms of federal policies leverage investments by focusing re- support, since the 1960s community develop- sources in targeted places and drawing on the ment has relied heavily on place-based aid pro- compounding effect of well-coordinated action,” grams targeting need and distress indicators, the guidance language stated. “Effective place- typically as a way to distribute limited subsidy based policies can influence how rural and dollars. metropolitan areas develop.… The prosperity, But more broadly understood, community de- equity, sustainability, and livability of neighbor- velopment is about boosting the vitality of com- hoods, cities and towns, and larger regions de- munities of all kinds, shoring them up as places pend on the ability of the Federal government to to live, raise a family, operate a business, and enable locally-driven, integrated, and place- meet other needs. And the field of community conscious solutions.”31(p1–2) development is increasingly concerned with the The administration’s guidance to agencies ways in which wealthier and poorer commun- went on to define place policy as something more ities are linked together within a region. One than a suite of aid policies for needy places. It did example is ongoing analysis of how underinvest- not propose to abolish vital aid programs but to ment in urban infrastructure and sprawling pat- improve them, and to focus more on assets and

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root causes of problems rather than on need promoting health in a cost-effective manner. indicators alone. And it included several over- First, the fragmented jurisdictions of the arching goals for place policy that are particu- congressional committee system make it diffi- larly relevant to the social determinants of cult to move forward with a policy proposal that health. seeks to integrate programs based in disparate The guidance said that policy “should promote federal agencies. improved access to care and quality of care Second, in “scoring” the fiscal costs or savings through coordinated local and regional ap- of various federal programs, neither Congress proaches, expansion of access to healthy food, nor the White House is likely to capture the ex- and the support of environmental health— pected gains from projects aimed at improving including clean air, water, and soil—and healthy health through community development. Even homes.” It also said that policy “must also work the best-measured community development pro- to generate opportunity for all and reduce dis- gram effects on, say, health care costs do not crimination and other barriers to opportunity, count as budget savings in the “score” assigned for example through equitable development to legislative proposals. within towns, cities, and regions,” and must And third, much congressional oversight, as “protect communities from external threats well as oversight by agency auditors such as in- and reduce insecurity, violence, and crime spectors general, remains focused on risk man- within communities, particularly in disadvan- agement—that is, identifying and preventing taged areas.”31(p5) waste, fraud, and abuse—rather than on promot- Early in his administration, President Obama ing positive accomplishments, such as better thus established a new leadership unit to co- outcomes for the money spent. ordinate action by a range of federal agencies Added to the above concerns is the larger issue on behalf of local communities, starting with of congressional gridlock. Passage of legislation metropolitan areas. And with an innovative typically requires a supermajority of sixty votes budget guidance document, the administration in the Senate. This means that ambitious, com- established a framework for reform and charged prehensive reform legislation will be rare, and agencies with reflecting that framework in their reformers often end up seeking “waiver” author- annual budget submissions. The framework in- ities so that implementers can experiment in cluded attention to the effects of “place qual- potentially useful ways within the existing pro- ity”—the fundamental concern of community de- gram structure. velopment—on human health. Still another obstacle is what policy makers These efforts have led to or expanded the in- and fiscal experts have called the “wrong pocket tegration of funding approaches across federal problem.” Much of the promise of community agencies and the use of collaboration in local development to affect structural determinants of and environmental sus- health hinges on programs funded through one tainability, as well as a range of proposals that set of agencies to affect health care costs and await congressional response. One example of outcomes in another set. For example, programs the latter is the interagency Neighborhood in the Departments of Justice, Education, and Revitalization Initiative. This proposal seeks to Housing and Urban Development might be fo- integrate competitively allocated housing cused on jointly supporting integrated strategies redevelopment investments by the Department to make at-risk neighborhoods safer, improve of Housing and Urban Development, evidence- housing and schools, and link supportive ser- driven safety improvements funded by the De- vices and community health. partment of Justice, and “cradle to career” educa- As outlined above, the Obama administration tional improvements in the Department of has proposed exactly this sort of coordinated Education’s Promise Neighborhoods program. effort. But if expenditures out of one agency’s “pocket” result in savings that accrue to another agency—perhaps as costs avoided by the Depart- Obstacles: Congress, The Budget, ment of Health and Human Services—it is diffi- And Bureaucracy cult for congressional authorizers and appro- What the president could not do was alter Con- priators to recognize and act on such savings. gress’s approach to authorizing, funding, and This is even truer, of course, if the savings accrue overseeing federal programs, to make it align at other levels of government. For example, some neatly with the new vision. The congressional of the savings from federal spending on the policy making, budgeting, and oversight proc- chronically homeless is realized by county jails esses—in particular, fiscal “scoring” rules—pose and other facilities that receive little or no federal major obstacles to any reform agenda that aims funding, so those savings do not accrue to the to expand the role of community development in federal government.18

2068 Health Affairs November 2011 30:11 Downloaded from content.healthaffairs.org by Health Affairs on November 9, 2011 at MASS GENERAL HOSPITAL In sum, for a variety of reasons, there are lim- change and new discoveries are made. Tools such ited incentives for the federal government to as health impact assessments are ready to be put make even the most rigorously designed and to use in this capacity. targeted preventive expenditures—unless the In the Obama administration, the Depart- spending and savings accrue to a single agency ments of Education and Housing and Urban De- or fall under the jurisdiction of a single velopment have worked with other federal agen- congressional committee, and unless the evi- cies to establish funds for innovation and fought dence of probable impact is very strong. This to sustain them in tough budget battles with is especially true in the current fiscal context. Congress. Nevertheless, in government agencies Community development reform efforts should and other organizations that are key to this dis- be designed to reflect that reality—for example, cussion, comprehensive systems of innovation by focusing initially on scaling up the most tested are nascent at best. Increasing their use is vital to interventions through funding and savings getting agencies to look beyond traditional mod- based, as much as possible, in programs of the els and modes of thinking and to support non- Department of Health and Human Services and traditional approaches that have merit as a cen- tied as closely as possible to the implementation tral part of the agencies’ strategies for impact, of health care reform. not merely in the form of demonstrations that start and stay small. Establish A Policy Advocacy Coalition Conclusion Second, a strong and well-focused policy advo- There are compelling and timely reasons for the cacy coalition is needed. Such coalitions are criti- federal government and its many partners— cal to inventing and achieving reform.32 Those state, local, and tribal agencies, as well as organ- who are a part of such coalitions help each other izations in the private sector—to address social identify shared interests across disparate insti- determinants of health through smarter and big- tutions and specialized policy and professional ger investments in community development. But debates; test ideas in the field; provide political institutional challenges to broad reform are con- and fiscal reality checks for each other; help rep- siderable, too. In this context, two strategies in licate promising approaches across states or in particular will be important. other “laboratories of ”; and play Embed Systems Of Innovation First, it will be other useful roles. vital to firmly establish and embed systems of Best documented in the environmental and innovation in federal, state, and local agencies, national security fields, such coalitions tend to particularly in the implementation of the Afford- be particularly important in cases where achiev- able Care Act. Systems of innovation are organi- ing broad goals requires the participation of ac- zational practices and support mechanisms that tors in multiple specialties and at multiple levels, seek continuously to test new models, refine collaborating to define those goals very clearly promising ones, bring to scale those that work and pursue them very strategically—and allocat- best, and restructure or terminate what does ing precious time, funding, political capital, and not—and to normalize this cyclical approach other resources to effect change.32 in the work of the organization (or network of Such a coalition is just beginning to emerge at organizations working together) as part of act- the intersection of health and community devel- ing strategically on mission. Such systems are opment, thanks to initiatives of the Robert Wood best known in the corporate sector. At Google Johnson Foundation and other philanthropies, and other technology companies, for example, the Federal Reserve System, and other organiza- they are considered crucial to sustaining a com- tions. But there is no guarantee that this emerg- petitive advantage. ing coalition of like-minded, forward-looking In the public sector, systems of innovation players will become well established, strategic, require investments of fiscal and political or effective. Grounded in the framework and resources—including the sustained attention of targets that we have highlighted, a well-focused managers, full-time advocates, policy analysts, policy advocacy coalition designed to connect and other determined reformers, whether they those working inside and outside of the health are inside or outside the agencies that fund or field—both public health and medicine—could deliver services. Systems of innovation create begin to shape policy focused on the social de- not only the enabling environment for particular terminants of health in powerful ways, moving innovations but also the conditions for scaling off the margins and into the mainstream. ▪ them and updating them over time, as needs

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NOTES

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of steps that government agencies opportunity and inequality, racial and others can take to forge even and ethnic diversity, and tighter and more effective linkages democratic governance and between the two fields. leadership. He formerly served as Arcaya is a doctoral candidate in associate director of the White Mariana Arcaya is a the Department of Society, Human HouseOfficeofManagementand doctoral candidate Development, and Health at the Budget under President Obama, at the Harvard Harvard School of Public Health and in the late 1990s he was a School of Public and is a Community Development senior policy official in the Health. Graduate Research Fellow at the Department of Housing and Urban In this month’s Health Affairs, Federal Reserve Bank of Boston. Development. ’ MarianaArcayaandXavierBriggs She is also a senior regional and Briggs s books include Moving to note that a combination of the public health planner at the Opportunity: The Story of an Affordable Care Act of 2010 and Metropolitan Area Planning American Experiment to Fight Ghetto the Obama administration’s Council, in Boston. Arcaya has a Poverty and The Geography of ’ approaches to urban policy creates master sdegreeincityplanning Opportunity: Race and Housing an opportunity to link community from the Massachusetts Institute of Choice in Metropolitan America.He development and health in new Technology. earned a doctoral degree in ways. The authors argue, however, Briggs is an associate professor sociology and education from that such efforts could be of sociology and planning in the and a master hampered by fragmented Department of Urban Studies and of public administration degree congressional jurisdiction and Planning at the Massachusetts from . current federal budget “scoring Institute of Technology. His rules.” They recommend a variety research focuses on economic

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