March 15, 2018; Health Affairs Blog
A new report finds that, broadly speaking, health legacy foundations “are expanding the scope of their grant making and initiatives to focus on the social determinants of health…[seeking] to impact a broad range of social and economic conditions, including housing, transportation, education, child care, job training, and economic development” write Douglas Easterling and Laura McDuffee in Health Affairs Blog.
But while addressing such social determinants of health is now common, as Easterling and McDuffee of the Wake Forest School of Medicine emphasize in their 42-page report—which surveyed 33 foundations in 25 states and was released last week—not all foundations take the same approach.
Among the 33 foundations surveyed, Easterling and McDuffee note that four foundations “positioned themselves as ‘health equity’ funders” and another eight “speak of health equity within their philosophy and strategies.” As for the other 21, these “aim to enhance the overall [emphasis in original] health of the communities they serve.” The risk of a such an approach, Easterling and McDuffee point out, is that, “Even if a foundation succeeds in improving the health status of a population, this might leave important disparities in place.”
Here, it is worth recalling just how large the disparities are. According to the Robert Wood Johnson Foundation, in metro New Orleans, for example, life expectancy can range from 55 years to 80 years depending on where you live. In Fresno, California, an eight-mile distance results a nine-year difference in life expectancy. The Center for Society and Health at Virginia Commonwealth University has developed similar maps for another 21 metropolitan regions.
The importance of health legacy foundations is great. According to Easterling and McDuffee, with notable exceptions like the Robert Wood Johnson Foundation and the Kresge Foundation, health legacy foundations make most of the grants that address the social drivers of poor health.
Grantmakers in Health (GIH) estimates that there are at least 242 health legacy foundations in the United States. These are created, Easterling and McDuffee note, when a nonprofit health organization creates a for-profit company. In such cases, the federal government requires that a percentage of assets remain in the nonprofit sector, typically in foundation form. In the states of California, Colorado, Missouri, Texas, and Washington, health legacy foundations have amassed more than $1 billion in assets. Typically, these foundations have missions that involve “improving the health of a particular community, region, or state,” observe Easterling and McDuffee.
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As for grants, Easterling and McDuffee identify eight primary areas: 1) community building, 2) education, 3) parenting and early childhood, 4) economic well-being, 5) built environment, 6) housing, 7) community safety, and 8) transportation.
In addition to grants, many health legacy foundations have sought to address social drivers of health through low-interest loans (program-related investments), capacity building initiatives, and policy change.
For instance, the Colorado Health Foundation, in Denver used a “program-related investment to the Colorado Coalition for the Homeless (CCH) to establish a revolving housing fund…to finance affordable housing projects including the development of 500 units of permanent supportive housing for families and individuals by 2025.” The REACH Healthcare Foundation in Merriam, Kansas, has launched a Cultural Competency Initiative, in which “health and human service groups in the Kansas City region were provided with individualized technical assistance to improve their services to uninsured and underserved populations.”
Policy change is a strong area of focus, especially among larger, equity-oriented foundations like the California Endowment, the California Wellness Foundation, the Colorado Health Foundation, the Colorado Trust, and the Missouri Foundation for Health. But small foundations invest in policy, too. A small equity-oriented funder, the Con Alma Health Foundation, in Santa Fe, New Mexico, “has an endowment of only $25 million, but policy change is a core element of its strategy…The foundation also funds Amigos Bravos to organize political participation within the affected communities,” Easterling and McDuffee write. The Northwest Health Foundation, in Portland, Oregon, another equity-focused funder, “hosted a high-profile dinner with the speaker of the Oregon House of Representatives to provide an audience for a grassroots group that had previously been unable to get attention focused on its policy priorities.” The Colorado Trust, Easterling and McDuffee note, also uses a community organizing approach.
Even among foundations with an equity focus, however, “Only a few…are seeking to fundamentally shift who has social, political, and economic power,” write Easterling and McDuffee. “In contrast, the vast majority…are working within existing systems and supporting key institutions in improving the services and resources they provide.”
Health legacy foundations, note Easterling and McDuffee, should “recognize this contrast between improving existing systems versus changing the fundamental structures that organize society.” The authors ask, “How much do things need to change to substantively improve the social and economic conditions that cause people to be either healthy or unhealthy?”—Steve Dubb