2020 has created a new urgency around investing in community health as a bedrock of individual and community quality of life. This year, disease and death data coming from the COVID-19 pandemic, alongside discussions around structural racism after the death of George Floyd, have reshaped the conversation.

The pandemic showed the vulnerable underbelly of health disparity. It became clear people of color and low-income populations disproportionately became infected and died. In fact, Black, Hispanic and American Indian people have been 2.5 times more likely to contract COVID-19 than white people and five times more likely to be hospitalized.¹

Deaths from coronavirus largely align with the overall racial composition of the United States with two notable exceptions:

• While only 13% of the U.S. population is Black, 21% of those who died from coronavirus are Black.³,⁴

• While only 18% of the U.S. population is Hispanic, 21% of those who died from coronavirus are Hispanic.²,³

Several forces led to people of color being disproportionately affected. First, there is a higher incidence of underlying health conditions such as diabetes, heart disease and lung disease that are associated with about 90% of the hospitalizations for COVID-19.⁵

People of color also have experienced greater risk exposure since they were slightly more likely to be essential workers—representing 39% of the U.S. population but 45% of essential workers.⁶ For many, being an essential worker made social distancing impossible, since their role required close contact with the public... and often no paid sick days.

While data from the COVID-19 pandemic was already enough to spark a meaningful discussion about race and health equity, the death of George Floyd then intensified conversations about racism and its impact on health status.

Right now, few of us are likely doing as much as we could to address these issues. However, we must leverage this moment of consciousness to push us forward in affecting positive change. In exploring the greater context of these opportunities, let’s discuss what we mean by health equity, the rationale for change, pathways to achieving it and what you can do now as a leader. Ultimately, the intent is to explore the dynamics in order to shape a path for action. Simply, we can no longer say this is not our problem or our role to address—this is everyone’s problem—so we must decide if we will be architects and activists for change or whether we will simply be bystanders.

Exploring Health Equity

As we begin our conversation, there is value to defining what we mean by health equity. Today in the United States, widespread differences in health status—such as illness, disability or mortality—are closely linked to race, ethnicity, socioeconomic status, gender, sexual identity and more. Inequity results in health disparities such as increased rates of heart disease, cancer, diabetes and asthma, as well as drug abuse and violence.⁸ The U.S. Department of Health and Human Services notes inequities are “unfair, unjust, avoidable, or unnecessary” conditions that can be “reduced or remedied.”⁹ So, simply, health inequity means select people in our country unnecessarily and consistently face greater health risks and experience poorer health because of their race, socioeconomic status or other identifiers.

Health inequity is largely fueled by consistent and avoidable differences in access to resources and support. So, it’s valuable to consider that a person’s health status is largely shaped by:

• individual risk factors such as behavior or genetics

• access to quality medical care

• social determinants of health

Social determinants of health have the most influence on health status. In fact, 80% of a person’s health is shaped by social determinants of health rather than the work of health care organizations. Social determinants of health are driven by social, economic and environmental factors that shape the conditions in which a person is born, lives, works and plays. These differences are deeply intertwined with socioeconomic status, educational attainment and social power. They also reflect social needs such as access to:

• Fresh, healthy, affordable foods

• Safe, stable, affordable housing

• Reliable transportation

• Safe places to play

• Social integration and support

Access to health care is also part of the social determinants of health. Key concerns are the lack of access to health care services and resources such as:

• hospitals and clinics

• physicians and clinicians

• culturally competent care

• medical technology

• prescription therapies and medications

Therefore, for many, social determinants of health are the visible face of structural racism. Structural racism is the most complex and entrenched form of racism. It is not about our individual attitudes, intentions and behaviors toward others. It is about macrolevel systems such as institutions, ideologies, culture, law, policy and processes that interact with one another to reinforce inequality.10 Structural racism leads to a “systematic disadvantage of one social group compared to other groups with whom they coexist.”¹¹

Clearly, there is a value chain here. Since social determinants drive 80% of health status, health organizations must tackle the root causes of poor health in the intertwined issues of structural racism and social determinants of health to truly elevate the health status. While health organizations have discussed the importance of moving upstream to address social determinants of health and social needs for more than a decade, most organizations have never substantively moved from discussion to action or have created fractured approaches— largely because of resource constraints. While impacting deeply embedded social, economic, environmental and structural factors that create health disparities and inequity is daunting, change must start somewhere...and fostering collective action through philanthropy and partners will emerge as a vital, new imperative.

Rationale for Addressing Health Equity

There are many reasons for health organizations to take a bold and proactive stance to address health equity. For example, it would align with a changing perception of the role of health care, elevate overall health status, achieve significant economic benefits and support expectations for collaborative solutions. All these things validate the rightness of deepening our resolve in this space. So, let’s look at the rationale for action.

Changing Understanding of Health Care

Amplified conversations about addressing disparities comes at a time when health organizations are already reconsidering and reimagining their roles. While hospitals and health systems have traditionally treated illness and injury, hospitals now face an expanding vision of their role that encompasses prevention and addresses social needs. Health care’s new measure of mission fulfillment is referred to in a lot of ways: community health impact, population health, addressing social determinants of health and more; however, the singular focus is to proactively elevate individual and community health status. A new article from McKinsey Global Institute articulates the opportunity well: “We must pay as much attention to health as we do to illness...The real question is how to shift from a focus on disease care to a mindset of disease prevention and health promotion while ensuring effective acute care services and sufficient capacity to deal with surges and crises. This shift involves ensuring that health promotion, preventive care, and early intervention are prioritized on a par with disease care and treatment.”¹²

Elevating Overall Health Status

As health organizations expand their vision of their roles, improving the health of individuals and communities remains at the heart of their mission. With that in mind, there are significant vulnerabilities in our current system if we fail to address health equity. Today, multiple sources rank overall health status and health care in the U.S. below that of dozens of other countries based on measures including mortality, disease burden, treatment outcomes and more. One of the obstacles frequently cited to explain the United States’ low rankings is the consistency and severity of health disparities.

KFF notes, “Disparities in health and health care not only affect the groups facing disparities, but also limit overall gains in quality of care and health for the broader population and result in unnecessary costs.”¹³

Harvard Business Review echoes and expands on those thoughts in adding, “Eliminating racial disparities in health care is vital to pushing the entire health care system toward improving quality while containing costs—so-called value- based care.”¹²

Exploring the Financial Rationale

Beyond elevating health status, there is a powerful financial argument for addressing equity. Simply, reducing health disparities would drive significant economic value. Today, the United States spends far more on health care than any other country in the world—and without having the health status to show for it. U.S. health care costs represent 17% of the value of all goods and services produced within our country in one year...also known as our Gross Domestic Product (GDP). This 17% spend is 50% more than the next highest spender, France, which spends 11.6%. This equates to the U.S. spending more than $9,000 per American per year on health care while most developed nations spend $3,000 to $6,000 per person per year.15 Further, a significant percentage of this annual spend is associated with racial health disparities including “an estimated $35 billion in excess health care expenditures.”¹⁶

However, we must have an honest moment here. The financial incentives for most hospitals are not currently aligned for them to prioritize this work. While our nation is moving toward a paradigm where hospitals are compensated based upon value rather than volume, many hospitals today still exist in a volume-driven, fee- for-service world, so reducing utilization reduces critical revenue. When hospital bottom lines are already fragile, this can provide a disincentive to proactively pursue community health.

Still, when we consider the long game, addressing disparities could not only reduce the total cost of care but also would support appropriate utilization of services and more whole care for patients.

Aligning with Expectations for Collaboration

Finally, we must consider the position health care organizations occupy on the field now. COVID-19 has pushed health to the top of the agenda of not only health organizations but also of governments, corporations, community agencies, funders and others. Therefore, it is unlikely health organizations will have sole purview to seek to solve these issues alone going forward. Further, the issues to address are complex and deep, so it would be impossible for health organizations to make a meaningful difference alone. With that in mind, there will be a growing expectation for health organizations to collaborate with others. However, collaboration can also be tricky...and a new breed of partnership is also likely needed.

Many health organizations serve as anchor organizations for community health partnerships. Health organizations often lead because they have the data, resources, organizational capacity and expertise to provide leadership in this space. However, health organizations have also been criticized for imposing their own vision and solutions rather than working in true partnership with other organizations and with the individuals and communities to be served. So, one of the new hallmarks of partnership will be seeking to listen and to understand the perspectives of other organizations and the lived experience of the people health organizations seek to help.

One of the new hallmarks of partnership will be seeking to listen and to understand the perspectives of other organizations and the lived experience of the people health organizations seek to help. Health organizations must also overcome their squeamishness around partnering with each other.

Health organizations must also overcome their squeamishness around partnering with each other. Within the COVID-19 pandemic, we saw multiple instances of market competitors working together to care for their communities. So, while the posture between hospitals in a single market has often been one of competition in a zero sum game for market share of commercial patients, we must find a way to supersede competition. Simply, the focus should be on end users of our services—patients and families—and we know health organizations combining their expertise, resources and geographic footprints would be powerful. Ultimately, pulling together the threads of a community to have a shared vision for impact and to harness the power of many resources, agencies, leaders and funders can be catalytic in driving real change...and is the only way we are going to be successful.

As health philanthropy leaders, you also know impact-driven donors and large health care funders want to see cross-sector collaboration. Health funders are also increasingly giving to those outside the traditional health care space— such as schools, housing organizations and food banks—to drive health outcomes. In short, new expectations for crafting broad and collaborative solutions have emerged whether health organizations are ready or not, so we need to be willing to shift our gaze from looking internally at the hospital to looking externally at all the possibilities for collective progress toward mutual objectives to elevate health status.

While genuinely improving the health of our communities is our shared goal, I feel sure some of you must be saying, ”health inequity is not the foundation’s issue” or “what am I supposed to do to address this?” However, one of our challenges is that it’s too easy for everyone to push it off their agenda. Clinical leadership often sees their primary focus within the four walls of the health organization. Hospital's community outreach departments are often positioned and resourced to do things like health fairs but not to address complex social issues. Community benefit offices are often immersed in ensuring compliance with creating the Community Health Needs Assessments (CHNAs) and filing the Schedule H, but often have little bandwidth or budget to drive meaningful implementation. So, we need to build cross-functional teams within our health organizations to ensure this is owned and advanced. And, within these teams, the foundation can play a key role. Here are five places to start:

1. Talk to your executive leadership colleagues to find out what is in the hospital’s Community Health Needs Assessment. All nonprofit hospitals are required to do one every three years and are required to file an implementation plan. Find out what’s in it...and what could have potential for philanthropic investment. While your role as a foundation is to raise money o support the hospital in fulfilling its mission, this new era of health care has already thrust community health to the top of many health care organization’s strategic agendas.

2. As health care organizations seek to advance health equity, it is a natural place for philanthropy. We all know “philanthropy” from the Greek spoke of demonstrating love of humankind, and voluntary giving to foster health equity would certainly be an expression of love. Philanthropy is also well positioned to take risks by investing in new ideas and approaches that may be untested but could be transformational. So, illuminate the opportunity to foster greater health equity to donors and health funders. Today’s donors are indeed social impact investors who want to affect real change. Talk to them about how the health organization can go upstream to address social determinants of health or social needs rather than treating illness and injury downstream. Or, talk about initiatives to support access, preventive care and more. Most hospitals will have a ready list of opportunities for charitable investment in community health articulated within the Community Health Needs Assessment.

3. Talk to the foundation board about how the foundation can be more strategic in its work. How can you ensure philanthropic priorities are not only tightly aligned with the health organization's strategic priorities but also embrace how priorities are changing as health organizations shift from a primary focus on illness and injury to a broader focus on elevating health status? Also, talk about how you can prioritize funding initiatives with clear and measurable outcomes to demonstrate impact.

4. While you are having these conversations with your foundation board, it's also a good time to engage the board in a larger conversation around how the foundation demonstrates its commitment to addressing health equity and racism by increasing diversity, equity and inclusion through board recruitment. Today, only 15% of nonprofit ward members are people of color. Talk about how your board composition can start to mirror your community to give a voice to all those you represent. ¹⁷

5. Support your health organization in forging community partnerships. Collaboration to advance health not only could unleash access to information, infrastructure and scale but also could support creating more robust solutions. Partnership provides access to more data to understand interconnected issues and to identify root causes. Coming together leverages limited resources and enables resources to be directed to areas of greatest impact. Community partnership creates an environment that is more conducive to building sustainable solutions and to identifying replicable best practices. Ultimately, collective action hospitals alongside other stakeholders best supports enhancing access to care, addressing social determinants of health and decreasing health inequity. So, utilize the strong relationship equity and trust you have built with the leaders of other community nonprofit organizations—such as food banks and housing organizations—to support the hospital’s goals for collaboration.Given that many donors are also community influencers, invite them to be part of building broader coalitions between businesses, nonprofit agencies, funders and others to affect change. There is power in synergy, shared resources and breaking down silos—and you can play a vital role in making connections.

Here’s the thing. Health organizations have intellectual capital, infrastructure, scale, business intelligence and access to key populations that ideally positions them to advance smart solutions to complex health problems. At the same time, health foundations have access to visionary donors and funders with the ability to invest in those solutions as well as access to potential collaborative partners. So, we must build on this moment of lift when governments, payers, funders, donors and others are mobilized and energized to address these issues. We also must understand the risk of hesitation. If the traditional health sector—including our hospitals and our health foundations—fails to step forward to address these issues...others will. So, we must decide if we choose to lead you or if we want to follow.

I believe you want to be a catalyst for affecting change that will lift up your community and will make health truly accessible for all. So, make a commitment to have conversations about how you can support the health organization in funding its strategic initiatives for community health and consider making the intention to support equity one of the elements of deliberation around selecting future projects for philanthropic funding.

You have an opportunity to spur collective action to create whole and sustainable solutions to enhance access to care, to address social determinants of health and to increase health equity. I believe you are ready for this expansion of your role, and it is aligned with the evolving changes in the role of health organizations. So, I urge you to explore how you will add value in this space alongside donors, partners and others who wish to support health.

¹ COVID-19 Hospitalization and Death by Race/Ethnicity. (Aug. 18, 2020). Centers for Disease Control and Prevention. https:// www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html

² United States Census Bureau. https://www.census.gov/quickfacts/fact/table/US/PST045219

³ Elflein, John. (Oct 5, 2020). Distribution of COVID-19 (coronavirus disease) Deaths in the United States as of September 30, 2020, by Race*. Statista. https://www.statista.com/statistics/1122369/covid-deaths-distribution-by-race-us/

⁴ Frey, William H. (July 1, 2020). The nation is diversifying even faster than predicted, according to new census data. Brookings Institution. https://www.brookings.edu/research/new-census-data-shows-the-nation-is-diversifying-even-faster-than-predicted/

⁵ Golden, M.D., M.H.S., Sherita Hill. (April 20, 2020). Coronavirus in African Americans and Other People of Color. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/covid19-racial-disparities

⁶ McNicholas, Celine and Poydock, Margaret. (May 19, 2020). Who are essential workers? A comprehensive look at their wages, demographics, and unionization rates. Economics Policy Institute. https://www.epi.org/blog/who-are-essential-workers-a- comprehensive-look-at-their-wages-demographics-and-unionization-rates/

⁷ The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S. (Oct. 15, 2020). https://www.apmresearchlab.org/ covid/deaths-by-race

⁸ Powell, Alvin. (February 22, 2016). The costs of inequality: Money = quality health care = longer life. The Harvard Gazette.https://news.harvard.edu/gazette/story/2016/02/money-quality-health-care-longer-life/

⁹ Health Equity Report 2017. U.S. Department of Health and Human Services Health Resources and Services Administration Office of Health Equity. https://www.hrsa.gov/sites/default/files/hrsa/health-equity/2017-HRSA-health-equity-report.pdf

¹⁰ Powell, John A. (2008). Structural Racism: Building upon the Insights of John Calmore. North Carolina Law Review 2008;86:791– 816. https://scholarship.law.unc.edu/nclr/vol86/iss3/8/

¹¹ Baciu A, Negussie Y, Geller A, et al., editors. (January 11, 2017). Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States, National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK425845/#__NBK425845_dtls__

¹² Linzer, Katherine and Remes, Jaana and Singhal, Shubham. (October 5, 2020). How prioritizing health is a prescription for US prosperity. McKinsey Global Institute. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/how- prioritizing-health-is-a-prescription-for-us-prosperity#

¹³ Artiga, Samanth and Orgera, Kendal and Pham, Olivia. (Mar 04, 2020). Disparities in Health and Health Care: Five Key Questions and Answers. KFF. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-five-key- questions-and-answers/ ¹⁴ Avanian, John Z., MD. (October 1, 2015). The Costs of Racial Disparities in Health Care. Harvard Business Review. https://hbr. org/2015/10/the-costs-of-racial-disparities-in-health-care ¹⁵ Squires, David and Anderson, Chloe. (October 8, 2015). U.S. Health Care from a Global Perspective. The Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective ¹⁶ Avanian, John Z., MD. (October 1, 2015). The Costs of Racial Disparities in Health Care. Harvard Business Review. https://hbr. org/2015/10/the-costs-of-racial-disparities-in-health-care ¹⁷ Leading with Intent: 2017 National Index of Nonprofit Board Practices. BoardSource. https://leadingwithintent.org/wp-content/ uploads/2017/11/LWI-2017.pdf