Social Determinants of Health Caucus – Request for Information Letter

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Attn SDOH Caucus Co-Chairs:
Congresswoman Cheri Bustos
Congressman G.K. Butterfield
Congressman Tom Cole
Congressman Markwayne Mullin

RE: Social Determinants of Health Caucus – Request for Information

Dear Members of Congress:

Please accept this response to the Request for Information from the Congressional Caucus on Social Determinants of Health, on behalf of the National Community Reinvestment Coalition (NCRC).

The National Community Reinvestment Coalition (NCRC) consists of more than 600 community-based organizations, fighting for economic justice for almost 30 years. Our mission is to create opportunities for people and communities to build and maintain wealth. NCRC members include community reinvestment organizations, community development corporations, local and state government agencies, faith-based institutions, fair housing and civil rights groups, minority and women-owned business associations, and housing counselors from across the nation. NCRC and its members work to create wealth-building opportunities by eliminating discriminatory lending practices, which have historically contributed to economic inequality. NCRC believes that health equity is the attainment of the highest level of health for all people in a community, valuing everyone equally, requiring a focused and ongoing effort to address avoidable socioeconomic inequalities in health, healthcare and community development.

NCRC applauds the launch of the new Congressional Caucus on the Social Determinants of Health. The COVID-19 pandemic has exacerbated deeply embedded health inequities, specifically within communities of color. Coordinated efforts to maximize federal investments in critical upstream drivers of health is especially essential as we work to recover from the COVID-19 pandemic.

The NCRC regularly convenes discussions with its members. NCRC conducts local meetings and capacity building training around health equity, healthy communities and community and economic development. We encourage our network of members and allies to respond to the Congressional Caucus Request for Information. The NCRC provides the following response to the Caucus.

RESPONSES TO INDIVIDUAL QUESTIONS

Experience with SDOH Challenges

Question 1: What specific SDOH challenges have you seen to have the most impact on health? What areas have changed most during the COVID-19 pandemic?

NCRC believes that housing is health.^[1] Homes may provide shelter and safety, as well as create a foundation for physical and mental health. NCRC believes that during the pandemic especially, we need to limit excessive trauma and maintain people in their homes, safely, by expediting the delivery of emergency rental assistance (e.g. H.R. 5196 Expediting Assistance to Renters and Landlords Act of 2021). THis relief is particularly important given the Supreme Court’s decision striking down the Center for Disease Control and Prevention’s eviction moratorium.

Question 3: Are there other federal policies that present challenges to addressing SDOH?

Loans and investments made as part of banks’ Community Reinvestment Act (CRA) activities are an important source of funding for hospitals and health systems to address social determinants of health. By funneling resources to address root causes of health disparities, such as poverty, economic mobility and supportive community resources, hospitals and health systems have the distinct opportunity to disrupt the cycle of inequity that stymies both health and economic outcomes. CRA modernization is crucial to these investments, ultimately supporting health equity, enhanced health outcomes in communities.

Along with directly contributing to community health, many CRA activities affect social determinants of health. Activities that promote affordable housing development can improve the health of low- to moderate-income (LMI) individuals and families by increasing healthy living conditions and financial accessibility to determinants of health. Families with LMI are more likely to experience unhealthy and unsafe housing conditions^[2] in neighborhoods that lack health promotion resources. Severely cost-burdened renters are less likely to have a usual source of medical care^[3], more likely to postpone clinical care and more likely to face food insecurity. Affordable homes can, therefore, allow greater access to food, healthcare and education — all of which are social determinants of health. CRA activities can also improve financial equity and wellbeing for local residents; similar to housing development, this can also increase the affordability of health-promoting resources and services. Lastly, investments or initiatives that improve the local economy and support small businesses improve community health, as research supports a link between economy and health^[4].

NCRC encouraged members and allies of health equity to comment on the Federal Reserve’s CRA Advanced Notice of Proposed Rulemaking in February 2021. The comment period resulted in 615 total comments to the Federal Reserve, of which 65 comments, or 10.6%, were related to the social determinants of health and ultimate health outcomes for low- and moderate-income (LMI) communities. While most of these comments came from national organizations, many local and state organizations and companies and individuals such as medical professionals participated. Some common themes among commentators were related to mental health outcomes, people with disabilities, and overall population health, especially in LMI communities.

CRA is a tool that allocates resources to underserved communities and it addresses affordable housing and community development needs that ultimately improve population health. For example, housing that does not contain lead paint hazards and other environmental dangers will clearly improve the health of lower-income communities. The content of the ANPR comments was filled overwhelmingly with emphasis on targeting underserved demographics, which inherently supports a strengthened CRA. NCRC urges the Congressional Caucus to collaborate with CRA regulators (Office of the Comptroller of the Currently, FDIC and Federal Reserve) on determining the CRA modernization efforts that may have the greatest impact on health outcomes.

Improving Alignment

Question 5: Where do you see opportunities for better coordination and alignment between community organizations, public health entities, and health organizations? What role can Congress play in facilitating such coordination so that effective social determinant interventions can be developed?

The majority of U.S. hospitals are nonprofit entities and as such must conduct Community Health Needs Assessments (CHNA) every three years, as required by the Affordable Care Act (ACA) to maintain tax-exempt status by the Internal Revenue Services (IRS). The CHNA includes a three-year plan or strategy to accomplish the goals outlined by community input. There must be enhanced collaboration between health and hospital systems, community-based organizations and other stakeholders, however, as the timeline currently exists, hospitals are already planning their next CHNA cycle less than two years into the implementation of the current cycle. The ability to measure health outcomes may be stymied by the short timeline^[5]. Consider studying and piloting a five-year CHNA timeline to determine health outcomes with reliability, while continuing to increase collaboration across community and economic development stakeholders.

Furthermore, nonprofit hospitals maintain their nonprofit tax-exempt status by providing community benefits, such as charity care. However, the IRS provides little specificity around what constitutes a community benefit, in terms of services and supports. Congress may seek to authorize the IRS to clarify. Perhaps more concerning is the lack of evidence from the IRS regarding community benefits violations^[6]. Communities deserve to know how their local hospitals are performing in regard to community benefits. NCRC suggests the Congressional Caucus study this issue and provide recommendations.

Question 7: How could federal programs such as Medicaid, CHIP, SNAP, WIC, etc. better align to effectively address SDOH in a holistic way? Are there particular programmatic changes you recommend?

Food scarcity can have long-term consequences for health. Research has found that individuals who experience recurring periods of hunger are more likely to choose to eat energy-dense foods, altering their metabolism over time, and leading to weight gain and the development of chronic disease.^[7] Another relevant concern is that many recipients exhaust their benefits early in the month^[8] – at cadences that would still exhaust the increased amounts^[9] – leaving open the possibility that cyclical shortcomings^[10] will still have negative consequences for health.^[11]

First, the USDA should conduct research to determine how it can refine the Thrifty Food Plan (TFP). Second, the USDA should take advantage of existing payment messaging capabilities to support the expansion of healthy food incentive programs.

I. We applaud the USDA’s TFP reevaluation, but further refinements are needed.

Last month, the USDA completed its re-evaluation of the TFP.^[12] The changes reflect research that demonstrated that the prior approach systematically understated the actual cost of feeding a family.^[13] The USDA should further update the TFP in the following ways:

• Not all individuals have equivalent caloric demands. Households with teenagers should receive additional funding. When women are pregnant or during breastfeeding, their caloric needs increase. They should receive additional support.
• The list of eligible foods should be revisited. Many healthy foods are disqualified because they are defined as “prepared foods.”
• The mix of fruits used in the TFP’s baseline overstates how frequently consumers buy apples, bananas, watermelon, and fruit juice; the TFPs eligible fish choices are canned tuna and salmon; and the TFP’s main vegetables are potatoes, carrots, leafy greens, and cabbage. These choices limit the variety of diets, may understate costs for feeding a household, and are inconsistent with the federal Dietary Guidelines for Americans.^[14]
• The USDA should incorporate online food and beverage transactions as a source for its food pricing data.
• The TFP does not take into account the variation in the cost experienced by beneficiaries of traveling to an affordable grocery store. In urban and rural areas, transportation costs may be higher.

II. Due to inconsistencies in the information flows between retailers, point-of-sale terminals, merchant acquiring systems, and EBT card PMs, it is difficult to take healthy incentive food (HIFs) programs to scale. By requiring PMs and retailers to share item-level PLU, UPC, and SKU data inside transactions using EBT cards, USDA could motivate external funders to provide financial incentives for HIFs.

a) Private and public funders have a desire to incentivize SNAP recipients to eat healthy foods, but cannot because of shortcomings in currently-utilized payment systems.

Many foundations, hospitals, and insurance companies would like to provide matching funds for HIFs. Foundations bring a motivation to achieve prosocial goals, but their total spending power is dwarfed by private corporate sources. Hospitals and insurers have shown an interest in funding HIFs, but they need more information, and SNAP’s limited payment messaging systems prevent it from happening.

Private corporations have a desire to support HIFs. The Affordable Care Act calls on hospitals that receive federal funding to provide benefits to their local communities. Often, this support takes the form of canceling charges for uninsured patients. Spending on food incentives presents a different value proposition, as participation may not be merely a cost center but also a tool to reduce expenses. Similarly, some health insurers – particularly insurers with contracts for state Medicaid programs – now seek opportunities to reduce the costs of claims for obesity, diabetes, hypertension, and other factors.

However, profit-motivated funders need two sources of evidence: a) records that demonstrate that a program participant improved his or her health and b) records that show that those participants purchased healthy food. The information can be used even if linked by an anonymous unique ID.

One emerging HIF model is to pay a match to SNAP recipients who participate in a HIF. Double Bucks programs often provide a 1 for 1 match, up to a certain ceiling, in these HIFs. These efforts already exist in 25 states.^[15] However, they do not have scale. They require extensive involvement from non-profit organizations or local government employees (collectively, NPOs).

The benefits of HIPS are well-documented. A 2018 study suggested that giving a 30 percent discount on fruits and vegetable prices to SNAP beneficiaries would avert 12,000 cardiovascular deaths over the next twenty years.^[16]

b) NPOs are hamstrung by the current process to meet health needs

NPOs have to work through a lengthy process to aid SNAP beneficiaries. The process typically takes this form: The NPO secures funding to operate a HIF. The NPO finds beneficiaries, usually on a county-by-county basis through free health clinics or local social service agencies, to receive the matching funds. The NPO helps the beneficiary to get a loyalty card at the participating grocery store. The beneficiary then returns to the NPO to register the card in a database. The participant uses their loyalty card and their EBT card at the POS, a capacity that requires programming from the grocer because the EBT card does not transmit their information automatically. The information is batch-filed and sent to the NPO. Incentives accrue on a periodic basis and payments are ordered on a manual one-off basis. Program evaluation is also labor-intensive.^[17]

For these, HIF programs have not achieved scale. Another approach – where NPOs distribute paper vouchers ^[18] – has similar problems with achieving scale and may compromise the privacy of beneficiaries.

c) USDA can and must require retailers and program managers to collect disaggregated information that reveals when beneficiaries have purchased healthy fruits and vegetables.

Improvements are technically feasible. Indeed, program managers (the two national PMs are the payment processors FIS and Conduent) for the Women, Infant, and Children (WIC) program already filter expenditures. WIC funding is treated as a prescription, where recipients receive support for specific items, in specific quantities, and during a finite period of time. According to FIS Government Solutions, one of the two large PMs in program management of SNAP and WIC, “because the program is product-and-measurement specific, the WIC point-of-sale transaction is required to capture the food products universal product code and unit of measure. This allows it to be compared to the assigned prescription to ensure the product and measurement matches before the sale proceeds.”^[19]

California is implementing a pilot program which will operationalize these systems. The description of the RFA describes its motives and intended outcomes:

“In partnership with the California Department of Food & Agriculture, the goal of this pilot project is to identify a technological solution for integrating disparate retail systems with California’s EBT system so that, no matter where a CalFresh recipient shops, they may earn supplemental benefits for purchasing California-grown fruits and vegetables. The outcome of this project is a report to the state Legislature of our findings and recommendation for moving forward with a statewide implementation. The recommendation will model best practices for integration with the EBT system, facilitating communication with a variety of point-of-sale systems, and scalability from farmer’s markets and small corner stores to high transaction-volume grocery chains.”^[20]

California’s analysis of the problem mirrors this recommendation, and its belief that the appropriate solution involves making updates to POS systems, matches our prescribed solution.

If the PM also owns and operates the POS it is easier to disaggregate spending by SKU/UPC/PLU. However, typically only very small grocers and farmer’s market vendors use the PM’s POS – and these makeup the majority share of Double Bucks locations, even though they generate a small fraction of total retail grocery revenues.

The solution can also take advantage of new trends in payment messaging. Many payment processors are moving from the limited messaging capabilities inside the SWIFT 8583 standard to the more expansive data capabilities of the ISO 20022 standard. ISO 20022 messages are far richer in the quantity of data they transmit, can support standardized APIs, and will function in request for payment messaging.^[21] The latter may become very popular as retailers increasingly develop the QR-code technology to arrange POS credit push transactions. However, 8583 data is enough – it is capable of carrying item-level information. The only obstacle is that retailers do not provide it with EBT transactions.

It would be very valuable if the USDA could help foster a scalable system to integrate SKU/UPC-level with card networks and EBT cards. The underpinning, universally standardized, payment protocol (ISO 8583) as well as the EBT-specific ANSI X9 standard already support the transport of such data, therefore, the problem is mostly one of encouraging retailers’ terminals to supply data elements that are already communicable.

d) The USDA should require participating retailers programs to collect “Level 3” payments processing data.

Level 3 data can include Item SKU, UPC, PLU, an item description, the unit price, a unit of measure, a commodity code, the presence of a price discount, quantity purchased, and other details.^[22] As an incentive, merchants who provide Level 3 information to card-issuing banks can include the transaction inside a lower-priced interchange category (Large-Ticket Interchange). Currently, banks only receive a fixed ten-cent fee for each transaction,^[23] so financial incentives could motivate grocers to speed up the transition to Level 3. Such a change would give interested parties the ability to implement healthy food incentive programs at scale, eliminating labor expense, and providing profit-motivated funders with the information they need.

Question 9: What opportunities exist to better collect, understand, leverage, and report SDOH data to link individuals to services to address their health and social needs and to empower communities to improve outcomes?

According to a recent report, 40% of nonprofit hospitals in the U.S. do not complete their ACA mandated CHNA or, they do not report the results of their CHNA to the public.^[24] This is a staggering finding. Additionally, the study found that the quality of the reporting documents from the non profit hospitals varied. At the very least, all CHNA data should be made publicly and easily accessible to all community members within the hospital’s geographic footprint.

Best Practices and Opportunities

Question 13: Given the evidence base about the importance of the early years in influencing lifelong health trajectories, what are the most promising opportunities for addressing SDOH and promoting equity for children and families? What could Congress do to accelerate progress in addressing SDOH for the pediatric population?

In a pre-COVID, developed nation such as America, Black women were already more likely to die in pregnancy or childbirth than any other racial demographic (3 to 4 times the rate of White women)^[25]. With the COVID-19 pandemic disproportionately impacting community of color, and specifically Black communities, barriers to quality care exist for Black mothers^[26]. The Black Maternal Health Momnibus Act of 2021 acknowledges that in the richest nation in the world it is unconscionable that Black women are dying at the highest rates as that of developed nations. Native American women are twice as likely to die from pregnancy related issues than White women. Hispanic and Asian Americans also have higher rates of maternal mortality in comparison to White women. The Momnibus includes significant investment in the social determinants of health, as well as invests in community-based efforts to prevent exposure to climate and health-related risks for mothers and babies. NCRC supports the full Momnibus Act.

Localized solutions include pre-pregnancy counseling for women with comorbidities (e.g. Tulsa Birth Equity Initiative), support for home-based care for the third and “fourth” trimester of pregnancy, elimination of maternal health care deserts and expansion of maternal telehealth, and group benefits screens (e.g. housing assistance, nutrition assistance, etc.), among other solutions.

Transformative Actions

Question 17: What are the main barriers to programs addressing SDOH and promoting in the communities you serve? What should Congress consider when developing legislative solutions to address these challenges?

In the communities that NCRC has convened SDOH stakeholders (public health, community economic development, civil rights organizations, faith based communities, government agencies, and banks and financial institutions), both pre-COVID and during the pandemic, the vast majority of participants mention struggles with mental health and trauma, community-wide food insecurity, and a stark lack of affordable housing as primary concerns. Of these issues the affordable housing crisis has no easy solution. Greater spending (via the American Jobs Plan) will create approximately 2 million homes^[27]. Local zoning codes that facilitate single-family homes at the expense of multi-family homes are exclusionary. Congress should support efforts, incentives that encourage municipalities to eliminate barriers to multifamily zoning production to increase affordable housing supply.

The Substance Abuse and Mental Health Services Administration (SAMHSA) recently distributed $3 million for mental health and substance abuse grants, via the American Rescue Plan.^[28] While is amount of grant funding is unprecedented, future funding levels must be increased to combat increasing mental health concerns, including a rise in suicide ideation, youth depression, increasing adult mental health (pre-Covid) and more.^[29]

Conclusion

NCRC applauds the creation of this very important Caucus at a time when the vast majority of communities across the country have been and continue to be deeply impacted by the COVID-19 pandemic. The health disparities we are seeing now have been a part of communities for some time, with the pandemic bringing to the forefront these deep seated issues. The foundation to better community health outcomes including longevity rests with the foundation of a strong, healthy and economically viable community. Zip codes should not be indicators of health outcomes.

NCRC urges the Caucus to work to maintain access to affordable housing, modernize and improve upon the Community Reinvestment Act, enhance the Community Health Needs Assessment process, strengthen IRS oversight of CHNA’s and readily make available CHNA data to communities. Support Black women especially as well as other non-white women with comprehensive maternal services and supports within their communities. On the heels of the COVID-19 pandemic, mental health and trauma and food security needs have increased and will require adequate funding and program alignment to minimize broad impact, while building the foundation of healthy communities through affordable, healthy housing.

Thank you for this opportunity to respond to the Request for Information. Please contact Brad Blower at bblower@ncrc.org if we may provide clarity on any of these issues or others.

Sincerely,
National Community Reinvestment Coalition

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