Many times the social and economic determinants of health are proxies for health inequalities within a community. Factors such as income, education, physical environment (where you live), social isolation, and the concentration of poverty often have more to do with the health of an individual or a community than availability or access to medical care. Because many people struggle with these larger structural issues on a daily basis, individual well-being or personal health can become impossible to achieve without addressing these broader issues. While it may seem that these factors only burden individuals, in truth hospitals and health systems bear some of these costs as well, through increased asthma visits to the emergency room, for instance, when their housing is in need of environmental interventions. It is in the best interests of both consumers and providers that providers address not only a patient’s specific health ailment, but also the root causes that lie in these social and economic determinants of health.  

 To help improve community health the Affordable Care Act (ACA) now requires that non-profit hospitals assess and attempt to address the unmet needs of the communities they serve through a Community Health Needs Assessment (CHNA) every three years. Under proposed IRS rules, non-profit hospitals must consult public health experts including local health departments, as well as “leaders, representatives, or members of medically underserved, low-income, and minority populations, and populations with chronic disease needs” for assessment guidance. Other providers, consumer advocates and non-profits, academics, and businesses should be engaged in the process.

 Hospitals must then use the CHNA to develop and adopt implementation strategies in a formal and transparent Implementation Plan that addresses the identified unmet community health needs. These strategies can include coalitions that reduce youth violence or substance use disorders, safe communal spaces like parks, safe and affordable neighborhood housing, food banks or farmers markets, training for community health workers, or even workforce development programs that insure a culturally competent workforce.

 By using the CHNA to conduct culturally competent discussions on community health concerns, hospitals can get both useful information about the community’s needs and simultaneously increase awareness and access to prevention and treatment options that address population health. When conducting the CHNA process, hospitals should be mindful of the fact that consumers unfamiliar with hospital settings and etiquette are often intimidated by long, technical surveys, or by surveys with forced choices that may not be in their native language. Consequently, to encourage participation in the CHNA process, hospitals should be careful to be inclusive in constructing their data collection methods. Surveys  should be available in the various languages spoken in the community along with translators who can provide assistance in clarifying concepts. Focus groups, stakeholder interviews, or community meetings should partner with organizations trusted by community participants. Culturally competent measures such as these are central to enhancing the ability of individuals to speak freely about personal or community health issues.

 CHNA-related conversations are an opportunity for hospitals to highlight the fact that health is not limited to surgeries or prescriptions. Health improvement interventions can address factors such education, employment or poverty in a culturally sensitive and competent manner. By shedding light on how social and economic factors impact an individual’s health, the CHNA can be a powerful tool to benefit both hospitals and community members, and to address health inequities. 


Jessica Liao, Health Equity Intern

Guest Blog

In Arizona, the month of August is usually associated with 100+ degree weather, swimming pools, sunscreen, and the occasional summer monsoon or dust storm. It also marks the end of summer break for students from preschool to university. For those working to educate consumers about their new health care options and enroll them in health coverage, several factors converge during the back-to-school season, creating an opportune moment to engage families. 

Across the country, many local departments, organizations, cities, and school districts are busy organizing back-to-school events for families. At the Arizona Children’s Action Alliance, we view this as a prime opportunity to work with other outreach and enrollment groups to maximize their participation at back-to-school events and help link families to health coverage.

Prioritizing Health Coverage at Community-Based Back-to-School Events

Often, we are so focused on families that we overlook the need to inform and include back-to-school event organizers, whether they are city officials or school administrators, about the importance of health coverage for kids. We’ve found that building relationships with event organizers greatly increases the tools and resources at our disposal during back-to-school events. Advocates should work with event organizers to maximize attendee exposure to and resources for health coverage. Most event organizers are extremely receptive to the idea; after all, there is a growing body of evidence showing that kids perform better in school when they have access to affordable health care. 

Leading up to the new school year in Arizona, we partnered with the Latino Institute to identify creative ways to capture the attention of parents and promote health coverage enrollment during back-to-school events organized by the City of Phoenix. This resulted in a series of actions that elevated the message of enrollment including:

  • health enrollment flyers in the free backpacks handed out to all children attending the events
  • a televised back-to-school panel where our job was to talk about health coverage
  • broadcasts about where parents can get help with enrollment
  • a condition that attendees must learn about health coverage from health assisters or Navigators present at events in order to enter raffles for prizes

These strategies greatly enhanced our participation and impact. The assister and Navigator organizations we worked with increased enrollment appointments four to five-fold compared to the prior year, when their participation was limited to manning display booths. The increased opportunity to promote the message of health coverage was made possible through proactive and robust collaboration with event organizers. 

Strategies for Increasing Enrollment During Back to School Events

There are many barriers—including multiple, competing priorities—which prevent families from successfully enrolling, even if they make the commitment to do so.  Back-to-school events provide a convenient opportunity for families to enroll in health coverage because it is folded into other back-to-school preparations. Working with event organizers to provide families with the tools they need to apply for coverage efficiently and effectively can help improve the chance of enrolling families who attend the event.

To help make sure that families are prepared to enroll, advocates should work with event organizers to distribute reminders, checklists, and other information to families prior to the events. One significant obstacle to signing up families for coverage is that parents rarely bring all of the documents and information they need to apply for Medicaid or Marketplace plans for their families. Therefore, our team found an application checklist envelope to be a useful resource. The envelope is printed in English and Spanish with a checklist of documents needed to successfully apply in one sitting. Parents then have a guide and an easy-to-use envelope to collect their documents, check corresponding boxes, and show up prepared. 

To reach parents before events, we worked to ensure that pertinent health coverage information, flyers, and the checklist envelope were available through events’ promotional websites and other media. For example, at one back-to-school event held at the Metrocenter Mall in Phoenix, we worked with event organizers to place information about how families could access flyers and the checklist envelope, as well as other health coverage information, at the food court in advance of the event. 

Not all back-to-school events include an enrollment site for families, even if families are ready to apply and assisters and Navigators are available. To ensure families who are ready to enroll are able to do so when they arrive at back-to-school events, advocates can work with event organizers to make sure there is private space set aside for assisters and Navigators to help families enroll on the spot. It’s important to have computers, scanners, printers, and internet available on hand to immediately help people who are ready to apply.

There is no secret formula to successful enrollment, and everyone working to link families to health coverage knows that persistence and a positive attitude are critical, despite the challenges. We encourage advocates to continue sharing with their counterparts and to regularly review best practices taking place across the country with the goal of improving efforts to cover more families.  

Joe Fu, Health Policy Director, Children’s Action Alliance Arizona

Workers in New York City now have a legal right to paid sick leave thanks to an incredibly successful campaign led by the Community Service Society of New York (CSSNY), a grantee of the Roadmaps to Health Community Grants Program, along with their key partner Make the Road-NY.

Until just a few months ago, 64 percent of low-income working New Yorkers lacked paid sick days – time they could take off from their jobs when they were sick or needed to care for an ill family member without losing a day’s pay. Having to make painful choices between earning a paycheck and taking care of one’s health or the health of one’s children threatens the health and financial security of these workers and their families. It also threatens the health of all of us. A 2011 study in the American Journal of Public Health concluded that a lack of paid sick leave led to an additional 5 million cases of adult H1N1 (swine flu), resulting in an estimated 23,000 additional hospitalizations and nearly 1,400 deaths. But we don’t need studies to tell us what is obvious – it isn’t good for any of us if people are forced to work when they’re sick or to send sick children to school, and paid sick days can have a beneficial impact on both the health and the financial security of struggling families.

In June of 2013, CSSNY and its coalition successfully overcame a mayoral veto to establish an ordinance that provided for up to five days a year of paid sick time for about one million New York City workers who previously had no legal access to that benefit. This year, on the heels of the election of new Mayor Bill de Blasio, an expansion of the original law passed as the first legislative initiative of the de Blasio administration, extending legal access to paid sick time to hundreds of thousands of additional workers. Workers began accruing sick time on April 1 and could start using the leave as of July 30.

CSSNY will continue educate the public about the new law and to collect stories – both positive and negative – about how implementation is going. This is an important part of making sure that the new law is enforced and workers can actually access the rights they now have. They will also use their annual Unheard Third survey to measure public awareness of the law. CSSNY already has a track record of using research to inform effective public education efforts. For example, in July 142 volunteers from Make the Road-NY handed out flyers about the paid sick leave law as part of a city-led day of action at subway stops. The city relied on CSSNY’s research to help determine which subway stops were chosen in an effort to target likely neighborhoods where workers would be eligible for this new benefit.

The impact of this campaign doesn’t stop in New York City. As the nation’s media and business capital, what happens in NYC attracts nationwide attention and has the power to influence similar efforts across the country. CSSNY’s successful campaign has inspired similar efforts in neighboring Jersey City and Newark, New Jersey, both of which passed paid sick leave laws modeled on New York’s. In addition, CSSNY was recently invited to do a presentation on the importance of paid sick leave to the Social Determinants of Health Working Group, a Medicaid redesign team in New York state. This team has begun looking carefully at the economic and social determinants of health, which are factors like education and employment that have a huge impact on the health of individuals. The team is interested in how addressing these factors might improve the health of Medicaid recipients and produce long-term cost savings. Specifically, they are considering what the state might achieve through workplace benefits, including the possibility of taking the paid sick leave policy statewide.

There’s no doubt that CSSNY and Make the Road-NY have helped lead a very impressive campaign over the past two years. With the support of the Roadmaps to Health Community Grants Program, they’ve used all of the advocacy capacities at their disposal – campaign development, communications, resource development, policy analysis and advocacy, coalition and stakeholder alliances, and grassroots organizing – and they’ve used those capacities strategically and effectively. This campaign can be a model for other cities and states, thereby helping not only low-wage workers in New York, but workers in other communities across the nation.


Community Catalyst manages the Roadmaps to Health Community Grants program, which is funded by the Robert Wood Johnson Foundation. The program is an important element of the County Health Rankings & Roadmaps program and supports two-year efforts among local coalitions of community organizations, policymakers, business, education, health care, and public health professionals who are working to create positive policy or system changes on the social and economic factors that impact the health of people in their community. No Robert Wood Johnson Foundation funding was used for lobbying in the CSSNY project. 

Last month, the House of Representatives was scheduled to vote on an agricultural appropriations bill that included a new waiver process allowing local school districts to opt-out of the new nutrition requirements enacted in the 2010 Healthy Hunger Free Kids Act (HHFKA). Weeks have gone by and still the House has not voted. Reporters who cover the food industry speculate that delays mean that a compromise is in the works, while others hedge that this is just the first pie to be thrown in a much larger food fight to come. The fact that the Healthy Hunger Free Kids Act, a law that vastly improves child nutrition, has come under scrutiny is a cause for concern, not just for school meals, but for child wellness in general.

But let’s backtrack for a moment.

The school meals program, which includes breakfast, lunch, snack and now dinner in some areas, serves meals to approximately 31 million children in more than 100,000 school districts across the country. Children at or below 185 percent of the Federal Poverty Level are eligible for free and reduced lunch.

Four years ago advocates celebrated the bipartisan passage of the Healthy Hunger Free Kids Act. For the first time in 30 years, the law created sweeping reforms to the school meals program and gave the U.S. Department of Agriculture unprecedented authority to set new nutrition standards for food served in schools. The new standards are based on the Institute of Medicine’s recommended nutrition standards for children and involve increasing servings of fresh fruits, vegetables and whole grains, limiting salt and fat, and switching from whole and 2% milk to 1% and skim. In short, the Healthy Hunger Free Kids Act ensures that low-income children participating in the school meals program are able to eat healthy meals, a major win for communities and families.

Yet four years later, political support has shifted for the new school lunch rules. This could not come at a worse time.

According to the Centers for Disease Control and Prevention (CDC), one-third of children and adolescents in America are overweight or obese. The extent of this public health crisis is even more pronounced among children of color and children in low-income communities. Obesity has been found to increase a person’s risk for a myriad of other health issues, including diabetes, high blood pressure and other cardiovascular diseases, and various forms of cancer. The rise in obesity has brought along with it the appearance of these chronic diseases in children – diseases that had previously only ever been seen in adult patients. Furthermore, obesity in children dramatically increases the risk of obesity into adulthood. This has already placed enormous strain on our health care and economic systems, and promises to do so into the future if current trends are not adequately addressed.

There are a number of strategies to curb the childhood obesity epidemic. One important strategy includes ensuring that children are served healthy meals in school while reducing the availability of unhealthy foods. The Healthy Hunger Free Kids Act is a key component in that effort, and it is particularly important for children at high risk of obesity. And evidence shows that children like the new, healthier meals. According to a new survey of school administrators released by the Robert Wood Johnson Foundation, respondents at 70 percent of schools surveyed reported students liked the new meals by the end of the first year of implementation of the new rules. Given these signs that the law is doing as intended, we are left to wonder why lawmakers would want to change it.

As we work tirelessly to help children and their families obtain coverage and access health care, we want to remind folks of the importance of working in concert with other policies that help keep children healthy. For health advocates, this means supporting policies beyond coverage – such as the Healthy Hunger Free Kids Act. As we move forward, it will be important for all of us to integrate the important work of pediatricians inside the doctors’ office with community-based services and the policies that guide them. The Healthy Hunger Free Kids Act is an important step to ensure that our environment promotes childhood well-being and does not hinder or degrade it. We will continue to highlight policies that promote children’s health and wellbeing – stay tuned.

You can find additional Healthy Hunger Free Kids Act updates here and an infographic summarizing why healthier school meals matter here.

Today is CHIP’s 17th birthday! As we reflect on the success of this important program, a recent report nicely summarizes its impact. The Impact of the Children’s Health Insurance Program (CHIP): What Does the Research Tell Us?, a report by The Kaiser Commission on Medicaid and the Uninsured, highlights CHIP’s real impact on providing coverage for children from racially and ethnically diverse backgrounds. According to the Kaiser report, Medicaid and CHIP cover more than half of Hispanic children (52 percent) and Black children (56 percent) compared to a little over a quarter of white (26 percent) and Asian children (25 percent), according to the Commission’s issue brief. This report is timely given that just last week, the chairmen and ranking members of the House Committee on Energy and Commerce and the Senate Finance Committee issued a letter to all governors asking for feedback about CHIP.

As the Kaiser report shows, CHIP is an important initiative to reduce health disparities and increase access for children of color. Coverage is the first step in securing better health outcomes for all children. And for children from racially and ethnically diverse backgrounds, Medicaid and CHIP play a vital role in opening a doorway to needed health care and, over the long run, healthier and more productive lives. Further, a New York CHIP program study finds enrollment in CHIP almost eliminates racial and ethnic health disparities across multiple measures related to access, unmet need, and continuity of care. While more work needs to be done across multiple sectors including economic security, educational attainment, and healthy food access, CHIP plays an important role in moving the needle on health equity.

Communities of color are important allies in safeguarding CHIP and amplifying its role in turning the tide on health disparities. As we activate our bases and encourage our coalitions to raise their voices to secure continuation of CHIP, it is important to re-evaluate if all the right people are at the table. Are racially and ethnically diverse communities represented in children’s health coalitions? Are their voices represented around advocacy planning and strategy? What does meaningful engagement of communities of color look like?

Community Catalyst put together a list of the Top Ten Tips in Engaging Communities of Color for Policy Change to support advocates in their efforts to reach and engage coalition partners representing racially and ethnically diverse communities. Important takeaways include: finding the right messenger, practicing team building, engaging beyond education, and celebrating successes. These will be important strategies to deploy in building support for the continuation of CHIP.

To learn more about how state consumer advocates have put these tips into practice, check out our blog series, Health Equity in Focus