Creating cross-sector collaboration to address the social determinants of health is especially challenging. Like many social issues, poor health is multifaceted. Research has shown that ZIP code can be as important as genetic code in determining long-term health and life opportunities. But we know environment matters too—from housing to neighborhood amenities to safety and its link to stress.
Public health policy seeks to prevent disease and promote good health through education programs, policies and regulations, services, and research. Community development seeks to build strong communities with infrastructure improvements and by investing in residents with financial, social, and political capital. Both sectors, in other words, focus on the health, physical security, stability, and well-being of groups and individuals.
Yet the fields have rarely worked in tandem. Now, a new approach is encouraging funders to pool their money to tackle the overlapping goals more effectively.
The problem starts at the source—the bevy of congressional committees that provide funding for social programs with many strings attached. HUD funding aimed at affordable housing, for example, cannot be used to address mental health issues. Such “categorical” funding leads to a maze of programs that often target the same issue, and sends families ping-ponging from office to office, program to program seeking help for interrelated issues. Rather than sharing information and coordinating, the departments compete for the same piece of the funding pie. This pattern replicates itself down the line among the nonprofits that receive the funding. They, too, tend to specialize and carefully guard their funding.
Categorical funding also makes for a lot of paperwork. As a HUD/Urban Institute report notes, “The challenge for providers is to keep track of which sources will fund what, when one needs to apply for them, who is eligible for services from particular funding streams, and who has time to do the applications.”
Blended or braided funding is one solution. Blending funds wraps two or more sources of funding together under one budget to pay for a set of unified services. Costs are not necessarily allocated and tracked by individual funding source. Braided funding, in contrast, coordinates two or more funding sources but funds are allocated and expenditures tracked by each categorical funding source.
There is a long history of attempts to prevent the ping-ponging from service to service that a family must undergo in a complex, uncoordinated system to receive care for a bevy of related issues. The early 2000s saw a surge in “one-stop” shops at welfare offices and workforce development departments to ensure that applicants received the wrap-around services they needed to succeed. But it fizzled. Block grants to states were an early attempt to break down silos and let states use federal funds more flexibility, though they still came with restrictions. Others have called for “infrastructure banks” to pool funding for regional approaches to roads and bridges.
Legislative actions in 1999 in California created flexible funding in programs targeting homelessness in cities and counties. The dollars could be used at the provider’s discretion for housing subsidies, rental assistance, mental health services, staffing, or clothing and food for clients. The initiative reduced incarcerations, hospitalizations, and homelessness, and increased employment, ultimately saving money at the local level.
More recently, the federal government has created incentives for collaboration. Performance Partnership Pilots (P3) offer states and localities more flexibility in pooling funds from federal programs serving similar populations and communities in exchange for greater accountability for results. The 2016 budget supported P3 efforts for disconnected youth and allowed the departments of Labor, Health and Human Services, and Education to enter into 10 partnership agreements. The 2017 budget aims to continue the effort. In addition, the National Prevention Strategy, created under the Affordable Care Act, is exploring how agencies from different sectors can work together more effectively at the federal level.
Continuum of Care programs are also coordinating funds. In Houston, integrated strategies among a group of 60 nonprofits and city and county agencies contributed to a 37 percent decline in the area’s homeless population between 2011 and 2014. “Integrated, community-wide strategies to prevent and end homelessness is the key to our success,” said Marilyn Brown, president of the Coalition for the Homeless of Houston and Harris County, which leads the area’s Continuum of Care.
In Los Angeles, the Funders Collaborative, which includes the U.S. Department of Veterans Affairs, the city of Los Angeles Housing Authority, Los Angeles County Health Services and Mental Health, and major philanthropies in the city, is both blending funding and coordinating action. Project “Home for Good” has developed a coordinated entry system to replace a confusing patchwork of entry points to homeless housing and services with a single computerized portal that reaches every corner of the county.
The National Academy for State Health Policy has created a list of federal funding sources that are currently used to address the health and housing needs of adult Medicaid recipients, including the National Housing Trust Fund, the HOME program, the Low Income Housing Tax Credit, Community Development Block Grants, and others. The list illustrates both the fractured nature of funding and the possibilities should blended funding prevail.
The opportunities seem ripe for blending funding to connect the public health and community development fields when tackling the social determinants of health. The two fields, after all, work along parallel tracks on many similar issues. But more federal action is needed if we are to truly blend our efforts. The Network is looking for stories of success and evidence of the impact – please share with us at email@example.com or @bhpnetwork if you have either!