In this recording of a live session that took place during Health Law Week 2022, Asha Scielzo, Director of the Health Law and Policy Program at American University Washington College of Law and AHLA Board member, speaks with Sarah de Guia, Chief Executive Officer of ChangeLab Solutions. They discuss the intersection between structural discrimination and health inequities and explore innovative legal strategies and best practices for health systems, providers, and policymakers to improve community health outcomes.
Watch the conversation here.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
This episode of ALA speaking of health law is brought to you by HLA members and donors like you for more information, visit American health law.org .Speaker 2:
Okay. Everybody let's get started. It's just a minute or two past the hour. Welcome from wherever you might be dialing in from. My name is Asha sheso and I'm so delighted to kick off this session today as part of American health law associations health law week, we have amazing programming this week in particular today's day has been , um , focused on how we can build an ideal community ideal starting for standing for inclusion, diversity, equity and accessibility in the law in particular in health law. So just a quick shout out Tola for putting together such important and meaningful programming for the entire national audience. Uh , myself, my name is Asha sheso and I serve as the director of the health on policy program at American university, Washington college of law. It's very important to us. It's our mission to graduate students who are practice ready . And when I say practice, I don't mean only private practice. I mean, becoming change makers , being able to move conversation forward and have an impact in particular on topics like we're gonna cover today. Um, I'm also joined by Sarah Dilla . Who's the CEO of change lab, and I'm so delighted , uh , to be sharing , um, Sarah's and change labs expertise with everybody today, she brings a wealth of knowledge and expertise. She has an amazing team behind her , um, that have put together some amazing resources and they're truly thought leaders in this space. So let me ask Sarah to introduce herself , um, and tell us a little bit more about the work that she she's doing at change lab and that her team at change lab is doingSpeaker 3:
Thank you , Asha , and thanks Tola for this opportunity and thanks to all of you for being here today . I really appreciate you taking time outta your busy schedule to have this conversation. Um , and before I get started, I wanna say thanks so much to , um , Sarah Bartel, my colleague who's behind the scenes today, but is really helping us out. Um , you managing the chat and the slides and who really helped me prepare , um , because of all Herve work , um , with healthcare partners in particular . So as the CEO of change lab, you know , I've had the opportunity to bring my own professional experience working predominantly with historically marginalized communities on state level policy, to, to change lab and to the team here to help us advance better health for communities across the nation. My experience I've had the chance to work on policy issues from expanding access to healthcare and language access in government and healthcare settings , um, to work on reproductive rights, public health, and immigrants rights work. So it's really a pleasure here to both speak , um , to my own personal experience, as well as change lab's work. So change lab solutions is a national organization, and we work with communities, local governments and state governments, as well as anchor institutions like healthcare systems and hospital systems to create healthy lives . For all our priorities are working with communities that are at the highest risk for , for poor health . Um , but over for over 20 years now , change lab has been working with these partners to help create lasting policy change , really using the tools of long policy. We know that a lot of places across the nation right now are working to achieve equitable outcomes. They might be struggling a little bit with how to do that. And so our interdisciplinary team of lawyers, planners, policy analysts, and others , um, are working with neighborhoods and hospitals, community partners, cities , and states to help create those thriving , um , communities. And just as an example, since 2019 change , that has been the legal and policy technical assistance coordinator for 18 communities across the nation in what's called the national build health challenge. And it's a multi funder pectoral team , um , who works to help advance their goals for systems change. We've been working with them to create access to healthy foods , increasing maternal and child health and promoting housing stability and affordability. Just to name a few of those examples . So thanks again,Speaker 2:
Thank you Sarah so much for being here and for sharing our expertise and for change lab, all the tremendous work you're doing that we're gonna get to hear a lot about today. Um, so what I thought we could do is let me just give a little bit of the run of the show for our attendees. Um, the goal really is to be able to illuminate and highlight the terrific work Sarah , you and your team, and really be able to dig deeply into these complex issues. Um, we are hoping they'll be able some time for questions at the end, but we know we have a lot of great content here. So if we aren't able to address questions, we definitely invite everybody in the audience to reach out to Sarah or myself, or take a look at some of the tremendous resources that we're sharing in the chat. Not only is the HLA website, a source for you. We've also put in a lot of change lab resources that we're gonna highlight as we go. So you can kind of get a sense of what these resources are and what amazing tools they are. So again, you'll notice that it is an active chat , um , in the sense of providing you with additional resources. So I always think it's important , uh , to start with kind of building a foundation together and making sure we're kinda on the same page, so to speak or using the same terms and definitions. So first I'd like to start with defining health and then talk about defining health equity , um, and then use that as a launching path for some of our conversation today, Sarah . So health , when we look at the definitions that we see from the world health organization or, and or the substance abuse , um , mental health services administration, I'd like us to think about health as not merely the absence of disease or infirmity, but in fact, a state of complete physical, mental, spiritual, cultural, and social wellbeing. So that gives us a good foundation when we talking about health, but let's move that to health equity. Then , um, some of the work of the national academies of sciences engineering medicine, I think is also very helpful for audience in a consensus study report in 2017 and some of their work or , um , surrounding communities to action and pathways to health equity. They define health equity as a state in which everyone has. Everyone has the opportunity. And I think that's such an important word. Everyone has the opportunity to attain their full health potential, and no one is disadvantaged in achieving that potential because of social position or any other socially defined circumstances. So with that sort of foundation of what do we mean by health? What do we mean by health equity? So I'd love for you to tell us a little bit more about why, why is the time now? Why is it important that we're talking about health equity today? Should we be thinking about this from a lens of the individual or is it the community or is it both?Speaker 3:
Yeah , thank you , Asha . I mean , it's really important , like you said , to name those definitions, just so we're starting from, from the same page and one of the things at change lab , when we , when we do our definitions, we also like to remind folks that , um , health equity is also the absence of these preventable , um , health disparities that are really fueled by injustices. That , um , are, that are embedded deeply into our systems laws . And now is the important time to really talk about health inequity , that specifically the role that structural discrimination and racism have played in limiting and, and also the role that they play in addressing equity. And I , I , I name that because I think COVID-19 really made visible for folks who maybe didn't necessarily see those injustices and those inequities. Um , COVID-19 really helped to make those much more visible . And I think it's important now too , because there's a momentum that has been created as a result of COVID . Um, the current administration is really dedicating resources. I think a lot of states and local governments are thinking about this and really because healthcare institutions and systems also play a , an extremely important role in helping to move that momentum forward. Um, because you know, and Sarah can, can show the slide here, but when we wanna think , when we think about health, it's not just the individual choice or even access to healthcare that are the main drivers of health inequities. Um, they play a role, but not the biggest role. And as we see from this chart, it's actually the physical environment, as well as social and economic, that play an extremely important role in the decisions that individuals make every day . So if we wanna see real change, we, we do need to focus on the individual, but we really need to zoom out and to actually look at the community and the systems, the laws and policies that have played , or that continue to play a role in our person's health. And there's a lot of data to, to , to support this as well. Now, this slide is a slide that there , this is actually a , a visual that we created at change lab . And I , and I love it because in this center, our people, it's our communities, our families, our children, our future, and, and surrounding those individuals are all the elements that make up a healthy community. We think about the systems that are in place like our transportation system and our food systems. We think about the institutions like our workplaces, our housing, even our retail, all the way out to government economic family, supportive systems. You know, just as an example, just to name a few. Um , and so the individual is deeply affected by the interaction of all of these different , um , systems and the laws and policies that really focus on how policies, resources are distributed to affect an individual's choices . So we need to really thinking much more broadly systems and S as well as individual behavior ,Speaker 2:
So compelling to see these graphics and visuals. Sarah, thank you. Because when we think about health, I think it would be sort of sometimes natural to think healthcare that's the basis of this. And of course it plays a key role in , in your previous slide. You know, we showed 20% healthy behaviors. We often wanna say, well, it's about the individual, right? And it's all about what he or she, or they choose to do. And we know that that's another 30 or so percent, but that that's 50% or while it's significant, there's this other half of your physical environment and your social and economic pieces. And so I think it's so important that you're illuminating this for us. Um , so if we , we take that framework of social determinants of health, and we, we sort of combine that with , um , the other materials that you had, the next slide, right? The elements of healthy community. If we sort of try to Mel these together and say, how does this help us really form a basis for understanding health inequity? Now, if we kind of shift our conversation to that , um, or in other words, what are some of the key drivers of health equity using kind of some of this foundation here?Speaker 3:
Yeah. So a change lab solutions, we believe that the most powerful risk factor for poor health are the laws and policies that perpetuate the legacies of segregation, racism, and discrimination. And so having a legal and policy framework can help us move towards thinking about the ways in which we can create healthy, equitable communities, because particularly we wanna center those who have been historically marginalized and excluded. And so with our blueprint for change makers and the five drivers of inequities here, we put together a guide for people like you. And for folks here that are, that are listening in lawyers, healthcare practitioners, community leaders, really anybody who wants to change , um , to make change. And we centered the blueprint around these five fundamental drivers of inequities, because inequities that we see today, they didn't just happen overnight, or even by accident. They have been created over time and really through intentional segregation. So intentionally through laws and policies. And so when we, when we think about, or when we really try to approach the change that we wanna make, it's, you know, education plays an important role, but we have to look farther and farther upstream. We need to really analyze the laws and policies, the social norms, and even our governance systems to really understand how they have either created a lack of opportunity or the ways in which they support good health. And so our five fundamental drivers of inequity really, again, provide sort of a framework for us to think about this , um , to both address current , but as well as historic inequities, by thinking about the consequences, the impacts and the distribution of resources and power through these five different lenses. So , number one , we're thinking about, you know, are we accounting for historical instructional harms that are in our systems that have perpetuated racial or other forms of discrimination that we call structural discrimination? Two , we really wanna think about who has what access to wealth and wealth building opportunities, because we know that income is actually directly correlated or very closely aligned with our healthcare status, our health status three. We also wanna think about what are the other types of opportunities that are available to individuals and their families and communities that promote health and equity such as food and education , um, parks and healthy environments for we wanna think about, you know, what, how are our systems and policies and structures creating power, or are they creating power? Are they limiting people's ability to have a voice in our , in our , um , civic systems and then five, what are the ways, again that our governance systems are set up to either give or to take away voice? So we use this framework in all of the work that we do with community based organizations, with local governments, with anchor institutions. And I'll say it has helped a lot of our partners just really shift their thinking about how they can be an influencer and a , and a power partner , um , in creating that those healthy, equitable environments.Speaker 2:
Absolutely. It's so important to be able to see these drivers and kind of how you described the basis really of the disparities. Um, so you mentioned earlier just a few minutes ago, how, you know, COVID has really shed light on this, but there's momentum now that there's in , in the environment to really , uh , hopefully be moving in the right direction. But at the same time, as we say that it also has highlighted for us how deeply entrenched these health inequities are , um, and that they're growing. Um, so with that in mind, I mean, highlight for us a little bit more in , in one of these, in these top five structural discrimination is where we wanna spend some of our time today. Um, if that's a key driver of health inequity , you know, how is change lab , um, working to tackle this, you know, what are some of the day to day , um , things that change lab is doing in this space?Speaker 3:
Yeah. Asha , thank you . And , and I'll name, I'll kind of give two examples. I think , um, social discrimination is one of those overarching ones that really touch on all of these different issues, but it it's really important. And I , the second example I wanna talk about is around governance . Cause I think it's helpful to , to an example around that too . So the first one is around housing because we know that home is where the health is, right. Again, having a home is really a strong predictor for whether or not we have good or poor health . Um, and we also know housing is a good example too, because there's very strong evidence about our past racist policies, particularly redlining and how they have had a lingering effect on certain, the health of certain communities. So if you look side by side at a community that was redlined versus a community that was not redlined, you can still see generations later , um , higher levels of health, inequities, and health disparities. Um , and a lot of it is linked back to the inability for people to have access to home ownership and also segregation. So, and then we also continue to have a national housing shortage. And so some of the , and , and as we've been working with different communities, what we've also recognized is that some of the policies that would actually help to expand affordable and safe housing have been blocked by state legislatures in a variety of different ways. And so change lab right now is partnering with eight local cross-sectoral communities that include a housing department , um , or planning department, as well as a community based organization to really dig in and look at what are some of the legal and policy barriers that they're facing that would , um , inhibit them from being able to expand access to affordable healthcare . So if you wanna learn more, you can look at our housing solutions collaborative on our website, but that's just an example of, you know, helping to weave through some of those legal and policy barriers in order to make sure that folks have access to, and kinda overcoming some of those historical inequities around housing. And then the second example , um , that again , will just kind of hopefully resonate with everyone on the call today , um, that we saw particularly during the COVID-19 pandemic was, you know, the role that public health laws played in helping to reduce the spread of infectious disease, such as COVID . Um, we know that it was important for people to comply with mask mandates or social distancing mandates and others. Um, but we also recognized as we looked at, you know, previous public health enforcement practices, that they themselves can have a disproportionate effect , particularly on low income and black and brown communities. So the , um, you know, the layering of fines for example, can be really challenging for low income individuals. And in some of our work around tobacco control, for example, where , um, an individual we , where we target the individuals for possession and use, for example, rather than looking at the institutions , um, who have power and resources to make changes. And also that's where the biggest effect would be rather than targeting individuals . So we put out a guide at our equitable enforcement guide to also help state and local jurisdictions really think about what is the goal for their enforcement and how can we use enforcement to encourage incentivize compliance rather than penalizing individuals or having a disproportionate impact on individuals who are already sort of facing over enforcement within their communities. So those are just kind of two examples of how we've been working with communities to use that , um , those five drivers.Speaker 2:
And you've mentioned law many times in policy, and we're gonna circle back to that importance there. Um, so housing, public health laws definitely really important and relevant and tangible for our audience. Other initiatives that you could talk about, you know, many audience members work with providers directly in the healthcare system, whether they're hospitals, et cetera . Um, are there ways to partner with hospitals and health systems to kind of build that stronger community and build those connections?Speaker 3:
Absolutely. So we've been working with healthcare and hospital systems for several years now , um , particular issues. So for example, a lot of healthcare systems or hospital systems , they wanna see that connection to their patient population. And so we've worked with them on again, tobacco control and how do we make sure that folks have access, or what are some of the policies that we can limit , um, access to tobacco, but we've also worked on issues like food insecurity, housing, mental health , um, you know, just to name a couple we, and through those different engagements, we actually produced our legal and policy strategies for healthcare and food system partners that again, help to break down some of those legal and policy barriers to addressing food insecurity. And we do it in a way that helps to think about, you know, if we wanna focus on individuals, but also thinking about it from an institutional perspective and all the way out to how you can have an effect even on the broader community. Um , so that's a really document and I'll actually give a couple of examples in just a minute, but I also wanted to kind of bring back the work that we've been doing for the build health challenge or the build health collaborative, because that is a national program. It's again, it's a multi funder program and what it does is it centers community, but it's anchored in working with the healthcare institution as well as a government agency. So it's really trying to get at these partners to kind of break down some of the silos to help translate across different sectors and again, to really center the community, to have a much more sort of equity driven policy solutions. Um , and so, and just, I also name that because build health is also seeking new grant , new grantees or new awardee right now. And so if folks are out there interested, they can , they can definitely apply , but those are , um , you know , healthcare and hospital systems play a huge role. And we'll talk a little bit more about that today , but , um, but there are some tremendous opportunities for healthcare systems to , to also , um , have a much bigger impact on the five drivers of inequities.Speaker 2:
Right. Thank you, sir . I definitely will circle back to hear some more of those specific initiatives with hospital and health system partners. Um, so we, we both highlighted the fact that a lot of our audience are legal professionals. They have that legal training that interest in the law and policy. Um, and what of course the American health law association is professional home for health law professionals around the country. Um, and so we , uh , have this particular understanding of laws and policies. And so while on the one hand you mentioned something very important earlier, you talked about a very powerful risk factor for poor health. In fact, our laws and policies, which are , which perpetuated different legacies of racism and discrimination, that being said. So in other words, these laws have played a role in creating the very discrimination we're trying to tackle. However, let's take a positive approach on that and sort of flip that and say, that means that laws and policies are also the best way to achieve health equity, right? So let's, let's focus on that piece of it where how can laws and policies , um, and other best practices. I should, I should say, tackle this and really turn this around. Um, I think that will be so helpful and powerful for our audience who are in the position to themselves and, or counsel others to have this kind of positive impact.Speaker 3:
Yeah, it's great. So thank you so much . This is like a great question. Um , cause it's , it's really a core to our work. I change that , but I also say on a personal level, I think , you know , lot working with laws and policies are really important because they really have an opportunity to center the change makers . Um, most people don't think about law in terms of how it affects their daily lives, but it really does have a profound effect on our lifetime trajectory. And if I think about some of the major pieces of legislation that have affected health in particular like the affordable care act and Medicare and Medicaid, the civil rights act, voting rights act, those are all , um, you know, they give the power authority resources and , um , the distribution of resources , um, in certain ways that are gonna either positively affect people's health or they have the potential to limit health. So those are great examples of how they've really centered people's health. Of course, no law is perfect. And we actually, in the United States, we have a long history of using laws to exclude , um , you know, certain groups of people based on race or gender or other sociodemographic status, but they are, as you mentioned, really powerful tools for change because of that exact effect because they do, they can name or mandate the way that resources are distributed. And so , um, when we think about the role that law policy has played in , in reinforcing discrimination, we wanna flip that on its head and we actually wanna make sure that laws and policies are accessible to people because oftentimes the policy making process can be very complex and it can feel a little overwhelming and daunting. So again, the blueprint for change makers tries to break that system down for our users so that it can be more accessible so that we, we try to translate some of the information to be , um, you know, to just make more sense to individuals. And then a big part of our work is to help breaking break down, you know, are these real barriers, are they perceived barriers? And if they're perceived barriers here , the way to navigate through some of those perceptions , and if they're real barriers, then here's how you, the individual or the , you know , the collaborative can work together to overturn or to change or shift some of those policies . And the reason why policies are so important is because , you know, unlike education or unlike, you know, direct services, which are still important and necessary policy solutions, they have a much bigger impact on a much larger number of people. Um, and they also have the ability to address historic harms. They have the ability to create the conditions for programs and services to be sustainable and to succeed over time. And I think the most important again, is that they really engage the change makers in the process because once you bring people into the process, you help , you can help to build trust for much better implementation as well as compliance with laws and policies. But I think even more important is that your laws and policies will be informed by their experiences, by their ideas, by their solutions, because we may not have all , you know , us and the institution. We may not always be thinking from that perspective. So it has the ability to bring in folks who have been marginalized or historically excluded so that we don't continue to perpetuate that same kinda discrimination.Speaker 2:
Absolutely. And you know , you've touched on so many important things and this audience is the perfect audience. I think because you've touched on this idea of making laws and policies accessible, making them digestible, you know, making them more transparent , um, making the process more transparent and less intimidating. Um, the real barriers versus perceived barriers. You know, we as legal trained professionals , um , are well situated to help others in our community to, to tackle those barriers. Right. And so I , so I think this is so important that you're highlighting , um , how laws and policies right. Can are , are powerful. Um , and the work that we do can have this positive impact. So , um, if you'll, if you'll speak a little bit about , um, I , I understand that change lab is really helping with some of these specifics, right? You're you have , um, I think training that you do for government staff, maybe if you'll speak a little bit about some of the different ways that you are helping , um, the industry , um , understand this better.Speaker 3:
Yeah. So we , um, we've, we do a lot, we provide services in a lot of different ways. You know, some of it is kind of through like we can contract with us, we have a lot of information on online, but we, again, really believe that, you know, productive, preventive and protective laws , um, they require that people have an understanding and legal concepts. And again, that's not always accessible to individuals. Um , and so, you know, part through , through our work, we're able to one train government staff and community based organizations or advocates and others who are working in anchor institutions like healthcare and hospitals or university settings to really understand the basics about legal concepts. So we have a whole, we actually have a free training certificate program on public health law . Um, again, just to help people understand. And especially during the pandemic, this was really important because we hadn't seen public health officials need to stretch to their entire, the entire authority. Um , you know, because we hadn't had a pandemic in a hundred years. Right. And so , um, you know, providing sort of an understanding of the different levels of government and how the authority works with different levels of government. So we do have that training program. We do a lot of research and analysis as well , um, using an equity framework or an equity lens to help really understand sort of the roles again, that , um, these kind of embedded , um, you know , segregation or racism could be playing. Um, and we offered a lot along a , a broad spectrum of work from, you know, our health sort of from birth all the way to our golden years. Um, thinking about the role again, that, you know, commercial tobacco products have played, but also community development, food development, et cetera . So kind of all the drivers that we talked about today. Um, and then again, we have an online , um, they call it online library . It's one of the biggest libraries , um , where we have a bunch of free toolkits and different kinds of guidance documents. And then we do provide , um, one-on-one technical assistance and training with a variety of different , um , sources, some of which are through kind of the cohort model, like the built health model, and then others are , um , through, you know, different kinds of contracts. So, but it's really a good way for us also to understand what is the community facing, where our healthcare systems and institutions and others thinking about what are some of the challenges that people are facing , um , and, and really gives us a chance to kind of innovate and think about the role that law policy can play to help improveSpeaker 2:
Well, that's wonderful. And what's so great about change lab and, and organizations like change lab solutions is the tangible tools that you're providing the industry in particular, those who are in the law policy space. So it's, it's phenomenal. And I would definitely urge our attendees to take a look at all these fabulous resources that are being put into the chat. So, one thing that you just said, I wanted to highlight for everybody, cuz I just circled into my notes and I think it's gonna stay with me. You talked about productive preventive and protective laws and policies. And I think it's just a wonderful way for those of us, all of us in the legal industry to be thinking about what is the purpose of the law and policy. It , it is meant to be productive, preventive and protective. That is the , that is the goal of every law and policy. And if it's not meeting that goal, what needs to be done to make changes or what are new laws and policies and best practices that can further that. So, so let's, let's take a , let's take almost like a deeper dive if we can, because you know, many of us , again, on the , on the call, we work with national clients, we're used to looking at national and federal considerations and that's obviously often the news or in the media. And while those considerations are very important, I believe in the work I've done. And, and I think this is consistent with change labs view is that a lot of action collective action to reduce health disparities happens at the local level. Um, and that what we do at the local level is very powerful. Um, and so that's where I want us to shift gears a little bit again, because it's important to understand the big concepts and have the framework, but understand the power of the work we do locally. Um, so if you'll help us kind of understand the connection, first of all , um, between, when we think about the federal piece of this and the , the federal and state authority and the local side, the local policy, local authority , um, there are certainly numerous federal laws and programs , um, that are going to create that structure for states and local landscapes and give them the authority and the resources they need. We all know that again, as health law professionals , um, and that structure can be an important lever for advancing health equity. So maybe if you can give us a little bit of that foundation of thinking about there's this, the federal structure, but within that, how the importance of the local work.Speaker 3:
Absolutely. And lemme just kind of kick this off by also saying that, you know, our health and the structures that enable or limit health, the public structures that are there such as public government, they're, they're really important. They play a very important role in our health. Um, I would, I would say that America's prosperity and really our quality of life depends on those public structures because they have created the systems that we use every day , our hospitals, our transportation systems, our health and safety agencies, just to name a few. And if we didn't have those structures in place , um , and the , as well as the policies and the , and the resources in place, it would be really hard for us to get a lot of our jobs done. It would be hard for us to get to our jobs every day , right? So we really need those federal state and local agencies to help protect us , um , through the creation of the quality standards that they develop are environmental controls for workplace and , and , um , product safety protocols, you know, just to name a few. And at the same time , the blueprint for change makers and a lot of our work at change lab , it really does speak to the power of local solutions because local policy change is much more likely to be grounded and a deeper understanding of the local health needs as well as the lived experiences of residents. Um, and so local change is often gonna be more lasting change. And I would also say from our perspective, local governments are kind of laboratories for policy change and they often provide great case studies as well as evidence of success to sort of set the stage for national and, and state level changes. Just as an example in California, I know our county level health systems , um, played a really key role in advancing healthcare coverage to cover all children, regardless of immigration status and regardless of income status. And I think that's paved the way to continue to expand. It's shown the benefits of adding access to healthcare and continue to pave the way for expanding access to, you know, other individuals, particularly , um , low income families and others. Um, and so again, local solutions play an important role, but local government derives its power and authority from the federal and state level government. So if Sarah can put the slide up , cause I think this slide does a really good job of just sort of showing , um , you know , you think about the federal government, you know , these agencies and institutions like the national Institute of health , um , the , the food and , you know , FDA , for example , CDC department of a , they all set the broad parameters for these programs and services. Um , and oftentimes they'll provide the funding for those different programs and service . And then the state government often takes those resources and then distributes them to the local level, through different boards or through different agencies. And then the local level government will get again, continue to see how those , um , resources get distributed from the local level . And , um, the , in the blue sort of far left side , you know, the , the arrow going down really shows again, federal government down to state down to local. The , they really , um , you know , put forth like what is the policy or the strategy or the funding kind of what's the oversight for the way that these funds and policies are gonna be distributed , um , and , and identified. And then oftentimes we'll have the data. And then the arrow going up is really to show how local government and as well as local advocates and kind of local institutions play a huge role in determining , um , and putting, giving input into that policy or into those systems. Right? So at a local level, we need to be sharing data and evaluation reporting, giving constituent input along the way to, to help assess, you know, how is implementation going? What are we learning from these programs and systems ? Um , so again, this is just kind of a nice , um , overview to show a sample of how the relationships of local government, but it's often important for local government or local , um , policies to kind of understand, you know, how is it that, that we derive our power from either the state or the federal government in order for us to be able to do as much as we possibly can at the local level. And also where can we give input along the way?Speaker 2:
Absolutely. And I love how it demonstrates really that synergy and how, you know, how much we are integrated with that. So while we know that action at the local level is very powerful and it , you know, community by community tailored, customized, collaborative, right. But at the same time, we know we have to exist within the broader authority of either state or federal regulation or oversight. And so , um, it really makes for, you know, a complex , uh , situation, but I think it's really important that we are sort of highlighting these relationships. Um, one thing that you mentioned earlier that I'd like to circle back to, and we have a great question in the Q and a are about some specific examples of what health hospitals, and health systems are doing. So what are some of these strategies and best practices then at the local level, for example, of how we might partner health systems or hospitals with communities? Um, I know that your organization has, has developed some of these initiatives that not only connect these organizations, working with healthier foods and beverages , um , trying to leverage other community benefit allocations . So it would be great to dive a little bit more, I think this is the right time to do it , um , into some more of those examples.Speaker 3:
Yeah. So again, I think healthcare and healthcare systems and hospitals have a play a really important role. And we have seen , um, just a phenomenal efforts , um, at the local level, as well as at the statewide level, through our partnerships with healthcare and hospital institutions. And, and really, I think maybe it feels a little overwhelming or daunting, but again, I think I wanna break down sort of some, some good examples, but , um, in general, the reason why we think that healthcare and hospital systems play such an important role is because one , you all have access or oftentimes they have access to data to help us identify and track health outcomes , um , you know, where some of the population health related issues, or just some of the challenges that they're facing within their healthcare system, cuz that can be a good indicator of what's happening in the broader community. Um, so that that's a really important role. The second is obviously access to patients again, both as a way to kind of integrate folks into what are we learning and hearing from the community, but also because you have a captive audience, if you will , right ? You can help work with patients to educate, inform them and engage them in different efforts and initiatives. Um, there's also oftentimes health county hospital systems. They have resources such as community benefits or other , um, you know, kind of resources to help bolster and compliment other funding initiatives like multi funder or government funding. Um, oftentimes because you're leaders in the community, you have connections to community partners for either referrals or other services. And I think one of the most important is because healthcare hospital systems are leaders in your local communities or your state level communities. You can influence policy decisions at the local state and federal levels or even internally within your institution. And so these are all the elements that we need in order to address the social determinants of health . Um , and as we've partnered with different systems, we've really had the chance to work through some of those kind of tricky, legal and policy issues that may be coming up, but also just to help institutions design and implement very successful equity driven strategies .Speaker 2:
Absolutely. And I know many of us work with some of these health systems who have a true , um , sort of mission , um, just last change lab or age , like have , uh , a real mission to advance these goals. And so I think you, you articulated so well for us because not only do they have the data, the patients, the resources, but they also have that leadership within the community, they have that voice, they have the reputation , um, and that's where it comes circles back to our earlier conversation about the power of doing things at a local level. And when you have a hospital health system with a local community, local providers , um, even if it's part of a larger, you know, national or international organization , um, there can be so much impact there. That's done community by community. And again, it goes back to being tailored and customized for what is gonna resonate with that community. So , um , maybe you could share a couple more examples. I know that again, this is something that I think our audience is gonna be really interested to learn more about. Um, how do we use community health needs assessments? You know, just what are some of the different initiatives that could help us take have some tangible takeaways that when we're working with our institutions and our clients.Speaker 3:
Yeah . So I thought I kinda share three examples , um , with you all. And I can pause in between just in case Asha , you have other questions, but , um , one of the tools that we have seen , so one of the big questions that we get sometimes from our healthcare partners is like, where do we start? You know, we understand that this is like social determinants of health is important. And we , you know, we really wanna make a change. We are mission driven , but we're not really sure where to begin . And so one of the tools that we've seen that is just a huge game changer for hospitals in particular, our community health needs assessments, which I'm gonna call CHNAs . Most people probably understand that. But , um , so the CHNA is it is required by federal law. So I think at the beginning to often , um , institutions sort of approach this as being like, oh, it's something that we have to do, but we have seen , um, healthcare and hospitals change this from sort of a dull , boring, required report into something that speaks to and tells the story of a really transformational community story. Um , that's actually filled with residents, voices and ideas that also helps to shape our health partners as well as the community's priorities. Um, and as in our work, we've both been able to provide technical assistance on what to ask, because there are some requirements about that, but also about how to ask questions. Because when we think about equity, sometimes the, how is just as important or sometimes even more important than the what. And when I talk about the, how, what I'm talking about is the process in which you're going out and engaging community or in which you're surveying the community to understand what are the priorities. Um, and so as we worked with partners, we've really helped them leverage how to be much more intentional with community engagement because that's already a requirement of the process . Um , but in building that relationship with community, what we've seen is that trust starts to be built , um, that you oftentimes, you're getting new and different perspectives perspectives from folks who are in the community who are living these experiences and who are bringing kind of a community based asset model. That's not, you know, oftentimes when we're doing assessments, we wanna understand what's the problem. And so we, we sort of frame it from a deficit model, but working with communities sometimes shifts it so that we can think about what are the assets in the community that we can build upon , um, in order to , um, move, you know , move something forward in order to build in those different solutions. Um, so we've been able to, to do that. And then the second thing on the, what is, we've also been able to help systems understand, dig a little bit deeper, to understand how to ask questions about the underlying structural issues. Um , rather than again, just sort of sitting at the surface, but really digging in to ask , you know, who has access to what well building or power building opportunities. Um , and then the third, I would say again, is that it's , it's again, a great opportunity to kind of fold in those community stories , um , to help define the , the hospital's priorities, cuz that's really what the requiring the requirement is with the CHNA . Um , so they can be really powerful tools , um, for helping to both assess the community priority as well as to think about , um, just much more of a community driven and equity informed process. The second example I wanted to raise is , um, we often hear again because , you know, when we are good attorneys, we are asking the questions about risk and liability and um , you know, what are, what are the requirements and the compliance that we have to follow . And so again , our legal policy strategies document that has dropped in , in the chat that has a number of considerations that have come over . So how do work around data privacy constraints when it comes to are some of the liability and risk issues that we need to be thinking about with volunteers , um, you know, our food handling and processing, if we're working with local vendors versus these other vendors, et cetera , um, you know, how does Medicare and Medicaid reimbursement processes, how do these all fit in ? And so our legal policy strategies document , it really does work through some of those very specific examples to help get over. Is this a legal barrier? Is this , you know , like a real legal or policy barrier or is it a perception ? And I wanna just name a perception that we've been able to kind of overcome when it comes to , um, uh , one of the, the connections to a, the WIC program, which is the women infants and children program. So again, through our build health challenge work , we've been working in , um , a leaf , which is an area in Houston, Texas. And , um, the program is centered around making sure that pregnant women and soon to be moms have access to all the sort of nutrition and healthy food supports that they need. And one of those is to get them enrolled in the w program, cuz that is a way to , um , help new, new and pregnant moms be able to get access to healthy foods . So in that program , the community realized that , um, most of the women's qualify most of the womens qualified for the program that they were not enrolled. And what they identified was that there was a barrier around an identification requirement on the website, on the web website. And so we did some research and found that at the federal level WIC identification programs are delegated to the states . So it is a state option to be able to determine what are those identification requirements. And the state actually had no apparent requirement for those forms of identification. And yet on the website, it said, this is, you know, a necessity. And so through the legal research and through the advocacy and through, you know, connections with these community based organizations, we were able to support working with that local government to be able to shift , um, the website so that we could, I , you know, so that it remove that perceived barrier for the local community to be able to then start to enroll , um , people into that program. So again, it was through that partnership, through that legal research, through that collaborative that we were able to , um, to make that change and this, so to me, this example just really speaks to the power of, again, those cross sector collaboratives and sort of breaking down the language and translating , um , you know, the , the different language between groups, but it also speaks to that connection, having somebody who's grounded in the community to flag some of these challenges that can bring , you know, who has trust with community based organizations. And then oftentimes it just speaks to like sometimes it's the power of interpretation and really being able to have those partners help you understand , um , you know , when it's a real true barrier versus when it's just that perceived barrier . So I'll pause there , just see if you had any questions .Speaker 2:
Yeah . Well , and I'll just sort of chime in , cause I know you have some more ideas and examples, but what's so brilliant about this is that you are really speaking, I think, to the legal professionals and the audience who have these skills who have been trained to do research as such to not be intimidated by some of the minutia of the laws to go deeper as you did. And your team did to say, you know, why does this website have this? It was sort of an unintentional barrier , um, because it was creating a situation where there was a requirement that maybe really wasn't a requirement. So something so tangible and discreet though, was having a real impact in this local community. Um, and so what I think is tremendous is that we listening have the skills , um, to, to take on this work. And particularly when you talk about community health needs assessment, I know many of us work with our hospital health system clients on , um, on that very important tool. And I love how you explain that it's more than just another report. Um, it's something that can be such a powerful tool , um, for the health system, but it also means for us as lawyers and other legal professionals, we are counseling our clients. We are being asked to sort of have a seat at the table with them and to be more than someone who simply writes a memo from time to time, but really collaborates provides ideas, suggestions, solutions. Um , so I'm just grateful that you're giving us these types of tangible takeaways that we can incorporate into our work. Um , but let me not stop you there because I know you have some other, some other thoughts that you wanna share with us before we kind of wrap up and have our call to action if you'llSpeaker 3:
Yeah . So the last I wanted institutions CHNA . Um, and so I , again, I think, you know, institutions themselves can also be models and just great places to start to think about that cross-sectoral , um, opportunity. So even within an institution that again, doesn't have a CHNA requirement, there are ways that systems and institutions can just start to look internally. So again, kinda looking at what is the mission, what's the mission alignment within our organization, or what are some of the other internal requirements that we have to survey communities if you don't have , um , the , the C H a requirement census data is a great way to understand, you know, what's happening in the community . Where are some of the hotspots, if you will , that we can identify , or what does the community surrounding the institution look like ? Um , so census data can be really important. And the other is partnering with , um, you know, departments of public health or departments of social services that may also be under , have an understanding of what are some of the local community needs to be able to inform and kinda move , move folks forward . But again, just looking internally within the institution, we've also had an opportunity to work with systems and institutions on their own, you know, role in food procurement, for example, to support healthy food within their systems so that their employees, that their patients, or even their visitors, when they come can have access to healthy, affordable foods at all. So healthcare systems and institutions can use their leverage, their purchasing power to even at the local level, to be able to work with local vendors, for example, to support the local economy, to help address climate concerns , for example, and even just to provide a really great boost in the local workforce , um , and more children's health more's children's health has put together a great study that shows some of the benefits that healthcare partners receive when they are doing this work even internally, but also when they're thinking about working across different sectors. So again, I , you know, it's a way to integrate and align with their mission to kind of , you know , build , um, cross sector collaboration within the institution , um , and also have an opportunity to sort of influence outside of the , the institution. Um, and then the last thing I would say is that again, it's a great way to kind of model , um , equity and health centered food, procurement , vending practices , um , supporting local vendors and local institutions , um , you know, by, by sort of looking internally to see what can we do even as an institution .Speaker 2:
Absolutely terrific examples. And, you know, in just an hour, I mean, we've only been together 55 minutes today, Sarah and you've, you've helped us understand, you know, the fundamental definitions of health and health equity. We've looked at the social determinants of health, which is the term many usre familiar with, but it's really helpful to see it sort of visually depicted and understand that healthcare is certainly a big piece of it as well, our healthy behaviors, but there's another big piece of that, which are the physical environment and the social and economic structures that we have. Um, and this is the distribution of money, power, and resources. Um , you helped us to understand the elements of a healthy community. Um, and you know, it's beyond our individual genetics, as you said, it's access to the quality of healthcare or even our behaviors. Um, and that we really have to understand this complex framework. If we want to dive into inequities and understand what those drivers are, you took us through all five, but we focused more on structural discrimination as, as an important one for date today's conversation. Um , you helped us to understand the role of federal government and state authorities in power, but at the end of the day, I think we have this takeaway of how powerful local action is community driven , action collaborating and listening within the local level , all of us as legal professionals, lawyers, and policymakers, consultants, providers , um, also understand that we can use our tools, our training as , uh , you know, in terms of research, writing collaboration, negotiation, right? All of these important skills that we have , um, to really , um, think about how we can ourselves be impact makers or change makers or assist others who are in a different position or better position to do so than we may be . Um, and what I love to do, and maybe it's a professor in me , Sarah , that , um, you know, sort of end class with kind of like, what are the takeaways or what are the action steps, you know? And so give us just a brief thought. I know we only have a few minutes left of what can our listeners, our audience do, our HLA membership, or just even the broader health law community. Um , do you know, to kind of start thinking how we can take some of these steps in, in using our skills in putting our skills into action.Speaker 3:
Thanks , Asha . I , I also think it's really important to walk away from these conversations to be like, okay , what's my next step? You know, what is it that I can do? And the good news is that, you know, there's so much work to build upon. We're not asking folks to start from scratch. There's so many great resources that are already out there. And so I think really what we're asking people to do is sort of take a moment to kind of carve out, you know, some time to really think about how to integrate these things into the first action I would say is, you know , download and read the blueprint for change makers because there's so many good . Um , it provides just a really good understanding of why is this important now? And we actually, we actually , um, printed that in 2019 . So this was way before the pandemic, but I think it's so much more relevant today even than it was then to really understand. I mean, we want institutions to be making investments in eliminating and reducing structural racism and discrimination, and there are some really good next steps. We just can't keep putting bandaid solutions on this gaping wound that the pandemic made us face . And so , um, reading the blueprint for change makers will just help to ground . And I think the case for why looking at the structural and the five drivers is is an important first step . And then the , I would say is , you know , there's a lot of , um , policy actions that are taking place right now today at the state level in particular, to roll back the way that public health officials can do their jobs. And so what I would recommend is, again, just kind of getting engaged in the conversation and you can start by joining the act for public health , email list and Lister , which will just give you some up to information around litigation thing I would say is to really start to think about how all of these things interact with your own institution. Um, and what are the ways that your institution can start to model policies and practices, even , even if that's internally. So I mentioned the legal and policy strategies document a lot would I didn't speak to was our health and housing starter kit and the health and housing starter kit is also a really great example of a , a spectrum of different ways in which healthcare institutions or hospitals or other change makers can get engaged in the housing conversation. Cuz again, I know housing is, is a really important issue that's happening today. Um, and so there's a great spectrum of like, you know, integrating asthma preventive services all the way up to how you can engage in the community to expand affordable housing. And then the last thing I would say is, again, look at your mission or your C H N a document to really start to assess, you know, what are the big, what's the big focus within your community or within your institution and how can we start to kinda talk to others within our institution , um, to just begin to identify , um , one place to start.Speaker 2:
Thank you, Sarah . And let , just wrap us up here since we're down to our last few minutes. Um, one thing that I know you've really emphasized here is how important a role law and policy plays. And we at the American health law association, the broader community change lab at my home university, American university, Washington college of law. We are well positioned because of our knowledge and expertise with law and policy. So I invite everyone listening in tuning in today or in the future to connect with us further. We have some social media and other , um , information here that you can follow us. Um, of course stay connected with American health law association. Um , all of us are working in this space , um, in , from coming from different perspectives and angles so that we can really move this conversation forward and have a positive impact. Um, with that, I also wanna thank , uh , American health association for allowing us to put together this program for you today as part of health all week, I invite everybody to participate. Um , some more this week, I'll see everybody around at further events. Um, and most importantly, Sarah , um, to you and to change lab , I know you have an amazing team , uh , supporting you , uh , a deepest thanks your organization is doing phenomenal work. You've, you've shared incredible, tangible, impactful resources with us today that we can, we can study and we can digest. We're gonna definitely be , um , staying in touch with change lab , through social media and other things. Um, but the work you're doing is truly inspiring. So just a personal thanks as well as the thanks on behalf of the American health association and the broader health law community . Thank you . All right . And with that , everybody. Thank you. It's four o'clock sharp Eastern time. I look forward to seeing everybody later this week at health events or other American health law association programming. Um , thank you all again . Thank you , Sarah . Take care everybody.Speaker 1:
Thank you for listening. If you enjoyed this episode, be sure to subscribe to ALA speaking of health law, wherever you get your podcasts to learn more about ALA and the educational resources available to the health law community, visit American health law.org .