September 21, 2021

Congresswoman Cheri Bustos United States House of Representatives 1233 Longworth House Office Building Washington, DC 20515 +	Congressman Tom Cole United States House of Representatives 2207 Rayburn House Office Building Washington, DC 20515 +
Congressman G.K. Butterfield United States House of Representatives 2080 Rayburn House Office Building Washington, DC 20515 +	Congressman Markwayne Mullin United States House of Representatives 2421 Rayburn House Office Building Washington, DC 20515 +

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Dear Leaders of the Congressional Social Determinants of Health (SDOH) Caucus:

CEO Action for Racial Equity (CEOARE) is a Fellowship of over 100 companies that mobilizes a community of business leaders with diverse expertise across multiple industries and geographies to advance public policy in four key areas — healthcare, education, economic empowerment and public safety. Its mission is to identify, develop and promote scalable and sustainable public policies and corporate engagement strategies that will address systemic racism, social injustice and improve societal well-being.

We applaud and recognize the convening of this caucus bringing together members of Congress to highlight the opportunities to improve health outcomes and increase existing and future federal investments in social determinants of health. In leading this work, we urge you to explore SDOH policies and legislation from a racial equity lens and recognize the role structural racism and bias plays in exacerbating health disparities specifically for communities of color.

Health disparities have been documented for decades and reflect longstanding structural, societal and systemic inequities rooted in racism and discrimination. From healthcare to food equity to education, Black Americans have not experienced the same quality of services and opportunities and race is the common denominator when it comes to these disparities.

To further highlight the correlation between structural racism and health disparities, we have included some key metrics below across the following categories:

• The U.S. Economy – $16 trillion in GDP has been lost over the last 20 years because of racial discrimination. By addressing SDOH and racial disparities, we can increase GDP by $5 trillion in a five-year span.¹
• Healthcare
  • Black Americans are hospitalized with COVID-19 at four times the rate of white Americans and receive worse care than white Americans in 40% of medical visits. ^{2, 3}
• Food Equity – 39% of Black households with children experience food insecurity and faced a food insecurity rate of 25% prior to the pandemic. ⁴
• Education – Black school districts receive $23 billion less than white school districts and face a funding gap of $5,000 per student per year. ^{5, 6}
• Income – Limited income to purchase effective and sustainable amenities for virtual healthcare (i.e., device ownership, digital literacy, broadband access and connectivity)

The COVID-19 pandemic has highlighted the importance of social determinants of health in health outcomes, as it is increasingly demonstrable that social inequalities in health are profoundly, and unevenly impacting morbidity and mortality. This is apparent in how much these disparities have been exacerbated. The life expectancy gap has increased from four to six years for Black Americans just in the last year. ⁷ In addition, the US spends $93 billion per year in healthcare costs that could be reduced by addressing inequities through SDOHs and mitigating the further widening of health disparities going forward.⁸

We appreciate the task now before this Caucus to collect stakeholder input on the challenges and opportunities in addressing SDOH and how to better facilitate effective social determinants of health intervention. We have submitted a response to your request for information and we are committed to working with Caucus staff to dive deeper into this important work in the time ahead. We hope to connect with you in the near future to see how we can collaborate and use our 100+ companies to help push these efforts forward.

Thank you for your leadership and commitment to driving this important work forward.

Sincerely,

CEO Action for Racial Equity
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Compiled Prioritized Areas for the CEO Action for Racial Equity Congressional SDOH RFI Response

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Experience with SDOH Challenges

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

To properly answer this question, we need to distinguish between two major challenges categorically:

• Improving governance and frameworks that manage and facilitate action related to SDOH, and
• The challenges faced across individual SDOH and the impact structural racism has had on exacerbating SDOH disparities across Americans of different racial backgrounds.

1. The SDOH challenges related to governance and carrying out meaningful action are as follows:

• • Lack of SDOH Funding
    • The research and data show that investment in SDOH has incredible returns on investment (e.g., 300%) and for this reason, should be prioritized in government budgets and funded more heavily.⁹
      

• • Inconsistent Data and Measurement of SDOH
    • Entities, tools, resources, and investment to track data related to SDOH are limited.
    • Methods for tracking SDOH are not clearly understood or defined.
    • Data measurements are not consistently disaggregated by race, gender, age, income, etc., in order to measure the impacts and disparities that exist across groups.

• • Limited Community Inclusion
    • Lack of inclusion of communities and community leaders in policy development at all levels of government, as well as program administration and implementation, leads to poor and inefficient prioritization of SDOH and unintended consequences.

• • Lack of Education for Healthcare Professionals
    • Healthcare professionals may not understand or take into account SDOH when treating patients to adopt preventive measures to improve health outcomes.
    • Healthcare professionals may not be closely linked with individuals responsible for SDOH programs and funding, leading to missed opportunities to help individuals and families.

1. • Limited Use of Racial Equity Lens
     • Policies and actions do not consistently incorporate the use of a racial equity lens to ensure that underserved groups are empowered by and benefit from government action.
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2. Some of the prominent and ongoing challenges faced across individual SDOH are even greater in minority communities due to the effects of structural racism and the unequal distribution of resources in these and other underserved communities. Examples are as follows:

• • Food Equity
    • Black families disproportionately faced food insecurity at 25% prior to the pandemic.¹⁰
    • Insufficient SNAP benefits and lack of healthy food options in urban and rural communities continue to exacerbate other adverse outcomes.

• • Housing
    • Housing, ownership and rental, is unaffordable or too expensive for millions of individuals and families which leads to further homelessness, poverty, and negative health outcomes.
    • Black individuals are 80% more likely to be denied mortgage loans than similar white individuals and have historically been denied opportunities to create wealth through home ownership.¹¹
    • 50% of the homeless population consists of Black Americans. ¹²
    • 30% of Black families spend more than 50% of their income on housing.¹³
    • Lack of home ownership for Black Americans explains up to 50% of the wealth gap. White American families have 10 times more wealth relative to Black American families.¹³

• • Healthcare
    • Black women are three to four times more likely to die from pregnancy-related conditions than white mothers.¹⁴
    • Black infants are twice as likely to die than white infants.¹⁵
    • Hospitalization – Black Americans are hospitalized with COVID-19 at four times the rate of white Americans. ¹⁶
    • Healthcare Costs – $93 billion spent in excess healthcare costs per year due to health disparities.¹⁷
    • Healthcare-based solutions, Medicaid, and Medicare are inadequate in many areas across the United States.
    • Insufficient health insurance for low-income individuals.
    • High healthcare costs deter individuals from receiving treatment in the most critical times.
    • Lack of income to purchase effective and sustainable amenities for virtual healthcare (i.e., device ownership, digital literacy, broadband access and connectivity) and limited access to telehealth for millions of Americans.

• • Education
    • Black school districts receive $23 billion less than white school districts and face a funding gap of $5,000 per student per year.^{18, 19}
    • School funding is often not allocated equally in low-income counties and neighborhoods, allowing those with more resources and access to receive higher quality education, continuing to widen income inequality.
    • 16 million K–12 public school students across America are caught in the Digital Divide without adequate broadband access to participate in school. Black students are disproportionately impacted by these disparities.²⁰

• • Criminal Justice
    • African Americans constitute 2.3 million, or 34%, of the total 6.8 million correctional population, despite making up roughly 13% of the US population.²¹
    • Black Americans are disproportionately incarcerated for non-violent crimes, which amplifies poverty through breaking up families and reducing employment opportunities for formerly incarcerated individuals.
    • Small fines and bail leave individuals in jail and can cause them to lose jobs and sometimes stay in prison for years despite never being convicted of a crime.

• • Technology
    • 4% (16 million) do not have a computer or broadband access, putting them at a disadvantage for employment, income, and healthcare. ²²
    • 70% of Black Americans report being underprepared with digital skills, affecting their employability. ²³
    • An increase of 10% in broadband access in 2014 would have resulted in more than 875,000 additional U.S. jobs and $186 billion more in economic output in 2019.²³

Some of the prominent SDOH challenges that have changed the most during the pandemic are as follows:

• Employment
  • Job Loss – The COVID-19 pandemic has caused tens of millions of people to lose their jobs, leading to loss of income and loss of health insurance. ²⁴
  • Remote Work – Less than 25% of workers are able to work from home during the pandemic.²⁵ There are insufficient virtual work opportunities for the poorest workers, and a lack of investment in online training offered to create better job opportunities.
  • Job Security – Limited job security for many industries and professions leading to unemployment and an inability to become re-employed during the pandemic.
  • Unemployment Benefits – Insufficient unemployment benefits to support individuals and families during the pandemic to cover all expenses.

• Food Insecurity
  • 39% of Black households with children have experienced food insecurity during the pandemic ²⁶ highlighting insufficiency of SNAP benefits, healthy food access, and overall access to enough food for individuals and families.

• Housing
  • Housing challenges have significantly increased due to unemployment, illness, and loss of productivity for millions of Americans, leading to further homelessness, poverty and individuals living in even more crowded spaces. More overcrowding in homes has led to a greater spread of COVID-19 and illness.

• Healthcare
  • Life expectancy of the Black population declined by 2.7 years in the first half of 2020, slicing away 20 years of gains. The life expectancy gap between Black and white Americans, which had been narrowing, is now at six years—the widest it has been since 1998.²⁷
  • The COVID-19 pandemic has exacerbated healthcare resource constraints in marginalized communities impacting access to quality care, diagnostic testing and vaccination.
  • Many patients, particularly Medicare beneficiaries, are only able to use telephone audio-only modalities to reach their providers which limits quality of healthcare that can be achieved through telehealth.

• Education
  • Black students make up 30% of disconnected students equating to roughly 4.5 million students. Studies conducted during the COVID-19 pandemic show that the Digital Divide could lead to an average of seven to 14 months of learning loss for disconnected students, an additional 232,000 high school students dropping out, and an annual earnings deficit of $110 billion across the K–12 student cohort.²⁸

• Technology
  • Lack of computer and broadband access has exacerbated and amplified employment, education, and health challenges.

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­­­­­­­­­­­­­­Is there a unique role technology can play to alleviate specific challenges (e.g., referrals to community resources, telehealth consultations with community resource collaborators, etc.)? What are the barriers to using technology in this way?

The strides in technology over the last 10 years have been groundbreaking. These improvements have allowed for many Americans to maintain a high quality of life during the COVID-19 pandemic and have been instrumental in allowing everyday functions to continue relatively uninterrupted. The ability to harness technological advancements to alleviate SDOH challenges has never been more important. Some of the positive impacts of increasing affordability and access to technology are as follows:

• Increase in Digital Equity
  • Digital Equity is a state in which all individuals and communities have the information technology capacity needed for full participation in our society, democracy, and economy. By making broadband and devices more affordable and accessible, we can help ensure that all individuals and communities have the information technology capacity needed for full participation in our society, democracy, and economy. Digital Equity is necessary for civic and cultural participation, employment, lifelong learning, and access to essential services.

• Improved Access and Efficiency of SDOH Programs
  • Increasing online functionality, utilizing mobile applications, and increasing presence on social media allows for more individuals and families to use technology securely and efficiently to make online purchases, have access to telehealth, and work remotely.
    • This is especially true in the arena of Food Equity. Technology has allowed for a decrease in fraud through the Supplemental Nutrition Assistance Program (SNAP), which eliminated paper food stamps and implemented a method of financial transaction that can even be used for online groceries.⁴¹
  • Telehealth Improvements
    • Telehealth consultations can play an important role in improving health outcomes and reducing the barriers both urban and rural communities have that deter them from accessing their healthcare providers and can also allow for greater access to diverse healthcare providers which may be limited during in-person appointments. Through the Public Health Emergency (PHE) declared during the pandemic, the federal government made revolutionary changes to telemedicine policies to preserve access to healthcare services, such as lifting geographic eligibility requirements and originating site restrictions leading to a substantial increase in utilizing telehealth services and demonstrating its potential to address longstanding inequities confronting Black Americans. While more data on telehealth usage is needed to understand impact to Black patients and other marginalized communities, telehealth enhancements such as adopted in the PHE will assist in alleviating disparities, gaining cost efficiencies and improving patient trust within the Black community. Additionally, supporting efforts to diversify the health professional community can help close racial disparity gaps.

While there have been many technological advancements there are still many barriers that exist that have increased inequalities. The “Digital Divide” refers to the gap between those who have access to broadband technology and those who do not, and this is at the forefront of technological and economic inequalities. Below are some key gaps that we have identified that segments our society into those who are able to take advantage of broadband technology and those who are not:

• Accessibility Gap – Defined as households with insufficient coverage to deliver broadband service, or where there is poor service quality (e.g., speed and reliability).
  • This has adverse downstream impacts such as the inability to make online purchases with a SNAP card, or not being able to receive SNAP-Ed programming, which is an essential resource for recipients as they plan out budgets and reference nutritional guidance.
  • Telehealth becomes impossible for those without connectivity.

• Affordability Gap – Defined as households lacking the ability to pay for reliable broadband connectivity and e-learning devices (e.g., a laptop, desktop, or tablet).

• Adoption Gap – Defined as households that have yet to sign up for broadband service due to barriers such as insufficient digital literacy and skills, language barriers, family mobility and homelessness, or distrust of programs.

• Data Gap
  • Accurate data is necessary to understand the intersection between racial equity and the Digital Divide. Data is required to understand the extent of the problem and to inform decisions regarding broadband affordability, accessibility, and adoption.

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Improving Alignment 

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?

It is imperative that all health and health-related organizations work together to share knowledge, leading practices, and key learnings. At CEO Action for Racial Equity (CEOARE), we also acknowledge that corporations can play an active role in helping to form and be a part of the overall coordination and alignment of these organizations. Companies can accomplish this by bringing innovation and technology, existing networks, and people to help broaden and strengthen these networks.

Opportunities for better coordination/alignment:

• General Collaboration Opportunities
  • Create central task forces and combine resources to measure and address inequities.
  • Increase cross collaboration between neighboring cities/counties/states to increase efficiencies and share successful tactics and improvement opportunities.
  • Work together to identify the most critical needs of high-risk populations.
  • Share knowledge and disaggregated data related to outcomes of investment in SDOH programs.
  • Share leading practices on doing work through a racial equity lens and how to effectively work with communities.
  • Leverage community health needs assessments to identify the significant health needs of the community.
  • Realize and integrate the value of non-traditional healthcare players and locations that are trusted by local communities (i.e., public libraries, community centers).

• Marketing and Building Public Support
  • Collaborate across communications and marketing teams on social media and marketing campaigns to spread awareness and education around SDOH.

• Educate Community Health Workers
  • Leverage collective learnings and knowledge to train and educate community health workers on how to better meet the needs of people in the local community.
  • Support culturally competent health care provider training, translation, and accessibility around digital health services.

• Identify Experts for Healthcare Consulting
  • Identify and utilize Patient Navigators who are credible sources in brokering healthcare resources towards communities, and to help navigate the complexities of the healthcare system.

• Centrally Communicate that all SDOH Affect Health
  • Have leadership from organizations work together to shift our focus to a broader point of view that acknowledges all SDOH working together, versus separately. This will allow for a better strategy in improving SDOH as a whole.

• Leverage Racism as a Public Health Crisis Declarations
  • Community organizations, public health entities, and health organizations can collectively push these declarations across municipalities and states to expedite the process for addressing SDOH as part of racial equity action plans for the most underserved communities.

Role Congress can play in facilitating coordination:

• Facilitate Building of Collaborative Networks
  • Encourage healthcare and technology industries to collaborate and advocate for Black community health needs in SDOH program and service design.
  • Connect major organizations through the creation of websites, social media and marketing campaigns to encourage organizations to join collaborative efforts.
  • Connect state and local officials to organizations to work together and leverage leading practices on SDOH initiatives.
  • Invest in technological infrastructure to optimize data collection and knowledge sharing.

• Clarify Roles & Responsibilities across Agencies
  • Appoint Centers for Disease Control and Prevention (CDC) or appropriate agency to manage guidelines and work with other organizations to improve leading practices across all organizations (i.e., for disaggregated data collection, what systems and databases to use, utilizing a racial equity lens in policies and actions).
  • Appoint agencies to collaborate on innovation to create programs, e.g., social services for organizations to use and communicate to clients.
  • Emphasize that all agencies and organizations must prioritize their focus on the impacts of structural racism on SDOH.

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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?

 To further address the social determinants of health in a more holistic way, we recommend the following:

• Centralize Application Process for All Programs
  • Create a simplified and central application to qualify for all programs, versus requiring complex and separate applications for each. Once an application is completed it should be linked to all federal programs.

• Centralize Data Collection Efforts
  • Align programs and data collection related to food and nutrition across USDA and other federal agencies.
  • Track data in a way that links efforts on improving health (e.g., through nutrition programs) to health outcomes (Medicaid, Medicare) to measure ROI and effectiveness of efforts.
  • Reduce barriers to sharing data and coordinating outreach across state-administered federal programs.

• Improve Technology
  • Adopt modern technologies for state program administration.²⁹
  • Create a mobile phone application / website that hosts recipient information and links all key program details and functionality together in one place.
  • Invest in better systems and databases that allow for more comprehensive and efficient data tracking.

• Increased Coordination on Health Education
  • Centralize approach across SNAP, WIC, Medicaid, and Medicare to improve nutrition and diet related health outcomes for recipients and children.
  • Work across Congressional agriculture and health committees to better align SNAP, Medicaid, Medicare, and other federal programs to improve the health of participants.
  • Recognize the links between diet, health and health care costs.

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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?

 The SDOH Caucus has a unique opportunity convene key stakeholders and subject matter experts to inform approaches on SDOH data collection. Data collection, specifically detailed demographic data collection on race and ethnicity, as well as disparity variables such as preferred language, tribal identity, disability status, sexual orientation, gender identity, socioeconomic status, social, psychological and behavioral health factors, are the foundation for identifying and addressing health disparities and SDOH.³⁰ It is therefore critical that the SDOH Caucus leverage this opportunity to drive a process across the different agencies within the Department of Health and Human Services for collecting meaningful patient data, especially with regard to the aforementioned disparity variables. Although robust demographic data collection is often cited as a critical component for reducing health disparities ^{31, 32, 33}, opportunities to maximize data collection through policy have been missed.^{34, 35} Enhancing the quality of race and ethnicity data to more closely reflect self-identification is critical as populations and communities are complex and addressing health disparities and SDOH must have targeted approaches to address the needs of those communities.

Specifically, fundamental components that should be considered in this process include:

• Standardization of collecting and reporting SDOH data;
• Standardization of collecting and reporting race and ethnicity data;
• A framework for building trust with individuals related to data use;
• Self-reported data from individuals as the gold standard;
• Policies to protect data privacy, security, governance and ownership;
• Standardization of SDOH data sharing and exchange.

• Collaborate with Organizations and Government Entities
  • Intentional collaboration with organizations to improve data collection, visibility, and specific measurements on how underserved and marginalized groups are captured in healthcare data.
  • Leverage and expand existing programs that target data driven SDOH research (data collection/data analytics) including United States Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality and Social Interventions Research and Evaluation Network (SIREN) and the Health Resources and Service Administration (HRSA) to optimize healthcare and social services for populations impacted by racism.
    • Within HSRA and HHS, work with the Office of Health Equity (HSRA), and Office of Minority Health (HHS), oversight committees, and state and local equivalents to share leading practices on data collection and data governance.
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  • Invest in Research and Data Management Using a Racial Equity Lens
    • Compile comprehensive research on the public health impacts of structural racism and develop federal guidelines to confront practices and systems that create racial disparities in public health and healthcare.
    • Expand and conduct research, investment and data collection around the public health impacts of structural racism and utilize the results to improve health policies and practices.
    • Utilize results of research and data analysis related to public health impacts of structural racism to intervene and proactively address identified racial disparities.
    • Collect and analyze data to track the success of programs that are created to address structural racism to measure the impact on improving health and well-being.
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  • Use Data Results for Educational Purposes
    • Utilize data results to inform the public on how the results will be utilized to address SDOH gaps effectively and efficiently in low-income communities.
    • Educate the public on the public health impacts of structural racism and public health interventions that address structural racism.

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Best Practices and Opportunities

What are some programs/emergency flexibilities your organization leveraged to better address SDOH during the pandemic (i.e., emergency funding, emergency waivers, etc.)? Of the changes made, which would you like to see continued post-COVID?

As a Racial Equity Fellowship we have not provided organizational examples, but there has been useful emergency legislation that has passed related to closing the Digital Divide which can serve to help address disparities related to SDOH in the domain of Education Access and Quality.³⁶ Specifically:

• R. 748 Cares Act (March 2020) – A $2 trillion aid package responding to the COVID-19 pandemic. Education funds were used for devices, connectivity, and online learning. An analysis of publicly announced plans for CARES Act funds indicates that 39 states have pledged funds to address the Digital Divide in K-12 education.⁴² Nearly $1.3 billion has been dedicated exclusively to supporting online learning, while an additional $388 million provides districts the option to address the Digital Divide.⁴²
• R.133 Consolidated Appropriations Act 2021 – $2.3 trillion spending bill that combines $900 billion in stimulus relief for the COVID-19 pandemic with a $1.4 trillion omnibus spending bill for the 2021 federal fiscal year. Specific funds allocated to close the Digital Divide include the creation of a low-income subsidy, the Emergency Broadband Benefit, and additional grant funds for National Telecommunications and Information Administration for broadband infrastructure deployment.
• R. 1319 American Rescue Plan Act of 2021 – Provided additional relief to address the continued COVID-19 pandemic. Funding was allocated for education and for to the Federal Communications Commission expansion of the E-Rate Program. Additionally, states were allocated billions of dollars to respond to the pandemic, of which the states can use to invest in broadband infrastructure.

The emergency legislation mentioned above is a great start to closing the Digital Divide. To build on these acts, CEOARE would like to see the continuance of a government subsidy for low-income households (e.g., Emergency Broadband Benefit), long-term infrastructure for underserved and unserved communities, including urban areas, to achieve complete coverage, as well as funding at the state and local level to increase broadband adoption.

CEOARE appreciates the flexibilities and policy changes that have been provided during the PHE specific to increasing access and coverage of telehealth. These flexibilities ensure Black Medicare beneficiaries have access and continuity of care to their health and mental health providers. Telehealth visits for some patients further reduces the time lost from work, transportation time, transportation limitations, and cost associated with in-person visits. For this reason, CEOARE supports the adoption of permanent waivers to permit Medicare and Medicaid patients to access care via telehealth. To that end, we encourage engagement from stakeholder to inform the racial equity components related to permanence.

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­Which innovative state, local, and/or private sector programs or practices addressing SDOH should Congress look into further that could potentially be leveraged more widely across other settings? Are there particular models or pilots that seek to address SDOH that could be successful in other areas, particularly rural, tribal or underserved communities?

The Farm to School program, which is made possible through funding by the Child Nutrition Funding Program (CNPF), typically includes one or more of the following core elements:

• Procurement – Local food is purchased, promoted, and served in the cafeteria or at meal times, as a snack or in classrooms.
• Education – Students participate in education activities related to agriculture, food, health and nutrition.
• School Gardens – Students engage in hands-on, experiential learning through gardening.

The Farm to School model is currently available in all 50 states, Washington, D.C. and U.S. Territories. They are currently seeking collaborations with organizations to commit and work towards their call to action: by 2025, 100% of communities will hold power in a racially just food system.³⁸

Farm to School is an approach to child nutrition that can advance equity in the food system and benefit everyone in our communities.³⁷ It is a win for children as it will allow for:

• An increased availability of nourishing food and ingredients.
• Participation in hands-on activities that provides nutrition education (e.g., gardening and agricultural benefits).
• Further information shared about the importance of where our food comes from. The Farm to School programming will also benefit farmers, providing direct opportunities for consistent sales and pay equity. This approach will also be a win for communities where food is grown, distributed, prepared, and consumed for the benefit of every community member.

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Transformative Actions

Alternative payment models help to measure health care based on its outcomes, rather than its services. What opportunities exist to expand SDOH interventions in outcome-based alternative payment models and bundled payment models?

Alternative Payment Models offer an incentive structure for health care delivery that more closely aligns with achieving the “Triple Aim”—centers patient outcomes and quality, reduces the cost of care, and improves population health—compared with fee-for-service payment structure. As health care cost and Medicare solvency are fundamental concerns of Congress, we encourage continued exploration and support of innovative models that achieve the “Triple Aim,” including those that impact SDOH. Innovation and technology continue to rapidly evolve, and we encourage this Caucus to amplify and support pathways towards innovative interventions that improve patient outcomes and reflect value-based care that address known health disparities and SDOH.

Specifically, we encourage this Caucus to:

• Convene stakeholders to explore ways to include social risk factors in risk adjustment methodologies used in outcomes-based and value-based models to ensure that providers who serve a population with disproportionately higher SDOH needs receive the appropriate support and resources necessary for serving that population. Current risk adjustment methodologies do not create a reliable distinction between poor quality of care and high social risk, which can inappropriately penalize providers who care for patients with SDOH.
• Standardized data on SDOH needs and services are critical so that accurate evaluation can occur to inform resource allocation and distribution for targeted interventions for complex individuals which will help inform more appropriate payment models.
• Encourage CMS to incorporate SDOH into demonstrations being tested by the Center for Medicare and Medicaid Innovation (CMMI). Specifically, digital innovations and telehealth services can be foundational tools for cohesive, patient-centered care delivery, and models that include these innovations should be supported.

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How can Congress best address the factors related to SDOH that influence overall health outcomes in rural, tribal and/or underserved areas to improve health outcomes in these communities?

Congress can best address the factors related to SDOH by taking the following actions:

• Fund SDOH Programs and Initiatives
  • Confirm adequate funding is available for the most critical needs such as housing, food insecurity, healthcare, and education.
  • Support community health centers, Federally Qualified Health Centers and similar safety net providers as telehealth qualified distant site.s
  • Provide patients access to telehealth services by permanently expanding coverage and payment.
  • Include reimbursement to healthcare professionals for screening of patients for SDOH inequities as form as prevention. Collect and utilize this data for baselining and measurement.³⁸

• Consider Utilizing a Framework for Taking Action – Such as Racism as a Root Cause (RRC) Approach³⁹
  • The RRC approach has four principles that function as guideposts to direct advocates trying to tackle a problem as pervasive as racism. Using the RRC approach will:
    • Prioritize specific, racialized groups for a precise, rather than universal, impact.
    • Work to change policies, systems, or environments, as opposed to changing people.
    • Be institutionalized and sustainable to create a long-term impact.
    • Repair historical injustices by shifting resources, power, and opportunities to racially marginalized groups.

• Optimize Policies and Practices
  • Create transparent processes and periodic reconsideration of standards to meet the societal needs of education, public safety, economic empowerment, and healthcare.
  • Modify or create policies that clearly link SDOH to health disparities across the affected communities.
  • Amplify Black community perspectives and patient voices in policy development and promotion.

• Educate Health Professionals
  • • Educate health professionals on SDOH and how issues such as poor air quality, food insecurity, and unstable housing (among others) can impact health outcomes.

• Collaborate with Communities
  • Work directly with communities and community leaders to understand where the largest gaps are in order to prioritize investment in SDOH.

• Invest in Technology
  • Invest in technology (systems, databases, etc.) to centrally collect and track data to measure ROI, understand the effectiveness of actions taken, and to provide reports on learnings that can be shared with governments, organizations, and communities.

• Digital and Telehealth Equity
  • Continue flexibilities and waivers for telehealth access while concurrently addressing the digital divide.
  • Identify pathways towards equitable permanence of telehealth coverage, including audio-only considerations.
  • Engage with the Telehealth Caucus to identify shared policy goals.

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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?

As it relates to addressing and promoting SDOH programs, there are a number of barriers in underserved communities that have prevented the progress needed to meaningfully address SDOH inequalities. These include, but are not limited to the following:

• Lack of Funding and Resources
  • Community-led programs that are producing results need to be supported more with funding and resources. Existing SDOH programs have led to larger ROIs that vastly outperform the market, demonstrated through the Montefiore Health System in Bronx, NY.⁴⁰

• Limited Legislation that Invest in SDOH
  • Bills that encourage investing in SDOH produce high returns on investment.
  • Bills should provide grant funding to identify leading practices, collect data, demonstrate improvements, and determine how to scale interventions, all actions that would have a positive impact for the Black community and serve to address SDOH.
  • Other bills, such as the Healthy, Hunger Free Kids Act of 2010 (which was the last time Childhood Nutrition Reauthorization [CNR] was completed) that expired on September 30, 2015, need to be revisited and reexamined to ensure a racial equity lens is applied to reduce unintended consequences and to promote equity across underserved communities.

• Inadequate Utilization of Government Agencies
  • Federal agencies such as the CDC, National Institutes of Health (NIH), Health Resources and Services Administration (HRSA), CMS, etc., have not been empowered enough to address SDOH issues.
  • Congress should also empower federal agencies to evaluate the role structural racism and racial bias has historically had on SDOH that have produced the stark health inequities we see today.

• Lack of Collaboration across Organizations/Government
  • Congress should devote a significant amount of time and resources identifying all the organizations and subject matter experts leading the work in addressing various SDOH, such as housing, food equity, healthcare access, digital equity, etc., to learn more about their best practices and establish effective collaborative relationships.
  • There is a great need to establish more dedicated taskforces to centrally manage SDOH efforts.
  • There should be greater collaboration and knowledge sharing across organizations to inform others on leading practices as it relates to SDOH programs, initiatives, and investments.

• Need for Increased Community Engagement
  • Marginalized communities and community leaders are not adequately engaged in the creation and modification of SDOH programs, which enables the risk that policies and actions are not tailored to meet the needs of the people.

• Limited Technology and Data Collection/Analysis
  • Lack of infrastructure to collect disaggregated health data by race, ethnicity, etc., and track disparities and the progress of SDOH programs.

• Insufficient Health Education/Literacy
  • More materials and education efforts should be created and implemented to teach people the importance of health/wellness check-ups, eating nutritious foods to prevent serious illnesses, and understanding how to monitor one’s own health metrics.

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