Finding Health in the Infrastructure Law: New Opportunities for Community Investments that Address the Social Determinants of Health
The Biden administration’s “once-in-a-generation” push to revamp U.S. infrastructure keeps people’s well-being at its heart.
Inflation has made it harder for working people to get ahead, and most economists don’t think the pain is going to end anytime soon. The impact has been especially hard on underinvested communities shaped by the impact of systemic racism and historically exclusionary policies. But hope persists, particularly with the bi-partisan Infrastructure Investment and Jobs Act (IIJA), which passed in Nov. 2021.
The law promises to grow the economy “sustainably and equitably,” as well as create 1.5 million jobs on average each year for a decade. However, just how the legislation will address other social determinants of health, such as the built environment, safe housing or transportation, remains an open question.
“Transportation is still a problem for many people, especially younger people,” Lisa Savage, a nurse at The Bridge, a Philadelphia-based nonprofit behavioral health treatment and youth opportunity program for adolescents and their families seeking to overcome substance abuse, mental health issues and other challenges, said. “In the beginning [of the pandemic], the city was giving shuttles to doctors and stuff, and after a while that stuff just stopped. You had politicians saying we gave cities and states billions of dollars but where is the money? What are you doing with the money? What is happening?”
Savage said that the students she cares for at the school have issues which tend to take precedence over health concerns. As a result, some don’t even have the most basic vaccinations they need to attend school, including measles, mumps and rubella. Worse yet, she said, is the sense of hopelessness that many of the students experience.
“You see it with the younger kids: They don’t believe things are worth it or that things can be fixed,” she said. “And the system can only do so much.”
Access to reliable transportation is one of Seven Vital Conditions for Well-Being a project of the Well Being Trust, coordinated with Community Initiatives and ReThink Health, with support by the CDC Foundation. The others include: basic needs for health and safety; humane housing; belonging and civic muscle; meaningful work and wealth; lifelong learning; and creating a thriving natural world.
By using the framework, organizations can begin conceptualizing the conditions needed to ensure that people are healthy. At the same time they can also help in developing a collaborative, multi-sector approach to improving community health by highlighting areas where investment can have the greatest impact and what kinds of investments are needed.
Redressing Historical Transportation Inequity
The Infrastructure Investment and Jobs Act, aims to provide all U.S. residents with access to education, safe transportation options and potable drinking water while simultaneously addressing the effects of climate change and promoting investment in historically underserved communities. Although not stated in the law itself, all of these elements can be expected to have positive impacts on community health outcomes.
One of its signature components is $89.9 billion in guaranteed funding for public transit over the next five years. The money is slated to expand public transit options in all 50 states, improve accessibility for seniors and people with disabilities and replace existing gas-powered vehicles with zero emission options.
The boost in public transit accessibility could be a boon to Savage’s students and their ability to access behavioral health treatment and support their mental health they seek. And, for community leaders such as Leah Shahum, executive director for the Vision Zero Network, the law represents an opportunity to redress years of community divestment and reduce traffic fatalities at the same time.
“I’m really thrilled to see this bill’s focus on recognizing the lack of investment or disinvestment in communities of color and low-income communities,” Shahum said. “This new funding and new direction around policy at the federal level recognizes many past wrongs when it comes to disinvestment. What we’re seeing is the government sending funds to communities that need it most.”
The Vision Zero Network is a collaborative, nonprofit campaign helping communities set and attain the goal of eliminating traffic fatalities and severe injuries among all road users while increasing safe, healthy, equitable mobility.
Shahum added that she is especially encouraged by the $5 billion Safe Streets and Roads for All discretionary program which will provide grants for regional, local, and Tribal initiatives to prevent roadway deaths and serious injuries for five years.
“What we’ve seen is lots of freeways, and a lack of sidewalks and transportation infrastructure that is literally built into our systems,” she said, noting that the concentration of high-speed traffic infrastructure in communities of color and low-income communities leads to more traffic and auto-related fatalities. “For a long time transportation and mobility wasn’t understood as clearly as an important social determinant of health. There’s a very clear one: let’s avoid being hit and killed by cars.”
Shahum added that while Vision Zero can’t apply for funding, it’s possible that it could work with cities or tribal groups in a training capacity in the future. But, for now, the organization is thinking about how it’s using data to support communities that need more funds than others.
“There’s a difference between spreading money equally and equitably and data’s part of the way to get there,” she said. The other part, she added, is through multi-sector collaborations which encourage people to get out of their respective silos. “We’ve got to think of all of this as ‘healthy living’ and I think this bill does.”
Electrifying Central California Communities
Through the IIJA, the federal government will make $7.5 billion available to build a network of 500,000 EV chargers. That infrastructure will accelerate the adoption of EVs, reduce emissions, improve air quality, and ostensibly create manufacturing jobs.
The legislation will also provide funding for deployment of EV chargers along highway corridors to make chagrin more convenient. For Kevin D. Hamilton, co-executive director and co-founder of the Central California Asthma Collaborative (CCAC), EVs are only the first step in advancing equity.
“The infrastructure piece is critical to take worry and stress out of people’s lives but you have to be in communities and available to them in order for them to harness the health benefits,” he said.
The Fresno, Calif.-based community benefit organization (CBO) interprets social determinants of health as “something that brings everything together,” Hamilton added.
There are a multitude of interrelated social and environmental factors that together influence a community’s health outcomes. Hence the importance of cross-sector partners and multi-sector collaborations that can address multiple factors rather than a siloed approach to improving overall community health. With this in mind, CCAC operates multiple programs to improve the lives of residents in low income communities across the San Joaquin Valley including the Clean Vehicle Empowerment Collaborative (CVEC) in partnership with other community-based organizations in the area.
As part of CCAC’s EV Equity Program, the organizations that make up the CVEC — including CBOs such as the Central California Environmental Justice Network (CCJEN), which works to eliminate negative environmental impacts in low income and communities of color in the Central Valley, and the Latino Environmental Advancement and Policy Institute (LEAP) which builds partnerships to promote sustainable development, clean energy alternatives, green jobs and the reduction of pollution and GHGs in concentrated clusters of poverty — collaborate to educate residents about EVs and help them bridge financial gaps to ownership.
At the same time, the organization is working with teams made up of in the central San Joaquin Valley to identify the places where charging infrastructure can be installed and to make sure that communities can use them.
Hamilton said one of the benefits of EVs for communities in the valley and beyond is reliable transportation. He added that the ridesharing model embraced by companies, including Lyft and Uber, don’t work in many rural communities, in part due to the expense. By comparison, an EV is a dependable vehicle with warranties as long as eight years that can sometimes be purchased for less than $30,000 used. This has relevance to health systems seeking to support access to care.
The CCAC operates by empowering local CBOs to operate independently to complement their work. Hamilton said partners can start out as subcontractors on a project and, ultimately, get 30% of the budget for a particular project in order to make sure that they have the capacity to do the work.
“It makes more sense to find out who’s doing work in the community, partner with them and, if capacity is an issue, talk about how to build and help them connect and get more of the good work they’re doing done,” he said.
CCAC is not just focused on transportation infrastructure either.
Hamilton said that, while the IIJA has allocated $50 billion for weatherization and the protection of structures against droughts, heat, floods and wildfires, the lion’s share is focused on commercial buildings. The CCAC, he said, is advocating for the state to put some of the money into home improvements.
Together with the Lawrence Berkeley National Laboratory, CCAC has developed a model and tested a pilot to look at the cost of putting solar on the roofs of houses, service the breaker boxes and weatherize and insulate the structures to make them more energy efficient, Hamilton said.
“We’ve found that if you do all of those things in homes, the cost would be between $40,000 and $45,000, but a family would have no electric bill for most of the year and they’d be healthy inside of the home,” Hamilton said. “It’s not just one piece.” These dynamics could be very advantageous in affordable housing and increasing housing stability, which is one of the vital conditions for well-being.
Hamilton noted that one area CCAC hasn’t been able to get funding for is in community health assessments. He said that the organization is committed to going into communities, talking to families and asking about changes to their health and added that CCAC doesn’t presently have enough data on the actual health benefits that are impacting communities. But, by including members of communities throughout the San Joaquin Valley, it is only a matter of time before CCAC can make good on its goal.
“Change only happens from the bottom up. Not even that: from this space and not this space,” Hamilton said. “It’s got to be from the community for the community to buy in. There has to be a catalyst to help but that doesn’t mean you move in and take over.”
Changing Health Outcomes by Connecting Communities
The digital divide is steep and, in the case of the Covid-19 pandemic, deadly.
In March of this year, University of Chicago researchers published a study in which the lack of internet access was identified as one of factors most consistently associated with a high risk of death from Covid-19 in the US. The researchers estimated that between 2.4 and 6 deaths per 100,000 people in any urban or rural county can be prevented for every 1% of people with internet access.
“Covid was a big demonstration of how having broadband gave you faster access to vaccinations, and testing,” Heather Gate, executive vice president of digital inclusion at the Bowling Green, Ky.-based nonprofit Connected Nation, said. “There’s a core relationship between access to healthcare services, info, how quickly reserve appointments. If you don’t have access you’re already a step behind.” This has implications for health well beyond the Covid-19 pandemic.
Many Black and Brown people in the U.S. are being kept behind. According to data from the National Telecommunications and Information Administration, roughly 77% of Black and Latinx adults report having broadband internet at home in 2021, compared to 82% of white adults. On tribal lands, only 49% of residents have fixed home internet service.
Part of the reason for this is that, generally, private internet service providers only set up broadband internet in markets where there is more demand, such as high-income areas, and where the cost of wiring is offset by profits. As a result, low-income communities and those dominated by Black and Brown people often have fewer, and more expensive, options for broadband access than their wealthier white counterparts.
According to the White House, more than 30 million people in the U.S. lack access to broadband internet. While the IIJA has allocated $65 billion for broadband deployment and for the reduction of internet service fees, Gates maintained that a critical part of the law’s success lies in how state offices engage with communities.
“A signature part of the requirement is for state agencies to collect information from people through listening sessions and engage with community-anchoring institutions,” She said. “If they want to succeed, they have to make sure that the communities in each state are represented.”
Gate said that, in addition to the infrastructure challenges involved in reducing the digital divide, state officials and stakeholders also have to address affordability, training and internet safety challenges. She added that it is crucial to have internet service providers and practitioners at the same table because the goal is to connect the state and local government, law enforcement, education and healthcare providers with the people they serve. Some might point out that this is a great opportunity for the kind of work across sectors that many have been preaching over the last decade, that impacts health outside of clinical walls.
Connected Nation develops and provides states and communities with the tools, resources, and methods necessary to help create and implement solutions to their broadband and digital technology gaps. Gates said that the organization sees itself as a representative for historically disenfranchised stakeholders including children from low-income households, seniors, people of color and rural communities.
Although the organization could potentially work for a city or community by drafting a broadband map, providing a template for community broadband, job and skill training and digital inclusion programming, its primary function is to bring local communities together to speak for themselves, centering that important community voice.
“Our role is to provide support,” Gate said. “We meet people where they are and get them from one place to another where they’re meaningfully adopting technology, because everybody belongs in a connected nation.”
More Support Needed
The Infrastructure and Jobs Act could be a game changer for communities of color but, just because there’s billions in federal funds available doesn’t mean that communities in need necessarily have an easy time accessing them. Structural barriers from decades of disinvestment can derail efforts.
“Part of helping them [communities] get access is not just making sure people know what’s available but having people there to help them get through the process of raising money,” Hamilton said. “You think: ‘How can anyone get through this when English isn’t their first language or they had to drop out of school in the sixth grade to take care of their families?’”
According to data from Enterprise Community Partners, many CBOs are generally undercapitalized, with a mean operating budget of $280,000 per year. Moreover, they tend to be grossly understaffed compared to the private sector, requiring many to rely on volunteers to support critical programming and operational needs.
These factors can make navigating the federal grant application process extremely difficult for CBOs but community development financial institutions (CDFIs) can make a difference in getting projects focused on the social determinants of health over the line.
“In many cases, CDFI funding can serve as a bridge to a large capital provider with whom they may already have a relationship,” Seth Julyan, executive vice president, network services at Opportunity Finance Network said. “It’s important to have as many options available for funding, and CDFIs can play a role in that.”
Julyan noted that, unlike more traditional financing sources such as banks, CDFIs are unique in that they are mindful of how their lending and blends with the needs of communities. One example he highlighted is the Invest Health collaboration between the Reinvestment Fund, a Philadelphia-based CDFI and the Robert Wood Johnson Foundation, which brought leaders from multiple sectors together to address social determinants of health in 50 mid-sized cities from 2016 until 2018.
“That’s a really good example of how a CDFI thinks about the impact it can make on a community level,” Julyan said. “It’s not just based on a set of assumptions: It’s more thoughtful and intentional.”
These kinds of CDFI investments have direct impacts on the factors that influence community health. But, the ability to identify specific areas of inequality depends on the availability of information generated from multiple forms of data, including qualitative data representing the stories and experiences of communities facing inequities.
Healthcare partners in multi-sector partnerships can make their own community-level, de-identified data available to planners, community leaders, and decision-makers. Information, however, generated from multiple forms of data, including qualitative data representing the stories and experiences of communities facing inequities, is critical for identifying specific areas to invest in.
Community residents are key to ensuring the relevance of a data-informed policy. CBOs, who have strong ties to their communities, are well positioned to engage residents in a participatory data collection process that will ensure the data will inform investments that are aligned with community needs and priorities. Involving them in every step, from developing survey questions and analyzing the resulting data, ensures that investments are aligned with community needs and priorities.
Although CDFIs can help CBOs make connections with funding sources and build relationships with organizations in other sectors such as health, locating ones with a particular bent toward the infrastructure projects outlined in the Infrastructure and Jobs Act can be challenging for some.
“How to find CDFIs with a track record of providing financing for infrastructure projects is an area where there is room for improvement. In some ways they’re not being seen or thought about [by CBOs],” Julyan said.
He added that, while CBO’s can reach out to organizations such as LISC or use the OFN’s CDFI Locator to find a CDFI appropriate for a given project, a little elbow grease can also make a difference.
One way to locate them is to “literally try to Google ‘CDFI’ and the location, or a particular project, and see what pops up.”
The Build Healthy Places Network links community development, finance, public health, and healthcare, positioning partnerships between these sectors to reduce poverty, improve health, and advance racial equity. Organizations interested in multi-sector partnerships can start by using our partner finder.
The Infrastructure and Jobs Act has made an unprecedented amount of money available to address the social determinants of health through infrastructure. Community organizations, community development corporations and healthcare partners can seize this moment to funnel that money into communities through partnerships across sectors.