 In San Francisco, here in the Los Angeles branch, rule number one for presenter or speaker, never set your notes down. I have no idea where I'm going to put them. OK. All right, so welcome. Welcome to Closing the Health Health Gap, Strategies to Reduce Health Disparities and Create Financial Opportunities. We're glad that you're here. We won't have more people coming in that we're finding a place to park. We'll go ahead and get started. What I'd like to do is talk to you a bit about why the federal users are involved in this issue and also in this subject. And I want to also go be a gender with you and we'll do a little bit of self-introduction. And then I will be introducing the director of the Legislative Director for the New American Foundation here in California, and I'm going to be in Colorado. So we will get to that. So first off, I have to tell you that I'm with the Community Development Group, which happens every year, and I'm seeing a heads turn on that one. Usually I do that in a community. That doesn't sound right. No reserve, no community development. Well, that's the group I'm with. We're actually, the group is still in the group. And we've been doing community economic development for that long. And in fact, we've been doing it really in response to the 1977 Community Reinvestment Act. It took us a while to get our act involved in the game. But we've been doing this for a very long time. We do it across the several strategies of community development. Typically our history has been for housing, small business development, job generation. And in the last several years, maybe the last five years, we've really come to understand that asset building, something that we've also been involved in, serves as a platform just like health and education. And everything you do seems to fall around now. So in terms of what is the Fed involved, in this particular subject today, and I'll call it health for right now. In 2009, we began to take a look at the nexus of public health and community development finance. And we did that if we had to end those other strategies that I mentioned, like affordable housing. We always wanted to be part of the solution. So when we worked in 2009, we saw that public health in its 100-year history is very well-developed and funded. And that the field of community development, because it's not quite grown up to be an industry yet, is rooted in the neighborhood of where we were born. And that, but the problem is, we're not very well-organized, such as some of this point. Okay, we're not very well-organized. We do not have commonly or on-definition. And we also have very little money in comparatively to public health. Yet what we do have is the vision to see that public health is coming out of institutions and into the communities where we were born. And we also have the insight to attract the best practitioners, academics, and funders, with already established financing mechanisms to invest and lend to community development financial institutions, to white banks, and only they don't take into thought those. And they do learning in the local neighborhoods. And so what we can do then for non-profits and community development financial institutions and also for the banks in the room, is we can bring visibility to them as a means of assisting public health in accomplishing greater positive outcomes in unaltered communities. Our role as an economic and community research institution beyond being the driver of our national monetary policy, the manager of the U.S. financial system, the monitor of economic growth, and the supervisor of regulated depository financial institutions, beyond that, we have the power to convene and to publish and to produce what we see and what we learn from those that we work with, one few, and in the hundreds of conversations that are going to take place until we finally get to a place where this mix of asset-building policies and health is united. The upside is we have years ahead of us to do this work. The subject is highly controversial and critical to our nation. The downside is we have years ahead of us to do this every work, to forge effective partnerships and collaborations to fund and invest in communities. So what I'm going to say if I boil it down is that we count on you to keep coming back and to keep your conversations like this, and it really helps me when I meet you again and again and I hear you say the Fed puts on really great topics or really great subjects and that's what brings me here because we do that with partners all the time, to Dan and partners from the American Foundation. So we count on you to keep coming back and for you to also, when you're here, think about how this work can inform what you do or what your organization does. For example, you have resources, you have services and some of you have products. And so the question is how can you better use those to enable both wealth and low income people to rise out of poverty, sustainable, long-term change in their economic condition. So if you would today, listen for that, listen for that opportunity and you'll hear it from each of our great guests today. So that's a good subject. So let's take a look at the agenda and you call that out. You can see that we're getting started just a bit late between these that you're going to have to talk fast at the break, you'll probably have to shorten that a bit. But what we'll do then is the leader will come up and she will make some comments and then she's going to lead us into the introduction to the moderator for the first panel. And they're going to discuss public policy strategies to the subject, the approach to the subject. And then following them, we'll take a small break and then we're going to have Lisa Richter from GPS Capital Partners who will be taking us into the private sector view and supporting these initiatives. And you're more than likely because there are many, many, many speakers that are able to speak to this topic. So when we bring them together, you're going to hear some a lot of different, perhaps viewpoints of the same, of somewhat the same grand topic, if you will. So then we will have some closing remarks. And so within each one of these panels, we'll have a little bit of time as well for any questions you might have. You'll see on the faculty agenda are the bios, you get a sense of who's who. And before I introduce Olivia, what we want to do is just ask you first if you would raise your hand if you were from a public health agency or organization. If you are a non-profit wealth builder, you work for an agency that does not have a wealth or a community. If you are a community development financial institution, CDFI, in the room, Alice? Or in any other industry that you're in the area, may not be a CDFI. Any other non-profit that are CDCs or, any non-profit, yeah, okay. Any foundations? Just a few, okay. And how about from the world of academia? Okay, so now we know who's in the room. So the challenge for you is that you have to today, this is the rule. You have to go up to three people and squint to try to read your name across a family of less names. Okay, all right, so that's your challenge. You gotta meet three. And we could complicate it and say, if you don't know, we don't have to do that, because if you will apply, it converts to three people. So I'd like to introduce you now to Olivia Calderon, the California Legislative Director of the New America Foundation. Olivia is based in Los Angeles and works in Sacramento as well. She helps California law makers hammer out laws to improve the welfare of California residents in a big way. In her role, she regularly testifies before the California State Legislature. She educates government officials and interest groups about asset accumulation, health care, education, and energy policies. She also develops related policy proposals, provides extra testimony on pending legislation, identifies partnerships to build broad policy coalitions to advance key policies and manages the capital's first bipartisan educational asset policy form, which she launched in August 2007. So I'm gonna say in a nutshell that she has a very distinguished career. She's done a lot of things, wrote a lot on a lot of issues and you can see that in the brief final. But for now, I give you a really thank you, Mallory, for that kind introduction. Again, Olivia Calderon, I'm so excited to be here with you today. I remember about a year ago, in the same room, when we were having a similar conversation, the Federal Reserve of San Francisco had asked the building practitioners, had folks from the financial industry, banks, folks in public health, talking about healthy communities. And Dr. Tony Eitron was talking about the social determinants of health and he was challenging us to break out of our cycles and to, and for us the builders, is something that resonated with me, to understand that we have a place in healthcare reform. He said that for those of us that are helping people permanently exit poverty and grow the middle class, he'll practice medicine. I was shocked. I couldn't wait to call my dad. My sister Vanessa is a doctor in New York City. She practices emergency medicine and I was like, hey dad, guess what? I'm doing something in health too. I'm doing something in health too. We're helping communities and individuals be healthy because of it. And for those of you in the room who helped to pass the ACA, the Affordable Health Care Act, and are now working to implement it, what she did was she provided a much needed financial tool, access to healthcare coverage and an array of opportunities to help families and communities get on a path to financial security, which is what we're gonna be discussing today. The first panel of course is gonna explore the public policy piece of this. The second panel will talk about the private sector role. But clearly, our roles are intimately intertwined and there are opportunities and they're real and the challenges are great. And so I'm thrilled to be here today and I just wanna thank again, Melanie Malva, for helping me make this event happen. The Federal Reserve Bank of San Francisco for hosting this conversation. And with that, because we need to get through this in short amount of time, let's get started. I wanna introduce Dr. Shana Alex Lavera. She's a professor at UCLA. Her bio's also included in your packet. But Dr. Lavera is a research scientist at UCLA, the Center for Health Policy Research. Her research focuses on discontinuing health insurance, particularly among low income children and its impact on end access to care. She received her Master's in Public Policy at UCLA School of Public Affairs and her PhD in Health Services from UCLA School of Public Health. So with that, let's get started with the conversation. Dr. Lavera. Good morning, everyone. I hope you can't hear me over here because if I go behind this podium, you sure won't be able to see me. I am so excited to be here. I really am. When I was asked to be the moderator for this panel, I jumped at the opportunity to just be in this room and be able to listen and to talk to all of you because I really feel that this panel and this discussion is so important and these partnerships that we're building are really what is going to be the building blocks for implementing the ACA, for implementing all of the changes that are coming even earlier than 2014, which I'm sure we'll hear about. And as we move into the future and really building a better country for everybody at all ends of the income scale. So a little bit more about myself. My Master's in Public Policy is in both Health Policy and Regional and Urban Planning. And I also have a Master's in Political Science. So you can see that those are kind of my building blocks. And then I started working at the Center for Health Policy Research out of my Master's program with the State of Health Insurance in California Project, which hopefully many of you are incredibly familiar with our humongous 100-page report that we've been putting out many times over the past decade. The new one is coming out soon, I promise. It's very, very soon. And I took over that project after receiving my PhD in health services. I realized health insurance and health policy is really where my passion is. I got my PhD in that. And now I'm Director of Health Insurance Studies. And I get the opportunity to do things like this. So that's about me. I can tell you that in my 12 years of working in this topic and doing all the research at both the national and the state levels in California with our California Health Interview Survey, what we've seen is that income is absolutely the driver when it comes to whether or not a person has health insurance. You can control for everything else. Racial ethnic status, citizenship. You can control for citizenship, including undocumented. And yes, there is going to be some effect there, but income is much bigger. And it's not even just your own income. There are separate effects for your own income, your own wage and what you get at your own job, and also your family's income, your household income. And so you can have two wage earners, and if they don't make enough income to get out of that lowest income bracket, then actually you might be a little better off because then you can get Medi-Cal if you have children. So it's that very, very low people that actually are getting some of the safety net. And then you get just a little bit above that. You make $11 an hour, and all of a sudden you're too rich for public coverage. I don't know if any of you have tried to live in Los Angeles at $11 an hour. I did right after college. It's not fun. It's really not a good place to be. You feel like you're in poverty and you really feel it at every level. And I didn't have kids then. My mind boggles that there are millions of people in this family alone who live at that income level with children and try and cover them with health insurance all the time. We're doing a really good job with kids because of public policies. We have almost, almost 100% coverage for kids. Very, very close. Our most recent data is from 2009. And from 07 to 09, when the economy tanked and unemployment went, let's not forget from 5.5% in 2007 to 12.3% by 2009, an unprecedented double, over doubling of the unemployment rate in just that time period, children's insurance coverage actually went up because of the public policies that were there when their parents lost their jobs and their incomes went, public coverage stepped in and was able to cover those kids. Their parents weren't quite so lucky, which is why we now have over 7 million uninsured in California alone. And nationally, the newest figure is about 15 million uninsured. So income is absolutely part of the discussion. I also wanna bring in the fact, something that I learned earlier this year, this year has kind of been my economic justice year. I started off the year on a panel myself that was hosted by the Los Angeles Alliance for New Economy, which if you haven't heard of that group, Lane, I would recommend you look into that. I think they're doing a lot of good asset building work and community organizing work in the Los Angeles and low income populations. They hosted a panel when they were talking about subcontracting workers of Los Angeles County. So these are people who had good government jobs that work in our hospitals here in Los Angeles, that work in our buildings that are the people that are security guards for the courthouses and looking at their training and also their health insurance and they had to take a look at the numbers. And I took a look and I said, I'm shocked because your numbers, among people who are insured in terms of how much they still have in medical debt, in terms of how much they have access to care, whether or not they can get the care they need, they're worse than the uninsured. And this is a population that was supposedly insured with good government jobs that are supposed to help people lived out of poverty. So I think there's a lot of work to be done and this panel is a good step to start talking about. So I'm gonna introduce the panel members. What we're going to do for this discussion is go through each presentation back to back and then at the end we'll take questions. So if you do have questions and I'm sure you will, topics will come up, please write them down and at the end I'll be moderating the discussion of questions and we'll be able to talk to all of you and if you still don't get them answered, well then we'll talk to all of you at the break and keep this going, you know, ongoing. But let me introduce our esteemed panelists at this point. Our first panelist is Mark Rucavina. He is the executive director of the ACCESS project and himself has a long and distinguished career in this topic. He has been a long-term fighter just in getting the topic of medical debt on the agenda and among the insured and making sure that this topic gets put into surveys like ours, which did get added to 2007. We were a little late to the party but at least it's there now. And it's talked about at the national and the statewide level. And he's going to be talking about what this issue is, our kind of broad macro level term and what are the possible public policy levers that can't address these problems and fix them. And then we will move on to Lee Paz who is a senior fellow in the health policy program at the New America Foundation. He has also been working quite some time on this and has been leading a series of conversations in California about the ACA and how it will be implemented. And he's going to talk about the nuts and bolts of what's in the ACA. For those of you who might not be aware of the nuts and bolts because it is a very complicated law. There's lots of moving parts. And then he will also talk about how it specifically relates to this topic because the ACA relates to a whole list of topics and you can do a entire graduate level course on it. So we're going to focus in just like in seven minutes. There you go. You've got to work it out for you. In seven minutes we're going to talk about that. And then we'll move on. Olivia, who has already been so ably introduced will talk to us about what is going on at the state level, specifically for California and what we're doing as an independent actor because California as always is a bellwether for the rest of the country and we are moving full scheme ahead and leaving the way in terms of our policies here. And then finally, we will go down to the community level and from a community organizing standpoint we have Jose Quinones, I apologize if I mess up your essay, who will be talking to us from his community perspective. He's the executive director of the Mission Asset Fund working in San Francisco County to build assets for people in the Mission District who are low income and he'll be speaking to us from that perspective and also introducing his new project. I have to mention this because I'm so excited about hearing about this, the financial facts label and how you can bring something as complicated as financial facts to something that's easily understood by everyone. I would also like to say we have all ends of the academic spectrum. We go from the East Coast to the West Coast here and fellow Bruno Olivia, so yay, go Bruno. And I'm looking forward to hearing what you all have to say. Thank you. You need some help here. Oh, thank you. I'm going to use this one. Please. Oh, just use that. So I want to thank the Fed for hosting this meeting. It's great to have the Fed convening on various topics and we appreciate that Fed is doing so today, bringing together these issues of health and well-financed. I also want to thank the College of American Foundation for the opportunity to speak today and to bring this issue of medical debt and healthcare foregilding into discussion around health building. Maybe I missed it, Melody, but are there bankers in the room? OK, great. Being an outsider to the federal services system, I wanted to ask that question because... Is that what you call making bankers on there? Other financial institutions represented? I think we're leaving. OK, great. Thanks. My slides are in the packet. I'm not going to go over each of the slides, but what I'm hoping to do today is give some high-level data in terms of healthcare costs. And I apologize to those in the room who are steep in this issue. We're going to talk about issues related to medical debt and then try to connect this issue of health and wealth. And I'm hoping that at the end of the session today, those of you who are on the wealth side of the spectrum here, doing the work of financial services and on asset building for low and moderate income populations, you will understand how important the health network to get engaged and involved in more and more important care that was mentioned previously. For those on the health side, really think about how health influences wealth and the development of assets among low and moderate income populations. So, the health figures in 2009, as a nation, we spent $2.5 trillion on health, but 17.6% of our growth domestic cost. And in spite of that, at nearly $50 million, I'm sure Shayna mentioned the new census data came up, the numbers for 2010, 49.9 million uninsured people. That number would have been several million people high, if not for certain provisions of the Affordable Care Act that are already in place, provisions that extend coverage to young adults enabling them to buy coverage or apply it to coverage under the parent's plan, but coverage to estimated million young adults in the country and their other provisions as well. The projections, though, I want to pay attention to the projections on this, because in not too many years, it's projected that we'll be spending over $4.5 trillion on health care. Nearly 20% of our GDP is estimated, I think we will represent. So, we're seeing the health care expenditures increase dramatically. Another way to talk about this is the effect that it has on families and many of us in the world may kind of notice intuitively, but this is a recent article from the Journal of Health Affairs which looks at health insurance coverage provided through employers for the typical family of four and other information. So, you see, over a 10-year period between 1999 and 2009, the adjusted for current dollars median gross and household income for this family of four was $76,000. That grew to $99,000 and $2,009. The portion of that being used to pay for health care in a variety of ways grew dramatically, much greater than the increase in those wages or the household income for those families. So, you can see monthly out-of-pocket insurance premiums more than double. Out-of-pocket monthly spending on health care nearly doubled and then there's also a line in there for a portion of income for taxes paid for Medicare and other government-sponsored programs increased probably the corresponding with the increase in income. But the take-home message here is that health care is eating financial resources for us as a nation and for families that were working in preserving the technique that the assets out of their health are. If we were able to contain the health care cost that simply the rate of inflation, people would have had nearly five times as much money from that gain in their annual income than they have as a result of these increasing health care costs. So, I thought that's an interesting chart just showing the way in which these ever-increasing health care costs are meaning of family financial resources. The Commonwealth Fund is a lot of surveying around health insurance issues and I also want to thank Shayna for both being here today and finding work that her Center does on this. I think you're fortunate that you're California to have the resources of people like Shayna in the Center doing similar work to what foundations like the Commonwealth and the National. You have other great foundations in the state as well, like the one you've done with others who flew out of track and gave you a lot of data to really work on these issues. But in 2010, these are national days now. 73 million American adults working in adults adults under the age of 65 had medical bill problems. These types of bill problems. You're not able to pay a medical bill were contacted by a collection agency for medical bills that they had said that they had changed their way of life in order to pay for health care in the country or were left with medical debt. The number of people with medical debt nationally is about one in four. 44 million people said they had medical bills that they were paying off over time in medical debt. Shayna mentioned this earlier. Prior to the recession here in California about 2.2 million residents in California had medical debt. So the number is less than the national figure. They're still a disturbing percentage of people with medical debt. So here kind of this health wealth nexus. As Shayna said, poverty drives health. But the other thing that happens here and I kind of want to put that over is health drives people further into poverty. People further into poverty. So issues related to affordable health care costs take a problem and amplify it even further for everybody's at risk here. But this problem calls disproportionate beyond low and moderate population. So what happens when people have medical bills that they're struggling to pay? Well many of them can't pay for other basic expenses like housing, heat, et cetera. But they also begin to deplete people's assets. That second bullet is incorrect. That's 29 million people who used up their savings to pay in medical bills. So that's about 40% of the people with these going problems exhausted their savings trying to pay in medical bills. One of the narratives out there in terms of people who have medical debt is that there's a cost loss. They're not paying for a cost of care. I can zip through these slides. People take out loans against their homes, take out other sorts of loans to try to pay off these bills, or put it on credit cards. We was going to cover issues in the Affordable Care Act. That is a huge opportunity in terms of this health-wealth connection and addressing problems related to health and medical debt. I want to talk about something else and the way in which medical bills are treated once people have bills that they can't pay. About 30 million Americans were contacted by collection agencies for medical bills in 2010. Studies done by the published in the Federal Reserve bullet in a following where half of the accounts in collection are medical in nature. So what happens when people have these problems? These are major bureaucratic accounts. They go into the credit history section of the credit report. The most heavily weighted part of the credit report drives down people's credit scores which increases the cost of accessing credit. So the wealth that people develop and the assets that people develop, and I would argue that a credit score is an asset. A credit score determines your ability to access credit and how much credit will cost. So it's very important. So what we see here is even very small-dollar medical bills having a disproportionate effect on people's ability to access a quarter of a month. I'm going to call your attention as powerful. In here, the National Proclosure Minimation Counseling Program, about 6% of the clients certain that program cited medical debt as the primary reason for their mortgage default. That was even greater than the people whose rates were adjusting just for rate mortgages, which is shocking to me to see that that figure was greater than the rate of recess. Okay, income drives us. So here's medical debt or a portion of these populations that are 133% of poverty or low, 133% will seem to be the sense of poverty. Nearly half of the people living out of the low, 133% of poverty are spending more than 10% of their income on health insurance premiums and auto pocket accounts. Problems related to medical bills and medical debt loans are going to see the same distribution. Fortunately, the Affordable Care Act is going to address some of these issues. There's going to be an expansion of Medicaid, Medicaid out under the Affordable Care Act for people at 133% of poverty and below. I'm not going to go into the Affordable Care Act, so I just want to move quickly to other things that can help to mitigate problems related to medical debt and we have some colleagues in the second panel bringing to talking about some of these issues. I want to talk about the charity care standards and transparency and what can happen at the federal level, at the state level can be very important. How medical bills are treated, whether or not they're sent into the credit bureaus and on people's credit reports, very important to wealth building. Currently, once in account, a sense of collection. Irrespective of why a sense of collection, and I'm sure if I had the time and we could do a brief poll here, people would have experiences of building a sense of collection that they later paid not true. Once a sense of collection is on a credit report at the state level for seven years, even if the balance due is zero. So there's some legislation in Congress to medical debt responsibility act which would require the removal of zero balance due accounts. So accounts that are either fully settled because maybe somebody called like the charity care program, got some other assistance, or are fully paid by the patient. It's really important because, again, those credit scores are outsets and those credit scores drive a lot of that wealth building work that is taking place in the public and then any of you who need to apologize about it. Thank you. I look forward to further discussions on this. Thank you. Good morning and thanks again for the Positively American Foundation. When I was a kid, we were still ministered to a Rorschach test where you look at black shapes and you decide whether they're a tree or a goblin, a Democrat or a Republican. And in the 18 months since this passage the Portugal character has become something a political Rorschach test. So much so that the bulk of the media attention is less on things that are actually in the bill and more on hypothetical things that can happen, might happen. At least all sorts of curious coal liabilities, even of the Americans who know it was passed 25% of those things started to repeal 30 to 40% of low-income Australians believe the situation would be worse because of the Affordable Care Act. So there's a great deal of non-information and misinformation out there which is crystallized in this wonderful poll started last year when it was passed whether it's the frightening matters or an independence of Easter and for a couple of minutes I want to leave this world of ideology and legend and return to the facts on the ground and talk especially in this assets context about the ACA as a toolkit on how it was passed and implemented, you know, roughly along the lines which it came about last year how we can do a great deal of good and in particular make it easier for low and mid-income Californians to remain healthy and to save more and in this respect as you've heard we very much hope that the ACA can be abridged and be a catalyst between those who concentrate on health reform and health policy and those who focus on poverty and financial security and social welfare issues even the supporters of the Affordable Care Act tend to see it perhaps mistakenly as a laundry list of reforms that aren't necessarily related and what I want to do here today is just that's not really the case and the way that I do it is by thinking it's like the Wizard of Oz or the Tim Whitman understanding of the Affordable Care Act I think it was having a heart a brains and some limbs and the heart of reform of course is the expansion of access to insurance coverage and the improvement of the quality of that insurance coverage the brains as I see it are the many incentives to improve the way the doctors practice and to bring down costs and the list of positions in that positive reform and in my other daily work I probably spend more time focusing on cost containment and getting doctors to practice differently which in the long run is absolutely critical to having care that's affordable for everyone given a certain cost structure that Mark laid out for reasons for it and I'm going to make one point here even with a limited time if you read nothing else in health care in the next couple of weeks the Affordable Care Foundation came out last week on the astonishing variation in elective surgical procedures in California and you can draw your own conclusions from that and then finally the limbs as of where I'm going to get to this at the end of the many provisions in the ACA far many of them are thought of an attempt to improve prevention in public health so taken as a whole the ACA should greatly improve the financial security of low and middle income California it will equalize access to quality affordable insurance coverage in fact the point of the ACA which is one central point is to try to bring everybody up to the standard employer coverage which is still not necessarily great because at least it better implore it will make it easier to avoid the medical death problems which Mark has laid out and lower the hassle of enrolling either in public programs or in private health coverage and also by giving individuals communities that built the tools to reverse health disparities in their own neighborhoods two very quick slides just for to recall why the Affordable Care Act was necessary if you look here at the numbers to get the commonwealth on the survey internationally those who went without medical care because of costs you can see that even those with their ultimately high incomes in the US had this problem and we can multiply this sort of data by a thousand times and you've probably seen it and if the Affordable Care Act hadn't been passed you probably would have seen it jumping in ensuring the high 50s mid 60s it increased employer health spending by almost 100% and uncompensated care costs those that are folks go to the emergency room with hospitals that are paid for by charity care again about 100% and as you hear the debate over the Affordable Care Act it's worth keeping that context in mind what would have happened if we hadn't done that anyway so the three pillars of the Affordable Care Act in terms of coverage the first is the large expansion of Medicaid or Medi-Cal in California and I'm proud of this Medicaid is health insurance because what I mean by that is before this passed the act Medicaid was still connected to its welfare roots it was still a category of eligibility now it is a programmer will be for anyone under 133% it's still a very low level but regardless of whether you're blind or disabled or have dependent children or the way that Medicaid used to be as a result of that about 1.7 million low income Californians are expected to gain coverage they're different figures one thing that's absolutely unique to California is this federal waiver that was received just before the passed the Affordable Care Act and as a result of that there's a maximum of $10 billion coming to California to help fund up to a half a million Californians who already have low income Californians who already have coverage or will gain coverage in 57 of 58 California counties that are signed up to participate in that there are however some big problems here and the biggest is as you all know California is a huge budget crunch in a budget crunch where you look you always look for MediCal 1.7 million in cuts for the most recent budget and there's very little low hanging fruit in MediCal we already have the lowest per capita Medicaid rates in the country the lowest rates for providers we could try to move to managed care but there's no certainty that will save money so the real concern here is that as the breaks are being applied to the program and the accelerator for the expansion may be stuck one other pillar of the Affordable Care Act is that the Strength and Safety Net for folks who are still uninsured after the Act is passed and in California as you saw in the last slide there's still going to be over 1.2 billion Californians mostly immigrants without legal status will be uninsured and so there's 11 million in funding for community health centers for clinics roughly 1 billion in California and as you see 3 quarters of all business for those clinics are made of people of color most of the budget mostly paid for through the counties and much of that is in LA County we can talk a bit more about that in the Q&A and finally the YM and it's again a really important and a bit of a good news bad news scenario California is the first state after the AC to create a health benefit exchange and what is a health benefit exchange it's really simply a kind of insurance market or where you get subsidized coverage from the private market and so if we look at the systems that are expected over 3 million Latinos almost a million Asians half a million African Americans are going to be eligible for private subsidized coverage there are already exchanges up and running very different ones in Massachusetts where you're much more comprehensive in Utah where it's more like a speedy exchange raises which is politically very important because it bridges that gap between low and middle income folks the market is not about the other families who we'll speak to as well enormous numbers of questions though about exchange and they are all the field of dreams questions if you build it, will they come who will come because if you get only expensive folks in exchange it won't work insurers won't want to offer affordable products and it won't work there's also a provision I got mentioned very briefly in the Affordable Care Act because we're covering we're spending low in 7-8 minutes called the basic health plan which has been a topic of discussion in Sacramento and that would cover instead of exchange that would cover folks up to 200% of poverty in a different program the pros there the negative you draw off a lot of people who are already in exchange and that would create its own issues and finally a couple of things in the ACA that are being supported in California that are extremely important the ACA through the exchange and through other mechanisms and again this is very important I think for folks in the asset field it simplifies the application for insurance tremendously through the exchange it's task to determine eligibility for public programs and a couple of bills in Sacramento particularly 8-12-96 Harry Bomania deep in this framework by the ACA by establishing a single standardized application form for Medi-Cal Healthy Families exchange and county programs important in its own right and very easy to see how that can be important to the currently fragmented services provided by county to beyond health care and finally I will be talking about this more in Q&A the ACA is a bit of an entering wedge to looking at the social determinants of health prevention and public health it doesn't stop at insurance coverage as important as that is the grass shoots in this prevention and public health fund and community transformation grants to try to get the bigger reasons why people are healthy or unhealthy and it's my hope that there's a reciprocal back and forth between those in the assets field and the health field in thinking about these issues I was very struck earlier this year that Thomas Friedman, the head of the Centers for Disease Control gave a speech in which he talked about the earned income tax actually as a vehicle for making people more healthy in the community and research that is being done that suggested that those who participated in the ITC actually ended up with better health outcomes so hopefully we will find here at the end missing light using the IT field and moving forward together and making it better How many in the room are familiar with the American Foundation? Show of hands How many are not? The rest of you guys do not get it for those who think that face to your hand is a really brief way the new American Foundation so we are a national non-profit policy institute we're based in Sacramento we're based in Washington DC and here in California our asset building program and our health program took on that challenge to break out of our silos and start working strategically with one another to advance a health wealth agenda in our asset building program what we do is we advance asset in all policies so policies in banking taxation education and health policies to make it easier for low income families to build their savings in their assets over their lifetime and we look for those key moments in people gradually to build assets this year as I mentioned we partnered with our health program and so through research and through legislation we advance this agenda and you have it in your packets before you the bills are moving through the legislative process and of these 11 bills that we were advancing with the broad array of partners in Sacramento six of them are on the governor's desk now we have mentioned the health bill and so what I want to do is I want to focus on the key financial empowerment strategies that we're using to leverage this health wealth agenda and I'm going to discuss in three key ways so the first of course is integrating existing asset building policies into state programs the second is tapping into the earned income tax credit that are available to low-income workers and the third is partnering with the state's assets coalition it's the first DATC in assets coalition in the state so the reason we've been doing this work is because we know that the need is great for many of us but when we read the census numbers it came out to say that poverty is a historic highs that about 6 million Californians are now living in poverty but when we think about poverty from an income perspective it only tells quite a bit of the story and us in the asset building it truly is the tip of the iceberg in trying to understand economic security of families throughout this country that we should really be looking at asset poverty in terms of households are asset poor meaning they would not be able to survive for three months at the poverty level if they were to lose their job or experience a medical emergency so asset poverty of course is more consequential and so we are working to advance these initiatives and these strategies to make it easier for families to build their assets and as with the historic passage healthcare reform as we've mentioned and the expansion of health coverage as we know Mark said that one of the key reasons why families are finally back for the CPI millions of Californians are still living with medical debt now so that there are these key initiatives that are going to expand machine services and resources to meet families but there are also existing programs and in time now when at all levels of governance we see nine of dollars there to be able to expand on these programs we shouldn't ensure that they're working as efficiently as possible and they're working for working families and so with that it's a great time again to integrate these asset buildings programs into the bank on California program the scholar share program the CaliWorks program the Califresh program and tax pensions programs that exist at the state level in 2008 they really helped Governor Schwarzenegger launch bank on California now bank on California was the first state effort to help unbanked and underbanked residents in California open up starter accounts, savings accounts and for many of the bankers here you've all been partners, many of you in helping to expand bank on initiatives and bank on efforts these starter accounts are important because without a bank account it's going to be nearly impossible to use fringe products and services to charge exorbitant fees for something as it was paying their bills and cashing their paycheck and so in 2008 Governor Schwarzenegger launched bank on California and since then there are now about five states throughout the country and seven cities throughout the country that have launched bank on efforts to spur these starter accounts and bring low income consumers into the mainstream into the financial mainstream now these bank on programs work really really well in the community where there are existing banks and credit teams but in communities where there are no banks we cannot launch these bank on initiatives because they work in partnership with existing financial institutions and so what the bank on California programs to do is integrate the bank on development district program the Federal Reserve the Broadway Federal Bank and for us to hold the role CBI here in Los Angeles have been very supportive of the banking development district program where the states and local entities local and state deposits available to financial institutions that agree to open up in communities where there are no banks or credit unions and agree to develop products and services that are tailored to the needs of momentary consumers now this has worked in New York State since 2002 and we believe that it can also work here in the state of California and it's for more bank bonds now as a first step Governor Brown is actually considering AB 38 which is a suddenly graphed legislation he selected from here in Los Angeles and AB 38 would basically require the Department of Financial Institutions to map out the state of California and provide legislators with a roadmap of where these communities are so that they could have targeted incentives and come out with a clear plan of how they're going to execute the banking development district program that strategically meets the needs of these communities throughout the states but when it comes to saving we've mentioned that tax time with the earning and tax credit we believe is the ideal time to get knowing from families to save Governor Schwarzmager also will sign legislation in 2006 he actually signed a split refund for legislation it's a bill that allows taxpayers in California to split the refund into a checking counter and savings account the split refund option that makes it easy for folks to save right on their tax time is just the beginning we hope that the administration will consider is allowing tax filers to roll a refund into existing college savings accounts all in one fell swoop right on their tax form and I'm working with a franchise tax board to try to help make this happen and are also looking at ways to continue to spur college savings I just have the one minute mark and I can't believe I've been up here for six minutes seriously has it fallen like six minutes to you say no okay four more minutes so and so we've developed these centers to try to make tax time be ideal time but to make tax time be ideal time to save for various goals is one of those goals and so by making it easier for folks to roll their refunds into an existing 529 plan I think that that's an easy way for families to be able to do so and are also looking at ways to eliminate the current barriers for low income families to participate in 529 college savings plan because knowing that low income families are now participating in the way that we should be in the state of California and also know that college savings is key to get our kids college bound because research shows that children who have college savings regardless of their income are seven times more likely to go to college than kids that don't have college savings now I'm going to move on over really really quickly to just elaborate a little bit more on this EITC because it also impacts the Agilentos we had a report last year that came out titled up on the table what we found was that low income families are not tapping into much needed resources and the EITC we're living over $1 billion of unplanned credits in T.C. coffers and that's $1 billion that we go into low income families pockets about 800,000 Californians are not having into this much needed resources and here at Alney County one of the largest counties in our study is leaving these EITC dollars on the table and that's money that goes directly into the pocket of low income Californians and it helps to stimulate local economies and so with the supports of various coalitions out there and in partnership with the Pathways Initiative at Center Carol Group from Los Angeles Launch we're working with various partners to highlight the work that's happening by nonprofits, religious groups business organizations throughout the state to conduct media outreach and get folks to tap into this much needed credit again the data is clear, the numbers out there are stark and communities of color we know that they're hurting even more and at many times it feels like it's daunting to be able to really overcome and tackle these challenges but the good news is in California as various partners out there that have come together collaboratively and have launched a statewide asset in the EITC coalition this is a coalition that is made up of the Federal Reserve Bank of San Francisco City Bank the Office of Financial Empowerment in San Francisco AARP Catholic Charities the Green Lighting Institute the New America Foundation we were founding members the coalition is actually going to be having a second annual gathering in Los Angeles on November 15 that encourage you all to attend it'll happen here in LA and they'll be highlighting many of these health wealth initiatives to build broader support for the promising potential of these policies that went back out those, thanks so much let me just start with UC is that UC? it's UC UC UC UC so again, my name is Jose Cunha I'm the Executive Director of the United Fund I know I have seven minutes I'm going to go through this as quickly as I can and these presentations they're a little bit bummed out I'm very impressed to hear that and I think I'm not a person of hope it's sort of a thought-finding issue talking about debt, medical debt specifically and from my perspective as a nonprofit organization working with immigrants it's overwhelming to think about all the difficulties and problems that the families have to face but you know what we do in the mission district is particularly focused on working with going from immigrant families trying to get them into that sort of purpose and so we've done that through a number of different innovative programs and services to help immigrant particular people that have no checking accounts or savings accounts or any digital history credit histories to kind of get them more and more into the financial mainstream the financial products and services so they can build them up over time that's the idea in the mission district just in case you put note of the problems that we face there 44% of the mission households have no credit history they have no credit scores in Chinatown there's a human example in the mission in itself 56% of Chinatown households have no credit history so if you have a credit report it is impossible to ask if you do anything you cannot do without that you can't get an urgent buy card and no one to start up a business and don't do anything in some cases you can't even get an apartment with that credit report and now you need to get a job you need a credit history so if you've done is to sort of tackle that problem by building again some innovative program I don't want to get into all of those that we did do on the perspective of a client of a consumer of a person what is it that they have that we can use to build from the perspective of where the clients are at we say where are they so that we can help them move from where they are not where we want them to be where we think they should be but more or less where they're at those are basically the two principles that we use to develop and I say those now because they're actually what led us to what we were talking to you about today about the financial tax tables so one of the things that we did was as we were preparing individuals to the financial mainstream we also realized that it wasn't just enough to get people checking the account it wasn't enough to get them to start a credit history that they needed some tools and products to help them because as you know in a market place it's pretty right with a lot of being bad players that they're just out there waiting to take out any assets or savings that would help people accumulate so what we did in the Mission District and tell me because I've been there we actually went and did a shaker shopper survey where we went to there's 57 financial services in the Mission the Mission is a very small community by the way it's about 1 or 2 mile radius on Mission Street there were actually more payday lenders than there were financial staff really a good answer a lot of other restaurants of course but more payday lenders than work back in the past so what we did was we kind of went through all those institutions and we had the very basic question how much does it cost to borrow a thousand dollars how much does it cost we wanted to know so we wanted to look at the information about that so at the end of the survey we had this long spreadsheet, excel sheet beautiful amount of information and then we were like well what do we do with this information because how do we use this information that we just gathered and to help our clients our mission residents to basically be better financial consumers so we asked the question well what do they do with information how do they actually receive information and at this point we started looking at consumers receiving information about complicated things like the things that actually are the stuff that we eat and so the past when we were at the nutritional facts label has been one of those sort of key models that we have been used to to inform the consumers so they can make good nutritional decisions as you might have noticed even on medications or things like that we've never seen drug facts you know and it's sort of like a very simple you know label no bells and whistles this is a very simple information to again to inform consumers so we basically then took the concept that well if we take what we gathered in terms of like you know how much it costs to buy a thousand dollars and trying to present that to our clients in a way that they actually make resonate with them then this is what we came up with and what we call the financial facts label the financial facts label was the idea that for bars for consumers to make good financial decisions for themselves they needed to know what it is that they were getting right in terms of a loan in this case a thousand dollars and what made this very true kind of a tool that made sense from a nutritional facts perspective is that we realized that nutritional facts label was based on this idea of two thousand calories right that they count well we realized that those two thousand calories were really nothing more than a budget of two thousand calories so that when you eat something that's five hundred calories you know basically they're telling you hey by the way that's twenty five percent of your two thousand dollar calorie budget for today right and so we thought well what is the equivalent of financials that one and then we came up with the concept of monthly debt budget you can't really see it really well in this public project but that percent of the monthly debt budget was sort of like our metric that we kind of came up with to sort of say well there's some parallel between what we eat you know in this product and what we're actually getting in a particular loan so that way we can very easily very quickly communicate to bars before they take our loans to sort of say hey can you actually afford this if you cannot afford this because you already over your budget maybe you should take out another one maybe you should wait another month, two months so that way you can start paying down some of your debt so this is you know basic principle of course a lot of ideas there you know in socially based on the concept that people should probably very knowledgeable because I attack myself to issues that are where entire communities are collectively learning and medicine on learning this morning's panel and I look forward to saying in this panel we have with us today three hundred people who really take some of those policies that we talked about this morning and activate them on the ground and innovate a program and so it wouldn't be on a slightly different order than on the agenda but Rochelle Ray gets better when we miss off from Catholic Health KLS that's the largest city in the hospital skin in the nature has a long term commitment to a range of other organizations that help communities to do those that are KLS better health outcomes and then we'll hear from Dr. Lynn who is the director of community benefit at California Hospital Medical Center at the foundation of Disney there was a hospital Lynn as many of you know is also the executive director of LAS Bates Network we're going to be remarkable under the programs we have here in Los Angeles County to help ensure better health outcomes and then we'll hear from Forest C. Kogan-Rolls who runs a community development financial institution or CDFI in Los Angeles that has for well over two decades by now provided a range of savings, asset buildings and credit products to low income and otherwise underserved families and individuals and entrepreneurs and she'll talk about how that work is that we're reframing it where they focus on building assets and building healthy communities and healthy households. So we'll leave Dr. Lucia. Good morning everyone I'm still kind of recovering from a cold here so I apologize if some coughing comes along I'm so happy to be here today I am pitch hitting for Pablo Bravo who is our director of community investment programs when he told me about this opportunity I couldn't really test it out because one of the main things about my job is to be able to tell our story or CHW's story and the work that we do in the communities that we serve so I'm so honored to be here and to be part of the learning and the discussion going forward about CHW it is our mission to deliver compassionate high quality, important health care services we exist to serve and advocate for our sisters and brothers who are important, disenfranchised and we partner with others in the community to improve the quality of life. This is essentially the core of who we are and when it comes to our values there are five that we absolutely look to the guidance and everything that we do and that's dignity respecting the inherent value of work of the individual collaboration without our ability to work together with other people to support common values and vision not if we would be in existence today justice that is so central to our sponsoring congregations of the criminal ministry we advocate for social change and active way of spectrum of respect for all persons and demonstrate compassion for our sisters and brothers who are powerless and stewardship that is such a huge value of ours I think without our ability to be able to take care of the resources that is entrusted to us we wouldn't be able to provide the services that that our communities look to us for so we cultivate these resources to promote healing and homeless and lastly excellence well you're always striving for excellence it's always good to know that there's humility involved every step of the way too that we are here to try to see expectations through teamwork and innovation I always like to start off with our mission and our values because as I tell my 10 year old son you know Tristan when things are kind of looking a little crazy out there when there are things that don't make sense and where sometimes it feels like you know things around you are hurting it's always good to know who you are and what you're about and so I start off with our mission and values to keep us grounded in this conversation so a little bit more about CHW I don't know if you know we are spread out in California Arizona and Nevada we've got 40 hospitals mostly which are in California where the 5th largest healthcare system in the nation and the largest private not for profit healthcare system in California and also the largest medical provider in the state we have over well close to 9000 acute care beds I know now we've got employees that are over 60,000 and in terms of community benefits and care for the poor we've provided 1.3 billion dollars now this includes traditional trading care shortfalls from programs including medical care and other proactive programs for the poor and the private community now it's important to say that CHW's commitment to healthcare in form has been set fast in fact since our founding in 1986 I want to say that our focus on healthcare reform is probably the reason why we came together as a system we were 7 healthcare systems from 7 different sponsored congregations and we came together knowing that we could do more in the communities that we serve we do it together because in the 80s as you know it was kind of trying time for healthcare systems in general and we knew we had to do something different we had to stay focused on our mission while being also relevant to the times of the day and so we very much we were very devoted to advocating for the passage of ACA even within the Catholic healthcare family let's just say there was quite a split about whether to support ACA going forward or not and with much discernment and focus on our missionary values the right thing to do was to weigh in and support ACA going forward. Our leadership is very very committed to successfully seeing to the implementation of healthcare reform and so we have been very very active since its passage to see about how we can change our infrastructure think about ways in which we can do things differently how we can partner with folks in communities that we serve a little bit about what we are thinking about in terms of key strategies going forward we have developed our horizon in 2020 and we wanted to make sure again that we remain relevant and meaningful in the communities that we serve that we remain viable and that we continue to focus on these key areas in quality and cost and growth and integration and connectivity and in leadership in terms of quality we are certainly looking to implement changes and initiatives that are necessary to raise CHW's clinical quality patient safety and service measures to top desktop performance nationally we want to improve national patient safety goals and we are looking to reduce unnecessary admissions and in fact we have been able to form an ACO like organization in our Sacramento area to do just that partnering with health plans to serve health members and we are already looking at tremendous cost savings there as well as decreasing weird admissions we are looking to enhance the patient experience reduce hospital acquired pressure ulcers for example improve evidence based medicine build out transformational care and implement product disease management and living on a corridor I know she is going to be talking to you folks about what is really going on at the local level and she is going to animate some of these things and I will be talking about in broad strokes in terms of looking at cost we are already looking at implementing changes in the CHW's clinical and administrative processes that lowers CHW's cost below medical reimbursement levels we are focused on improving worker safety improving Medicare performance and clinical resources pursuing revenue services and strategic planning streamlining supply and purchase services managing salary and benefit costs in terms of growth it is important that our healing ministry continues to expand access and market share in the service areas where we are and we are looking more and more to enter in the service areas and significantly expanding our community-based wellness and regulatory non-acute care services it is important that we increase our return on access for a commercial volume and ensure diversity in our acute holdings and again continually entering into these service areas where there is greatest need now integration is so very key to us going forward we know that we can't operate in a silo we've never been that way and I don't think we'll stop ever looking to see how we might be able to come together with others to improve the way healthcare is delivered because if we don't do that we just know that healthcare going forward would not be sustainable if we don't try to work together to lower costs we need to offer our patients the whole spectrum of care and prevention to post-acute through the development of health plan capacity we're looking to building partnerships for a physician alignment and also many of our service areas are certainly looking at developing the kind of care organizations and through clinical integration we're looking to building partnerships between physicians and other possible systems with plans to improve our outcomes on hospital pay performance measures and establish a very competitive market across our service areas because we believe that that is key in making sure that we can provide affordable care services going forward now in terms of connectivity we need our toys you know and the way to go right now is really to make sure that electronic connectivity is up to par with what the needs are of physicians or patients and nurses of all the caregivers that are involved we're really looking to achieve superior service experiences and high quality outcomes and we're going to need to do this by certainly investing and expanding in electronic health records implementing physician electronic records and connectivity implementing enterprise data strategies again using patient connectivity is probably the most important because we need to give the tools to those who are consumers of health care and so we need to be able to be able to provide that for them now leadership obviously is key for us in our size matters I know as the largest health care private health care organization in California size means a lot to people and size comes with a lot of responsibility and leadership is about that responsibility we want to strengthen CHW as an organization we need investments and employees and acquisitions play a more active role in public policy and advocacy in many ways we've done so much in the policy we need to move the ball forward but I know that there's always more to be done we are focused in continued development of a culture of innovation and collaboration and we look to have a great role for our foundations in raising community funds to help build and maintain programs that we do have and again to continually look at where the needs are and to rigorously focus on meeting those needs in the communities that we serve so as the nation begins the journey towards a more just health care system CHW takes seriously as leadership role in improving quality of care that we deliver while also reducing costs we know that hospitals have such a heavy responsibility in leading that charge I don't know how systems can continue to flow if they don't move with the tide and if they don't make sure that not only a few care services are provided but looking at the overall health of the community so I think it's really important for hospital leadership to be in the game and in leading that charge I wanted to mention that as we look at the implementation of ACA I know that our system is very much looking at innovative ways in which we can partner with other health plans and other hospital systems and as I mentioned earlier our collaboration with health physicians, medical group of California in the service area of Sacramento has been really, really fruitful and has been inspiring to other service areas that we are at we've been able to see a 16% drop in readmission and about a $16 billion cost savings in that market alone so we hope that these achieved results working together with our patients and our physicians and our health plans to deliver excellent care that is moving in the right direction and we know that when we're providing the right care at the right time so much fruit comes from it and we free up a lot more resources to be able to do the things that we need to do in the communities that we serve so earlier when you had mentioned that ACA is a bridge to the health well connection and CHW certainly sees its role in all of that we very much are in support of expanding health insurance coverage that has so much meaning to us because we know all too well how our patients how our patients are separate under this and so we are in that direction to help expand coverage we're looking to improve quality and reducing the deaths streamlining eligibility is quite important and again as I mentioned earlier addressing the social determinants of health is primary for us we not only provide care services we've never been in the business of just doing that we absolutely see the responsibility that we have and being able to provide for our programs and really looking at what the needs are and assessing those needs and being able to meet those needs through the programs that we do provide I will end with that I hope that we continue to work with you to partner with you keep us humble, keep us challenged let us know how we can better do the work that we're interested to do in the communities that we serve and I look forward to things that you might have later and again please if you don't know about CHWD go into any of our facilities see what you can do to partner with us go into our website and learn more about it thank you I would like to thank Dr. Mokoro on how the theater used footage I'm delighted to be here and share with you one of our community benefit programs that I think best fits with community development on a grant California Hospital Medical Center as it says here is committed to improving the health and well-being of our community by helping people help themselves and I think those words are very important and you'll see as I go through this talk why that is it was about two blocks away from here right down Grand Avenue it was founded in 1887 it is a non-profit hospital with a very busy birthing center and a level 3 NICU either an obstetrician with sub-specialty in Sheryl's medicine so that is why I came to California Hospital back in 1992 as all non-profit hospitals in California we do a tri-annual community needs assessment which is quite a big undertaking and after it's written it sits on the shelf for the next three years I'm looking forward to this new era will probably invest in healthy community networks web-based system this is very exciting and I encourage you to look at Health Matters in San Francisco if you're not familiar with that website Health Matters in San Francisco made by the same group and it includes a community dashboard with about 75 to 150 indicators they're all colored codes it's easy for everybody to understand how you're doing on that particular topic promising practices that might address any deficiencies or problems in that area as well as Healthy People 2020 tracker you can also track local initiatives as a website and then community health needs assessment and changes that will be nested in the website of each individual hospital so this is what's good about this is it's a living document it's updated as new data becomes available it's constantly updated and it's updated that you can find the best practices and other things as well so this is something I really look forward to LA County plans to invest in this for the whole of LA County and that's helpful because then each of the hospitals gets a 40% discount discounted rate that participates so we're grateful for the Department of Public Health to move you in this direction but they're going to be partners to help fund it this is California hospitals service area and basically it's all in white which means it's a very high need area and it's made up of primarily young Latino families many of them were formed more extremely poor low literacy low educational attainment working in low wage jobs living in overcrowded housing stock often multiple families living in one apartment I have a patient where her part their part was the walking closet a family of four was living in the walking closet there's insufficient license child care capacity high rates of disability in most school children and unfortunately most of the schools are in the lowest performing life as Lisa told us at our last meeting in july poverty in our childhood poisons the brain and children are building neurons making synapses making connections hundreds in a second so those early first three or four or five years are really critical in the life of children and as she pointed out we tend to make our investment in children late so we can see that what's causing the problem about poverty is the amount of stress that children are under when they're living in persistent poverty and this results in reduction in their working memory such that as they enter school they have a 60 percent cognitive performance entrance exams and their middle class peers and a deficit of about 30 million words and then you consider after entering low performing schools you can just imagine that this gap is going to continue to widen and that they're going to become very frustrated and they will drop out of school around middle school and it's sort of self-proclaimed prophecy we know what hurts and what helps what hurts is the amount of stress from poverty and it's effect on brain development they also suffer from inadequate nutrition and health support they live in unsafe unstable homes often moving frequently and intermittently homeless they lack language support and that's evidenced by their fewer words as they know when they enter school and a lot of the words that they hear are very negative what helps is the provision of high quality early care and education good schools and parent support groups they safe and healthy communities with strong infrastructure that we enjoy in middle class communities obviously with health and doing cost benefit analysis is important so we can document what works and convince funders to fund it so I can't cure poverty and I can't create world peace so we have to look at what works to promote health and healing even in the face of tremendous challenges and risks and what makes a child resilient is being surrounded by caring relationships hearing high expectation messages like Olivia talked about this morning and being given opportunities to participate in a very meaningful way not just to surface pressing but really having them participate and contribute to the good of others so this just gives you an overview of a little bit more depth about caring relationships high expectations and opportunities for participation and contribution and these are themes that I will come back to as I progress through the rest of the slides quickly we deliver approximately 5000 babies every year at California hospital and our question was back in 1992 how do we optimize the life course trajectory of each baby that's born in our hospital if I stand seven or eight months working closely with the mother from the virus pregnancy and she has a good outcome both she and the baby are healthy at the end that's great but not if it just falls off a precipice into back into the community where there are no no supports for that family and at that time people you didn't have no services in fact we have so few services the Department of Children and Family Services can't even create a community service directory for it because there weren't enough services to list so that was our starting point and we aimed at starting an organization which is going to turn into a program soon that is focused on enhancing the overall development of children strengthening the economic self-sufficiency and the stability of families much in the way that you do but a little bit different perspective and enhancing the community service delivery system for young children and families because that's what we have in our community importantly the underlying philosophy of Hope Street is based on mutual respect partnership partnership with other agencies partnerships with the families etc and an understanding that in the war in front of an agency like Hope Street to truly serve the community it must not only listen but also a loud sell to be actively guided by the voices we did and indeed the parents are the administrative body that controls Hope Street and they do the hiring and firing they go over the budget of the organization every year so we nested Hope Street at a hospital with a busy birthing facility and I think that makes a lot of sense because that's where lives are starting and we wanted to get them early so that we could intervene and offer early intervention if necessary and early support as well so these on the inner circle are the primary programs of Hope Street and on the outer circle are just a few of our many partner agencies and I'm going to just give you a quick overview in blue are all the home visitation programs home visitation programs start during pregnancy and continue for a variable number of years depending on the particular program we have three child development centers that are high quality full day programs so the parents have the ability then to go to work or go back to school and know that children are receiving high quality care in their absence one is at the hospital one is at an affordable housing place across the street in Mercy housing and one is at a church Angelica Lutheran Church we focus on a lot of literacy literacy as you know is linked to health outcomes very closely and so we have family literacy school readiness programs of course early head start is itself a literacy program we have a continuation high school classroom in the hospital one of the first three in the United States with a 90% graduation rate and we have behavioral health programs to maintain the mental health family members responsible fatherhood program and a marriage program that teaches couples how to really communicate in a very healthy way between each other and then it goes from the family but out into the community of the populated lot of school boards with our parents as well so this gives you an overview and in the slides are a lot more in-depth descriptions of these serious programs that the goal is to provide children with those three opportunities that we talked about so that they grow up resilient and families are given control they set their own goals that they work on throughout the year and so the focus of control is internal to the family and not external families the practice of these two hospitals in the domain of development that the things that they're doing looking out for the programs that they're associated with are ones that we have financed in the field of community development over the years and what's in substance is going on here with a great deal of promise for preempting problems and containing costs and we'll come back from the other side from the community development side where her organization is diversifying these products to create a platform for better health among its residents and businesses. Thank you and you can just turn this off you may cheer right now we're doing slides and so what I'm going to do is bridge the gap and I'm happy to do that because it's important to really talk clearly about the work that we do as a wealth creation transformation of lives strategy and what health care and healthy food and all of those components meaning to bring them together so I have a couple of stories for you maybe two minutes of my stories to prepare you and then eight minutes on the work that we're doing in partnership with the California Endowment and hopefully some other investors that we're working with around what's now being called food deserts so one is my husband and I were very blessed to have legally adopted our two grandchildren one is five years old we did this three years ago when they were two or three years old with a traumatic brain injury so Trinity is developmentally delayed and goes to a special school and does all the things that special kids do so she doesn't necessarily like fruit she spits it out but she loves sweet potato fries right and her brother is for no delays at all in fact he's as smart as a whip the reason I bring that up is because a child at Trinity's school died about a week and a half ago and the doctors diagnosed it as he's nine years old who died from obesity they are very clear and know that the parent is feeding this child his son three times a day Burger King, I'm not calling out Burger King but the bottom line is he had breakfast lunch and dinner at Burger King we knew this child and I would see him and I'd say why is he much fine with them and the staff would say that they should try to feed him differently that's a point that just happened within the last couple of weeks, nine years old second thing is when I was in Brazil several years ago so many people say, yeah Brazil what I'm going to say this to you for is not because I went but because of what I've witnessed and experienced when I went and when you're walking on the beach if you've been there you know this when you're walking on the beach there are not options to buy Coca-Cola there's not options to buy hamburgers you know what the options are you can get at a food cart fresh fruit water mango, watermelon honeydew melon waters and they're fabulous you can get from on a stick you can get grilled meats and you can walk along the beach completely different so the mindset is different and so I was there ten days I never had Coca-Cola because it wasn't an option and then the third thing is capitalism breeds greed and I love capitalism because that's where we live and that's where I was raised on right but I think there's a mindset shift that has to happen when we start to talk about food and this will get me to my point food deserts you know I've really been thinking about that and that terminology really did not resonate with me when it started and I'll tell you why because there's plenty of food in the communities that we serve in fact there's so much bad food that it's not a food desert in fact it's a food media because you've got all kinds of food I mean I was thinking about this I've been thinking about it a long time when we started to come up with what does it mean to be working in an area and CFRC will be 20 years old next year we started briefly after the riots in 1992 and it was a tripartite partnership between the financial institutions America, Wells Fargo, at the time San Juan Bank was rounding down and purchased by Bank of the West I could go on but 39 banks helped to start CFRC to respond to these unmet credit needs and the disenfranchisement that happened within low income communities particularly South LA and East LA the city of Los Angeles and the Federal Reserve Bank led the effort and you know even then I don't know if you remember the data but one of the challenges that came out of RLA was that in low income communities there was only one grocery store for every 50,000 people that was what started this whole thinking around food deserts you know lack of access to good food blah blah blah and you fast forward that to now and the other side of that statistic was in affluent communities there's one grocery store for every 25,000 people so you have double the number of stores for fewer people the other thing that was important was when you started to look at where the restaurant types of restaurants were in low income communities specifically South LA, East LA that's where people were doing all the research because that's where the riots really happened you found that there were one restaurant for every 15 to 20,000 families and in more affluent communities there are 10 restaurants to 20 restaurants for every 10 to 15 20,000 families so you have much greater variety and a broad brush of opportunities to get the kinds of food that you want so let's fast forward to me to now the reason I'm concerned about that is food desert means that there's no food or there's just a lack of food well I think we have to change that mindset to there's a good food desert and I think we have to redefine what good means healthy you know what I find when you say people eat the healthy option you know I think I was watching the McDonald's summary on one of these CNN news channels or something a couple of weeks ago in a hotel and I was sitting there going you're kidding me, McDonald's has found that parents even though they had this healthy food option with the apples and you dip it in the caramel sauce the parents, I know it's really healthy the parents are still ordering the French fries because the kids are in the backseat yelling French fries, French fries so there's this mindset that I'd much rather have so there's this thinking this mindset distinction that has to happen and so I'm wondering how as a capitalistic society we give more time and more commercials and more advertising to fast food restaurants than we do poet service announcements that advocate healthy food and healthy choices so that's one thing so in the midst of trying to figure out how does wealth creation and you saw statistics that came up from Dr. Lin and by the way, that made me depressed oh great, we don't have enough money to do what we need to do in our community even though we know it works we constantly have this data that demonstrates that when people have jobs that when people are running their own businesses that they have health and when they have health insurance and they can take their kids where they need to go on a regular basis that they're healthier, happier and you have a healthier community you still fight the battle of getting funding into non-profit organizations I'm not just advocating for money into non-profit organizations that do the work that we know that works I remember when the federal government cut the budget for health for a head start what the heck, everybody knows head start works people get a meal the kids are trained and they are educated, they do wealth throughout high school they go to college, we have all this data so what does it mean for an organization like CFRC to be getting into health we didn't just get into this realm, what we've done is we formed it in a way that I think transforms what we do into the health care world and by the way I have to say right now that Catholic Health Care was say hi to Pablo for me they were early investors in our microlending program about 10 years ago and for a health care organization to do that showed I think a lot of foresight on their part about how those two things meshed together and so what we did was last year CFRC actually for the past three years has been involved in an initiative discussion with California Endowment called the Healthy Food Healthy Communities Initiative and South LA is one target point and so I was attending those meetings with my economic development head on our organization was one of the few economic development focused organizations while the other 50 folks in the room were social services and we kept going what are you talking about these people need jobs that's why they don't have health care these people need jobs that's why they're not happy people need to work because as human beings our self-worth is connected to what we do and you're sitting around I think there's one in your side there's this depression that happens and you're not healthy and you're not working and you're not having sleep in a closet and you're out there and you've got sunshine and you've got a healthy environment that makes you feel good and so I came up with this thought that maybe there's some relationship between job creation and healthy food right and so as we were talking fast forward to this concept about street vendors and I don't know if you've seen the street vendors it reminded me very much of what was happening in Brazil you could go down the street and buy some healthy food you can actually buy healthy food on the streets of the low income community in Los Angeles and most of the food vendors that are out there are selling fruit if you've noticed right or they're selling tacos or I saw a food vendor on Criccia and 54th the other day selling gumball these folks are out there selling healthy good food and so how do we get them into the mainstream society with good health licensing that's been they have a public health license they learn good good food preparation techniques because they've gone to the classes that we get them licensed with small business licenses and if they need a loan then we give that to them and they earn that because they do the work to get there and so we came up with this street vending cart initiative it's the first one it's called healthy food cart vending initiative and it's the first one funded by the California Endowment they recently funded it last December we're coming up on our first year we formalized the work that we've done as an organization in micro lending to focus in on food vendors that are working on the streets in the evenings during the daytime to really sell to meet the needs of their family and asking them would they like to become formalized and encouraging them to do that and one real encouraging note for them to do this is that there's not a food policy in the city of Los Angeles that allows for street vendors so a lot of them get arrested and they get taken in by the police and even though you're not doing anything that would be detrimental to society they are breaking the law so we have a number of cases even the guy who sells at the corner of King & Figaroa my staff goes over there and buys food from him sometimes every couple of months he comes up missing and we go oh he must have gotten arrested and it's true oh he must have been they should stop that they should get the criminals and they should and so one of the part of the work that's being funded by the endowment is for CFRC to begin the process again if you will we actually about ten years ago worked with the city of LA to do a street vending initiative citywide it was a two year pilot project and then the money fell apart and the funding went away and so there's no street vending policy for the city of LA although when you go to Chicago, New York, Washington DC there are other major cities so we were funded a very small amount to begin the advocacy work around citywide policy I'm hoping it can go county wide and hopefully statewide because I think that's something we have to work on but we also want to make sure that we get our vendors up to health code and up to business code because the thing about the work that we do and I think this is working out in here and I'm happy to take you and am trying to speak to my ten minutes here is that people think that micro loans and micro lending and street vendors and people that started business with $500 don't make a difference we did our own and we collect the debt on a regular basis we did an analysis of the tax dollars paid by CFRC micro borrowers from 2003 to 2007 they paid $220,000 in city taxes alone during that period of time the other very important pieces that we do individual development accounts savings I think there was a lady over here talking about the savings earlier we now have our most recent data that demonstrates that we had 220 families saving from 2004 to 2008 they saved and the minimum contribution was $25 a month they could do more than that if they wanted they saved $178,000 in that amount of time so we know that it works it's slow and building but those wealth creation strategies allow people to get to a level of confidence thinking that allows them to say you know what I can do this my kids can go to school I can go back to school I can start a business and I can make this work for me so in there there's so much more I'd love to say I look forward to hanging around and talking to you if you'd like to talk more about this but I believe that this conversation has to continue because the the work between public and private sector around how we build our communities from the ground up starts here thank you very few moments for questions and we'd love to hear from you yes and please tell us who you are my name is Michael Bannevue I'm from America question for Dr. Yanukura I was really fascinated by the Hope Street framework that you shared with us and was very curious about the genesis of the of creating that framework what caused it and how did it flourish over time what caused it was again my concern about what was going to happen to the babies that we delivered at our hospital who went back to a community with little in the way of support or resources and we really went to a lot of the local thought leaders particularly clergy in the community and asked them what they thought the community needed what types of services types of programs would be beneficial and then later we listened to all the families that were participating they were the ones for example who wanted us to start an after school youth program and at first we thought it was just going to be extra arts and crafts and things like this that they weren't getting in school but then we did standardize reading tests on all the children and found out they were reading way below grade level so we implemented a language arts mentoring program that was very efficient at bringing them up to grade level they worked with their usually a community member it could be a you know now they're lockdowners but they were lost back then but there were people that worked in the community that wanted to volunteer some time to mentor young children in reading and they could help the child bring their reading level up about three grade levels in a year which was very efficient and because of the way the program was designed and also we should say that for this audience that a banker from San Juan Bank created an incentive program for the children so if they came to after school mentoring they got points if they improved their report card they got so many points and they could save the points and purchase items from our covered which mostly has school supplies, backpacks you know different types of things that school children need but the children learned that they could get immediate gratification and get something that's like staff or they could begin to build their points and maybe get something really nice like soccer ball so it's a way of teaching children sort of banking principal but in a way that young children particularly could understand I think the most touching time for me was when the young child said well he was going to save because he had so many points and we couldn't figure out what he was doing and he says well it's my mother's birthday and so he was going to buy her a backpack and you know he'd been saving all these points for that one we were all so touched it gave him a backpack but I think we need to listen to the community you're serving and very wise and we are focused on strengths and their internal assets and we build on those we don't embrace a deficit model other questions or comments yes please there's been some a little bit of maybe you seem to call it backlash but there have been some change in the grocery store that leads on national change in a lot of cities in the country New Haven, Seattle, Harlem and I've talked to some of the senior executives of the store they pointed out to me that they're dismayed that the take up of the good foods in the grocery store and even the traffic in those stores hasn't been what they expected and wanted is that just a matter of time and commitment or are there other factors involved how do you respond to that that's something you have to say in our communities we haven't seen very many new stores come in so I don't know if that's true I think if they come in fact you've seen a lot of stores I've been watching this Ralph's for instance in South LA has closed 8 of the stores over the past 10 years whereas only 3 new ones have opened and that would be the housing stores which of course senior citizens and smaller families don't like because you have to buy a bulk and then you waste a lot of it so I don't know about in other cities as such I did tour of the new grocery store in Harlem but that was like 5 years ago and as I recall they were doing really well but it could be a function of the economy too now that people are out of work and you don't have as much disposable income the first thing to go is how can I live in my budget on food I'm not going to buy a $3 apple that's an organic apple when I can buy one for $1 on the corner and you know I can still feed my family they not taste as good so that would be my I might leap in on that one as we wrap up and have the factibility you're probably familiar with the California Freshworks Fund which is a program spearheaded by the California down in another avenue that they're taking to work on this matter of what men call actually food swamps and that's relevant because even in the conventional grocery store or and certainly in the corner stores that are more commonly loaded in communities who come in in the first products to see the cigarettes, the alcohol products the candies and so on so part of the California Freshworks Fund is a combination of regular bank financing but then also some subordinated mission driven financing and grants Catholic Health Care West being one of the partners again in this venture and that blend of financing enables them to help the retailers take on some product innovation as to how they place products in their stores in order to incentivize and motivate folks to come in and get the healthier goods many of the supermarkets that are the model for this program in the state of Pennsylvania and the original Healthy Foods financing initiative have a meeting and space to learn about healthy foods some of them have kitchen so you can get some healthy cooking instruction so I think we're at the very beginning of a revolution in how we increase access and incentivize healthy foods in lower income communities but I think that that illustrates the importance of the various sectors working together, philanthropy in this case health systems and their community benefits are by the way a huge resource for us to think about strategically it's about $12 billion a year across all non-profit health health systems in the country and the conventional financial services are really there where I couldn't help think today would it be nice if we had another credit vote for the financial services industry but what we see today and heard about are instances where we take the tools of credit and financial services and try to make them the basis for building assets and promoting health and I hope that all of us can continue talking after the formal end of today's session to figure out more ways to build them the successful models we've heard about today and thank you Melody again for hosting us here thank you announcements and then I'm going to ask Olivia if she would join me here and to close out the session today so the first thing I wanted to mention was Liz if you want to see anything about the Robert Wood Johnson conference or if you're working that area and actually it's Melody's vision that made this a morning symposium we approached Melody to have the host or the LA event but this is really a speaker series that the New America Foundation has launched with an array of parkers and I welcome you if you have contacts and colleagues and friends in Oakland or Fresno to please let them know that the symposium is coming their way we're going to have a forum at the East Bay Community Foundation tomorrow during the lunch hour and then we'll be at Fresno State University on the 29th so Oakland on the 28th and Fresno on the 29th and we'll be talking about the specific health authorities that those communities are experiencing as well as local strategies to try to bridge the divide I also want to with the office of Assemblyman Ricardo Lada thank him for being here thank the Assemblyman who's the chair of the select committee on financial empowerment select committee at any state house in this country that's focused on asset building and wealth preservation it's a bipartisan select committee with seven members they represent all of California and they actually have the first hearing in Los Angeles in southeast LA on August 18th and they're going to be meeting again in San Francisco on October the 4th so if you're in the Bay Area and want more information get in touch with Juan Cabrillo and then again this symposium is going to be on November the 15th hope to see you all there and we'll be happy to make sure that the group gets the invitation so thanks so much again for being here and look forward to completing this presentation