Laura Bliss is CityLab’s west coast bureau chief. She also authors MapLab, a biweekly newsletter about maps (subscribe here). Her work has appeared in the New York Times, The Atlantic, Los Angeles magazine, and beyond.
Repealing the ACA could eliminate groundbreaking initiatives that ease urban health disparities. Bronx Health Reach is one.
Midway through services on a Sunday morning in March, the congregants of the Cosmopolitan Church of the Lord Jesus rise from the pews, lift their hands, punch the air, and sway from side to side.
They’re not praying: These West Bronx churchgoers—mostly older black women, many in bright wool jackets and fur-trimmed hats—are taking an exercise break. For ten minutes, the parishioners twist their torsos (12 repetitions each) and march in place. Soon, the pastel-colored windows have faintly fogged from their exertions. “Spiritual health may be our priority, but we are also charged by God to be good stewards of our bodies,” says Susan Mendoza, the trim 57-year-old who’s been leading the breaks for the past year.
Stretching in an AME church might not be the first thing that comes to mind with the Affordable Care Act. But Cosmopolitan’s current regimen—which also includes diabetes awareness classes, low-sodium Friday night dinners, and seminars from local doctors—is one manifestation of a little-known public health program that comes courtesy of the ACA.
It’s made possible by Bronx Health REACH, a nonprofit focused on tackling racial health disparities among the nearly 300,000 people who live in the southwest reaches of the borough. Much of their funding comes via REACH—Racial and Ethnic Approaches to Community Health—an initiative of the Centers for Disease Control and Prevention. Since 1999, REACH has existed to address health disparities in communities of color, many of which suffer disproportionately from diabetes, obesity, cardiovascular disease, asthma, and poor access to vaccinations and prenatal care.
For the past several years, most of the money for REACH (and about 12 percent of the CDC’s overall budget) has come from the nearly $1 billion Prevention and Public Health Fund, which was established by the ACA in 2010. Though it has received less attention than other features of federal healthcare policy, this fund is the first item up for repeal in the GOP-backed healthcare bill that abolishes and replaces the ACA.
With nearly 90 percent going to CDC programs, the Prevention Fund goes a long way for state and local health initiatives. It funds a diverse range of programs: infectious disease research, toxic lead eradication, mental health and vaccination efforts, and community bike plans, among many other sundry items. The REACH program, though small, stands out for its impact on particularly vulnerable communities in cities around the country. Forty-nine local entities (some public, some nonprofit) from Oregon to Maine received REACH grants in 2014, amounting to $35 million. These grants end in September 2017, contingent on continued support from the CDC. If the new bill is passed, and if neither CDC nor Congress designates another source of funding, vulnerable populations in major U.S. cities stand to lose millions of dollars for all types of preventive services.
Hundreds of thousands of individuals served by REACH would likely feel doubly hurt, since the ACA has been a boon to lower-income Americans of color, particularly those seeking access to Medicaid. (With expected cuts to agencies like HUD and DOT, the suffering may be magnified further.) The ACA expanded Medicaid so that the program covers all adults who earn up to $16,400 per year; previously, participants had to qualify based on age or disability, in addition to having very low income. Largely because of this, an additional 11 million people in 31 states and D.C. are now covered.
According to the Congressional Budget Office’s new analysis, 24 million fewer people would be have health insurance ten years from now under the GOP’s new plan, between the bill’s Medicaid rollbacks and the higher premiums it would establish for older, sicker Americans. (Younger, wealthier, and healthier Americans might save some money.) Coupled with the elimination of the Prevention Fund, “hundreds of thousands of lives would be lost,” says Charmaine Ruddock, the project director of Bronx Health REACH, who also serves as chair of the board of directors at the National REACH Coalition. “Especially those who are poor, and no matter their color. But especially those who are of color. When they talk about repealing the ACA, that is the implication.”
The CDC has funded Bronx Health REACH since 1999; before the Affordable Care Act, it used general funds from Congress to support REACH programs. But right now, virtually all of BHR’s budget comes out of the ACA’s Prevention Fund.
Those Sunday morning stretches are a single example of the kinds of health interventions and initiatives BHR has built up in the South Bronx. Think of them as one small brick in a dam to push back against a river of challenges.
Since 2010, the Robert Wood Johnson Foundation has listed the Bronx dead last in its county health rankings for the state of New York. The mortality rate for diabetes among women ages 18-64 has been estimated to be 20 times higher than in Manhattan’s very white Upper East Side, just ten minutes away on the subway. Nearly one in three adults in the Bronx are obese, compared to one in four across New York City; childhood obesity rates are also high. In 2012, the Bronx saw more than 3,000 potentially preventable cases of hospitalization for cardiovascular conditions like hypertension and congestive heart failure—this accounted for more than 20 percent of all such admissions across New York State. A lack of healthy food options, high poverty rates, substance abuse, and unstable housing are a few leading risk factors, according to research by the New York Academy of Medicine.
In 18 years, BHR has worked with more than 70 neighborhood groups—churches, hospitals, schools, social service agencies, transportation advocates, economic development groups, and others—to improve health and nutrition in the southwest Bronx, and to raise the importance of bodily well-being in the collective consciousness. The organization has gotten chronic-disease awareness and fitness programs into nearly 50 local churches. In 2006, it helped ban full-fat milk in 1,579 New York City schools. It has helped make fresh, heart-healthy foods available in dozens of bodegas and restaurants. Driven by the needs and desires of its “partners,” BHR has nudged thousands of community members to think, and act, on matters of the heart, brain, lymphatic system, and respiratory tract.
“In the 39 years I’ve been leading this congregation, I don’t know of anything that’s happened in the Bronx that compares with what they’ve managed to achieve since 1999,” says Reverend Robert Foley, the head of Cosmopolitan Church and a longtime local civil rights leader. “It has evidenced great staying power, as it has reinvented itself, over and over, to address the conditions of the people.”
I meet Ruddock, BHR’s founding leader, at Dominican snack bar called Delmy on E. 149th Street. Over the noise of a Spanish-language soap opera and a thrashing smoothie blender, we both order plates of fresh greens, mango, black beans, and corn, with a hot sauce-infused dressing. This is a Bronx Salad, the borough’s new “signature” dish, which BHR helped create and launch in February. It’s now available in eight restaurants and grocery stores.
Like many other REACH programs, BHR dispatches materials and educators to churches, schools, and other institutions teaching the importance of healthy eating. But that can only go so far, according to Ruddock. “People told us, if they know they’re supposed to eat healthy, but they don’t find their local restaurant selling the right food, then they have no way to implement the action.”
As one solution, BHR partnered a local Filipino-American chef, King Phojanakong, to concoct a salad with healthy ingredients would telegraph the many cuisines at home in the Bronx, then worked with economic developers and businesses to market and sell it. BHR has also pushed some of the many, many southwest Bronx bodegas to supply other fresh food items, and it has funded research into local shopping habits in order to increase awareness of healthier choices. That’s on top of its work to build fitness and better eating practices into religious institutions and schools, to advocate for safer streets, and to lobby for policy changes at the city to create healthier schools.
The organization also agitates to reform New York State’s healthcare system. For years, they’ve pushed to end what Ruddock calls “medical apartheid” at some of the largest academic hospitals in the city. In New York City, blacks and Latinos are more than twice as likely as whites to be publicly insured or uninsured, which often leads them to outpatient clinics instead of private practices. The “clinic system” often translates to longer wait times and inconsistent care, their research shows.
No state laws addressing potentially discriminatory health care practices have been passed yet. But peer-reviewed research on BHR’s legal interventions on the issue found that “the related community mobilization efforts have raised public awareness about the impact of disparate care … and garnered support among many city and state legislators.” As BHR’s coalition has grown, Ruddock has increasingly brought scholars and experts to coalition meetings, so that the history of the Bronx—and the real-estate redlining and government disinvestment that effectively segregated the borough—can be understood in the context of the area’s current public health challenges.
“Some people get depressed when they learn. Some people get angry,” Ruddock says. “But my next question is: Where are our elected officials, what are they doing about it, and how can we hold them accountable?”
This consensus-building model was also deployed in the predominantly black and Latino neighborhoods of South Los Angeles, where a coalition funded by REACH dollars managed to officially ban new fast-food restaurants. (That ban didn’t curb obesity by itself, researchers later found, but it’s notable that the push still came from activists in the community itself). In Minneapolis, a $500,000 grant has given nearly 153,408 Asian-American and black community members access to exercise and stress-relieving activities, in a special effort to create a network of “bi-cultural” connections. In Denver, a similar grant has allowed the Stapleton Foundation for Sustainable Urban Communities to designate residents of two predominantly black neighborhoods as “block captains” in local policy discussions concerning street safety and access to parks. The REACH program of the Inter-Tribal Council of Michigan has worked to strengthen tobacco-free building policies, set up farmer’s markets, and build “food sovereignty planning committees” within local tribes.
In Ohio, another CDC REACH grant allowed Cleveland’s Asian Services in Action (ASIA) to build a “multi-sector coalition … to address access to physical activity within Asian American/Pacific Islander (AAPI) communities in Greater Cleveland, Ohio,” writes Cathy Vue, an assistant manager at ASIA.
Losing funding for REACH, then, may not just be a matter of losing momentum on exercise activities and carrot sticks. It would mean losing support for a network of coordinators who are holding communities together to think about health, and to improve quality of life as a collective. “That was the genius of REACH as the CDC authors envisioned it,” says Ruddock. “They had the sense that communities themselves knew what they needed.”
While not all REACH programs have data demonstrating quantitative success, a number of them do: The CDC reports that REACH programs around the U.S. have improved rates of physical activity and childhood immunizations, lowered hospitalizations for preventable conditions, and increased prenatal care visits in their target communities, among other metrics of success.
Dollar for dollar, certain preventive health measures save more lives, and money, than others—efforts that take place outside clinical settings are particularly promising on the second count. But the GOP healthcare bill allocates nothing specifically for prevention. Some Republicans in Congress would be happy to see the Prevention Fund gone. At a House Committee meeting in March—at which an amendment that would have preserved the fund failed to pass—Representative Tim Murphy (R-PA), called it a “slush fund” and raised questions about some of the ways it has been spent, US News reports:
$7.5 million had gone toward a program in Nashville, Tennessee, offering free pet spaying and neutering; $1 million went to Boston for urban gardening; and $235,000 went to Waco, Texas, to offer residents massage therapy, aerobic, kickboxing and Zumba classes, and kayaking and paddle boarding.
Other members of Congress—not only those on the left—see the CDC’s work as less frivolous. “What CDC does is probably more important to the average American than, in a sense, the Defense Department,” Congressman Tom Cole (R-OK), who leads one of the panels overseeing CDC’s budget, told reporters. “Those investments are extraordinarily important for the protection of the country.”
Cole was talking about the CDC’s infectious disease research, but he’s also been a major advocate of the REACH program in the past, according to Ruddock. So has, she says, the South Carolina’s GOP Senator Lindsey Graham. (I’ll update this story if and when Cole’s and Graham’s offices return requests for comment.) Party affiliations are, evidently, not the best predictor of REACH’s supporters. While the major public health advocacy groups organizations mobilize, Ruddock herself has been working overtime to reach out to various “champions” in Congress, and at the CDC, to protect the fund.
REACH might slide through unnoticed, even if the Prevention Fund itself is slashed: it’s a tiny drop of funding in a massive federal budget. Or not. “CDC is focused on working 24/7 to protect the health of Americans,” Kathy Harben, a CDC press officer, stated via email. “We don’t yet know how a new budget might affect our work.”
If they lost their support from REACH, members of the Cosmopolitan Church of the Lord Jesus say they’ll keep exercising. “We’ll be resilient,” says Dorothy Faison, a 77-year-old Verizon retiree who volunteers as the church’s liason to BHR.
Mendoza, who leads the stretches, has a larger concern in mind. As the current director of a local homeless shelter, she sees Bronx County’s woeful health ranking first-hand every day, and knows how poorly people of color can be treated in the existing healthcare system.
“But if you have well-educated, knowledgable people, you can’t get away with that anymore,” she says. To her, that’s the most precious part of what Bronx Health REACH has been developing: “They’ve built a sense of awareness—that there is something called better.”