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Banking and Community

ISSUE 2 2010

F e d e r a l

Rese r v e

B a n k

o f

D a l l a s



can affect health
outcomes, including
infant mortality, life
expectancy, and the
development of chronic
diseases. We know that
neighborhoods “get
under the skin.”
— Center for Population
Health and Health Disparities,
RAND Corp.

Building Healthier Communities
from the Ground Up

ISSUE 2 2010

Banking and

Federal Reserve Bank of Dallas
Community Affairs Office
P.O. Box 655906
Dallas, TX 75265-5906
Alfreda B. Norman
Assistant Vice President and
Community Affairs Officer
Wenhua Di
Senior Economist
Julie Gunter
Senior Community Affairs Advisor
Jackie Hoyer
Houston Branch
Senior Community Affairs Advisor
Roy Lopez
Community Affairs Specialist
Elizabeth Sobel Blum
Community Affairs Research Associate


ow to reform the American health care system—in terms of access, cost and

quality—is a conundrum this country has struggled with for years. On March 23, 2010,
President Barack Obama signed into law health care reform legislation designed to help
more people acquire health insurance.
Amid the wrangling over solutions, a movement to improve health on the community
level has been gaining traction. This movement promotes not only access to health care
but access to healthier environments and nutritious food.
This issue of Banking and Community Perspectives focuses on some nonlegislative
efforts to foster healthier communities, particularly in low- and moderate-income
areas. These efforts are led by both public and private organizations across the Federal
Reserve’s Eleventh District.
The initiatives are important to community well-being because, as the Center for

Editor: Kathy Thacker
Designer: Darcy Melton

Population Health and Health Disparities reports, “Where you live affects your health.

June 2010
The views expressed are the author’s and
should not be attributed to the Federal
Reserve Bank of Dallas or the Federal
Reserve System. Articles may be reprinted
if the source is credited and a copy is
provided to the Community Affairs Office.

Neighborhoods can affect health outcomes, including infant mortality, life expectancy,
and the development of chronic diseases.”

This publication and our webzine,
e-Perspectives, are available on the
Dallas Fed website,

Alfreda B. Norman
Assistant Vice President and Community Affairs Officer
Federal Reserve Bank of Dallas


Banking and Community Perspectives

Federal Reserve Bank of Dallas

Building Healthier Communities
from the Ground Up
By Elizabeth Sobel Blum


he American health care
system is more ecosystem than system. No
central entity coordinates the activities of
health care providers and insurers. Nor do
the fundamental laws of supply and demand
apply, with little information about cost and
quality available to the public.
Health care spending has been rising
faster than the nation’s nominal gross domestic product, and health insurance premium
increases have been surpassing the growth

in workers’ earnings.1 At the same time, an
estimated 46 million people in the U.S. are uninsured and thus have limited access to care.2
Recently passed health care reform addresses uninsurance, among other issues, to
some degree.
Lack of insurance is particularly problematic because the uninsured are less likely
to get timely preventive care or care for illnesses. As a result, they tend to have worse
health outcomes.3 Uninsurance also has

significant economic consequences. The value
of better health outcomes from uninterrupted
coverage for all Americans is an estimated $65
billion to $130 billion a year.4
The recent recession increased the
national unemployment rate, pushing up the
number of uninsured. For every 1 percent
increase in unemployment, the number of
uninsured people rises by 1.1 million and the
number of Medicaid and Children’s Health Insurance Program (CHIP) enrollees goes up by

Photo courtesy of Grant County Healthy Kids, Healthy Communities

Federal Reserve Bank of Dallas

Banking and Community Perspectives


Healthy Kids, Healthy
Communities invests in local
partnerships to advance policy
and environmental changes so
that children and families have
more opportunities to be active
and eat healthy.

Photo courtesy of Tarrant County Public Health

a total of 1 million.5 Meanwhile, state general
fund revenues decrease 3 to 4 percent, which
means that states have smaller budgets while
facing larger demands for subsidized care.6
Health care reform may address uninsurance, but problems remain. Among them is
access to primary care providers, who are
already in short supply for Medicare and
Medicaid patients.
One way to allay the severity of the national
health care problem is to help communities
become healthier—which can reduce demand
for health care services. Public and private
organizations are promoting access to healthier
surroundings, nutritious food and medical care
across the country, including low- and moderateincome areas where such access is limited. This
report highlights some of their efforts.

Access to Healthier Environments
Major initiatives that promote healthier
lifestyles are planned or ongoing in the
Federal Reserve’s Eleventh District, which
includes Texas and parts of New Mexico and
Here’s a look at Vision North Texas
and Healthy Kids, Healthy Communities,
two wide-ranging efforts to create healthier


Vision North Texas
In North Texas, public, private and academic entities have developed Vision North
Texas, a partnership to build awareness about
the region’s projected growth, serve as a
platform for dialogue among stakeholders and
generate support for initiatives based upon a
shared vision. One goal is to create healthier
communities by increasing access to exercise
programs and facilities, affordable healthy foods
and primary care and wellness services.
The partnership’s Health Research Team
is leading the way. Other participants are Blue
Cross Blue Shield, the city of Fort Worth, the
North Texas Council of Governments, Parkland
Health and Hospital System, Tarrant County
Public Health, the Texas Health Institute, Texas
Health Resources, the University of North
Texas Health Science Center and the University
of Texas at Arlington School of Nursing.
Participants have established guiding
principles that promote health and well-being.
They will create community action plans to
help municipalities in the 16-county region
plan and implement projects that create
healthier environments for residents. Plans
will look at such indicators as the number
of community gardens, full-service grocery
stores within a certain radius, schools with

Banking and Community Perspectives

walking programs and safe routes, and shared
fitness facilities through school, hospital and
community partnerships.
Participants are already supporting North
Texas’ shared vision through independent
and joint programs. Among these programs is
Tarrant County Public Health’s Live a More Colorful Life, which offers education on healthy
eating and supports farmers markets in Pantego and Richland Hills and two community
gardens. The first garden is a joint effort by the
Arlington YMCA, Amos Elementary School and
the United Way of Tarrant County. The second
garden is a partnership between the Greater
Fort Worth YMCA and United Healthcare.

Healthy Kids, Healthy Communities
Healthy Kids, Healthy Communities is a
$33 million program to reverse the childhood
obesity epidemic.7 Operating in 50 communities across the country, the initiative invests
in local partnerships to advance policy and
environmental changes so that children and
families have more opportunities to be active
and eat healthy.
The program is supported by the Robert
Wood Johnson Foundation, whose mission is to
improve the health and health care of all Americans. The foundation provides support to indi-

Federal Reserve Bank of Dallas

viduals and organizations focused on advocacy,
action and research addressing the country’s
most pressing health and health care issues.
In these 50 communities are neighborhoods where obesity is exacerbated by issues
such as high levels of poverty, unemployment,
crime, dangerous traffic and too few freshfood retailers. Over a third of the sites are in
the southern U.S. because this region has the
highest prevalence of obesity. Four are in the
Eleventh District: El Paso, Houston and San
Antonio, Texas, and Grant County, N.M.

El Paso
Healthy Kids, Healthy Communities
recently started in El Paso’s El Chamizal neighborhood, home to approximately 2,000 children and adolescents. The program has over a
dozen partners that include the Pan American
Health Organization (PAHO)/World Health Organization (WHO) U.S.–Mexico Border Office
as well as housing and public health authorities, park services, universities and the media.8
The partners’ first step is to assess and
map Chamizal’s healthy living assets and
needs. These include access to fresh food;
public lighting as a safety feature in parks and
on pedestrian and bike routes; in-school and
after-school opportunities for sports and exercise; and zoning that promotes or inhibits the
growth of a healthier living environment. The
partnership will disseminate its results to federal, state and local authorities and community

leaders. It will recommend which parks, recreation areas, sidewalks and other infrastructure
should be maintained or revitalized to increase
residents’ physical activity. Recommendations
will also address how to improve the community’s access to healthier food.
The partners’ vision is for Healthy Kids,
Healthy Communities to be community-driven
so that it is sustainable. Youth leadership is
critical, so the initiative has introduced Ecoclubes ( to promote and
develop youth leadership on environmental
health issues. Ecoclubes exist in about 30 countries but haven’t been in the U.S. until now.
These organizations are made up of young
people who meet to decide upon objectives,
bring in specialists as trainers and educators,
and develop activities that raise community
awareness. Working with local entities, they do
outreach through the media and activities such
as plays, exhibitions and parades.
Maria Teresa Cerqueira, chief of the
PAHO/WHO U.S.–Mexico Border Office, says
a variety of indicators will demonstrate the
partnership’s success: The community will see
more people walking and biking, more kids
involved in well-structured after-school activities, more accessibility of affordable nutritious
food and more public awareness of healthy
food choices.
The partnership hopes to open a neighborhood farmers market and a community
center that teaches dance, music and cooking.

Photo courtesy of the Pan American Health Organization/World Health
Organization U.S.–Mexico Border Office © 2010

It also plans to document community changes
with photos, track students’ body mass index,
and survey students, parents and teachers.
Partners will publicize their findings and best
practices to promote investment in this healthy
living campaign.

CAN DO Houston (Children And Neighbors Defeat Obesity) is a nonprofit organization created in 2007 by several community
groups including the Mayor’s Wellness Council,
Houston Wellness Association and the University of Texas School of Public Health. Its
mission is to prevent and reduce childhood

The mission of CAN DO Houston
is to prevent and reduce
childhood obesity in the city,
which in some neighborhoods
has overweight and obesity
rates as high as 46 percent.

Photo courtesy of the Pan American Health Organization/World Health Organization U.S.–Mexico Border Office © 2010

Federal Reserve Bank of Dallas

Banking and Community Perspectives


In January, the organization received a Healthy
Kids, Healthy Communities grant from the
Robert Wood Johnson Foundation to develop
policy and environmental changes.
CAN DO Houston and its partners are
monitoring the initiative’s impact by tracking
children and families’ participation in healthy
food and exercise programs, assessing HISD
information on children’s weight and physical
activity in school, and surveying parents and
teachers on their satisfaction with CAN DO.
The organization is also meeting with community members and local policymakers to
advocate changes that foster safe exercise environments and affordable healthy food options.
Program leaders plan to expand collaboration
and identify additional support so that their
work becomes sustainable.

San Antonio
Photo courtesy of Grant County Healthy Kids, Healthy Communities

obesity in the city, which in some neighborhoods has overweight and obesity rates as
high as 46 percent.
CAN DO Houston’s founders saw that
groups in Houston were independently working to address obesity, and many were unaware of existing programs to improve access
to nutritious food and physical activity. They
created this nonprofit to identify community
needs and available resources to deal with
childhood obesity.
CAN DO Houston’s partners include the
city’s parks and recreation, health and human
services and police departments, plus the M.D.
Anderson Cancer Center, Houston Independent School District (HISD) and Recipe for
Success. Still in its early stages, the organization is working in three of Houston’s 88
neighborhoods.9 Plans are to one day reach at
least 17,000 youths, especially those who are
low-income and minority.
To date, CAN DO Houston has worked
with police to increase safety at a local park to
encourage participation in after-school physical
activity programs there, created an elementaryschool walking club, supported an after-school
cooking class for students and parents, and
held a parent education program on nutrition.

The Healthy Kids, Healthy Communities Coalition, formerly the Healthy Active San
Antonio partnership, is developing and implementing the initiative in the Alamo City. This
partnership’s focus is the city’s densely populated West Side, where poverty, unemployment and poor educational achievement are
high relative to the rest of Bexar County. The
initiative has four components: the Complete
Streets Coalition, Healthy Restaurants Coalition,
Neighborhood Nutrition Assessment Coalition
and Shared Use Agreement Coalition.
The Complete Streets Coalition, whose
primary partners are city planners and engineers, will complete a work plan this fall and
push for adoption in spring 2011.
The Healthy Restaurants Coalition—
whose primary partners are local restaurants,
registered dieticians and the San Antonio
Restaurant Association—plans to provide
financial and technical assistance to at least
five restaurants over the next four years as
part of a healthy menu initiative designed to
evaluate menus and establish food and beverage guidelines. A pilot is already under way
at one restaurant.
Meanwhile, the Neighborhood Nutrition
Assessment Coalition, composed of University
of Texas Health Science Center School of Nursing staff and students, is evaluating the com-

munity’s nutrition levels in cooperation with
the San Antonio Metropolitan Health District
and plans to finish the project this summer.
The newly formed Shared Use Agreement
Coalition includes the Westside Development
Corporation, the South Texas Area Health
Education Center and the city’s Community Development Advisory Committee and parks and
recreation department. By winter 2010, coalition
members hope to build the support of local
leadership and identify facilities for shared-use
agreements to encourage sports and exercise.
The San Antonio Metropolitan Health
District, St. Louis-based public health firm
Transtria and Chapel Hill, N.C.-based Active
Living By Design are working together to
evaluate and measure the initiative’s progress
and provide technical assistance to Healthy
Kids, Health Communities’ grantees so that
they can help in the assessment process.
Bryan Alsip, project director and assistant
director at the San Antonio Metropolitan
Health District, says the partnership will have
succeeded when policy changes that promote
healthy eating and active living are enacted
and the community’s overall health improves.

Grant County, N.M.
Grant County is home to fewer than 30,000
residents, nearly half of whom live far from this
rural county’s four incorporated towns. Almost
three dozen of the county’s communities are

Photo courtesy of Grant County Healthy Kids, Healthy Communities


Banking and Community Perspectives

Federal Reserve Bank of Dallas

designated as colonias because they lack quality housing and sufficient water, sewage and
street systems. They also have limited access to
affordable healthy food. One result is that, on
average, a third or more of school-age children
are overweight or obese.10
A group of local food and health organizations and government entities is tackling
these issues as part of the Healthy Kids,
Healthy Communities initiative.
The Gila Regional Medical Center Foundation is the initiative’s grant fiduciary. The Grant
County Community Health Council, whose 30
members represent a diverse group of stakeholders, is leading the implementation. Other
partners are Farm to Table, Grant County Cooperative Extension Service, Grant County Public
Health Office, Hidalgo Medical Services, Southwest New Mexico Council of Governments and
The Volunteer Center of Grant County.
The initiative’s goal is to enable and
inspire all residents to live healthier lifestyles
by increasing the availability and affordability
of fresh food and creating physical activity opportunities. The county health council already
supports three community gardens and two
farmers markets, some of which are in lowincome neighborhoods. Program partners are
investigating the use of cold-storage facilities
for growers and the local food pantry as well
as a purchasing cooperative for grocers, restaurants and schools to enable the expansion
of local production. Partners are also supporting the creation of safe walking and biking
trails that connect towns and parks, and are
advocating extended hours at public facilities
for sports and exercise.
The county health council recently finished a two-month community assessment to
determine if city, county and school officials
would support or have already put into place
policies or ordinances that influence healthier
eating and greater physical activity levels. The
council conducted focus groups with farmers
and recreation, transportation and land-use
experts to explore how to make fresh food
and exercise opportunities more available to
residents. It also interviewed families to better
understand what helps or hinders their efforts to
lead healthier lifestyles. In addition, the council

Federal Reserve Bank of Dallas

trained student nurses to go into assigned grocery stores to check the availability and price of
healthy food items.
To help make its efforts sustainable,
the council conducted an online survey of
community-based organizations’ programs and
needs. It also plans to develop a food policy
council, giving farmers, food vendors and
distributors a seat at the table.
Andrea Sauer, coordinator of the Grant
County Healthy Kids, Healthy Communities
initiative, says that the partnership will know
that real change is occurring when community
gardens proliferate, public policies promote
healthier lifestyles and residents’ nutrition levels,
physical activity and overall health improve.

website,, is designed to inform parents and children about healthy food
choices and ways to increase physical activity.
Another initiative—British chef Jamie Oliver’s
Food Revolution—has also focused national
attention on the need for healthier diets (see
box, “A Food Revolution”).

Access to Nutritious Food
Food insecurity, obesity and inadequate
access to fresh and healthy food are problems
that millions of Americans face. More than 17
million U.S. households were food-insecure
at times during 2008, according to the U.S.
Department of Agriculture (USDA). That means
14.6 percent of all households could not consistently afford adequate food for all household
members, up from 11.1 percent in 2007.11
Households that had rates of food insecurity higher than the national average tended to
have incomes near or below the poverty line,
live in principal cities of metropolitan areas,
or have black or Hispanic individuals or single
women with children as head of household.
Food insecurity was most prevalent in the
South (15.9 percent) and least prevalent in the
Northeast (12.8 percent). States with the highest rates of food insecurity were Mississippi
(17.4 percent), Texas (16.3 percent), Arkansas
(15.9 percent), Georgia (14.2 percent) and
New Mexico (14.1 percent).12
Efforts to improve access to nutritious
food and encourage healthier lifestyles can be
found across the U.S.
Let’s Move!, a new national campaign
spearheaded by First Lady Michelle Obama,
seeks to solve the problem of childhood
obesity within a generation. Major players are
the independent foundation Partnership for a
Healthier America and the White House Task
Force on Childhood Obesity. The campaign’s

Photo courtesy of Jamie Oliver’s Food Revolution, Chris Terry

A Food Revolution
British chef Jamie Oliver’s Food Revolution is a high-profile initiative to combat obesity
and diet-related illnesses. His six-episode Food
Revolution television program, which aired this
year, was set in Huntington, W.Va.—a city in
the unhealthiest metropolitan area in the country
based on a U.S. Centers for Disease Control and
Prevention study.
Oliver chronicled his experiences as he
tried to inspire schools, children, parents and
the community at large to make healthier dietary
He told viewers that today’s generation
of children is expected to be the first to die at a
younger age than their parents due to obesityrelated bad health. To change this trend, he said,
schools and families need to learn how to make
healthier food choices and cook healthy meals.
He demonstrated how on his show and continues
to provide guidance through recipes and cooking
videos on his website,

Banking and Community Perspectives


Pennsylvania’s Successful Model
The Pennsylvania Fresh Food Financing Initiative, the forerunner to the proposed Healthy Food Financing Initiative, provides funds to grocery operators who cannot obtain enough credit and infrastructure financing
from mainstream financial institutions.
As of March 31, 2010, The Reinvestment Fund (TRF) had leveraged $59.6 million in New Markets Tax
Credits for the initiative.1 With the support of its partners—the Greater Philadelphia Urban Affairs Coalition,
The Food Trust and the Commonwealth of Pennsylvania—this mid-Atlantic community development financial
institution (CDFI) has enabled the growth and development of more than 1.6 million square feet of retail space
for supermarkets, farmers markets, neighborhood markets, corner stores and grocery stores and helped to
create or retain over 5,000 jobs.
A 2006 study on the economic impact of Philadelphia supermarkets draws upon work commissioned by
TRF and completed by Econsult Corp., which estimates the impact new supermarkets had on the city’s neighborhood housing values. Housing units that were within a quarter to half mile of the new retailers increased
in value an average of $1,500, or 4 to 7 percent, after the store openings. This effect was larger in weaker
neighborhood housing markets.2
The stores also had measurable multiplier effects. Using data from the Bureau of Economic Analysis, the
study quantified economic multiplier effects arising from the stores’ construction activity, operating expenditures and employee earnings. For every dollar in direct expenditures and earnings paid, an additional 50 cents
(multiplier of 1.5) circulates throughout Philadelphia County in the form of indirect and induced economic
activity from increased demand for goods and services.
Building on the success of the Pennsylvania initiative, The Food Trust is convening policymakers in
Colorado, Illinois, Louisiana, New Jersey and New York to promote a similar approach to addressing local food
deserts. With a Robert Wood Johnson Foundation grant, the organization is moving into eight more states,
including Texas, where it is reaching out to public and private stakeholders to build broad support.

See “Pennsylvania Fresh Food Financing Initiative,” The Reinvestment Fund,
See “The Economic Impacts of Supermarkets on Their Surrounding Communities,” Reinvestment Brief, issue 4, The Reinvestment Fund,



Healthy Food Financing Initiative
Nutritious food is essential to good health
and the prevention of illness. Yet an estimated
23 million U.S. residents live in areas with
inadequate access to supermarkets—and 83
percent of them live in low- and moderateincome census blocks. Economically underserved neighborhoods that have little, if any,
access to fresh and healthy food are sometimes
referred to as food deserts.13
To address this problem, the Obama
administration is backing the seven-year,
$400 million-plus Healthy Food Financing Initiative, a national model of the successful Pennsylvania Fresh Food Financing Initiative. The
national initiative is the culmination of work
by California-based nonprofit PolicyLink along
with The Reinvestment Fund, a community
development financial institution (CDFI) in the


mid-Atlantic area; Philadelphia-based nonprofit
The Food Trust; the White House; and the
Congress. The Healthy Food Financing Initiative is featured in the Let’s Move! campaign.14
The initiative, which would be financed
through three U.S. government departments, is
now in the budget appropriations process. The
Treasury Department is expected to provide
$250 million in New Markets Tax Credits and
$25 million in financial and technical assistance
to Treasury-certified CDFIs. The Health and
Human Services Department estimates that it
will inject up to $20 million into its Community Economic Development program, which
awards grants to community development
corporations. The USDA plans to use $50 million in grants, loans, promotions and other programs to leverage $150 million in public and
private investments.15

Banking and Community Perspectives

The Pennsylvania initiative, a $30 million
state grant and loan program, has helped
finance 87 projects in more than half the state’s
67 counties. It has increased fresh-food access
for over 400,000 Pennsylvania residents and
had a visible economic impact in terms of
increased housing values, new jobs, new-business development and retail spending (see box,
“Pennsylvania’s Successful Model”).

Sustainable Food Center
Community gardens, farmers markets and
farm-to-cafeteria programs are some of the
many grassroots activities going on across the
country to promote health and wellness, help
the environment, support local food producers
and reduce food insecurity.
Community gardens are typically developed on city or private land, divided into plots
and self-organized and self-regulated. Local
residents rent plots to plant food or flowers. In
Austin, the Sustainable Food Center (SFC) has
an array of programs that include not only community gardens but also farmers markets, farmto-school, farm-to-work and farm-to-cafeteria
programs and cooking and nutrition classes.
The SFC’s Grow Local program provides
education and resources for Central Texans
to start and manage community and school
gardens. It teaches them how to do organic
gardening and provides lists of landscapers,
garden stores and other information. It also
helps the community share harvests with food
pantries and families in need.
Other programs are The Happy Kitchen/
La cocina alegre and Farm Direct. The Happy
Kitchen teaches parents and children how to
shop for and prepare healthy, affordable meals.
Farm Direct is a network of farmers markets
and neighborhood farm stands that sells produce grown within 150 miles of Austin. Some
of these markets are at Women, Infants, and
Children (WIC) clinics and at community centers in low- and moderate-income areas. All of
the SFC’s markets accept WIC Farmers Market
Nutrition Program vouchers and food stamps.
Farm Direct also encompasses the center’s
farm-to-cafeteria and farm-to-work programs.
For the last five years, the SFC has served as
a link between farmers and local hospitals,

Federal Reserve Bank of Dallas

Figure 1

Level of Need for Health Services by County
Through their business
activities, community health
centers generate an estimated
annual economic impact of $560


million in Texas alone.


El Paso

San Antonio

Major cities
FQHC sites


Very low
Very high

NOTES: FQHCs are Federally Qualified Health Centers. The need indicator is based on poverty levels, uninsurance rates, primary care
physician-to-population ratios and rates of minority populations.
SOURCE: Texas Association of Community Health Centers.

universities and other organizations by coordinating orders, delivery, billing and payments.
The SFC’s farm-to-work and Sprouting Healthy
Kids programs help workplaces and schools
offer locally grown fresh fruits and vegetables.
Sprouting Healthy Kids also provides classroom
and after-school nutrition education to Austin
Independent School District students, 61 percent
of whom are economically disadvantaged.16

Access to Health Care
Access to a healthy environment and nutritious food goes hand-in-hand with access to
health care in improving the well-being of individuals and communities. One major provider
of medical services to low- and moderateincome people is the network of community
health centers (CHCs).
CHCs offer primary care, dental and preventive services. Many of them also provide mental

Federal Reserve Bank of Dallas

health, substance abuse, lab, pharmaceutical
and radiological services, plus case management, translation and transportation services in
hundreds of locations nationwide. These services
are important to CHC patients because almost all
are low income and from medically underserved
communities. Some are in isolated rural communities. About half are in urban communities.
From a social and economic standpoint,
CHCs are important because they help improve
access for underserved populations, provide
culturally appropriate services, improve health
outcomes and reduce health disparities. Through
their business activities, these health centers
generate an estimated annual economic impact
of $560 million in Texas alone. This number does
not include the millions of dollars that CHCs save
taxpayers and health care providers by significantly reducing the number of emergency room
visits and avoidable hospitalizations.

Sixty-eight CHCs in Texas are Federally
Qualified Health Centers, or FQHCs. Sixtyfour of these CHCs are funded by the federal Bureau of Primary Health Care and four
are FQHC look-alikes. Look-alikes meet the
requirements for health center funding but do
not receive federal grants and are not required
to submit a Uniform Data System report to
the U.S. Department of Health and Human
Services. The American Recovery and Reinvestment Act of 2009 funded eight new community
health centers in Texas in 2009. Together, these
organizations support over 350 service delivery
sites across Texas.
Figure 1 shows Texas FQHC sites, with
colors identifying the level of need for health
services in each county. Counties along the
U.S.–Mexico border region clearly have the
highest need.
In 2008, Texas CHCs provided care to
almost 815,000 individuals, who made 2.9 million visits. Fifty-six percent of them were uninsured, and 23 percent were insured through
Medicaid. Sixty-three percent of Texas CHC
patients were at or below the federal poverty
line, and 19 percent fell between 101 percent
and 200 percent of the poverty line. CHCs see
the poorest of the poor in the state.
When asked for their ethnic/racial information, more than 62 percent of patients identified
themselves as Hispanic or Latino, about 58 percent identified themselves as white and about
12 percent said they were African-American.17
The remainder identified themselves as Asian,
Native American or more than one race.

Banking and Community Perspectives


Demand for CHCs’ services is outstripping
their ability to supply them, says Jose E. Camacho, executive director/general counsel at the
Texas Association of Community Health Centers
(see interview, page 11).
As the case studies in this report show,
building healthier communities from the
ground up is a multidimensional process.
Public and private entities are partnering in a
number of ways to increase households’ access
to healthier environments, nutritious food and
health care services.
How effective can health care reform be in
improving access to quality health care for all
households? It depends not only on the work
of health-focused organizations but the work of
entities that focus on community and economic
development, education and other disciplines.
That’s because where people live, their gender,
race or ethnicity and their socioeconomic position all affect their level of health.
Health disparities are part of the broad
and complex conversation about how to
expand quality care for all. According to Chloe
Bird, a senior sociologist at nonprofit research
firm RAND Corp., improving care in those seg-

Photo courtesy of Texas Association of Community Health Centers

ments of the population with unequal access
or poorer care will require more than “more of
the same.” It will require that constraints faced
by economically disadvantaged populations are
overcome. For more in-depth information on
health and health care in America, see the box
“Recommended Reading.”

Recommended Reading
• Q-DART: Tools for Assessing and Responding to Disparities in Health Care Quality, a RAND Health
• Active Living Research: Building the Evidence to Prevent Childhood Obesity and Support Active
• County Health Rankings: Mobilizing Action Toward Community Health, Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute,
• Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, ed. Brian D. Smedley,
Adrienne Y. Stith and Alan R. Nelson, Washington, D.C.: The National Academies Press,
• “Defining Disparities: Opportunity for Change in Fort Worth and Dallas,” Center for Community Health,
presentation by Katie Cardarelli and Marcus Martin, March 2009
• Reinventing Public Health: Policies and Practices for a Healthy Nation, ed. Lu Ann Aday, San Francisco:
Jossey-Bass, October 2005
• Gender and Health: The Effects of Constrained Choices and Social Policies, by Chloe E. Bird and Patricia
P. Rieker, New York: Cambridge University Press, 2008

For GDP data, see Figure 2, “Average Annual Growth Rates for
Nominal NHE and GDP for Selected Time Periods,” in the report
“Health Care Costs: A Primer, Key Information on Health Care Costs
and Their Impact,” The Henry J. Kaiser Family Foundation, March
2009, For earnings data,
see Figure 9, “Cumulative Changes in Health Insurance Premiums,
Inflation, and Workers’ Earnings, 1999–2008,” in the same report.
See “The Uninsured: A Primer, Key Facts about Americans
without Health Insurance,” The Henry J. Kaiser Family Foundation,
October 2009, The
data don’t include Americans who are underinsured, defined by
Kaiser as those who have health benefits that don’t adequately
cover their medical expenses.
See note 2 and “Expanding Health Coverage to the Uninsured,” The
Henry J. Kaiser Family Foundation, May 2008,
See Hidden Costs, Value Lost: Uninsurance in America, by the
Committee on the Consequences of Uninsurance, Washington,
D.C.: Institute of Medicine of the National Academies, June 2003.
See “Rising Unemployment, Medicaid and the Uninsured,” by
John Holahan and A. Bowen Garrett of the Urban Institute, The
Henry J. Kaiser Family Foundation, January 2009,
According to the Urban Institute, decreases in state general fund
revenues represent the difference between anticipated and actual
revenues, net tax changes. The unemployment rate acts as a proxy
for economic changes; a causal relationship between the unemployment rate and state general fund revenues was not established.
For details, see “Landmark Program to Reverse Childhood
Obesity Encompasses 50 Communities Nationwide,” Robert Wood
Johnson Foundation, January 2010,
product.jsp?id=53468 and
For more information on the El Paso initiative, see www.
The targeted neighborhoods are Magnolia Park, Sunnyside and
Near Northside. For neighborhood boundaries, see the city of

(Continued on back page)


Banking and Community Perspectives

Federal Reserve Bank of Dallas

Community Health Centers: Successes and Challenges
Community health centers (CHCs) played an important role during the recent economic recession as the
demand for their services grew significantly. Recently, the
Federal Reserve Bank of Dallas interviewed Jose E. Camacho, executive director/general counsel at the Texas Association of Community Health Centers, to learn more about
the challenges his constituents now face.
How has the recession affected Texas-based CHCs
and their patients?
The recession has increased demand for services.
CHCs have seen 149,000 new patients during the recession.
Fortunately, 65 centers in Texas have received $108 million
in American Recovery and Reinvestment Act funds. Part
of the money ($14.4 million) went to eight new centers,
$20 million went to fund increased demand and the rest
went to capital investments such as new equipment and
buildings for existing centers.
Who are Texas-based CHCs’ partners?
CHCs get a lot of support from municipalities, counties, hospitals, residency programs and mental health
centers. The degree of support varies by site and a community’s ability to help the underserved population.
What are Texas-based CHCs and their partners’
biggest successes in meeting the needs of their
Their biggest successes are providing care to lowincome and medically underserved populations and communities when they need these services so that patients do
not have to wait until their health problems become a crisis.
In addition, CHCs generate significant taxpayer
savings. According to a Brandeis University study, Texas
Medicaid patients who received the majority of their primary care at health centers cost the Texas Medicaid program $631 less per month than patients who received the
majority of their primary care at hospital outpatient departments or emergency rooms. Also, CHC patients’ inpatient
costs are 48 percent lower, on average, than inpatient costs
for patients who receive primary care in hospital outpatient
departments or emergency rooms.1
What are Texas-based CHCs and their partners’
biggest challenges in meeting the needs of their
Their biggest challenge is that the need for their services is outpacing their ability to supply them. CHCs currently operate on 1 percent to 2 percent margins. Roughly

Federal Reserve Bank of Dallas

one-third of their revenues comes from a federal discretionary grant program for CHCs; another third comes from
Medicaid (25 percent), Medicare (4 percent) and the Children’s Health Insurance Program and other federal funds
(3 percent); and another third comes from state and local
governments (18 percent) and patients (10 percent).2
States are facing huge fiscal deficits, so many programs that we rely on for funding at the state level are facing cuts. On the other hand, nationally centers will receive
$11 billion in new funding over the next five years from
the federal government. Centers have to compete for this
funding and no one is guaranteed funding.
A serious challenge for us is that the Texas FQHC
Incubator Program is on the chopping block. Founded in
2003, this program provides $5 million annually to help
established Federally Qualified Health Centers (FQHCs) win
federal funds to expand their services and help entities that
want to become FQHCs develop into competitive candidates.
The Texas Health and Human Services Commission
(HHSC) has proposed that the incubator program be cut in
2011; $2 million is no longer available in fiscal year 2010.
This program has been highly successful in Texas. Prior to
the incubator program, Texas centers received an average
of only 3.6 percent of the federal funding available during any cycle. After the incubator program, Texas centers
received an average of over 7 percent. As a result, FQHCs
were able to increase their total patient load by 49 percent
from Sept. 1, 2004, to Dec. 31, 2008.
This incubator program is slated to lose its funding, which would make it difficult for Texas-based CHCs
to compete with others around the country for the federal
CHC funds.
Ironically, the Texas program is being touted as a
model for other states to adopt in order to successfully
leverage the $11 billion of new federal funding.
Do the issues faced by Texas-based CHCs differ
from issues faced by CHCs in other states? If so,
Our major issue is the same as other states: meeting the growing demand while funding fails to keep pace
with demand. The degree of this problem is daunting in
Texas because of the huge number of people who do not
have insurance and lack access to care. The Texas HHSC
estimates that in our state, 6.5 million people are currently
uninsured. Even if we implement the coverage options
available under federal health reform in 2014, HHSC estimates that 2.6 million people will remain uninsured.

Currently, Texas has 16 times the number of uninsured people as Massachusetts had when it implemented
universal care. Now we’re seeing that Massachusetts does
not provide enough access to care because it lacks an adequate supply of primary care providers. There simply are
not enough providers who take new patients, Medicare or
Medicaid. Reimbursement is a very large issue.
Also, Texas has not invested in the infrastructure to
serve the poor. There’s not enough capital, health care providers or operational money for these providers. As more
people fall into poverty or stay in it, more subsidies will
be needed to support their care. So the cost of care could
spiral out of control if we do not deal with the supply of
providers and infrastructure issues.
How do you anticipate health care reform to affect
Texas-based CHCs and their patients?
A greater percentage of our patients will be insured;
however, at the same time, CHCs will serve an even larger
proportion of the uninsured in the state. We think that all
CHCs will have to be health care homes for comprehensive care so that centers can serve as one-stop shops for
people dealing with medical, dental, substance abuse and
mental problems. The reason it’s so important to provide
comprehensive care is that it helps prevent further progression of the illnesses, particularly chronic diseases
such as diabetes and asthma. This kind of care also is
important because it has an educational component that
teaches people how to get the support they need and better
manage their own health and health care.
These data are an average of 1999–2004 expenses. See
“High-Performing Community Health Centers: What It Takes in
Texas (Final Report: Phase One),” by Deborah Gurewich, Donald
S. Shepard, Karen R. Tyo and Junya Zhu, Brandeis University,
Schneider Institute for Health Policy, June 30, 2009.
All patients are charged on a sliding scale and demonstrate
need by bringing in any document that proves their income
(check stub, tax return, etc.) and residency in the CHC’s target
area. Without proof of income and residency, they are expected
to pay 100 percent of the charges.

—Elizabeth Sobel Blum

Banking and Community Perspectives


(Continued from page 10 )
Houston’s super neighborhoods webpage at www.
These are body mass index data for the 2009–10 school year
in the Grant County Healthy Kids, Healthy Communities’ areas of
focus: Cobre Consolidated School District (Mining District) and
Silver Consolidated School District (Silver City and Cliff/Gila).
For more information about food insecurity, see “Household
Food Security in the United States, 2008,” by Mark Nord, Margaret
Andrews and Steven Carlson, U.S. Department of Agriculture
Economic Research Report no. ERR-83, November 2009, www.ers.

Data for three years, 2006–08, were combined to provide more
reliable statistics at the state level. Estimated prevalence rates of
food insecurity during this period ranged from 6.9 percent in North
Dakota to 17.4 percent in Mississippi. See USDA data at www.ers.
See “Estimating Supermarket Access: Summary of TRF’s
Research and Analysis,” The Reinvestment Fund,
There are four pillars of the Let’s Move! campaign: access to affordable healthy food, physical activity, healthier schools and healthy
choices. For details, see

and “Solving the Problem of Childhood Obesity within a Generation,”
White House Task Force on Childhood Obesity Report to the President, May 2010,
The USDA has also launched the Food Environment Atlas,, which compiles data on community
characteristics, food choices and health and well-being.
See SchoolMatters,
The numbers do not add up to 100 percent due to the way the
bureau counts patients. There is a double count when patients
identify themselves as both Hispanic/Latino and white.