Dear friends,

Here in Los Angeles, we know what it feels like when the earth shakes. But these days, health equity advocates across the country, in even the most quiescent tectonic zones, know it too.

Federal actions are hitting programs and policies that form the foundation of enabling health for all—and threatening to shake far more in the days ahead. Proposed cuts and restrictions to Medicaid funding threaten to increase the number of uninsured Americans, while parallel efforts in Congress threaten to strip critical social supports including the federal food assistance programs like SNAP.

At the time of this writing, House committee members are voting on a budget reconciliation bill, introduced late Sunday, which proposes the largest cuts to Medicaid ever, and removes some protections of the Affordable Care Act. If enacted, more than 13.7 million Americans will lose coverage, and millions more will see their monthly and out-of-pocket costs increase. (Here are ways to send a message to Congress). Along with deep proposed cuts to SNAP benefits and other social assistance programs, these actions will decrease access to affordable health care and cause a surge in unmet health-related social needs. That means more families will be forced to make tradeoffs between rent, food, utilities, and healthcare. And more Americans will experience expensive and preventable downstream illnesses and harm.

For my health equity colleagues and me, one of the biggest worries this raises is about the sustainability of critical social services, healthcare, and public health services—and the institutions that deliver and bring these services together. Already, many CBOs that we work with face existential threats and the possibility of shuttering. Our healthcare-system partners are grappling with the pressure to reduce services, while public health departments are having to choose which work to preserve. The economic uncertainty and scarcity that results from proposed cuts will be felt not only by people and communities, but by healthcare institutions, community organizations, and public health agencies alike.

The crisis demands a response from all of us across these sectors. And one of the most powerful levers we hold is collaboration.

At its simplest, collaboration means weaving together health and social care and bridging healthcare and public health. Yet doing so effectively always—and especially now—requires deep and deliberate connections between cross-sector partners. Six years ago, we introduced a six-level framework for healthcare, social sector, and public health partners to improve HRSN/SDOH collaboration that begins with coordination and moves through increasing levels of collaboration and integration. We’re working with health systems to apply and update this tool because, with the foundations of health for all shaking, we need our institutions to invest in collaboration now more than ever.

Why collaboration? Because when widespread policy threats to health equity put many institutions at economic risk, the best response is to share risks and resources rather than go it alone. Collaboration across health care, social services, and public health agencies includes shared risk assessment and shared response. It means pooling and braiding resources. Transferring capabilities and sharing tools from better resourced to under-resourced institutions, and strengthening collaborative approaches to governance, community engagement, and data sharing.

Healthcare institutions, as anchors in their communities, can and should lean into their ability to help build the structures for this collaboration. Local health jurisdictions, Medicaid managed care plans, and philanthropies—anyone who has the responsibility to steward resources and marshal them for community support—have a critical role to play in accelerating collaboration. The early multi-sector collaboratives that have grown in recent years, such as accountable communities for health models, have laid down the infrastructure that we have to leverage now. Like social capital for individuals, it is the quality, density, and strength of institutional relationships that will help us all feel less isolated and more hopeful.

With the proposed cuts to Medicaid and vital social assistance programs looming and with this renewed interest in collaborative efforts will come the need for better ways

• to accelerate collaboration (stay tuned for our updated framework for HRSN/SDOH integration),

• to bridge healthcare and public health,

• to mobilize in defense of institutional integrity (see the Health Equity Mobilization Network), and

• To capture and communicate the real value of collaboration, which affects far more than the bottom line. Effective health and social sector collaboration and integration fuels a range of critical financial, economic, and social outcomes, and these impacts are measurable and valuable. (Our upcoming May 22 webinar on Blended Value will help show the way to do that.)

Together is how we work best on any territory, and the only way we stand and protect our institutions and our communities when we’re on shaky ground.

Best,

Rishi Manchanda, MD, MPH.