Q&A with Episcopal Health Foundation

By providing millions of dollars in grants, working with congregations and community partners, and providing important research, the Episcopal Health Foundation supports solutions that address the underlying causes of poor health. The foundation was established in 2013 and is based in Houston. With more than $1.2 billion in estimated assets, the Foundation operates as a supporting organization of the Episcopal Diocese of Texas and works across 57 Texas counties. 

In this interview, Emily talks to CEO and President, Elena Marks, and Chief Communications Officer, Brian Sasser, about the foundation’s goals, this legislative session, and how to shift the conversation of health care around the social determinants of health. 


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EV: Tell me a bit about Episcopal Health Foundation. How did it begin, and what are some of your greatest achievement to date?

Elena: Sure, the origin of the foundation dates back to 2013. The Episcopal Diocese of Texas was the owner of the St. Luke’s Episcopal Health System, which is a large system with a number of hospitals and other assets in the greater Houston area. And, the ownership was transferred to Catholic Health Initiatives and resulted in proceeds of $1.26 billion to the Episcopal Diocese of Texas, and leaders created the foundation to receive those proceeds. The foundation is dedicated to improving the health of the people that live in the 57 counties of the Episcopal Diocese of Texas, which covers essentially east, southeast and central Texas, with a population of almost 12 million.

EV: How do you deal with health challenges in different counties? Texas is such a large state, and these counties must vary in some fundamental ways. What are some of the largest challenges between these geographic areas that you see?

Elena: They are all different from one another, but even within a large urban area like Houston there are communities within the city that are different from one another. It is almost like if you have seen one community, you have seen one community. There are of course differences between a smaller rural town and a larger city like Houston, but when you are actually on the ground working in the community you have a small group of people, even if they are part of a larger group. We do a lot of work in rural and urban areas, but we have set up our strategic plan not to distinguish between the two. So the goals that we have are the same goals whether you are in a rural or urban area. We may act on them differently because of the people and they needs and capacities in a rural versus urban area, but the types of things that we are trying to accomplish are really the same in a rural and urban area.

EV: The uninsured rate in Texas is increasing, especially among children. What work has the foundation been doing to address this issue, and why do you think the rate of uninsured is increasing across the state?

Elena: We have been doing a lot of work on that. We have been part of a coalition that has been working to expand opportunities for more health insurance. And that covers everything from a traditional Medicaid expansion, to opportunities in the context of a Medicaid waiver, and local governments becoming more involved in solutions. We work with others, and we know that the best solution would be a typical Medicaid expansion because that would bring in the largest number of people. We also know that the Texas leadership is not ready to do that, despite the economic benefits of doing so.

EV: What bills did you keep your eye on this legislative session? Where they any that you thought would improve this high uninsured rate?

Elena: In this last legislative session, for example, there was a push to expand Medicaid for pregnant women to 12 months after delivery. The reason being that we see high rates of maternal morbidity and mortality when mothers have complications that arise with their pregnancy, not just within the current 60 days postpartum that is covered. When problems arise three months after, the women are out of coverage again and do not have health care resources to address those problems. Even that small expansion did not pass. The opportunities for a wholesale improvement in the uninsured rate in the state are also pretty grim. And, as you mentioned, the rate of uninsured children is rising, and it has risen for adults as well. In terms of children, this has to do with a policy that the state has adopted administratively, which requires that after a child has been on Medicaid for six months, the family has to file paperwork to demonstrate eligibility monthly thereafter. Data shows that these kids are getting dropped because of paperwork errors. We are seeing thousands of kids per month dropped from Medicaid who are eligible under current guidelines. A fix for this was introduced in the legislature, but that also did not pass. You couple that with the state and federal attacks on the Affordable Care Act, and we have seen that for the first time, our enrollment numbers in Texas are going down, and we have a rise in the number of adults and children in the uninsured population.

Brian: We fund enrollment groups across the state and other organizations that enroll people in various benefits, including the ACA, Medicaid, CHIP, and other programs. This year, we’ll spend $1.6 million for that. We make sure that these organizations have a process to track the people who sign up for the programs to make sure that they are actually using the benefits. This is a way of getting more Texans covered, but obviously statewide policy change will accomplish much more. We fund and work with these groups to get some of these things done, but the big changes have to come from policymakers and this has not happened.

EV: Do you think Texas is behind in policymaking when it comes to focusing on the social determinants of health?

Elena: I think Texas is behind many other states in discussing and recognizing the value of the social determinants of health, but there is a little bit of movement. I would say a session ago this was not a term even familiar to many legislators. It is still unfamiliar to some of them today, but there is some movement. While we strive to get people insured and believe it is important to get them insured so they have access to medical services, addressing the social determinants of health is our goal. Our biggest goal is to change the conversation to focus on health, and not just health care. This is where the social determinants of health come in. Almost all of our national health expenditures – 97% — are devoted to medical care. Yet, if you look at the factors that determine health outcomes — how long people live and how healthy they are — only 20% of those factors are clinical care. The other 80% are social determinants and non-medical factors. We do not have a system set up to address the root causes of these health conditions.

We have been working on how to fold the social determinants into the health financing system. If the solution to a problem lies outside of medical care, why would we not fix it? EHF spends a great deal of time working in the Medicaid space with managed care organizations to help them integrate social determinants into their system. We have a bit of a structural problem in Texas because Medicaid only allows the plans to count certain types of expenditures, typically only medical expenditures.

Recognizing the benefits of social determinants in the health care financing system is happening, but it is happening really slowly. Trends in the country typically follow whatever Medicare does, so when Medicare says that this [social determinants] is important, then the country will follow.

EV: How do you change the conversation to focus on social determinants of health? Is it data collection?

Elena: That is a piece of it. You clearly have to demonstrate that this actually works. You also have to have stories that bring this situation to life so that people understand it. We talk and we write about this topic any place that we can. We try to educate the general public that each individual has a role to play in this. Next time you are talking to somebody about health, catch yourself and think about, did you mean health care like medical services, or did you mean health? Use this as a conversation starter when you hear people using the words interchangeably. Isn’t health really the end game? Health care is just one means to an end, and that end is good health. The only way we are going to change the conversation is to get more people to recognize it.

Brian: One of the other things that we are doing is working with county governments on a research project to see if they change the way they use county funds, could those changes improve health outcomes for the county? This is not adding any money to county budgets, but looking at current spending patterns. For example, if counties shifted more money to libraries or housing development, could that actually improve health outcomes and the health ranking for that county. Researchers at Arizona State University researched counties across Texas and found that small changes in the way counties spend their money can have an impact on health outcomes. Now, we’re spearheading and funding a detailed analysis in several East Texas counties and cities, plus in Houston and Harris County. This is one way to focus on health, not just health care in a much different way.

EV: Lastly, is there anything else that you think Texans need to know? Anything else you want to tell me?

Elena: For us, it is really that we need to change the conversation to improving health, not just health care across Texas. We even use the hashtag #HealthNotJustHealthcare. We’re always looking for solutions to address the root causes of poor health that really improve health outcomes and community health, but that do not involve building more clinics and hospitals.

This Q&A has been edited for length and clarity.