Proceedings of a Workshop—in Brief

Economic Systems as a Structural Driver of Population Health Through the Lens of Partnerships

Proceedings of a Workshop—in Brief

WELCOME

On September 27, 2024, the Roundtable on Population Health Improvement hosted part three of the workshop series on Elevating the Structural Drivers of Population Health, focusing on economic systems. Roundtable cochair Ana Diez Roux of Drexel University noted that the series began in March 2024 and featured presentations on how economic systems affect health and well-being.¹ A June 2024 event² focused on narrative shift and culture change pertaining to economic systems and the implications for health and well-being. The September installment focused on different approaches to partnerships, highlighting three related concepts across three panels: solidarity, value, and movements. Diez Roux explained that solidarity refers to common ground for partnerships working toward an economy that benefits everyone but particularly effects the most vulnerable groups. The concept of value is about building prosperity in ways that are more inclusive and equitable and that promote the well-being of all communities. Finally, Diez Roux added that the panel on movements would discuss how to mobilize, build the necessary infrastructure, and drive the kind of systemic change needed for a well-being economy.

OPENING TALK

Victor Roy, assistant professor of family medicine and community health at the University of Pennsylvania and director of the Health and Political Economy Project (HPEP)³ at The New School, discussed the systemic discrimination faced by patients at a community health center in Dorchester, Massachusetts, during the pandemic. He emphasized that the most common underlying condition in his patients was not diabetes or hypertension but the effects of unjust economic systems. He presented vignettes of various patients whose stories underscored the broader link between economic insecurity and health deterioration:

• An older Black woman whose diabetes worsened due to the inability to afford refrigerator repairs for storing the insulin
• A single mother whose housing became unaffordable in the third trimester of pregnancy
• A young immigrant from Bangladesh who developed an ulcer from the stress of supporting his family on his low-wage job

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Roy referenced a study that compared U.S. mortality rates with those of other wealthy nations; the United States experienced a high proportion of excess deaths—citing more than 600,000 excess deaths per year before the pandemic and more than one million in both 2020 and 2021. Roy noted that the study pointed to economic policies and economic precarity in American society as reasons for this avoidable mortality.⁴

Roy argued for moving beyond strategies that mitigate the health harms caused by economic inequities and instead focusing on creating economic systems that nurture health equity. He said this involves transitioning from “harm-mitigation partnerships” to “power-building partnerships” that foster a more just economy capable of producing health equity. He shared as an example of harm-mitigation partnerships; his patients were routinely screened for risks such as homelessness or difficulty affording medications. When patients screened positive for these economic insecurities, community health workers were recruited to help, but Roy pointed out that community health worker–facilitated intervention was often “delayed, insufficient, or even nonexistent,” reflecting a gap between identifying needs and providing effective support.

Roy introduced the concept of “downstream drift,” which highlights the tendency to justify health interventions based on structural barriers to health (often called “upstream” factors) but in practice to focus on individual actions (or “downstream” factors). This, he argued, treats economic insecurities as personal traits rather than societal problems and overlooks the structural changes needed to address these issues systemically. Roy shifted the conversation to partnerships and multisector collaborations focused on “upstream” changes, citing examples of health systems investing in housing solutions by leasing or building units. He asked why health systems can make these investments while local governments often struggle to do so. Roy referenced a 2020 JAMA article⁵ that argued the market power of health systems enables them to charge high prices, effectively transferring resources from households and governments. This dynamic, he suggested, exacerbates financial insecurity for households and limits the capacity of governments to address housing needs. He quoted Seth Berkowitz of the University of North Carolina, who noted that multisector collaborations often respect existing hierarchies of power, which can perpetuate the same inequities they aim to resolve. To form partnerships aimed at transforming economic systems, Roy said it is important to confront these challenges and work to shift existing power dynamics.

Roy described HPEP as a catalyst for building a more inclusive and just economy that promotes health equity. This vision, he said, aims to reorient the political economy toward a “solidarity economy,” that empowers individuals and communities.

Roy outlined three interconnected areas of focus for HPEP:

1. Capital: reorienting public and private finance toward long-term investments in health.
2. Care: developing caregiving systems that invest in people’s capabilities to maintain health throughout their lives.
3. Culture: shifting societal narratives to better link health and the economy.

Roy advocated for partnerships that can offer alternatives to the concentration of corporate power in the economy, giving the example of California’s public manufacturing strategy for insulin, which aims to increase affordable access for millions. This example, he explained, demonstrates how public initiatives can address economic and health concerns. He stressed the importance of partnerships between civil society organizations, academic researchers, and policymakers to shed light on exploitative practices and build momentum for change. Such partnerships can challenge the existing corporate shareholder-maximizing model by asking critical questions about how public capacity—both governmental and community—can be strengthened to shape the economy toward health, he added. Roy outlined three potential focus areas for building such partnerships: (1) people-

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powered ownership and control over resources, (2) enhancing the capacity of public institutions and communities to address systemic inequities, and (3) preventing health harms from the economy in the first place. Roy closed with a thought experiment, asking what kind of economic systems and partnerships could eliminate the need to screen for economic insecurities in health care. He encouraged the audience to think about how to create an economy where these insecurities no longer exist, where health and equity are not just byproducts but are foundational elements.

During a discussion session, a participant from the University at Buffalo raised the question of how to challenge the health care business model. In response, Roy emphasized that health care constitutes 20 percent of the U.S. gross domestic product⁶ and serves as a microcosm of larger economic patterns. He argued that there is a need to redirect how health care intersects with care delivery systems and economic thinking. Roy pointed out that health care has become “financialized,” meaning it increasingly functions under profit-driven models, but he also noted that health care is only one part of a broader conversation about economic systems.

Vinu Ilakkuvan with PoP Health expanded on this idea by highlighting the role of pharmaceutical companies and shareholder-driven motivations in the health care system. Ilakkuvan agreed that health care reflects the broader economic system, in which corporations and for-profit interests play a dominant role. Tackling this issue, said Roy, requires addressing the concentration of corporate power in health care. He suggested turning to the antimonopoly movement to build alternatives to the current power structures. Rather than opposing the existing concentration of economic power, he added, the focus should be on creating inclusive practices and systems that foster equity and health.

SOLIDARITY: EMBRACING A PARADIGM OF MUTUAL COOPERATION, AND COLLECTIVE NARRATIVE AND ACTION

Tiffany Manuel, executive director and CEO of TheCaseMade, moderated a panel on solidarity, focused on moving beyond narrative exploration to building solidarity to address population health equity and well-being. Manuel emphasized the need for action toward a well-being economy that delivers equity. She framed the discussion as addressing how to “build power together,” with the aim of reshaping societal structures for a more equitable economy that improves health outcomes.

Chris Benner, professor at University of California, Santa Cruz, highlighted the structural inequities laid bare by the COVID-19 pandemic, specifically as seen in racial disparities and economic vulnerabilities. He began by sharing alarming statistics: in the third quarter of 2024, 46 percent of Americans could not access $400 in an emergency,⁷ and by age 60, 80 percent of Americans will have experienced at least one full year of poverty or joblessness.⁸

He noted the paradox of the wealthiest economy in history linking health insurance to employment, resulting in millions losing health coverage during the pandemic due to job loss. Benner stressed the need to center racial equity and antiracism in the conversation about economic reform, given that current economic structures are rooted in historical injustices like land theft and slavery, which continue to influence today’s inequities.

Benner introduced the concept of solidarity economics,⁹ which he described as an approach grounded in collective instincts for connection and community. He outlined three key principles for building a new economic narrative. First, economies are human-made and infused with values and power relations. Benner emphasized that economies are created by people and shaped by societal values and power structures. Second is building trust and mutuality. He highlighted research that links greater diversity, equity, and inclusion within organizations boosts economic performance. He noted that companies prioritizing inclusive hiring practices and equitable workplace cultures drive innovation and productivity, benefitting the broader economy.

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Benner’s third point was about movements. Benner argued that the economy is structured the way it is because powerful individuals and entities drive it in that direction. He urged investing in movements that can change the economy through mutuality and solidarity, highlighting the roles of “weavers” (those who build bridges across sectors) and “warriors” (those who engage in protests and activism). He concluded that building a solidarity economy can address social determinants of health and prevent economic and health crises more effectively and cost-efficiently than current reactive systems.

Benner emphasized the need for large-scale economic investments in care sectors, such as elderly care and childcare. He called for challenging traditional notions of skilled labor, particularly for roles in fields like early childhood education. Additionally, he highlighted the economic benefits of addressing social determinants of health, underscoring the need for prevention rather than merely treating illness. He pointed out that the United States spends more on health care but achieves worse health outcomes than other advanced nations, largely due to a lack of investment in public health infrastructure and affordable housing, which he described as a drag on the economy.

Chris Krehmeyer, president and CEO of Beyond Housing and the Once and For All initiative, reiterated the need to view the economy as “our economy” rather than an abstract entity that functions independently of people’s choices and values. He described the work of Beyond Housing,¹⁰ an organization in Saint Louis that partners with housing, education, health, employment, and government sectors to foster thriving families and communities.

Krehmeyer outlined the Ask, Align, and Act framework, which guides Beyond Housing’s actions. Ask refers to seeking community input to identify priorities. Align refers to bringing together resources—financial, organizational, and individual—based on those priorities. Act refers to implementing community-driven solutions to foster lasting, systemic change.

He emphasized the importance of not merely engaging with communities in terms of dialogue but delivering tangible resources that drive real change. Community members, he said, are often weary of hearing promises without seeing action. Beyond Housing works closely with community members—homeowners, business owners, and residents—to address their needs, providing both crisis intervention and support aimed at helping individuals and families achieve long-term goals and aspirations. Their staff, including community health workers, housing resource coordinators, and family engagement liaisons, are embedded in local public schools to address issues like food insecurity.

Krehmeyer then described the Once and For All initiative,¹¹ which seeks to address the root causes of Saint Louis’s long-standing challenges, including failing schools, high crime rates, and slow economic growth. He highlighted that everything in communities is interrelated and interconnected, underscoring the need for comprehensive and coordinated action. Additionally, he gave the example of providing low-cost recreational activities, such as affordable movie tickets at a newly opened community movie theater, which fosters a sense of community.¹² The movie theater, Krehmeyer said, hires local high school students and enrolls them in a match-savings program where every dollar saved is matched by the employer for postsecondary education. He concluded by asking, “Can we invest differently? Can we expect different outcomes?” suggesting that with the courage to shift investments, entrenched economic and social outcomes can change.

Manuel asked the panelists how individual and community-level change could be scaled to structural and systemic transformation, noting that COVID-19 demonstrated the possibility of making structural changes during crisis. Krehmeyer emphasized that efforts should be transformational, not just transactional. Benner referenced Elizabeth Berman’s Thinking Like an Economist (2022) to illustrate how federal investment can shift over time, requiring a multidecade effort. Krehmeyer highlighted the importance of framing conversations differ-

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ently and using language focused on “equity of opportunity” to achieve better outcomes.

Manuel pointed out that racial and economic segregation has been intentional and referenced Columbia, Maryland, as a successful example of integrated community design. Benner cited Jonathan Metzl’s Dying of Whiteness (2019) to explain how constructs like racism hurt everyone and advocated for investing in communities of color, as they represent the future workforce, particularly with the demographic shift projected to occur by 2043.

Krehmeyer emphasized addressing immediate needs before broader community engagement, while Deon Auzenne from Howard University highlighted successful models like Krehmeyer’s Beyond Housing and asked how effective approaches can be more widely disseminated to the public to drive systemic change. Manuel acknowledged the difficulty of bringing uplifting stories into mainstream media, which often focuses on negative narratives. Krehmeyer stressed the need for a stronger hook to capture public attention, citing the Once and For All initiative as a successful local narrative.

Henry-Louis Taylor from the University at Buffalo emphasized integrating storytelling into movements, while Benner mentioned organizations like the Center for Story-Based Strategy¹³ that provides resources for narrative-building. Anthony Iton from the University of California, Berkeley, discussed why successful models are not scaled, identifying the “extractors”—individuals or entities focused on short-term gains rather than systemic change. He explained that these extractors benefit from maintaining the status quo and resist efforts to scale models that challenge existing power structures. Benner called for making these power dynamics visible and highlighted a real-life example of a solidarity dividend in the Alaska Permanent Fund.¹⁴

VALUES: CHANGING CONCEPTS OF VALUE, CREATION, OWNERSHIP

Moderator David Erickson, senior vice president at the Federal Reserve Bank of New York, led a discussion with panelists Amanda Janoo of the Wellbeing Economy Alliance and Henry-Louis Taylor. Erickson opened by emphasizing the Federal Reserve’s role in supervising bank reinvestments, which allocate approximately $500 billion annually to low-income communities. He introduced the concept of a “virtuous cycle,” exemplified by BlocPower,¹⁵ a business model focused on decarbonizing buildings through solar utilities in Brooklyn, New York. This model, led by CEO Donnel Baird, had decreased asthma-related emergency department visits, lowered rent for residents, and fostered economic value by creating middle class jobs through local hiring. Erickson highlighted that government funding for such community-focused initiatives often remains underutilized, explaining that this is partly due to a lack of awareness about the existence of these resources and, in other cases, a lack of knowledge or capacity to navigate complex application processes. He suggested there is significant potential for more effective application of these funds if these barriers are addressed. He defined “impact investors” as individuals or entities seeking social or environmental returns on investments, pointing to the Global Impact Investing Network¹⁶ as a key player. Additionally, he referenced the Inflation Reduction Act,¹⁷ bipartisan infrastructure law,¹⁸ and antipoverty programs as supportive frameworks for such initiatives. Erickson further discussed the high health care expenditures in the United States—totaling 4.8 trillion dollars annually, with 90 percent directed toward preventable chronic diseases and mental health conditions,¹⁹ which are closely linked to poverty. He also described the Federal Reserve Bank of New York’s Making Missing Markets initiative,²⁰ which aims to address gaps in community investment.

Janoo discussed the distinction between “value” and “values,” highlighting that the current economic system often prioritizes financial “value” over societal “values.” She explained that activities rooted in compassion, generosity, and stewardship—those that support

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the well-being and cohesion of society—are typically undervalued or uncompensated in the current economic system. In contrast, she added, industries that may prioritize profit over people or environmental sustainability tend to generate significant wealth. This imbalance, Janoo argued, reflects a misalignment in what society deems valuable financially versus what is truly valuable for collective well-being.

Janoo cited that 68 percent of Americans believe the economy should prioritize the health and well-being of people and nature over profit.²¹ She said this viewpoint aligns with the “well-being economy” movement, which integrates solidarity, regenerative, and postgrowth principles. Janoo described the economy as “the way we produce and provide for one another,” advocating for a paradigm shift from economic growth-centric metrics to those that can help us assess the economy’s contribution to people’s and planet’s health and well-being.

Janoo highlighted several U.S. states organizing toward solidarity-based economies, with initiatives like Hawai‘i’s ‘Āina Aloha Economic Futures,²² which works toward COVID-19 recovery grounded in Indigenous values. This framework emphasizes abundance, community well-being, and regeneration, a perspective increasingly integrated into government and private-sector strategies. Vermont’s Prosperity Project,²³ another example she mentioned, focuses on social and environmental progress through sustainable business practices. Janoo also described Wales’s Well-Being of Future Generations Act²⁴ as a framework that promotes preventative, long-term governance mechanisms. She spoke of the need to strengthen strategies (nonmonetary, community-based activities) that enhance social connection and underscored the mutual relationship between economy and democracy. Janoo emphasized that participatory, deliberative decision making in economic matters is essential for building equitable systems and for countering authoritarian trends, which often thrive in environments with centralized power and limited public engagement.

To conclude, Janoo shared a vision for an economy that ensures dignity, purpose, and a just distribution of wealth, power, and time. Responding to Erickson’s request for a concrete example of a business that embodies these ideas, she mentioned Patagonia, a B Corporation, which directs its profits toward environmental sustainability. This example demonstrates that the economy includes a broad range of entities, beyond financial institutions, encompassing nonprofits, governments, communities, and even nonmonetary interactions.

Taylor shared his insights on neighborhood-level transformations as a critical pathway to abolishing health inequities between Black and White communities in metropolitan Buffalo, New York. He discussed the establishment of the African American Health Equity Task Force,²⁵ which began by investigating the root causes of adverse health outcomes in underdeveloped Black neighborhoods. Their research found that these outcomes were closely linked to neighborhood social determinants (e.g., rent exploitation, joblessness) and that 80 percent of health issues stem from these conditions, not health care quality or access alone.

Taylor argued that improving health outcomes requires transforming Black neighborhoods into thriving communities. He traced the underdevelopment of these neighborhoods to weak labor market connections, insufficient governmental enforcement of equitable resource distribution, a predatory economic system, and a racialized residential structure that devalues Black communities while prioritizing affluent White neighborhoods. Taylor explained that addressing these issues required a dual focus on health care and neighborhood transformation, as well as rethinking how business investments can create social value alongside profits.

Taylor said a significant finding was the problem of wealth extraction from Buffalo’s underdeveloped neighborhoods. In response to that problem, Taylor explained, the task force focused on developing organizations capable of addressing these systemic issues, identifying four essential types: an advocacy organization for policy translation, a university-based research institute for health and environmental studies, a countywide office of

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health equity to coordinate policy, and a neighborhood planning and development unit for community transformation. Over the past decade, he said, three of these institutions have been established, with ongoing efforts to secure funding for a center dedicated to leading neighborhood transformations.

Taylor encouraged local businesses and corporations to adopt shared-value business models, aligning profit generation with the needs of Black communities to foster social benefits. He underscored the importance of partnerships with universities, businesses, and communities to collaboratively address community needs while creating economic opportunities. Taylor concluded by highlighting the three core components in Buffalo’s model: neighborhood transformation, decentralized health care services, and a neighborhood solidarity economy grounded in shared value and social enterprise, all aimed at improving health outcomes through comprehensive neighborhood reform.

In response to Taylor’s remarks, Janoo highlighted that housing issues extend beyond supply, underscoring the need for neighborhood governance and critiquing the commodification of shelter. She advocated for multistakeholder partnerships and academic support to address root causes rather than treating symptoms. Taylor shared the importance of training health equity researchers and noted that the University at Buffalo is a recipient of National Institute of Minority Health and Health Disparities Centers of Excellence Program grants. He asserted that the U.S. homeownership model fosters wealth disparities through structural devaluation and mentioned efforts toward legislative solutions like rent control and community land trusts.

Mary Pittman, roundtable cochair and emerita president and CEO of Public Health Institute, asked about limiting housing price increases to preserve affordability. Krehmeyer responded that discussions focused on methods like land trusts and rent control to stabilize housing stock and to prevent gentrification. Megan Greig from the National League of Cities highlighted the need for organizational flexibility to adapt to ongoing change. Janoo explained that housing trusts could serve as adaptable frameworks and emphasized that time—often overshadowed by productivity demands, especially during the COVID-19 pandemic—is crucial for people to adjust to change.

Manuel raised the concept of decommodification, asking whether certain essentials (health care, housing, education) could be removed from market-driven approaches. Taylor emphasized that achieving this shift would require cultural change, with a focus on valuing human life as a foundation for redefining what society commodifies. Janoo referenced historical movements that successfully decommodified elements like education and voting, emphasizing the potential for systemic change through movement and power building. Research shows that nonviolent movements can achieve transformative change when at least 3.5 percent of the population is engaged.²⁶ Pittman asked Erickson if establishing virtuous cycles is central to the Making Missing Markets initiative, and Erickson provided an example emphasizing the impact of early life interventions to support children, boost productivity, and improve outcomes. He also called for redirecting funding for social welfare upstream to create systemic change.

In closing, several panelists expressed optimism about how message shifting and movement building could help drive meaningful change in the United States.

BUILDING MOVEMENTS AND POWER

Tyler Norris, visiting scholar at the Federal Reserve Bank of New York, moderated the third panel, which focused on movement building and how it applies to improving population health. Norris reminded the audience of the earlier discussions on the importance of continued learning, shifting narratives about the connections between health and the economy, investing in social determinants of health, and building population-level partnerships. However, Norris stated that these efforts alone have been insufficient to drive a population level impact and that something different is needed. He shared that his mentor Maureen Bisognano at the Institute for Health Care Improvement once said to him: “When you know that what you’re doing doesn’t work, it is unethical to continue doing it and pretend that it will.” He said that throughout his career and when chief executive officer

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of Well-Being Trust, he has examined the qualities of successful movements and found that “distributive leadership,” where people “lead from where they stand,” is an important aspect and equally as important as “collective leadership,” which requires an effort by everyone to move forward. He noted research on other qualities that create a successful movement ecosystem, including policy and advocacy, courageous philanthropy, evidence demonstrating progress, and strong communication and messaging.²⁷ Norris highlighted that the United States is moving backward regarding health and well-being and said the solution requires policy, practice, structural changes, and new investments occurring simultaneously to create enough momentum for population-level outcomes.

Norris introduced the first panelist, Phela Townsend, strategic advisory consultant at Innoshift Solutions and doctoral candidate at Rutgers School of Management and Labor Relations. Townsend stated that her career has been focused on employment and labor relations with an overall theme of building worker voice and power. She asserted that the opinions and views of people in positions of power get adopted as prevailing norms, and those people determine which research or policies advance. Interventions to change these patterns require shifting power, Townsend said. She added that to create a society that is more just and equitable requires shifting power to groups that are most marginalized and shifting resources to make that possible.

The second panelist, Ra Criscitiello, deputy director of research at Service Employees International Union (SEIU) United Healthcare Workers West, a labor union of approximately 110,000 allied health care workers across California, spoke next about their work. Criscitiello noted that allied health care workers are those with technical and professional classifications such as radiological techs, and vocational nurses, as well as low-wage workers including janitorial and food service staff. They explained that their movement-building work is at the intersection of organized labor and solidarity economy work and expressed appreciation for this opportunity to focus on the partnership-building aspect, which is often in contrast to the day-to-day adversarial nature of labor unions. As an example of interconnectedness of movements, Criscitiello shared their work in bargaining to create funds that affect many aspects of workers’ lives, including a recent innovation that involves bargaining for non-unionized workers for access to similar types of funds. SEIU United Healthcare Workers West bargained with Kaiser Permanente to create a fund to give nonunion workers free education and health care training to help them achieve the credentials (qualifications and certifications) required for health care professionals, they noted. Another example of movement organizing that Criscitiello shared was working with education and training partners to provide payment for health care training clinical hours to give more people the ability to enter these professions. Additionally, in the policy and legislation area, they said SEIU United Healthcare Workers is collaborating with organizations outside California to support ballot initiatives, including Medicaid expansion, paid family leave, minimum wage, medical debt and collections reform, and abortion access. Finally, Criscitiello shared the example of creating worker-owned health care staffing cooperatives.

Norris then introduced Anthony Iton, lecturer and impact fellow at University of California, Berkeley, who began by reflecting on how he came to understand the important role of power during his career. Iton shared how when he was attending medical school, he had the opportunity to work on Capitol Hill with the Labor and Human Resources Health Subcommittee and quickly learned the difference between policy, or “very good ideas,” and politics, which he described as “power”: “Policy was necessary but insufficient, and you needed power to make change.” Iton said that in law school he worked on an HIV project at the Berkeley Community Law Center, and one of his responsibilities was to represent individuals with HIV in court proceedings. He explained that while there, he witnessed hundreds of cases involving patients who were “essentially driven into bankruptcy” by the government-owned county hospital where they had received care. Iton said this experience showed him that the U.S. health care system was “not just extractive, but it was in fact predatory.” Discussing his experience as the director of the Alameda County Public Health

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Department, Iton stated that comprehensive studies on life expectancy showed a large discrepancy (up to 22 years) between neighborhoods. This, he continued, led him to realize that political intervention was needed to disrupt this pattern. Iton said that the health department hired community organizers to build power in communities that were disproportionately affected by health inequities.

Community organizing was also a theme of Iton’s work at the California Endowment, where, he shared, he worked on the largest place-based health improvement initiative in the country, with the goal of disrupting drivers of health inequity in 14 communities across California by targeting social determinants of health. Through this initiative, approximately half a billion dollars were spent on community organizing over a period of 12 years, Iton stated. He also said that movements are, in a way, about “creating a political crisis,” to disrupt the status quo and create a situation where decision makers must act to develop an “equitable distribution of health protective resources.” The California Endowment, Iton added, was involved in Health for All, a movement driven by undocumented young Californians that resulted in health insurance coverage for approximately five million more people in California. Additionally, the foundation was involved in the Schools Not Prisons movement and the Parks for All movement, the latter of which brought billions of dollars to enhance and improve parks in the lowest-income communities in the United States. Iton closed by emphasizing that to create meaningful and lasting change, an important step is building movements that are invested in democracy.

Norris homed in on the theme of power building and invited Townsend to share more about her experience mobilizing power. Townsend said that throughout her career, she has interacted with various levers of power, including corporate power, legislative power, policy work, academic research, and movements. However, she shared that movements have been the primary mobilizing factor that causes shift or change. She spoke about her research in Black worker centers²⁸ and how the organizational structure that people choose to build is a function of power and “how they’re positioned in our racialized class society.” Many workers of color and immigrants were excluded from labor laws throughout history, Townsend continued, emphasizing that these practices, many of which are tied to slavery, have shaped organizing and the employment landscape in the United States. To understand movements, she said, including both how they are created and how to sustain them, requires understanding how the workers that make up the movement are structured in the broader society and the extent to which they do or do not hold power. Although unions are critically important to building worker power, Townsend explained that many workers (including those in Black worker centers) are not in unions for a variety of reasons. She said her research has aimed to explore these reasons and has found that community ecosystems are unique and require different community actors to advance movements, including policy makers, advocacy organizations, unions, and researchers.

Norris asked Criscitiello to elaborate on the infrastructure and conditions that allow for power building. Criscitiello shared that openness, risk taking, yielding of power by those who have it, and narratives and storytelling are some conditions that increase the likelihood that a movement will have impact and create change. They also highlighted two approaches of movement building—working within the systems and structures that currently exist and aiming to change them in a meaningful way or creating something entirely new—and said that having clarity on which approach to take is a condition for success.

Before opening the discussion to audience questions, Norris invited Iton to share his perspective on power building and what he sees as the distinction between incremental versus more transformative change. Iton first mentioned the important role that institutions can play in investing in infrastructure to support movements and highlighted the example of the Schools Not Prisons campaign, which garnered support and resources from the U.S. Department of Education and the University of California, Los Angeles. Additionally, at the California Endowment, he was involved in a $100 million investment into a movement infrastructure center that brought

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together movement organizations throughout California to share ideas and strategies. Regarding the question about incremental versus transformative change, Iton said, it “is in the eye of the beholder” and about taking advantage of opportunities as they arise. Townsend spoke about the conditions for power building, including crisis or a sense of urgency; a political opportunity where an opening is created; mass building of the movement, including people with the skills needed for it to be successful; and a way to funnel resources toward the problem. She agreed with Iton that the distinction between incremental and transformative change is “in the eye of the beholder” and that the tension between the two depends on how close one is to the problem.

Amanda Janoo asked Norris and Iton about their thoughts on the speculation that economic system movements are underfunded due to fear that they pose a threat to wealth holders and their ability to maintain endowments. Iton shared his opinion that foundations’ spending philosophy is a contributor to the problem and said that although foundations are required to spend a minimum of five percent of their assets every year, most spend no more than that.

Janoo also asked Townsend and Criscitiello whether they have seen the labor movement confront the “extractive function” of the financial industry. Townsend said yes and provided the example of Jobs with Justice as an organization that has recognized the role of financialization in systemic issues and confronted the problem by examining the connections at play (i.e. money flowing through financial systems can be owned and governed by several companies). Criscitiello agreed, saying that unions are conducting activism related to executive compensation and cooperatives are endeavoring to create their own banking systems.

Lucy Marcil, a pediatrician and health policy fellow working in Congress through the Robert Wood Johnson Foundation Health Policy Fellows program, asked whether health care providers’ building movements to address upstream drivers of poor health is an effective approach, considering the extractive nature of the health care system. Iton responded that he thinks physicians should be on the front lines of health care institution changes, especially because many enter the field with a desire to improve people’s health and well-being. He said, “It’s incumbent upon physicians to hold those institutions accountable from within.” Townsend concurred.

Manuel asserted that movement building seems to take place “on the backs of folks who are already working two and three jobs and have very little resources to share.” Manuel asked if there are examples of people with power who are organizing to dismantle the system so that the marginalized are not further burdened in the process of fighting for change. Iton said the answer is to make use of “targeted universalism,”²⁹ or describing the problem in a way that speaks to those not directly affected by it, inspiring them to engage in the movement for change. Townsend said that Manuel had identified the core challenge of this work, that change must be driven by those in the worst position to do it. She agreed with Iton that there are opportunities to bring a larger group of people into the movement.

To close the session, Norris quoted Frederick Douglass:

Power concedes nothing without a demand. It never did, it never will. Find out just what any people will quietly submit to, and you have found out the exact measure of injustice and wrong, which will be imposed upon them. And these will continue until they are resisted either with words or blows or with both. For the limits of tyrants are prescribed by the endurance of those whom they oppress.³⁰

CLOSING DISCUSSION

Pittman moderated the closing dialogue with Mara Heneghan, associate director of the Health and Political Economy Project at The New School’s Institute on Race, Power and Political Economy. Heneghan also served as policy director in Cook County, Illinois, during the height of the COVID-19 pandemic, which Pittman noted was an opportunity for altering social and economic structures.

Heneghan began by highlighting her work on the Health and Political Economy Project and reminded the audience that HPEP explores the “iterative dynamic between our economy, our politics, and our identity stratification.”

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She spoke about her experience creating and implementing policy agendas as both the director of policy in Cook County, Illinois, and as the first deputy of policy for the City of Chicago. As she has worked at the intersection of typically siloed domains, such as health and housing or sustainability and infrastructure, Heneghan shared that she has been particularly eager to work on “economic policies through a local government lens.” She provided examples of these initiatives, saying that all have had “profound health impacts”: a guaranteed income program, a publicly funded program to buy and cancel medical debt in Cook County, and paid time off legislation in Chicago. Additionally, Heneghan said she has done research on the European Union regarding housing and financial legislation, the right to housing, and tenant organizing and is currently conducting mutual aid organizing on food distribution in Chicago. She emphasized how her worldview was profoundly shaped by her experience working in Cook County during the pandemic and seeing how health and economic inequities “magnify each other, especially in moments of crisis.” Heneghan encouraged the audience to think more deeply about the role of government in partnerships and how to engage others, especially public health departments, in the conversation.

Pittman asked Heneghan if she could elaborate on the local policymaking aspect of her work and how to develop partnerships in which the community trusts government—a significant challenge during the COVID-19 pandemic. Heneghan said this issue is about both increasing trust in government and using organizations that already have the trust of communities to advise governments. The latter is a way to help ensure that the messenger of information is one that communities will trust and listen to, she continued, saying that this strategy was used during vaccine rollout campaigns and involved identifying communities’ primary sources of information. Pittman also mentioned the “COVID cliff,” where a large amount of funding was directed toward many organizations and then stopped, and asked Heneghan if she has any lessons regarding how to maintain a sense of readiness for the next crisis. Heneghan acknowledged that “not forgetting” is challenging because “there’s such a desire to move beyond this horrible hard thing” on both a collective and individual level. She continued, “If individually we are all trying to frankly block out some of what we experienced, then how do we expect our organizations and our movements” to behave differently? Documenting the policy innovations is important, Heneghan said, as is continuing to talk about what was possible during that time and moving forward, making sure that resources are deployed effectively to meet the scope of the problem. In response to Pittman’s question about the funding that organizations received, Heneghan said that the money that was allocated to local and state governments through the American Rescue Plan Act must be allocated by the end of 2024 and spent by the end of 2025, and therefore there will probably be another “COVID funding cliff.” It is important to prepare for that now and to highlight success stories around what that funding accomplished, she continued.

Pittman also asked Heneghan if she is engaged in any national efforts focused on building a movement to address the funding issue. Heneghan said that during Cook County’s work to alleviate families’ medical debt, a contributing factor to its success was to use these onetime funds strategically to have a meaningful effect on people. Using time-limited resources often will not be able to make structural changes, she continued, but that does not mean initiatives cannot create individual or community-level change. Heneghan shared that other local governments have followed suit, including Toledo, Ohio. Finally, Pittman asked Heneghan to reflect on one practical step she heard during the workshop that can be used to create a health and well-being economy. Multisector partnerships, Heneghan said, require multisector funding, and it is important to recognize that partners are currently competing for resources and instead develop ways to address this issue as well as create new funding streams and metrics to measure success.

As the discussion transitioned to audience questions, Madeline Tatum, a fellow at the National League of Cities, asked Heneghan to elaborate on the stakeholders involved in the medical debt relief she spoke about. Tatum said she had worked at the Indiana Department of Health and can imagine the challenges with successfully implementing such a program. Heneghan said that the health and hospital system, department of public health, the Cook County board president, state hospital associa-

tions, board of commissioners, communities, and people across government, including elected and civil servant positions, all served as partners and recognized the benefits that debt relief would have. However, she acknowledged that it was unlikely these partnerships and conversations would have occurred if not for being in a moment of opportunity and given the federal resources that were available. Pittman followed up by asking whether there are any publications that document these success stories, and Heneghan responded that several ongoing case studies are examining the use of the American Rescue Plan Act funds and that those findings will hopefully be helpful moving forward.

Pittman reflected on the day, saying, “We’ve had really tremendous presentations and discussions about the theory, about the research, and about the practice that’s creating a new paradigm for mutual collaboration, cooperation, and creating a collective narrative.” She also acknowledged the discussions about value and building movements and power. She noted the importance of continuing to work toward changing power dynamics to create equitable economies, highlighting the example of building policy for equitable housing and wealth building opportunities. Pittman highlighted Erickson’s work on creating missing markets to address social and economic issues and Janoo’s work at the Well-Being Economy Alliance and the global perspective she brought to the conversation. Additionally, Pittman mentioned Iton’s discussion about the California Endowment’s 12-year investment on an initiative that shifted narratives about building community power, health, and well-being. She said that the discussions laid a strong foundation for the roundtable’s next session in this workshop series, which will be focused on the relationship between the economic system and governance and democracy. In the work of transforming the economic system, Pittman said, it is critical to understand who is making decisions and who is benefiting from them.

Pittman invited members of the planning committee to highlight ideas they heard that resonated with them and could help drive society toward action on these issues. Marc Gourevitch, New York University Langone Health, reflected on the coalition building happening in Saint Louis and Buffalo and posed the question of how to think about expanding those efforts on a larger scale (i.e., taking locally grown initiatives and figuring out how to develop them into a more national movement). Sheri Johnson spoke about the “beacons of light and hope” where solidarity and economic change is already happening as something that stood out to her. For example, Johnson noted SEIU’s work across state lines to build worker power; she also expressed gratitude for those with the courage to carry hope that things can change and who are prepared to “barrel through that window of opportunity” when it opens. Diez Roux agreed with Gourevitch that an important next step is thinking about scaling up this work to create broader systems change. Diez Roux also echoed Johnson’s appreciation for recognizing that the economic system was created by people and therefore can be changed.

Manuel said that from her perspective, the discussions were about addressing something deeper than solely population health. She stated, “If we stop just at the conversation around population health, we actually get stuck in a set of systems that don’t recognize some of the broader root causes of what we’re trying to do across a number of areas.” Furthermore, Manuel said, this work requires grappling with the reality that “the most marginalized among us have to do the heaviest lifting” and that the work is “under resourced and undervalued.” Planning committee member Hilary Heishman, Robert Wood Johnson Foundation, also reflected on the day, saying the discussions led her to think more broadly about the health care financialization work that the Robert Wood Johnson Foundation is pursuing, and opportunities to connect to other funders.

Pittman opened the discussion to the audience. Kim Boller from the American Psychological Association reflected on Roy’s presentation, saying she was disappointed to hear there are people who do not understand that the savings from upstream population health interventions outweigh the downstream illness effects and emphasizing the importance of communicating that more effectively. Ilakkuvan highlighted three things she heard related to shifting power to drive change: decreasing power of corporations, institutions, and industry; increasing community power; and narrative and metric shifts that change how success is defined and that

lead to public and political buy-in. Roy mentioned three ideas from the day: creating virtuous cycles in the health and economy intersection, recognizing the distinction between technocratic and democratic strategies, and power building and making use of the energy of conflict to incite change.

Iton expressed gratitude for these “ambitious ideas” for reimagining a more equitable economic system and the idea of “market justice versus social justice” to which the missing markets work could be impactful. Erickson added, “it doesn’t sound right to say we’re [going to] use markets to solve problems caused by the market,” but community development finance has been effectively doing this and discussed how having downstream savings creates a cash flow for further work. An audience member commented about missing markets and said that last year she attended a meeting at the Federal Reserve Bank of New York and was struck by the idea that because markets are crafted by people, they can be recrafted in a way that meets collective objectives. Pittman closed the workshop by noting that the day’s discussions showed there are various possible pathways to creating a more equitable well-being economy.

DISCLAIMER This Proceedings of a Workshop—in Brief has been prepared by Stephanie Puwalski and Alexandra Andrada Silver as a factual summary of what occurred at the meeting. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution. This workshop was planned by Ana Diez Roux (Cochair), Drexel University School of Public Health; Mary Pittman (Cochair), Public Health Institute; Philip Alberti, Association of American Medical Colleges; Marc Gourevitch, New York University Langone Health; Hilary Heishman, Robert Wood Johnson Foundation; Sheri Johnson, University of Wisconsin–Madison; Tiffany Manuel, TheCaseMade, Inc.; Bobby Milstein, ReThink Health; Kosali Simon, Indiana University; Monica Valdes Lupi, Kresge Foundation.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Vinu Ilakkuvan, PoP Health, LLC; Lucy Marcil, Boston University Chobanian & Avedisian School of Medicine; Sheri Johnson, University of Wisconsin Madison. Leslie Sim served as the review coordinator. We also thank staff member Stephen Maher for reading and providing helpful comments on this manuscript.

SPONSORS This workshop was partially supported by Association of American Medical Colleges, Blue Shield of California Foundation, the California Endowment, Fannie E. Rippel Foundation, Kresge Foundation, Nemours, NYU Langone School of Medicine, Robert Wood Johnson Foundation, and Thomas Jefferson University.

STAFF Maggie Anderson, Research Assistant; Alexandra Andrada Silver, Program Officer; Alina Baciu, Roundtable Director; and Stephanie Puwalski, Research Associate.

For additional information regarding the workshop, visit https://www.nationalacademies.org/event/43288_09-2024_economic-systems-as-a-structural-driver-of-population-health-partnerships-a-workshop.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2025. Economic systems as a structural driver of public health through the lens of partnerships: Proceedings of a workshop – in brief. Washington, DC: National Academies Press. https://doi.org/10.17226/28879.

Health and Medicine Division Copyright 2025 by the National Academy of Sciences. All rights reserved.