Tax Credits for Funding Population Health
The health and well-being of the populations in regions across the United States is produced by a variety of conditions and determinants—including safe environments, housing, education, and economic conditions. Clinical health care is but one of these. Absent a shift in focus to population health, chronic conditions and health care costs will continue to rise, productivity will suffer, and deep health inequities will remain.
Yet, despite the critical nature of this mission, most partnerships are funded on a shoestring budget, and overwhelmingly by grants. There are a number of more substantial and sustainable funding sources to which we might turn, but none are especially easy to develop. ReThink Health explored one possibility: tax credits.
Tax credits are a type of tax break. They work by reducing the cost of a good or service, thereby stimulating the markets for those goods and services, leveraging private capital in the process.
We sought to identify the conditions under which a tax credit policy would provide:
- A sound and sustainable financing source for population health.
- A sound investment for taxpayers.
Here’s a summary of what we found:
Tax breaks are widely used at both the state and federal levels, spanning numerous sectors, including health. At the federal level, tax breaks were claimed on 169 million tax returns, estimated to total $1.5 trillion in 2017. But, outside some notable and important tax credits that impact the social determinants of health, such as the Earned Income Tax Credit and the Low Income Housing Tax Credit, this ubiquitous instrument is not being used for population health.
The design of a tax credit program matters greatly to its success, and we can pinpoint what those design features are. It’s important to acknowledge that not all tax credit programs are effective at producing the desired outcomes. Indeed, certain types of tax breaks, especially the $45 billion in business incentives offered by state and local governments each year, have been shown not to be effective at creating jobs and economic growth.
A tax credit program for population health could be constructed to ensure positive returns on investment for taxpayers. There is a sizeable and growing set of evidence-based population health interventions with enough financial return on investment (ROI) to be stimulated by tax credits. Limiting the tax credit to evidenced-based interventions with positive ROI ensures that the tax credit serves as a sound investment for taxpayers and accomplishes its health objectives.
Compared to the federal government, states have a unique set of incentives and opportunities to enact a tax credit for population health. First, containing Medicaid costs is increasingly important for states. All states except Vermont have some type of a balanced budget requirement, and Medicaid is the second largest expenditure item behind K-12 education. Second, states are becoming increasingly aware that their $45 billion investment in business incentives is failing to produce as expected. The Pew Charitable Trusts has called for improved accountability measures and evaluation, and since 2012, 21 states have enacted laws requiring regular evaluation. Because health and the economy are linked, states desiring higher ROI could choose to redeploy their tax credit dollars in population health instead. Finally, some states are showing willingness to use tax credits for singular population health investments, including the administration of an opioid program in New Hampshire and a lead abatement program in Massachusetts.
One constraint on the use of tax credits for population health: most service providers are based in the nonprofit or public sectors. A tax credit will not be valuable to them because they have zero or limited tax liability. Our analysis focused on how tax credits might help fund a portfolio of population health investments (which can be tailored to local needs) and identified two possibilities.
Providing Tax Credits to Self-insured Employers or Health Plans
Both health plans and self-insured employers have huge financial interests in containing health care costs. While the population covered by such a tax credit is limited to those with private insurance, it is quite significant. For-profit health plans fully insure 62 million Americans (with total enrollment of 122 million Americans), and an estimated 100 million Americans are covered by self-funded employer plans. We should also expect that these private companies would be primarily interested in interventions with relatively short payback periods. Nonetheless there are many important investments that could be made.
For example, an evidence-based opioid program analyzed by the Washington State Institute for Public Policy was shown to have a total cost of $356 per person and was shown to create financial benefits of almost $2,700 and social benefits of $5,300, both accruing over two years. But these returns are split between a number of beneficiaries, including taxpayers who save $370 in health care costs and health plans that save $383 in health care costs. (Participants in the program save $79 in health care costs and earn an additional $1,279.) As it stands, neither the taxpayers nor the health plans have much of an incentive to invest because their returns are about the same as their costs, and it takes two years to break even. Now imagine the cost of the program is split between a health plan and taxpayers with the use of a 50% tax credit. The net cost to each would become $178 and both would more than double their money in two years.
A Charitable State Tax Credit
Tax credits could be used to spur charitable giving—for instance, to wellness funds. A number of states offer tax credits for donations to specific organizations or purposes. The largest of the state programs raised $20 million in Arizona (for specified anti-poverty organizations), $40 million in Michigan (for homeless shelters and food banks, a program ended in 2011), and $24 million per year in Iowa (for community foundations). Colorado’s tax credit for donations to child care providers has raised an average of $12.6 million in each of the past eight years.
Research suggests that the demand for charitable giving can be spurred through tax credits, although giving seems to respond to a variety of factors: the health of the economy, the sector being donated to, the income of the giver, whether it is structured as a match, and other features of the state tax code. If a tax credit were offered for population health donations, we would want to ensure through the design of the program that the amount of giving will actually increase. A poor outcome would be paying for a donation that already occurs and/or shifting the donation from one sector to another without increasing the overall level of giving.
Meet Our Project Team
Ella D. Auchincloss
Ella D. Auchincloss
“At Rippel, we pursue an inspiring, yet daunting transformative agenda for equitable health and well-being; it’s about a lot more than health care. We’re willing to strategically tackle the big issues, but with a sober sense of what is doable.”—Ella D. Auchincloss, Director of Enterprise Innovation
Joined Rippel: 2011
Current Roles: Ella serves as Rippel’s Director of Enterprise Innovation as well as a key contributor to the ReThink Health initiative’s Hospital Systems in Transition and Portfolio Design for Healthier Regions projects.
Career: Ella has spearheaded many resident engagement efforts for Rippel’s ReThink Health initiative, coaching a wide variety of partner organizations and teams in change leadership, and developing Community Activation for System Stewardship, in which she and her team advised the Center for Medicare and Medicaid’s Quality Improvement Organization Leadership, Organizing in Action program. She also directed a research project exploring tax credits’ potential as a source of sustainable financing for population health. Before joining Rippel, she founded The Leadership Development Initiative, a faith-based teaching and coaching program for resident outreach. She is also a fellow of the Leading Change Network at Harvard University’s Kennedy School of Government. Prior to her work in resident engagement, Ella worked in the financial services sector.
More about Ella: In 2015, Ella was awarded the Barbara C. Harris Award for Social Justice by the Episcopal City Mission in Boston, Massachusetts for her founding of The Leadership Development Initiative. Ella is a recovering Wall Street professional, and is most at home in drafty church basements and other community settings, leading story slams and singing freedom songs. She is at her best when she is near the ocean in the company of her beloved dog.
Education: Harvard Divinity School (MTS), Babson College (BS)
“The dream of people and communities who are healthy and well is universal. Rippel is dedicated to helping leaders discover how that dream can move from imagination to reality.”—Stacy Becker, Former Vice President of Programs
Joined Rippel: 2015
Current Roles: Stacy oversaw Rippel’s initiatives and projects, including ReThink Health and FORESIGHT.
Career: In her former role and previously as Rippel’s director of sustainable financing, Stacy was a guiding force as Rippel and rose to meet the challenges at the frontiers of stewardship and health system change. She previously served as budget director for the City and County of San Francisco and the City of Saint Paul, as well as the public works director for Saint Paul. For 18 years she ran a policy consulting business, providing expertise in a variety of areas important to communities, including housing, education, community development, nonprofit management, citizen engagement, and financing.
More about Stacy: Stacy has earned a black belt in tae kwon do and taught children the practice for several years. She also plays the harp (she has three of them of various sizes).
Education: Harvard University (MPP), London School of Economics (MS)
“I love that Rippel is a place where challenging the status quo is the status quo.”—Nina Burke, Consultant, Learning and Evaluation
Joined Rippel: 2016
Current Roles: As a consultant for organizational learning and evaluation, Nina contributes to the design, management, and implementation of Rippel’s learning and evaluation methods and processes across the enterprise. She also co-designs and facilitates internal organizational learning activities.
Career: Nina has provided project management, design, research, and evaluation to more than six projects in the ReThink Health portfolio. This includes advising the California Accountable Communities for Health Initiative (CACHI) on distributed leadership and leadership transitions and coordinating and evaluating the Center for Medicare and Medicaid’s Quality Improvement Organizations’ Leadership and Organizing in Action course as part of the Community Activation for System Stewardship project. As part of a research project exploring tax credits’ potential as a source of sustainable financing for population health, she co-authored a paper for the National Academy of Medicine (2018). She previously was project manager of a homeless prevention and re-housing project for a Boston-area nonprofit.
More about Nina: Nina is certified in conditions for effective teams; loves all things public: public space, public libraries, public transit; chatting with strangers; and cooking for the people she loves.
Education: Boston University (BS, MPH)
“Momentum is building in the movement toward a more equitable and sustainable future for health and well-being, which creates so many opportunities for collaboration and distributed leadership in all sectors—and at Rippel I get to bring that inspiration to action.”—Maggie Cooke, Senior Strategic Partnerships Associate
Joined Rippel: 2016
Current Roles: Maggie Cooke provides Rippel with project management, grants administration, proposal development, and high-level support around the development and cultivation of new partners and emerging projects. Working side by side with Rippel President and CEO Laura Landy, Maggie has helped lead the significant fundraising and strategic partnerships efforts of FORESIGHT.
Career: As part of a research project exploring tax credits’ potential as a source of sustainable financing for population health, Maggie co-authored a paper for the National Academy of Medicine (2018). This work also earned her an award of distinction for her practicum project at the Dartmouth Institute for Health Policy & Clinical Practice. Before joining Rippel, Maggie worked at Johnson & Johnson for 10 years, most recently as the senior executive assistant to the chief strategy and business transformation officer, and was a service coordinator at the Alaska Housing Finance Corporation before that, where she assisted residents by connecting them to critical resources in order to empower them in maintaining independent housing.
More about Maggie: Maggie enjoys living on the Delaware River with her family and is an active member of her community, participating in the Hunterdon County Anti-Racism Coalition, and serving on both the Frenchtown School Advisory Council and the Frenchtown Planning Board.
Education: Dartmouth College (MPH), University of Alaska Fairbanks (BA)
“Rippel is solutions-oriented; for instance, instead of lamenting the lack of funds and resources for health and well-being, we find streams that already exist and just need to be unlocked, redirected, and approached creatively—and then we spread the word about them.”—Amanda McIntosh, Senior Communications Associate
Joined Rippel: 2015
Current Roles: Amanda manages Rippel’s editorial and visual production as well as its social media efforts. She also leads Rippel’s work to measure its outreach effectiveness and serves as a member of FORESIGHT‘s Implementation Team.
Career: Amanda has provided critical research, design, and project management support to national-level Rippel projects, including the Convening of Catalysts leadership group that brings together health system transformation trailblazers. As part of a ReThink Health initiative project exploring tax credits’ potential as a source of sustainable financing for population health, she co-authored a paper for the National Academy of Medicine (2018) and contributed greatly to advancing high-level conversation and interest in the topic via various platforms and mediums. Amanda formerly worked to support nationwide programs and outreach campaigns for consumer health advocacy organizations, serving as program associate to Community Catalyst’s Roadmaps to Health project and as statewide coordinator at Health Care For All.
More about Amanda: Amanda grew up on the island of Martha’s Vineyard, not as a summer resident, but as a third-generation “year-rounder.” She had some of the same teachers that had taught her father when he went through the island’s school system, decades before. On a recent visit, she found a rare fossilized Megalodon tooth.
Education: Drexel University (MPH), College of Charleston (BA)
“Before joining Rippel, my work was confined to individual nutrition and health interventions with specific populations, funded solely by grants. At Rippel, I get to be part of work that breaks through the silos to help stewards move down the path towards sustainability—both of their finances and their mission.”—Katherine Wright, Project Manager
Joined Rippel: 2016
Current Roles: Katherine leads the cross-coordination of Rippel’s three ReThink Health initiative project teams focused on jumpstarting transformative change, and provides high-level research and content support to ReThink Health’s Portfolio Design for Healthier Regions and Hospital Systems in Transition teams. She also continues to promote and present on Beyond the Grant: A Sustainable Financing Workbook (published in 2018).
Career: Katherine previously worked on multiple sustainable financing and R&D projects for Rippel’s ReThink Health initiative, where she explored topics like social impact investing, resident engagement, and the potential of tax credits as a source of sustainable financing for population health. Notably, she co-authored Beyond the Grant: A Sustainable Financing Workbook. Katherine led the design of the workbook’s Financing Wizard that lets users create and practice the art of financial planning for their collaborative population health work. Before joining Rippel, Katherine coordinated and provided research and evaluation support for interventions focused on healthy eating, SNAP-ED, and women’s heart health with Tufts Friedman School of Nutrition Science and Policy, the Jean Mayer USDA Human Nutrition Research Center on Aging, and Michigan State University Extension.
More about Katherine: Katherine was ranked second in the Indiana SkillsUSA Commercial Baking competition, which helped inspire her career path to health and nutrition work.
Education: Friedman School of Nutrition Science and Policy at Tufts University (MS), Michigan State University (BS)
Could Tax Credits Be a Source of Sustainable Financing for Population Health?
We clear up some misconceptions about tax credits and go over the basics of how they might be used to fund population health efforts. It’s time to cut through the myths and see where the real opportunities lie.
Exploring the Potential of Tax Credits for Funding Population Health
In this paper, published by the National Academy of Medicine, ReThink Health’s Stacy Becker and our Tax Credit R&D Team explore the potential for stewards to use tax credits as a means to fund efforts to transform the system that produces health and well-being.
Establishing a Charitable State Tax Credit to Finance Regional Wellness Funds
We developed a prototype for how stewards might introduce a tax credit that encourages charitable donations to wellness funds (pools of money for funding efforts to improve health and well-being). We explain the key differences between a tax credit and a tax reduction, and explore why local—as opposed to federal—control is key to directing funding where it is needed most.
Incenting the Private Sector to Invest in Population Health: A Tax Credit for Self-Insured Employers
We developed a prototype for how state policymakers could create a tax credit for self-insured employers, which would engage the private sector in transforming population health.
Getting Smart About Tax Policy: Reflections from the NASEM Conference on Financing Population Health
Some key takeaways from our tax policy research team’s presentation, titled Exploring Tax Policy to Advance Population Health, Health Equity, and Economic Prosperity, to the National Academy of Sciences, Engineering, and Medicine’s (NASEM) Population Health Roundtable.