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Suggested Citation:"4 FaithHealth Collaboration on Health Policy." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
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Suggested Citation:"4 FaithHealth Collaboration on Health Policy." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
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Suggested Citation:"4 FaithHealth Collaboration on Health Policy." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
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Page 25
Suggested Citation:"4 FaithHealth Collaboration on Health Policy." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 26
Suggested Citation:"4 FaithHealth Collaboration on Health Policy." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 27
Suggested Citation:"4 FaithHealth Collaboration on Health Policy." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 28
Suggested Citation:"4 FaithHealth Collaboration on Health Policy." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 29
Suggested Citation:"4 FaithHealth Collaboration on Health Policy." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 30
Suggested Citation:"4 FaithHealth Collaboration on Health Policy." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 31
Suggested Citation:"4 FaithHealth Collaboration on Health Policy." National Academies of Sciences, Engineering, and Medicine. 2019. Faith–Health Collaboration to Improve Community and Population Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25375.
×
Page 32

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4 Faith–Health Collaboration on Health Policy Terry Allan, health commissioner at the Cuyahoga County Board of Health in Greater Cleveland, Ohio, noted the impressive depth and breadth of the partnerships discussed thus far at the workshop, especially those geared toward addressing the social determinants of health. Faith- based institutions are well positioned in their mission to address the social determinants of health and well-being by giving power and voice to those who have been marginalized by society, Allan said. In this session of the workshop, the discussion focused on how faith–health collaboration can help to build common ground for public health policy. Mandy Cohen, secretary of the North Carolina Department of Health and Human Services, shared her perspective on how the health of the community is much broader than the provision of health care, and on the need to bring community resources and health care resources closer together. Donna Weinberger, member of the board of Greater Cleveland Congregations (GCC), discussed how faith–health collaboration can build bridges for health-promoting public policy. The discussion was moderated by Allan. (Highlights of this session are presented in Box 4-1). A PERSPECTIVE ON HEALTH POLICY: HEALTH BEYOND HEALTH CARE Cohen described several examples of how she brings a broader lens to the work of the North Carolina Department of Health and Human Services. She began by sharing her personal 4-1 PREPUBLICATION COPY: UNCORRECTED PROOFS

4-2 FAITH–HEALTH COLLABORATION TO IMPROVE COMMUNITY AND POPULATION HEALTH story of how she came to think differently about health and health care. When she was nearing the end of her training as a primary care physician in Boston, she saw a 24-year-old woman who was losing weight, losing her hair, and generally not feeling well. The patient was a full-time college student and was insured. Cohen took a standard patient history and ordered laboratory tests, thinking perhaps the patient might have anemia, Lyme disease, or a thyroid disorder. However, all of the patient’s laboratory test results were normal. Upon seeing the patient again, Cohen asked some additional questions and ordered a CT scan of the patient’s abdomen, now considering cancer or another serious illness as the cause. The CT scan was normal, however. At the patient’s third visit, 8 weeks after Cohen has first met her, the patient still looked and felt ill. As Cohen was conferring with her mentor about which specialist she should refer the patient to, the medical technician who had taken the patient’s vital signs suggested to Cohen that she really needed to ask the patient if she was getting enough to eat. This was a very difficult, humbling, and embarrassing moment, Cohen said. After eight weeks conducting expensive tests, Cohen had not asked this very important question about the patient’s health. It also occurred to Cohen that she did not know what to do if the answer was that the patient did not, in fact, have enough to eat. After asking the patient if something was going on at home, Cohen found out that the patient had recently fled a violent relationship and was living out of her car because all of her money was going toward tuition. The patient did not know who or where to ask for help (and felt she could not ask her family). Like Cohen, the patient had not made the association between her personal life and her health. Cohen realized that she had only been focused on health as health care (ordering lab tests and imaging, referring to specialists), and said that this experience shaped her perspective on health, moving forward. In her current position, Cohen is charged with the health and well-being of the population of North Carolina. The health status of North Carolina’s population is below average nationally, she said. There is a range of statistics indicating poverty and care needs in this area; for example, one in four children in North Carolina go to school hungry, and 48 percent of women in North Carolina have experienced some sort of intimate partner violence. Cohen said she wants to think differently about what health means for North Carolina. Although most of her budget is committed to purchasing health care, health is more than that, she said. She added that all elected officials have a responsibility to think about health. The North Carolina Department of Health and Human Services (NC DHHS) is looking at ways to bring the health care sector and community resources closer together. Cohen highlighted transportation as one element in the community that is closely linked to health. Transportation can impact whether or not an individual gets the health care they need or whether they can get to their job. Transportation also includes greenways where people can bike and walk for health. Resources are limited, and health care already comprises a significant portion of the state budget, she said. The challenge is to sit together with other sectors who interact with the same residents and identify ways to meet the needs of residents differently and better. The NC DHHS is also focused on early childhood, particularly ages zero to five years. The department pays for half of the births in the state, pays for childcare subsidies, runs the North Carolina Pre-K and Smart Start programs, and administers Child Protective Services. She reiterated that the focus is not on creating something new, but on working differently and better PREPUBLICATION COPY: UNCORRECTED PROOFS

FAITH–HEALTH COLLABORATION ON HEALTH POLICY 4-3 across the domains, and being more thoughtful about how the state is helping children to get the best start possible for being successful, regardless of the zip code they are born in. As a result of reforms to the health care payment system, health systems are starting to think differently about how they interact with the community, Cohen said. For example, the Medicaid program in North Carolina is now asking patients standardized questions about food insecurity, housing insecurity, lack of access to transportation, and interpersonal violence. Cohen said she hopes to also deploy this screening tool to the Medicare Advantage population and the commercially served population in North Carolina, and she is working with other payers and health systems to make that possible. Once these questions about the social determinants of health have been asked, there must be a way to guide patients to resources, Cohen said. The NC DHHS is developing a platform that will bring together community resources and health care resources. The platform will link to the electronic health record so that, for example, when a provider enters that a patient has screened positive for food insecurity, they will see a list of community resources they can refer the patient to. Through the platform, the provider could send a message to the foodbank to tell them to expect the patient, and to alert the provider if the patient does not go so the provider can follow up. Finally, Cohen said, it is important to pilot interventions to learn what works best for patients who have essential health needs that are not necessarily traditional health care needs. As an example, Cohen described a pilot program in which carpeting was replaced, and air filters installed, in the homes of children with asthma who were frequent visitors to the emergency department. It was not surprising, she said, that the number of emergency department visits for these children declined. As a result, the children were not missing school, and the parents were able to stay at work. An emergency department is the most expensive place for care, she added, so this intervention also saved health care dollars and resources. Another example is interventions in the homes of elderly residents to reduce their risk for falls. Other home-based interventions might target women with high-risk pregnancies, or children who are experiencing chaos, violence, or trauma in their life. The next step is to take successful pilot programs to scale. Discussion Allan highlighted the purchase of replacement carpet and air filtration equipment with health care dollars, noting that such spending is not common, but is the type of creative thinking needed to make a difference. He asked how Cohen was able to move beyond the status quo and convince others to come together and try such innovative interventions. Cohen observed that there is a lot of division around health care, and it has become a partisan and contentious issue. However, there is alignment around wanting individuals and communities to be healthy. The legislature is concerned about rural health, access to care, and the issues of food deserts, transportation, and broadband internet access. This is also alignment around keeping children healthy and safe, and providing access to learning. With regard to health care, payment for health care is changing, and hospital systems are thinking differently about their emphasis (e.g., moving away from keeping hospital beds full, and moving toward engaging community partners). Cohen was hopeful that there is growing alignment across sectors and stakeholders around goals, and PREPUBLICATION COPY: UNCORRECTED PROOFS

4-4 FAITH–HEALTH COLLABORATION TO IMPROVE COMMUNITY AND POPULATION HEALTH more openness to intentional partnerships. She emphasized that money and priorities drive change, and she highlighted the need to take advantage of the new opportunity that is being driven by health care payment reform to drive these partnerships. Allan asked Cohen for her perspective on the challenges and opportunities for governmental, public health, and faith-based institutions to work together around real transformational initiatives. Cohen reiterated the value of different sectors coming together in the same room. Although similar efforts might have failed in the past, this is a different moment, she said, and it is important to engage different partners, beyond traditional public health partners. Phyllis Meadows of The Kresge Foundation supported Cohen’s optimism that the time is right to start bridging these conversations across sectors. She asked what might be different now than in the past that would allow for success. Cohen gave several examples. First, the pressure around resources is real for everyone. That pressure pushes people to a creative place, which is good for partnerships. Health care payment reform has also driven stakeholders to think differently about health care more broadly. This combination of tight budgets and changes to payments is forcing people to be creative, she said. North Carolina is aligned around health and is prioritizing resources accordingly. The state is working to take innovations to scale and to create the infrastructure to allow collaborations that bring the pieces of the puzzle together (health systems, payors, providers, social services, community resources). Stancil asked about innovative interventions for the prevention of trauma and intimate partner violence. Cohen said that prevention involves factors related to substance abuse disorder, overall stress related to poverty, and the lack of job opportunities, for example. The goal is to move upstream to the root of these factors to make investments. Prevention is multifactorial, and the department is approaching it from many different directions. In addition to prevention, the department is focused on making children and families more resilient. Trauma will be a part of the human experience, she said. What tools can be provided to help people ascend beyond that trauma? What is it that makes some people who experience trauma resilient? In this regard, the department is looking to academic partners for help. BUILDING FAITH–HEALTH BRIDGES FOR HEALTH-PROMOTING PUBLIC POLICY Greater Cleveland Congregations (GCC) is a county-wide, multifaith community organizing group of 43 congregations in Cuyahoga County, Ohio. GCC unites people across race, class, and religion to fight for the common good, Weinberger said. In its short six-year history, GCC has had major victories in Cuyahoga County in criminal justice reform, gun violence reduction through its national “Do Not Stand Idly By” initiative, education, and employment. Its first, and one of its most important victories was to help bring Medicaid expansion to the state of Ohio in 2013, which provided desperately needed health care to more than 700,000 previously uninsured Ohioans, she said. PREPUBLICATION COPY: UNCORRECTED PROOFS

FAITH–HEALTH COLLABORATION ON HEALTH POLICY 4-5 GCC and Medicaid Expansion in Ohio A principle of community organizing is that it takes organized people and organized money to effect change. Weinberger noted that Medicaid expansion was one of GCC’s first campaigns, and it was a true test of the organization’s resilience, relationships, and strength. Weinberger suggested that the first lesson of community organizing is to always be looking for opportunities, and she described how the opportunity to influence Medicaid policy presented itself. In July 2012, through the work of its criminal justice team, GCC was able to influence Governor John Kasich and the Ohio legislature to pass and sign a major collateral sanctions reform bill. The bill signing took place at a member congregation, Elizabeth Baptist Church. Weinberger reminded participants that, in late June 2012, the U.S. Supreme Court upheld the Patient Protection and Affordable Care Act (ACA) and ruled that Medicaid expansion under the ACA was optional for states. After the collateral sanctions bill was signed, Kasich spoke with GCC members at length about the recent Medicaid expansion decision. The governor is a religious man, Weinberger said, and in his subsequent speeches on Medicaid he spoke of the morality of the expansion and “bringing people out of the shadows.” Although the governor hinted to GCC that he was open to expansion, he also expressed concern about the impact on the state budget, and he referred GCC to both the Medicaid director and the director of the Office of Health Transformation for the state for further conversations. After hearing the governor’s potential openness to expansion, GCC began to research the possibility of taking on the issue. At that time there were an estimated 600,000 uninsured Ohioans at the bottom of the income spectrum who would get health insurance if Ohio moved forward with Medicaid expansion. This included 80,000 people in Cuyahoga County, many of whom were in GCC member congregations. The uninsured individuals included unmarried, childless adults earning less than $15,000 per year, and parents earning between $20,000 and $30,000. Expansion would also help the ex-offender population, a large population in Cuyahoga County that is represented in GCC member congregations. GCC also learned that Medicaid expansion would cost very little in the first three years and would slowly increase in cost, but it was estimated that expansion would bring in $1.43 billion over 8 years. This made the pursuit of expansion seem like an obvious choice, Weinberger said. In its conversations with the State Office of Health Transformation, GCC learned that the administration was also considering the potential of Medicaid expansion to be a key component of driving health care reform. The state was interested in a front-end financial investment that would lead to a focus on primary health care, mental health care, and prevention (all of which GCC member clergy and faith communities were very interested in). Finally, GCC’s research suggested that a campaign for Medicaid expansion was winnable, she said. Having decided to campaign for Medicaid expansion in Ohio, GCC began the process of assembling a diverse coalition of organizations that became known as the Northeast Ohio Medicaid Expansion Coalition, or NEO-MEC. Weinberger said that establishing this coalition was probably the most important role that GCC played in the expansion. She felt that GCC, as a group of leaders from faith-based organizations, was probably the only organization in town that could bring all of the stakeholders to the same table. There were, for example, competing PREPUBLICATION COPY: UNCORRECTED PROOFS

4-6 FAITH–HEALTH COLLABORATION TO IMPROVE COMMUNITY AND POPULATION HEALTH hospital systems that did not otherwise interact that joined the coalition. Weinberger added that NEO-MEC served as the model for five other similar coalitions throughout the state of Ohio. Throughout the fall and winter of 2012, the coalition strategized and in January 2013, word spread that the governor was becoming more and more open to Medicaid expansion. GCC and NEO-MEC members publicly gathered to show their strength and their support for expansion. GCC organized a health care assembly of about 1,300 people in one of the member churches. The event included testimonials from uninsured Ohioans, providers, small business owners, and senior leadership from all four major hospital systems. GCC and NEO-MEC also participated in almost weekly “lobby days” in the state capitol. GCC trained citizens to take action, and to participate in the democracy that is supposed to represent them, Weinberger said. Congregants learned how to present messages to legislators, how to work as a team, and how to handle a range of reactions from legislators and their aides. These efforts paid off, Weinberger said, and on February 5, 2013, Kasich announced that he would include Medicaid expansion in his 2 year budget. This was not the end, however. The Republican-led legislature was very resistant. In April of 2013, the Ohio House of Representatives stripped Medicaid expansion from the budget. GCC took five buses filled with members of its congregations and joined other coalitions throughout the state at a rain-soaked rally on the statehouse steps. The intent was to put the legislature on notice that they could strip expansion from the budget, but the coalitions were not going away, she said. GCC kept applying pressure with additional lobby days and press. GCC also canvassed in three strategically targeted swing districts in Northeast Ohio, urging voters to contact their state legislators to support expansion. In the spring, the legislature added a line item in the budget prohibiting Medicaid expansion, but the governor struck it out before signing the budget. In community organizing, Weinberger said, the key is persistence, persistence, persistence. Following the summer legislative recess, GCC worked with Kasich in a coordinated state effort to get Medicaid expansion on the ballot for a vote. In this way, GCC pushed the legislature to either come to a vote themselves, or face the prospect of putting the issue before the voters. GCC member congregants, trained by GCC’s union partners, were instrumental in getting petitions signed to get the issue on the ballot. After about six weeks, however, it became clear that the governor had made a deal. On October 21, 2013, Kasich did an end run around the legislature and brought the matter of Medicaid expansion to the Ohio Controlling Board. In a deal to stop the ballot petitions, the Ohio House Speaker agreed to replace two members of the Controlling Board with sympathetic members right before the vote. The Controlling Board voted five to two to accept $2.55 billion in federal money to cover the cost of expanding Medicaid in Ohio through July 2015. It was thought that once this funding was in place, it would be very difficult to remove the entitlement later. Again, victory was not quite assured, Weinberger said, as lawsuits were immediately filed with the Ohio Supreme Court challenging the legality of the Controlling Board vote. Finally, on December 21, 2013, the Ohio Supreme Court deliver a ruling that cleared the way for expansion of Medicaid to uninsured Ohioans. PREPUBLICATION COPY: UNCORRECTED PROOFS

FAITH–HEALTH COLLABORATION ON HEALTH POLICY 4-7 Current Status of Medicaid in Ohio In addition to providing health insurance coverage for about 750,000 people, Medicaid expansion in Ohio has reduced the homeless population, reduced food insecurity, and dramatically increased access to mental health care, Weinberger said. Ohio has been devastated by the opioid crisis, and expansion has provided real treatment opportunities for those who previously could not access care. Medicaid expansion has also provided additional resources to cities and towns throughout Ohio. Expansion has been crucial to the economy as health care is the second largest industry in the state of Ohio after agriculture, she continued. The Cleveland Clinic is the second biggest employer after Walmart. Since its passage, there have also been numerous threats to Medicaid expansion, mainly focused on eligibility restriction (e.g., bills that would require drug testing, cost sharing, or work requirements). The faith community has risen up when needed, Weinberger said, by successfully stopping these bills in the legislature or persuading the governor to veto them. She noted, however, that this governor’s term ends in November 2018 and it is not known what will happen after that. Lessons Learned Weinberger shared several lessons learned. First, community organizing is all about relationships, she said. Public relationships (e.g., coalitions) are vital to effecting change. A community organizing principle is that there are no permanent friends and no permanent enemies. Ordinarily, for example, GCC might be on the opposing side of the Cleveland Clinic regarding their lack of investment in the surrounding community, or on the opposite side of Kasich when it comes to his record on guns. However, both were GCC partners in Medicaid expansion and success would not have been possible without them. The second lesson is that power is not a dirty word. It takes a willingness to understand power, and how to wield it when necessary, in order to win. Politics can be dirty and nasty, she said, and this can be difficult for clergy and people of faith to deal with. Finally, GCC had to remind itself often that it was working with the world as it is, not the world as they wished it would be. In a perfect world, politicians would do what was right and moral. In the world as it is, politicians are immersed in the world of dirty money and primaries. It behooves activists to understand what is in the self- interest of politicians and to move forward from there. Sometimes that self-interest can be surprising, she added, and it is not always about money and reelection. For example, Kasich told GCC that his brother had a severe mental illness, and when he talked about getting people out of the shadows, he was thinking of his brother. Moving forward, GHCC has been able to use its relationship skills and coalition-building skills to work on other issues, including mental-health crisis centers to keep people with severe mental illness out of jail. PREPUBLICATION COPY: UNCORRECTED PROOFS

4-8 FAITH–HEALTH COLLABORATION TO IMPROVE COMMUNITY AND POPULATION HEALTH Remembering Why We Do This In closing, Weinberger shared a brief story that reminded her why GCC does the work it does. After the Supreme Court ruling, she and the other two health care cochairs went out to celebrate. Upon ordering drinks, the waitress asked if they were celebrating something. They said yes and explained that they had been working on Medicaid expansion for a long time and were finally victorious. Most people become disinterested when the talk turns to Medicaid, but the waitress nearly had tears in her eyes as she said she had been waiting for this day for years. At age 26, she had not had health insurance since she was 18. She told of sharing an asthma inhaler with her mother because she could not afford one, but how that ended when her father was forced to take early retirement and then had no insurance either. She cobbled together her health care using the community health center and the dental school, but that usually required many hours of lost work time, and so she usually skipped health care all together. The waitress wanted to by their drinks but they declined. In the end, the waitress did buy their coffee, and Weinberger realized that it was important for her to feel bonded with them in this victory. The victory, they reminded themselves, is for the people like this waitress. DISCUSSION Michelle Ries of the North Carolina Institute of Medicine asked about the involvement of GCC in spreading the word about Medicaid expansion and eligibility and in recruiting those who might be eligible. Weinberger said that after the expansion was passed, GCC made sure that the navigators were visiting their congregations and that enrollment was taking place. GCC moved on to other issues, returning to Medicaid as threats emerged. Weinberger was asked to expand on what GCC is taking on next, and how it is using its faith–health relationships. She responded that GCC’s criminal justice team is currently working to get persons with mental illness out of prison. The goal is to have two mental-health crisis centers built, one on the east side and one on the west side of Cleveland, where law enforcement can drop off persons with mental illness. Thus far, GCC has brought together a coalition of judges, the Mental Health and Addiction Board, and the county prosecutor’s office. She emphasized that the respect GCC earned during the Medicaid expansion process has led these organizations to want to help on other issues as well. GCC’s coalition-building skills have also been essential in this process. Allan asked about the key considerations for sustaining a broad-based coalition. The main approach to maintaining these relationships, Weinberger said, is to not be reactionary. There were times, for example, when one hospital system would say that they did not want to work with the coalition anymore. It was easy to be reactionary and to feel as if the entire effort was going to fall apart. She had to keep reminding herself that every organization involved had a self-interest in the outcome, and it made no sense for them to walk away. Being faith-based, GCC opens all activities with a prayer and that helps everyone to settle down and focus on the wider good in that moment, rather than their ego or self-interest. Angeloe Burch of the Interdenominational Ministerial Alliance asked about the involvement of African American churches. Weinberger replied that the coalition includes a PREPUBLICATION COPY: UNCORRECTED PROOFS

FAITH–HEALTH COLLABORATION ON HEALTH POLICY 4-9 number of African American churches. She acknowledged that there is somewhat of a political split because some of the churches do not want to ally themselves with GCC. She observed that the pastors who do work with GCC tend to be on the younger side and see this kind of coalition as very powerful because it is interfaith. Burch questioned why this might be the case, suggesting that African American and Latino pastors are often wary of Caucasians coming into the community trying to help. He emphasized the need to engage the African American and Latino pastors at the start, rather than later when organizers realize there are few people of color at the table. Weinberger agreed and noted that of the three health care cochairs in GCC, two are African American. BOX 4-1 Key Points Made by Individual Speakers • Innovative interventions are needed for patients who have essential health needs that are not necessarily traditional health care needs. Community health is broader than health care. (Cohen) • Although there is a lot of division and partisanship around health care, there is alignment around wanting individuals and communities to be healthy. (Cohen) • The combination of tight budgets and changes to health care payments is forcing creativity, which is good for partnerships. (Cohen) • A lesson of community organizing is to always be looking for opportunities to effect change. (Weinberger) • Public relationships are vital to effecting change, and faith-based organizations might be the only organizations in town that can bring all of the stakeholders to the same table. They can help partners focus on the wider good, rather than their ego or self-interest. (Weinberger) • It takes a willingness to understand power, and how to wield it when necessary, in order to win. Power is not a dirty word. (Weinberger) NOTE: This list is the rapporteur’s summary of the main points made by individual speakers and participants (noted in parentheses), and does not reflect any consensus among workshop participants, or endorsement by the National Academies of Sciences, Engineering, and Medicine. PREPUBLICATION COPY: UNCORRECTED PROOFS

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On March 22, 2018, the National Academies of Sciences, Engineering, and Medicine convened a workshop to examine the collaboration between the faith and health sectors, and to highlight the unique opportunities these collaborations offer to help improve population health outcomes. This publication summarizes the presentations and discussions from the workshop.

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