National Association of Community Health Centers Issues Public Comment on FEMA Notice

WASHINGTON, Sept. 24 -- E. Benjamin Money, senior vice president for public health priorities at the National Association of Community Health Centers, Bethesda, Maryland, has issued a public comment on the Federal Emergency Management Agency notice entitled "Request for Information: National Flood Insurance Program's Community Rating System". The comment was written on Sept. 21, 2021, and posted on Sept. 22, 2021:

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On behalf of the National Association of Community Health Centers (NACHC), thank you for the opportunity to provide input on the challenges and opportunities of the National Flood Insurance Program's Community Rating System.

For over 50 years, the National Association of Community Health Centers (NACHC) has served as the national membership organization for America's federally qualified health centers (also known as FQHCs or health centers). The nation's 1,400 Community Health Centers serve 28 million people across all 50 states and territories, in both urban and rural communities through 14,500 clinical sites. The majority of health center patients (91%) live below 200% of the federal poverty line; 81% are uninsured or publicly insured. Racial and ethnic minorities comprise 58% of health center patients. Health centers are nonprofit, community-directed provider clinics that serve as the health home for over 28 million people, including 1 in 5 Medicaid beneficiaries and 1 in 3 people living in poverty nationwide. Lower socioeconomic status and limited access to recovery resources are contributing factors to vulnerabilities that exacerbated by flood risk. Health centers respond to their communities' needs prior to, during, and after disasters. Many health center patients live in flood prone communities. Health centers have been on the frontlines of disaster response and have coordinated processes in place to support patients during emergency events. FQHCs are, in part, federally funded or supported through the national Community Health Center Program, administered by the U.S. Health Resources and Services Administration (HRSA).

It is the collective mission and mandate of over 1,400 health centers around the country to provide access to high-quality, cost-effective primary and preventative medical care as well as dental, behavioral health, and pharmacy services and other "enabling" or support services that facilitate access to care to individuals and families located in medically underserved areas, regardless of insurance status or ability to pay. In our current weather environment where an increasing number of natural disasters can be linked directly to our changing climate, the community health center mission of advancing equity in the nation's disaster and pandemic response is now more critical than ever. Since their very inception over 50 years ago, health centers have been central to so many of America's low-income communities, directly in touch with conditions and circumstances at the local level, delivering care and strengthening many of our most vulnerable communities and populations, including communities of color and among special populations - the elderly, homeless and agricultural workers. In good times and bad, health centers provide critical primary and preventive care services, deliver crucial services and supplies, and connect community members with housing, food, and other crucial services.

NACHC appreciates the opportunity to provide comments on the National Flood Insurance Program's Community Rating System (CRS).

Background:

Due to decades of redlining, segregation and other factors have relegated communities of color to environmentally hazardous areas. Many historically black communities have also been developed in flood-prone areas, making risk of total loss from natural disaster high for Black homeowners.

The EPA in their recent report/i on climate change and social vulnerability states that climate change, including current and future sea level rise (SLR), is expected to exacerbate many long-standing inequities that affect socially and economically marginalized groups in the coastal zone. Devastating storms in recent years have provided stark examples of the impacts facing these vulnerable coastal residents, and the long-term consequences for these communities remain uncertain. Minorities, those with low income, people with limited English proficiency, and certain immigrant communities are at increased risk of exposure to flooding given their higher likelihood of living in risk-prone areas and locations with poorly maintained infrastructure. Residents of low-lying affordable housing in the coastal zone tend to be low-income individuals living in old and poor-quality structures, which are especially vulnerable to coastal floods. Additionally, many of these communities are located near toxic waste sites further exacerbating the damage, degradation and danger caused by flooding.

Federal homeownership policies concentrated minority families in neighborhoods where old, poorly maintained homes dominated the housing stock. Redlining and other racist housing policies (many of which are still in existence today) have subsequently resulted in a disproportionate exposure to flooding, diminished home equity and overall economic inequality for Black families. According to the EPA, there is a greater likelihood that socially vulnerable populations live in areas that might be excluded from adaptation if adaptation investments are made solely based on comparison of economic costs and benefits. Additionally, nature-based infrastructure projects, such as those designed to protect against flooding, often exclude socially vulnerable groups and instead end up displacing lower income residents.

Low-income families lack the financial resources to prepare and recover from disasters. Minority homeowners are more likely to take on more debt to purchase homes with lower down payments, resulting in higher debt-to income ratios. Black and Hispanic homeowners also have lower incomes relative to white homeowners, limiting their ability to save and invest. Black borrowers in similar income and credit ranges pay a higher interest rate on mortgages than do Whites making them more housing burdened. Black and Hispanic homeowners also have lower incomes relative to white homeowners, limiting their ability to save and invest. A larger portion of a Black/Latinx homeowner's net worth is held in their home, and they have fewer liquid assets and lower retirement and traditional savings, so they have more to lose if disasters hit. Additionally, socially vulnerable populations are less likely to know their flooding risk and may not be prepared for the damages that their properties could face.

Insurance can provide greater and faster funding than federal aid, but many residents living in lower-income areas pay more a year, on average, than wealthier residents in the same cities.

When flooding occurs, they are least likely to be insured, resulting therefore in greater loss, bankruptcy, and ruined credit. To be eligible for reasonably priced flood insurance through the National Flood Insurance Program (NFIP), the homeowner's community must participate in the program and comply with the minimum standards for floodplain management. Disaster recovery programs are not designed to deliver resources to the most vulnerable first. Current policies can under-compensate low-asset households, effectively widening the racial wealth gap. For many federal programs, post-disaster assistance is based on the appraised value of the home, rather than the cost of repair. The disparity in the appraised values between homes in white neighborhoods and communities of color continues to widen dramatically, despite fair housing laws. As a result, low-income households can be left behind during the eligibility stage of the recovery process because the damage to their homes falls below an eligibility threshold or because their repair costs are underestimated.

FEMA Individual Assistance grants are often insufficient to fund rebuilding, and the appeals process has become increasingly complex and prolonged. FEMA denials for the Individual Assistance Program are higher among low-income households disproportionately impacting communities of color. State and local housing recovery and repair programs utilize federal (HUD) CDBG-DR funds intended to serve the most vulnerable disaster survivors. The process typically takes at least 14-18 months from the time of disaster to the moment when funds start to reach clients; most take 5+ years to reach all eligible survivors. People caught in this limbo are unable to front the costs for repairs and subsequently must pay rent on a temporary home while continuing to pay the mortgage on their damaged home, they are forced to make quick decisions regarding their economic survival, such as whether or not to sell their home in order to regain lost financial assets. These losses, the hassle and frustration of dealing with complicated bureaucratic systems, particularly when many of the necessary documents were lost in the flood, magnify the emotional trauma of flooding, creating significant mental health stresses often leading to fractured families and community social structures. Socially vulnerable groups may be less able to migrate away from adverse climate effects leading to repeated instances of flooding, loss, and trauma.

Changes are needed to the Community Rating System to make it more equitable.

Recommendations:

* Direct significantly greater FEMA resources towards racial and ethnic minority communities historically disadvantaged by decades of discriminatory housing and disaster recovery practices.

* The CRS Program should conduct an equity analysis based on the Centers for Disease Control's Social Vulnerability Index/ii and provide assistance to communities at high risk of flooding to move towards compliance.

* Homeowners in communities with high SVI scores that have a history of redlining or other housing discrimination should be immediately eligible for coverage and should automatically qualify for Class 1 premium discounts regardless of their community's eligibility for NFIP.

The CRS program can provide better outreach to households in disadvantaged communities to encourage participation in the NFIP.

Recommendations:

* Provide plain language and low-literacy materials to Community Health Centers for distribution to persons in high-risk communities for flooding.

* Include Community Health Centers in emergency operations plans, hazard vulnerability analysis, emergency preparedness drills, and incident command structures.

* Consider utilization of community health workers to educate homeowners in high-risk areas about the need and availability of low-cost insurance through the NFIP. CHWs should be trained and employed to assist persons in high SVI flood-prone communities with the application process.

In closing, NACHC implores you to keep at the forefront the patients served by the nation's community health centers. The recommendations provided here will significantly improve the equity of the National Flood Insurance Program's Community Rating System.

We appreciate the opportunity to provide comment on this request for information as you consider next steps. Should you have any questions about our comments, please feel free to contact me at [email protected].

Sincerely,

E. Benjamin Money, MPH

Senior Vice President, Public Health Priorities

National Association of Community Health Centers

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Footnotes:

i/ EPA. 2021. Climate Change and Social Vulnerability in the United States: A Focus on Six Impacts. U.S. Environmental Protection Agency, EPA 430-R-21-003. www.epa.gov/cira/social-vulnerability-report

ii/ Centers for Disease Control's Social Vulnerability Index https://www.atsdr.cdc.gov/placeandhealth/svi/at-a-glance_svi.html

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The notice can be viewed at: https://www.regulations.gov/document/FEMA-2021-0021-0001

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