Master's Project Title:

Kids Can’t Wait: Using Policy to Address the Social Determinants of Health (Culminating Experience Executive Summary)

MCH Student:

Bridget Roby

Date of Defense:

April 1, 2016


Executive Summary


Nearly 7,000 Minnesota families are currently on the waiting list for public child care assistance (Minnesota Department of Human Services, 2016). Many of them will wait years before they get help (Horowitz, 2016). Without affordable child care, families experience economic hardship, have difficulty maintaining stable employment, and often have to piece together patchwork care arrangements or resort to low-quality care (Children’s Defense Fund Minnesota, 2016). Without child care, many families can become mired in poverty (Greenberg, 2007).

While this might traditionally be considered an issue for social workers or policy makers, there is growing recognition that poverty is also an issue of public health. Research has shown that social determinants of health—including the amount of money, power, and resources that people have—impact the health of individuals and their communities (Adler & Newman, 2002). Minnesota Behavioral Risk Factor Surveillance System data show that people in poverty are almost 9 times more likely to report fair or poor health compared to wealthy people. Similar patterns of gaping health disparities exist in comparisons across race/ethnicity, educational levels, and other measures of socioeconomic status (Minnesota Department of Health, 2014).

According to the CDC, policy is a powerful force shaping the social determinants of health (Centers for Disease Control and Prevention, 2014). As such, policy is also a powerful tool for public health to use to eliminate health disparities. This internship experience for PubH 6049: Legislative Advocacy Skills for Public Health offered me the opportunity to learn how to use policy as a vehicle to address health disparities in Minnesota.


As an intern, I work with the Amherst H. Wilder Foundation and the Kids Can’t Wait coalition to learn how to develop policy and advocacy around affordable child care in Minnesota. The overarching goals of this experience are to (1) better understand the state legislature as an arena for public health practice; (2) develop skills necessary to operate in that arena; and (3) to analyze the emergence, development, and resolution of legislative issues of public health importance. Although my internship with the Wilder Foundation is still ongoing, I have already made significant progress toward these learning objectives.

My day-to-day tasks are performed under the supervision of Wilder’s Policy Director Patrick Ness, a registered lobbyist and Wilder’s single staff member dedicated to policy advocacy. Our work on this issue is situated within the context of the Kids Can’t Wait coalition, an alliance of more than a dozen organizations working together to advocate for accessible, affordable child care. As a first step, I read news articles and issue briefs and interviewed advocates to better understand the issues surrounding child care in Minnesota and the complexities of Minnesota’s public child care programs. To better understand the state legislature as an area for public health practice, I have participated in more than a half dozen coalition meetings; observed a joint Senate committee meeting related to child care and other health and human services; and taken part in six private meetings with legislators asking them to support the coalition policy initiatives this session. I have also developed important skills in the legislative arena through my work creating and organizing coalition documents and campaign plans, working with legislative aids to schedule meetings with legislators, and drafting coalition communications including social media messages and weekly email updates. These experiences have afforded me a deeper understanding of how the legislature—through appropriations for child care assistance and other public programs—plays a powerful role in shaping the social determinants of health. With the legislative session beginning March 8, my work with the coalition will accelerate and adapt as we navigate the complex policy process of an atypically short bonding year session.


The Amherst H. Wilder Foundation is a 501(c)(3) nonprofit organization dedicated to promoting the social welfare of those in the greater Saint Paul metropolitan area with a focus on children and families, older adults, and community engagement and empowerment. Its work can be divided into three main arenas: direct service programs, research, and community initiatives. Wilder’s relatively new and small policy arm falls within the latter. Under the leadership of current President and CEO MayKao Hang, Patrick Ness was hired as Wilder’s first Policy Director in 2012 with the mandate to advocate for policies that benefit the lives of those they serve. With a nearly $50 million budget in fiscal year 2015 and a policy staff of one, policy advocacy remains a relatively small part of Wilder’s work despite its potential for dramatically improving the conditions in which their beneficiaries live—a critical part of the Wilder mission.

Lessons Learned

While my internship with the Wilder Foundation is brief and incomplete, the lessons I have learned so far are significant and enduring. This experience has afforded me an inside view of the political process at the state level, including the pillars of advocacy work, the importance of coalition building for public health, and the protean nature of passing an idea into a bill into a law. I have also come to realize that the world of policy at the state level is relatively small and insular, and that voices for the marginalized—those for whom the social determinants of health pose the greatest threat—are few. This political, economic, and social disenfranchisement, I have come to firmly believe, is the business of public health. As Adler and Newman (2002) purport, reducing socioeconomic disparities in health require policy initiatives addressing the components of socioeconomic status (SES)—income, education, and occupation. The issue of affordable child care cuts across all three dimensions of SES, and is foundational to financial security, employment stability, and family well-being. When children develop in stable, nurturing environments, they flourish in health, in school, and in their careers. As the Harvard University Center on the Developing Child report title affirms, the foundations of lifelong health are indeed built in early childhood (Center on the Developing Child, 2010).


As our understanding of what creates health evolves and expands outside the realm of health care, so too must our public health interventions. According to Frieden’s (2010) five-tier pyramid of interventions for improving health, efforts to address socioeconomic determinants of health— those at the base of this pyramid—hold the greatest potential impact. To make significant, lasting reductions in health disparities, public health should expand its policy research, training, and advocacy so that the health effects of social and economic policy become a natural consideration in policy-making and evaluation. Furthermore, organizations like the Wilder Foundation should amplify the voices of the marginalized by devoting significant resources to public policy advocacy, even if it means creating a 501(c)(4) branch. While undoubtedly challenging, investing in policy and systems change to address the social determinants of health has the greatest potential to benefit the health of those they serve.


My experience with the Wilder Foundation and the Kids Can’t Wait coalition has broadened my understanding of the realm of public health work and incited a passion for public policy as a tool for eliminating Minnesota’s unconscionable health disparities. Fully funding CCAP, while insufficient in and of itself, is a critical step toward reducing the magnitude of inequalities in socioeconomic resources that lead to health disparities, and I have been privileged to learn about and advocate for this step forward at the Minnesota legislature this session.


Adler, N. E., & Newman, K. (2002). Socioeconomic Disparities In Health: Pathways And Policies. Health Affairs , 21 (2), 60-76.

Center on the Developing Child. (2010). The Foundations of Lifelong Health Are Built in Early Childhood. Harvard University.

Centers for Disease Control and Prevention. (2014, March 21). NCHHSTP Social Determinants of Health. Retrieved March 8, 2016, from Centers for Disease Control and Prevention:

Children’s Defense Fund Minnesota. (2016). CHILD CARE. Retrieved March 12, 2016, from Children’s Defense Fund—Minnesota:

Frieden, T. R. (2010). A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health , 100 (4), 590-595.

Greenberg, M. H. (2007). Next Steps for Federal Child Care Policy. The Next Generation of Antipoverty Policies , 17 (2).

Horowitz, B. (2016, March 3). Minnesota Budget Bites. Retrieved March 12, 2016, from Minnesota Budget Project:

Minnesota Department of Human Services. (2016). Child Care Assistance Program . Retrieved March 12, 2016, from Minnesota Department of Human Services:

Minnesota Department of Health. (2014). White Paper on Income and Health. Center for Health Statistics.