Impact Investing for Health Equity: Lessons from The California Endowments ACA and Prevention Program Related Investments

The passage of the Affordable Care Act (ACA) in 2010 brought with it countless opportunities, both to expand access to uninsured populations systematically excluded from the healthcare delivery system, as well as to strengthen and innovate beyond the existing system's status quo. The California Endowment became an early champion, providing over $350 million to support ACA implementation with a range of grantmaking strategies focused on outreach and enrollment, health workforce development, and systems change innovations. As part of its effort to understand the impacts of its ACA and prevention-related grantmaking, The Endowment contracted Engage R+D to develop a series of learning products between 2017-2020.In May of 2013, The Endowment's Board approved a $30 million program-related investment (PRI) commitment to expand community health centers in alignment with the foundation's Health Happens in Prevention and ACA campaigns. Program-related investments fall under the broader umbrella of impact investing and include loans, equity investments, or guarantees made by a foundation to advance its charitable mission. These investments seek to strengthen systems infrastructure in ways that benefit populations who are frequently excluded from or have limited access to a variety of critical resources, including quality health care, housing, and healthy food.This learning brief explores the ways in which The Endowment is leveraging this powerful strategy, provide case examples of two federally qualified health centers (FQHCs) receiving PRI financing, and identifies a set of key considerations for other philanthropic organizations interested in tapping into PRIs as a tool to advance health, racial, and economic equity