From Four Years of Listening, Following the Money, and Building Trust
As a fiscal justice organization rooted in municipal finance and community needs, Activest daylights the bias in financial systems that govern community access to capital. Shaped by decades of structural racism and intentional disinvestment, these systems continue to produce racially disparate outcomes because they are working as designed. Capital flows to the easiest lifts. Property is valued over people. The result is the under-resourcing of essential community needs across our country: care deserts in Black and brown neighborhoods, and a maternal health crisis that is a direct consequence of how money flows away from communities that need it most.
We completed two phases [1, 2] of fiscal justice research documenting that landscape in New Jersey. Municipal finance tools are administered in ways that reproduce the very exclusion they were designed to correct. Take Low-Income Housing Tax Credits (LIHTC): competing for those credits in New Jersey requires two successful developments already on record. Currently, only one Black developer in the state has cleared that bar. The financing architecture is not accidentally exclusive—it is structurally so. The same logic that shuts Black developers out of affordable housing shuts community-rooted maternal health organizations out of the capital they need to build and sustain the infrastructure their communities depend on.
What follows here is our follow-up to those phases of work in New Jersey: a Fiscal Justice Deal Book mapping a practical pathway to resource wellness across the social determinants of health for Black and Brown communities. We crafted this work in New Jersey but it resonates with the settings of Black and brown life across the United States. We have heard the desire and momentum toward community autonomy in birth justice in Mississippi, in North Carolina, and from our colleagues supporting it across the country. This is a template we are eager to share, in the hope that it can catalyze opportunities in your community. Are you operating a community healthcare practice that needs stable revenues and expanded facilities that serve the upstream needs of your people? Please keep reading!
The Harm We Must Undo
For Black Americans, New Jersey shares the highest maternal mortality rates in the country with Georgia, Mississippi, Arizona, Montana, and New York. And New Jersey also shares the largest percent increases in Black maternal mortality in recent decades. The other states with increases over 93% were Louisiana, Georgia, Arkansas, and Texas. Obstetrical units dwindled for decades—366 shuttered between 2003 and 2013 alone. In NJ’s 2024 Hospital Maternal Care Report Card, 55% of all births were to non-white parents. Non-Hispanic Black birthing parents had the highest rates of severe maternal morbidity and obstetric hemorrhage. These are not statistics about individual risk, but rather outcomes of policy choices about where capital flows, which communities receive infrastructure, and whose lives are treated as worth protecting.
Sources: A. J. McGregor et al., “Obstetrical Unit Closures and Racial and Ethnic Differences in Severe Maternal Morbidity in the State of New Jersey,” 2021. | Hoyert DL. Maternal Mortality Rates in the United States, 2023. NCHS Health E-Stats. 2025. | Activest: NJ Fiscal Justice Credit Analysis. March 2025
The New Jersey Reparations Council’s 2025 report, For Such a Time as This, situates today’s maternal outcomes in the long history of structural disparities. Today, more than 90% of pregnancy-related deaths in New Jersey are preventable. We are not confronting an intractable problem. We are confronting a failure of will and coordination. And it is needlessly expensive to the community and state. Consider how in 2019 alone, the national cost of maternal mortality was estimated to be $32 billion. If Black infant mortality were reduced to the same frequency as white infant mortality, it would generate $206 million in additional personal income flowing through New Jersey families—every single year, compounding indefinitely. With its prominent maternal mortality disparities, New Jersey is continually losing community wealth that could instead be growing family, neighborhood and municipal thriving.
A New Frame for Economic Development
We posit a new frame for economic development, one structured around inter-generational family development. Where women and birthing parents start from a healthy and thriving place long before they are pregnant. A place of economic security for them that guarantees they are not falling financially when they choose to have a baby. And that security holds families, families which hold neighborhoods, neighborhoods which hold a city. And the community clinic can be a hub that sponsors this vision. A clinic that serves residents in a breadth of basic safeties: maternal and infant wellness, safe food access, stable and safe housing, child care, elder care…meeting the specific needs of those it serves and growing a diversity of revenue streams that prevent it succumbing to austerity or worse.
Supermarkets, hospitals, schools, and universities have always been the original impact investments—but they have never been invested in equitably; instead, capital flowed toward communities where wealth already existed, compounding advantage rather than correcting it. The traditional maternal care financing model is broken. Reimbursement structures are fractured and insufficient. Federally Qualified Health Centers (FQHCs) operate on thin budgets and cannot absorb more debt. And when institutions do come to the table, prevailing economic development norms prioritize property over people. This is why clinics are closing—not because communities don’t need them, but because the systems funding them aren’t prioritizing them as essential long-term community infrastructure.
The revenue puzzle at the center of maternal care makes this work urgent. A freestanding maternal clinic cannot be profitable on its own while delivering the time-intensive, doula- and midwife-supported care that actually saves lives. And the solution is clearly not the status quo of operational austerity, it is innovation. And the innovations come through community ownership and program-driven financing: merging programming and financing so that every social determinant of health—food access, child care, and housing stability—becomes not just a service but a revenue stream that benefits the wellness center. Ownership that bypasses extraction is a primary design principle behind the community wellness hub model described here.
Community Ownership as Sacred
“We need to get things off the ground—but sustainability means looking for resources outside of grants, diversifying revenue, and building real organizational capacity. For the folks who are able to [issue a] bond: how can you be the guarantee? How can you see the value in what they are doing and take on risk through patient capital to actually create a proof of concept?”
— Community development corporation executive director, February 2026
The Fiscal Justice Deal Book for New Jersey was undertaken in the hopes of identifying an exemplary project that can grow fiscal justice on the ground in real life. The truth is that a myriad of such projects already exist—in efforts to control land, prevent displacement, and restore harmed people to safety, wellness, and economic dignity—projects like Back in Our Hands in Trenton. What usually limits their success is the failure of institutions to endorse their independence, fund them amply and persistently, transfer ownership to them, protect them from predation, and craft policy that ensures their future.
A successfully redeveloped property, even one that leases to community-serving organizations, cannot address the health and economic inequities that communities experience. True transformation requires reparative capital to flow into families, neighborhoods, and the organizations that serve them, without the types of punitive austerity and debt that strain current and subsequent generations’ economic foundation. It requires enabling community flourishing without sparking the kind of development that displaces the very people who have carried these communities through the hardest times. In brief, the people need to own it and institutions need to coordinate to facilitate that.
Revenue Streams That Sustain the Model
Community wellness hubs are envisioned to generate multiple, stable revenue streams that reduce dependence on any single funder and protect against austerity. With each of these programs, upstream challenges faced by community members is addressed directly: food insecurity, housing insecurity, inaccessible child care. And with each a new revenue stream is threaded into wellness center operations. Sometimes these are competitive-to-market charges or leases, sometimes they are subsidized. But in each the wellness center can rely on steady cash flow that is not tied to a grant cycle.
Four Project Archetypes
In the Fiscal Justice Deal Book we highlight 4 archetypes of wellness hub projects. These, and the example capital stacks for each, are meant to cover a breadth of project circumstances directly relevant in real estate development, economic and community development, and nonprofit or CDC management. A piece of the puzzle that can be leveraged in any case is public and faith institution property property. Across New Jersey’s highest-need cities, there are more than 1,400 foreclosed or tax-lien properties and 2,500 vacant land parcels owned by public agencies. These could be positioned directly for public benefit as wellness hubs. And Trenton’s Back In Our Hands is a prime example of a faith institution supporting a wellness center with its land.
TYPE I: LONG-TERM, VALUES-ALIGNED GAP FINANCING
This type of project centers on an existing wellness hub operator and program with control of a property that needs to be redeveloped. They are already substantially financed but need gap funding to launch facilities expansion, cover debt service until revenues flow, or – critically – to expand staffing to carry project management.
TYPE II: ADD-ON / COMPLEMENTARY EXPANSION
This type has an existing community health facility expanding space to include maternal and infant services, as well as space for entwined services like child care, affordable housing, pharmacy, fitness centers and leasing for aligned institutional anchor tenants. They are going to build a new wing or building to expand an existing facility.
TYPE III: ADAPTIVE REUSE / BROWNFIELD
This type of project applies when a redevelopment or improvement authority (or a community clinic operator) seeks to redevelop abandoned structures converted into community-owned wellness hubs, using Federal Historic Tax Credits to offset remediation. We look to the redevelopment of the Roebling properties in Trenton as a primary example, particularly with regard to its part-owner occupant, the Trenton Health Team (THT). THT owns a prominent space within the redeveloped Roebling factory buildings, and also owns a community conference space that provides THT a revenue stream from rents.
TYPE IV: GROUND-UP CONSTRUCTION
This type relies on a community health center operator’s access to publicly-owned vacant land for a newly-constructed wellness hub. A payment holiday is built in until revenues stabilize. In New Jersey, the City of Salem is an excellent location for Type IV since the City has started a land bank in partnership with the Cumberland County Improvement Authority and controls hundreds of properties. And in East Orange, the municipality controls more than 200 vacant and foreclosed parcels. New Jersey as a whole benefits from statewide land bank enabling legislation for municipalities.
We have included example capital stacks for each of these types at the end of this piece. Before getting to those, it’s important to address partnerships and the players needed to pull this off.
A Table Built for This Moment
“How can [philanthropy] and Activest become the de-risking entity? There is a moment of political will right now. The Economic Development Authority, Home Mortgage Finance Agency, and Division of Community Affairs have credit ratings—they are guarantors for communities without access. The question is, who holds the strategic investment fund, and who is willing to drive the bus?”
— From Activest’s workshop in Trenton, February 2026
Community wellness hubs do not fit neatly into existing funding categories. They are not revenue-driven enough for traditional real estate finance. Too cultural for federal health grants. Too capital-intensive for philanthropy alone. Too community-owned for conventional bond markets. This is precisely why building them now requires key partners at the table to act. Here is a vision of the key partnerships we think can do this work in New Jersey communities, but also across the U.S.
BIRTHING JUSTICE AND MATERNAL CARE PRACTITIONERS
The primary leadership for developing wellness hubs are the people currently developing and running primary care, maternal and infant care, and birthing clinics in their communities. No one knows better the current pain points in funding and operations, or sees more clearly the influence of social determinants of health on birthing parents and their babies. Important challenges they encounter need to be addressed first. Among them are how to add staffing capacity that can hold and successfully implement a property development project, without drawing time and resources from caring for their community. Also, funding has to be flexible, low-cost, and patient to ensure debt doesn’t threaten their survival before a new pharmacy, child care center, or collection of affordable apartments starts generating revenues. The extractive nature of debt is what we are aiming to break here, after all.
PHILANTHROPIC FOUNDATIONS
The most consequential design choice in this entire financing structure is the first-loss guarantee provided by a philanthropic foundation. In our New Jersey case, the Robert Wood Johnson Foundation is a very visible and capable candidate. Without the first-loss guarantee, the capital stacks for Black-led CDCs like Greater Mt. Zion remain unbankable. With it, the perception of risk changes, as the philanthropic foundation’s risk profile stands in for that of the bond issuer but also the community wellness hub borrower. In this way an entity like the Robert Wood Johnson, Ford, Kresge, William K. Kellogg or other Foundation can leverage its substantial assets and Program Related Investment (PRI) funds to guarantee or de-risk the community organization receiving the funding to establish a wellness hub under flexible and supportive terms.
IMPROVEMENT AND REDEVELOPMENT AUTHORITIES
County improvement and redevelopment authorities (sometimes operating regionally) exist to redevelop properties for public benefit. Often they are focused on managing and maintaining key pieces of civic infrastructure like solid waste facilities. But authorities they can do much more, including housing development, economic and business development campuses, green energy infrastructure and health facilities. Some authorities can operate outside their local county jurisdictions as well, if contracted by another local government for a particular project. In New Jersey, the Cumberland County Improvement Authority has done a variety of these kinds of projects.
CREATIVE CAPITAL MANAGERS
Monge Capital and Orchid Capital Collective have been involved in our efforts in New Jersey. Each understand the mechanics of finance and the operational challenges faced by community programs. Identifying partners like these is essential for community healthcare pracitioners to deepen their understanding of real estate finance, share key project development roles, and leverage their capacity to attract other institutional credits and investment.
STATE HEALTH DEPARTMENTS AND ADVOCACY GROUPS
In New Jersey there are statewide advocacy and perinatal care networks like Perinatal Health Equity Initiative, the Southern New Jersey Perinatal Cooperative and others offering direct services, trainings, and advocating for policies and programs. They are each essential for an equitable future. But New Jersey also has benefited from years of strong political will to improve maternal and infant outcomes, particularly from the governor’s office while Tammy Murphy was first lady from 2018 to 2026. This led to a prevalence of deeper understanding across funders, government offices, nonprofits and service providers of the structure of the care industry and state roles in it. It also led to the creation of a Maternal and Infant Health Innovation Authority, with lateral ties to the Economic Development Authority.
The Maternal Health Infrastructure Funding Model: A 4-Level Capital Stack
Below is an example capital stack we crafted to illustrate the roles each participant plays in funding a community wellness center. Each level of funds and finance activates the next—creating a circular economy where state innovation, community trust, and foundation credit unlock the potential to fund service and care delivery.
The Philanthropic Enhancement Dividend
The most consequential design choice in this entire financing structure is the RWJF first-loss guarantee. Without it, the capital stacks for Black-led CDCs like Greater Mt. Zion remain unbankable. With it, the perception of risk changes, as the philanthropic foundation’s risk profile stands in for that of the bond issuer but also the community wellness hub borrower. In this way an entity like the Robert Wood Johnson, Ford, Kresge, William K. Kellogg or other Foundation can leverage its substantial assets and Program Related Investment (PRI) funds to guarantee or de-risk the community organization receiving the funding to establish a wellness hub.
A Network of Community Wellness Hubs
“We need to move away from surviving childbirth and toward assets and thriving. Wellness isn’t just a birthing clinic—it’s mentally, physically, and spiritually caring for the whole person and family through housing, food access, and workforce development. This isn’t a poverty issue. It’s about how social determinants of health intersect and have profound, lifelong consequences. Middle-class families are being squeezed too.”
— Maternal care practitioner in New Jersey, February 2026
Activest envisions a statewide network of community-owned wellness hubs growing year after year, catalyzed by an initial bond issuance from an improvement or redevelopment authority. This bond is structured to deliver annual tranches of financing to sites in order of readiness. In this New Jersey case, the Cumberland County Improvement Authority or NJ Redevelopment Authority are very visible and aligned potential issuers. But similar entities exist in states and localities across the country. A benefit of it coming from one if these entities is their ability to offer below-market rates and rents on the community side, since they operate as public entities developing public property.
With this template, it is possible that individual local projects may benefit from a new, more generous funding and revenue structure. Perhaps five or ten can be identified across a state to ensure resilient community care in locations facing the hardest maternal and infant wellness disparities. Further still, we look at the revenue challenges faced by Federally-Qualified Health Centers, or FQHCs, across the country and believe so many of them can benefit from the leap to this blend of caring community services and the revenues associated with them. Not unlike the network of Public Housing Authorities in the U.S., FQHCs also find themselves navigating austerity as they deliver the most essential support people need.
Staging a Change of the System
The disparities in health, wealth, and well-being that community wellness hubs are designed to address were not produced by accident—they were produced by policy, by deliberate disinvestment, by financing systems engineered to exclude. Closing a gap that took centuries to open requires more than incremental adjustment to existing tools. It requires solutions that are themselves unprecedented: new financing structures that create ownership not extraction; unlikely cross-sector partnerships; and a willingness to treat community health infrastructure with the same institutional resolve we have historically reserved for highways and stadiums.
This is why the community wellness hub model cannot be evaluated by the standards of conventional real estate development or traditional healthcare financing. It emerges from the intersection of both and exceeds what either framework, on its own, was built to support. The structural racism embedded in municipal finance, in tax credit allocation, in Medicaid reimbursement policy, in property values in Black and Brown neighborhoods—each element amplifies wealth and wellness gaps across generations. Reparative efforts must be equally layered, equally intentional, and equally long-term in their thinking.
We see each new community wellness hub belonging to a long-term arc dedicated to structural change: the adoption of new economic development practices and, ultimately, persistent guaranteed state funding for the reparative work of community wellness hubs.
TIER 1, SHORT-TERM:
A local or regional improvement authority or redevelopment authority serves as bond issuer, leading the field as a mission-aligned and flexible community partner with existing relationships and goals with regard to Black and Brown developers and community wellness. This issuer sets the standard with the issuance of a series.
TIER 2, MEDIUM-TERM:
A state agency such as an economic development or redevelopment authority issues a bond as a follow-up when the initial series is complete. In the time between, partners in this effort coordinate with state agency to cultivate the next stage and demonstrate the efficacy of the bond.
TIER 3, LONG-TERM:
Once the state agency has also participated and there is a track record of impact in communities, ongoing funding for community wellness hubs is written into the state budget as a recurring line item.
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This framework intends to center families and deliver lifesaving care and services where they need them most. When we talk about closing the maternal and infant health gap, we are talking about specific mothers in Trenton, in East Orange, in Salem and in communities across the US. Women who are three times more likely to die in childbirth than their white counterparts. Current systems that are supposed to support them were not designed, funded, or programmed to prioritize their short- and long-term well-being.
A state-supported architecture has the power to change this lived experience for mothers and infants of color—not through another study, another pilot, or another demonstration that loses momentum when a grant period ends. Together, we can build the infrastructure, community ownership, and an innovative financing model that is innovative, reparative, and delivers the types of programming and services that moms need.
If you’re interested in sharing knowledge, or connecting this vision to your community please reach out to us through our website. And if you want to get a glimpse of community wellness centers moving toward this vision right now, check out these programs on the web:
South Ward Wellness Center (Newark, NJ)
Back In Our Hands (Trenton, NJ)
Perinatal Health Equity Initiative (East Orange, NJ)
Community of Hope (Washington, D.C.)