Month: February 2023

By Jennifer Horton

The U.S. has a shortage of affordable and available rental homes for extremely low-income households — those whose incomes are at or below the poverty guideline, or 30% of their area median income, whichever is higher. There are just 36 affordable and available rental homes for every 100 low-income households — a deficit of 7 million homes nationwide. For extremely low-income renter households, 71% are severely cost burdened, meaning they spend more than half of their income on housing, making it more difficult to afford healthy food and health care.

In 2022, a person working full time in the U.S. needed to earn $25.82 an hour on average to afford a modest, two-bedroom rental home — $18.57 higher than the $7.25 federal minimum wage. In some states, the two-bedroom housing wage is even higher — up to more than $40 an hour. The average worker earning minimum wage would need to work almost 96-hours-per-week to afford a two-bedroom rental at the national average fair market rent of $1,324.

With the rapid increase in home and rent prices over the last several years, millions of low-income renters struggled to afford their rent even before the pandemic. The economic impacts of COVID-19 exacerbated the problem even further as low-wage workers lost income. While temporary eviction moratoriums and Treasury Emergency Rental Assistance programs kept millions of disadvantaged renters housed during the pandemic, as these programs end, the need for affordable housing for the lowest-income renters will not.

The pandemic also had a negative impact on the nationwide poverty rate, with the number of people living in poverty increasing by 3.3 million in 2020, leaving 11.4% of the population in poverty, struggling to avoid basic necessities like housing and putting them at risk of homelessness.

As of January 2020, the most recent date for which comprehensive data is available due to disruptions in surveying during the pandemic, there were 580,466 people experiencing homelessness in the United States. While this number has been steadily increasing since 2016, some subgroups of the overall homeless population, such as homeless veterans and homeless families with children, have seen significant reductions in homelessness. This is due, in part, to increased attention and resources, showing that reductions in homelessness are possible.

Rates of homelessness vary widely across the states. New York state has the highest rate at 46.9-per-100,000, while Mississippi has the lowest at 3.7-per-100,000. In some instances, the high rates could be attributed to high housing costs, while in others it could be attributed to high rates of poverty. Such nuances facing each state suggest a need for a variety of solutions.

Legislators have taken a range of approaches to address homelessness and increase affordable housing, including transitional housing, changing zoning laws and streamlining the development review process.  

Homelessness

Housing First
Housing First (HF) is an evidence-based approach to ending homelessness that provides people with immediate access to housing and support services without preconditions. Based on the belief that people need to have their basic needs met before addressing other issues like employment or substance abuse, the HF model emphasizes client self-determination within a trauma-informed, harm-reduction framework. The model has been successful when applied to a range of circumstances, including families who became homeless due to a temporary crisis and chronically homeless individuals. The U.S. Department of Veterans Affairs cites HF as a best practice and uses it in its Housing and Urban Development Veterans Affairs Supportive Housing (HUD-VASH) program which currently serves almost 90,000 veterans across the U.S.

There are two common models that utilize the HF approach depending on a person’s needs and whether they need long or short-term assistance. One model, permanent supportive housing, provides long-term rental assistance and supportive services to individuals with chronic illnesses, disabilities, mental health issues, or substance use disorders who have experienced long-term or repeated homelessness. A second model, known as rapid re-housing, provides short-term rental assistance and services to help people obtain housing quickly and increase self-sufficiency so they can remain housed.

Research indicates people assisted through the HF model access housing faster and are more likely to remain housed, with studies showing a one-year housing retention rate ranging from 75-98%. The approach tends to also be cost-efficient, generating savings through reduced usage of emergency services, hospitals, jails and emergency shelters.

Through city council resolution number 20110728-031 passed in 2010, the city of Austin, Texas, directed the city manager to develop a comprehensive strategy to construct and operate permanent supportive housing units and prioritized the city’s affordable housing resources, including local and federal funding, for permanent supportive housing (PSH). Elected officials also pledged to create 350 housing units for those most vulnerable to homelessness by 2014. The goal was surpassed, leading to the passage of resolution number 20141002-043, which established PSH as the primary intervention to end homelessness in the city and set another target of 400 additional PSH units in four years.  

California SB 1380 (2016) required all housing programs in the state to adopt the HF model, which it defined with specific core components. 

Transitional Housing
Some states have paired rapid re-housing with Critical Time Intervention (CTI). Referred to as Critical Time Intervention for Rapid Re-Housing (CTI-RRH), the evidence-based model provides support for vulnerable individuals during periods of transition by facilitating housing stability, community integration and continuity of care. CTI has successfully supported a return to housing for people in a variety of situations, including those with serious mental illness, veterans and others experiencing homelessness.

Several states have implemented CTI-RRH or some form of transitional housing to prevent homelessness in vulnerable populations.

California CA A 592 (2021) requires a transitional housing unit with a host family to include supervised transitional housing services provided by the licensed transitional housing placement provider and authorized a transitional housing placement provider to provide supportive services to a non-minor dependent placed in a certified family home or resource family of a foster family agency if that provider signs a memorandum of understanding with the foster family agency.

In 2010, Connecticut leveraged the American Recovery and Reinvestment Act’s Homelessness Prevention and Rapid Re-Housing Program (HPRP) to expand its rapid re-housing services, re-housing 3,100 people in more than 1,600 households in three years. The Connecticut Coalition to End Homelessness looked at the outcomes for these 3,100 people and found that 82% of singles and 95% of families had not returned to a state shelter three years after being housed. Currently, the state’s Department of Housing’s rapid re-housing programs are conducting a pilot program directed by the National Alliance to End Homelessness and the Center for the Advancement of CTI implementing CTI as a way to prepare individuals for independent living.

The state’s Department of Housing was established by Public Act 12-1 as the lead agency for all housing-related matters, including housing development, community development, housing affordability, and individual and family support programming, and provides assistance funds to a wide variety of programs utilizing rapid re-housing and other methods to address homelessness.

Hawaii S 471 (2019) appropriated funds to homeless programs, including outreach, rapid re-housing, the Housing First Program, family assessment centers, law enforcement-assisted diversion programs, and coordinated statewide homelessness initiatives, and established and appropriated funds for a long-term rental assistance pilot program for certain categories.

New Hampshire HB 400 (2017) instructed the department of health and human services to develop a 10-year plan for mental health services, the findings of which were released in 2019 and led to the launch of a statewide CTI program designed to connect people discharging from psychiatric hospitalization with services and supports. The nine-month, no-cost program provides participants with help securing housing, finding employment, and arranging additional mental health and social supports to improve quality of life and prevent homelessness and/or readmission.

The Veterans Administration (VA) has developed a CTI toolkit to assist in the implementation and evaluation of CTI across 32 sites in seven regions over four years. While homelessness has been trending upward in recent years, veteran homelessness has gone down by 47% since 2009. Three states and 83 communities have announced they’ve ended veteran homelessness, defined as having systems in place that ensure homelessness is prevented or is rare, brief and occurs only once.

Washington WA H 1860 (2022) seeks to prevent homelessness among persons discharging from inpatient behavioral health settings, in part by mandating housing-related care coordination services.

West Virginia WV H 3304 (2021) authorized the Division of Corrections and Rehabilitation to establish a Reentry and Transitional Housing Program.

Affordable Housing

Zoning Changes to Facilitate the Construction of Higher-Density Housing
Florida Statute 163.31771 (2021) allows localities with a shortage of affordable rental housing to adopt an ordinance permitting accessory dwelling units in single-family residential areas to increase the availability of affordable housing for low and moderate-income individuals.

Massachusetts State Statute 40B enables local zoning boards of appeals to approve affordable housing developments under flexible rules if at least 20-25% of the units have long-term affordability restrictions. 

Oregon HB 2001 (2019) implemented state-level legalization of “missing middle” housing. It expands the areas across the state available for duplex construction.

Streamlining Development Review Process
California Assembly Bill 2162 (2018) encourages the production of supportive housing statewide by mandating streamlined and expedited approval for such projects and the elimination of minimum parking requirements for developments located within half a mile of public transit.  

Other
Iowa House File 772 (2019) amended the administration of the workforce housing tax incentive program, allocating $10 million to qualified housing projects in small cities located in counties that have been declared a major disaster and where individuals are eligible for federal individual assistance.  

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Additional Resources

• State by State Analysis of Tools to Address Housing Affordability 
• National Conference of State Legislatures Housing and Homelessness Legislation Tracker
• National Alliance to End Homelessness: Congressional Legislation to Address Homelessness and Low-Income Housing
• National Alliance to End Homelessness Rapid Re-Housing Resources

By Jennifer Horton

Location can be crucial in determining a patient’s experience with the U.S. health care system. For example, residents of Texas are six-times more likely to be uninsured than those living in Massachusetts. In Utah, the rate of premature death from preventable causes in adults under 75 is half that of West Virginia.

The Commonwealth Fund’s Scorecard on State Health System Performance, which provided the aforementioned data, assesses state performance across several measures, including overall health outcomes, access and affordability, and prevention and treatment. The 2022 scorecard was the first to assess the impact of the COVID-19 pandemic on Americans’ health.

While all states suffered, the impact of COVID-19 depended on how stable a state’s public health foundations were before the pandemic began. States with stronger health systems, indicated by low uninsured rates, strong primary care capacity and effective care management, experienced lower rates of preventable deaths due to COVID-19 and had healthier populations. The health of a population is marked by rates of premature death, health status, health risk behaviors and other factors.

To address health care deficits — some that predated the pandemic and those that were created by it — states are taking a wide variety of policy approaches, including expanding access to care, improving maternal health outcomes, reducing the cost of prescription drugs and expanding direct care.

Access to Care 

Opponents of Medicaid expansion object to the lack of a work requirement for eligible parties and worry an expansion could impact a state’s budget, among other concerns. The federal government covers 90% of the cost of Medicaid coverage for adults under the expansion, leaving states to pay the remaining 10%. The American Rescue Plan Act of 2021 offered states an additional fiscal incentive to implement the expansion by increasing the federal match to 95% for two years, an estimated net benefit of $9.6 billion to the eligible states, but no states accepted the offer. Proponents pushed back on economic concerns caused by the potential influx of federal dollars on local economies, citing analyses conducted by expansion states suggesting the expansion actually reduced total state spending.

In 2014, the Affordable Care Act gave states the option to expand Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level and provided states with an enhanced federal matching rate. As of December 2022, all but 11 states had adopted the expansion. An analysis by the Kaiser Family Foundation revealed states that adopted the expansion experienced budget savings, revenue gains and overall economic growth. Research indicated the expansion also improved access to care, affordability, utilization of services and led to coverage gains and reductions in the number of uninsured citizens, particularly among low-income and vulnerable populations.

While the debate continues, several states took action to expand Medicaid or make enrollment easier:

• In January 2016, Gov. John Bel Edwards signed executive order JBE16-01, instructing the Louisiana Department of Health and Hospitals to expand Medicaid to adults who are ages 19-64, have an income less than 138% of the federal poverty rate, do not already qualify for Medicaid or Medicare, and meet the citizenship requirement. The state’s Medicaid Expansion Dashboard compiles data on the order’s impact on residents and access to health services.
• Maryland Senate Bill 802 (2019) established the Easy Enrollment Program, allowing state residents to indicate their interest and facilitate enrolling in Medicaid, the Children’s Health Insurance Plan or subsidized exchange coverage by checking a box on their tax return.
• Utah House Bill 3 (2022) directed $3 million to establish the One Utah Health Collaborative, an initiative designed to reduce health care costs, improve health outcomes, close gaps in health care and improve quality of life through a public-private partnership centered on patient needs.
• Washington Senate Bill 5526 (2019) established “Cascade Care,” a semi-public option health care plan offering premium subsidies to allow individuals whose incomes are less than 500% of the federal poverty level to purchase individual market coverage on the state health benefit exchange.

Maternal Health 

Roughly 700 women die each year from pregnancy-related causes in the U.S., resulting in the highest maternal mortality rate among all developed countries. In 2018, the latest available year of data, the national average was 17.3 pregnancy-related deaths per 100,000 live births. But the averages cover up crucial differences in sub-populations: Black people are three times more likely to die in childbirth than white people. Some states have taken steps to address racial disparities in maternal mortality rates:

• California Senate Bill 464 and Maryland House Bill 837 require health care professionals involved in perinatal care to undergo an evidence-based training program.

States have approached improving the maternal mortality rate from a variety of angles, including doula care, home visiting programs and workforce training.

Research shows pregnant people who receive doula care are more likely to have healthy birth outcomes and positive birth experiences. Medicaid reimbursement for doula services can increase access to health care and strengthen birth outcomes for Black people experiencing pregnancy.

• Minnesota (SPA 14-07, 2014), New Jersey (SPA 20-0011, 2021), Oregon (SPA 17-0006, 2017) and Virginia (SPA 21-0013, 2021) reimburse doulas as an optional Medicaid benefit. A chart summarizing the components of each state’s Medicaid doula benefits can be viewed here.

Home visiting programs, which helps deliver babies and connect pregnant people and new parents to social, health and educational services, are another strategy for improving health outcomes. Studies show the programs can reduce child abuse and domestic violence and improve maternal and child health outcomes while also delivering long-term cost savings. Federal funding is available to support home visiting services in the U.S., with at least 20 states using Medicaid to support their programs.

• New Jersey Senate Bill 690 and Oregon Senate Bill 526 established voluntary statewide home visiting programs providing free services to support healthy child development, strengthen families and provide parenting skills. 

Prescription Drug Pricing 

At least twenty states have enacted co-payment caps to reduce the cost of insulin, with most caps only applying to people with private insurance. Minnesota is one of the only states with a co-payment cap for the uninsured and requires insulin manufacturers to provide universal discounts. Other states take different approaches to help make prescription drugs like insulin more affordable, as shown in Table 1 below.

TABLE 1

State Actions To Make Prescription Drugs More Affordable

State	Bill or Action	Status	Summary
Alabama	House Bill 249	2021 Enacted	Required a health benefit plan that provides coverage for prescription insulin to cap the total amount of any cost sharing or co-payment, without regard to the policy deductible, regardless of the amount or type of insulin needed.
California	State Budget	2022-2023 Enacted	Allocated $100 million to launch an effort allowing the state to contract and make its own insulin at a lower price.
Illinois	House Bill 119	2021 Enacted	Formalized the legal process for donating unused prescription drugs to certified pharmacies or health departments for reuse by eligible populations.
Kentucky	House Bill 95	2014 Enacted	Capped the cost-sharing requirements for prescription insulin.
Louisiana	Senate Bill 165	2014 Enacted	Required health benefit plans that cover prescription drugs and use a specialty drug tier to cap copayments or coinsurance.
Maryland	House Bill 761	2014 Enacted	Capped copayments and coinsurance for specialty prescription drugs.
Minnesota	House File 3100	2020 Enacted	Created the Insulin Safety Net Program, allowing eligible individuals to receive a free 30-day supply of insulin in an emergency and caps the insulin copayment for a 90-day supply at $50.
Oklahoma	House Bill 1019	2021 Enacted	Capped cost sharing for a 30-day supply of covered prescription insulin. The bill also requires insurers to provide coverage for equipment and supplies for the treatment and management of diabetes.

Direct Care Direct Care Workers, a broad umbrella term that includes personal care aides, home health aides and nursing assistants, who support older adults and people with disabilities, comprise the largest workforce in most states and provide essential support to millions of people in a variety of settings. Currently, both a worker shortage and an inability to meet the growing demand for long-term services and support hinders the field’s growth. States approach the long-term care crisis from a variety of angles:

• New Jersey Senate Bill 3847 (2020) established a program allowing a family member or approved individual of an enrollee in Medicaid or NJ Family Care who is under 21 years old to be certified as a certified nursing assistant and provide services to the enrollee under the established reimbursement rates.
• Washington state’s Long Term Services and Supports Trust Act (2019) established the WA Cares Fund, a long term care insurance benefit for all eligible Washington state residents to address the future long-term care crisis. The law provides individuals with access to a lifetime benefit amount up to $36,500.

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Additional Resources

• National Conference of State Legislatures Prescription Drug State Bill Tracking Database 
• NCSL Health Innovations State Law Archive Database 
• National Academy for State Health Policy: State Legislative Action to Lower Pharmaceutical Costs 
• NCSL Health Care Policy Toolkit for State Legislators