State Approaches to Address Homelessness and Increase Affordable Housing

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.  

Additional Resources

State Actions to Improve Health Care

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

StateBill or ActionStatusSummary
AlabamaHouse Bill 2492021 EnactedRequired 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.
CaliforniaState Budget2022-2023 EnactedAllocated $100 million to launch an effort allowing the state to contract and make its own insulin at a lower price.
IllinoisHouse Bill 1192021 EnactedFormalized the legal process for donating unused prescription drugs to certified pharmacies or health departments for reuse by eligible populations.
KentuckyHouse Bill 952014 EnactedCapped the cost-sharing requirements for prescription insulin.
LouisianaSenate Bill 1652014 EnactedRequired health benefit plans that cover prescription drugs and use a specialty drug tier to cap copayments or coinsurance.
Maryland House Bill 7612014 EnactedCapped copayments and coinsurance for specialty prescription drugs.
MinnesotaHouse File 31002020 EnactedCreated 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.
OklahomaHouse Bill 10192021 EnactedCapped 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.

Additional Resources

Bridging the Gap Between Policy and Technology: Statewide Data Privacy Laws

By Caroline Wills

The need for critical data privacy and protection laws continues to increase in the digital era, where sensitive information can be compromised due to data breaches or collected by third-party companies without consent.

According to the United Nations Conference on Trade and Development, 137 out of 194 countries have passed laws ensuring personal data and information collected by third-party organizations and individuals is secured and protected. As of January 2023, the United States has no single comprehensive personal data protection law. In absence of a comprehensive federal privacy law, state and federal legislators have passed hundreds of data privacy and protection laws related to sector or specific kinds of data.

Given the rapid pace of digital innovation and advancement, and the relatively slow process of passing legislation, addressing data privacy in the U.S. is often reactive rather than proactive. As conversations about data privacy and the business that collect, store and sell users’ personal data become more common, Americans are growing concerned and confused about the safety and security of their personal data. The PEW Research Center found in 2019 that 75% of Americans think there should be more government regulations on what companies can do with personal data.

What are data privacy laws and why are they important?
Data privacy laws are federal or state laws or regulations that provide a legal framework on the protection and privacy of personal data in how companies, organizations and individuals collect, store and use personal information or data. The Health Insurance Portability and Accountability Act of 1996 and the Family Educational Rights and Privacy Act of 1974 are federally mandated data privacy laws designed to secure and protect personal data within the health care and education sectors. These acts specify how certain data is stored, who has access to it, and who is allowed to release it under what circumstances.

Data privacy laws and regulations are important to secure and protect vulnerable and sensitive personal data and information. With personal data being weaponized and misused, from widespread data breaches to cyberattacks, data privacy and integrity laws are essential to safeguarding the fundamental individual right of privacy and freedom in the digital world. Policy solutions to data privacy concerns in the U.S. include allowing consumers to access and delete their personal information, opt out of having their data sold to third parties, and consumers getting immediately notified after a data breach.

States with Comprehensive Data Privacy Laws
In 2023, there are five states that have passed comprehensive legislation to secure data privacy: California, Colorado, Connecticut, Utah and Virginia.

California:

  • The California Consumer Privacy Act of 2018 (CCPA) allows California consumers to have more control over their personal information collected by businesses. The CCPA allows customers the right to ask companies to reveal any personal information they may have on them, as well as the complete list of third parties with whom their data has been disclosed. CCPA also permits consumers the ability to opt out of the sale of their personal data and delete any personal information the company may have collected. CCPA also ensures that companies cannot discriminate against consumers who exercise these rights.
  • The California Privacy Rights Act (CPRA), also known as Proposition 25, effective January 2023 through the enforcement of the California Privacy Protection Agency, amends and expands the California Consumer Privacy Act. According to PrivacyRight.org, the Consumer Privacy Right Act gives specific provisions to CCPA and consumer data protections including the right:
    • For consumers to correct inaccurate personal information.
    • For personal data collected by firms subject to purpose limitations and data minimization.
      • Definitions:
        • Purpose Limitations — Personal data collected must be for a specific and legitimate purpose or objective and may not be used for a different purpose.
        • Data Minimization — Limiting and restricting data collection for what is necessary for a specified purpose.
    • To opt out of a firm’s uses and disclosures of sensitive personal information — health, specified demographic, personal communication information, geolocation and more.

Colorado:

  • Colorado SB 21-90 (2021) establishes the Colorado Privacy Act within the Colorado Consumer Protection Act, effective July 1, 2023. The Colorado Privacy Act regulates and protects the collection, use and dissemination of a consumer’s personal data collected by companies operating in Colorado. It also authorizes the attorney general and district attorney to enforce the law and violations of SB 190 (2021), and defines terms relevant to the Colorado Privacy Act.

Connecticut:

  • The Connecticut Personal Data Privacy and Online Monitoring Act (Public Act 22-15), effective July 1, 2023, offers a comprehensive framework of consumer data protections in how personal data is controlled and processed by companies. Public Act 22-15, like other state data privacy laws, allows consumers to obtain a copy of their personal data, correct inaccurate information and opt out in a company’s selling or sharing of their information.

Utah:

  • The Utah Consumer Privacy Act, SB 227 (2022), is effective Dec. 31, 2023, and grants consumers the right to know what personal information a firm collects, how the data is used and if their information is sold to third parties. Utah SB 225 (2022) safeguards consumers’ personal data by allowing consumers to access and delete their information and opt out of data collection.
  • The Utah Consumer Privacy Act provides companies with guidelines and regulations of how to protect consumer data and is enforced by the attorney general.

Virginia:

  • The Virginia Consumer Data Protection Act, effective Jan. 1, 2023, establishes a framework for how businesses control and process data in the Commonwealth. The bill outlines responsibilities and privacy protection standards for data controllers and processors. This bill also allows consumers the ability to access, delete, correct their data, obtain a copy of their data and opt out of the processing of personal data for advertising purposes. The Consumer Data Protection Act only applies to non-government companies that (I) control or process data of at least 100,000 consumers, or (II) earn over half of their gross revenue from the sale of personal data of at least 25,000 consumers. This law is exclusively enforced by the attorney general and the Consumer Privacy Fund.

Data privacy laws are necessary in the digital age for allowing individuals the right to have control over their personal information and making informed decisions about who has access to their data. Michigan, New Jersey, Ohio and Pennsylvania have proposed comprehensive data privacy laws using previously enacted laws as model legislation. With states enacting data privacy and protection laws to protect individual liberties, policymakers can close the gap between technology and public policy.

Additional Resources

Expanding Health Care Access: Undesignated Glucagon in Schools

By Sandi Abdelshehed and Daniel Clothier

In 2018, registered nurse Jennifer Jacobs attempted to treat a middle school student experiencing symptomatic hypoglycemia, otherwise known as low blood sugar. She first used snacks to try to increase the seventh-grader’s blood sugar, but the student ultimately lost consciousness. Jacobs also attempted to use glucose gel inside the student’s cheek, but application of the medication was ineffective. As a last resort, she used her only accessible glucagon kit belonging to another student.

Jacobs, who for 21 years has been a certified school nurse at Glenview Middle School in East Moline, Illinois, administered the glucagon knowing it was prohibited and could put her license and career in jeopardy.

“I chose to use a life-saving medication to treat her; however, it was prescribed for another student,” Jacobs said. “Knowing full well I could get fired, I knew it was the only answer to this situation. How could I not? Her life in my hands was larger than anything else.”

Recognizing a school nurse should not have to risk their career to treat a student, Jacobs worked to instill change in Illinois state policy.

Diabetes is a chronic disease that affects 37.3 million American adults and is one of the major causes of blindness, kidney failure, heart attacks, stroke and lower limb amputation. The number of people with diabetes has also increased exponentially over recent decades.

Individuals with Type 1 diabetes suffer from symptomatic hypoglycemia, on average, twice a week. It occurs when sugar (glucose) levels drop in the person’s blood. If left untreated, diabetic hypoglycemia can cause seizures, unconsciousness and, at times, death. Glucagon injections can be used as an emergency medicine to treat severe hypoglycemia  

Access to this life-saving medication has become an equity issue as it sometimes poses financial or logistical challenges for families with children with diabetes. Families with limited financial resources or insurance coverage may not be able to supply the medication to their children’s school, increasing the chances of adverse outcomes in school settings.

To help address this issue, Jacobs worked with Illinois state Rep. Michael Halpin and Sen. Neil Anderson. The two policymakers sponsored HB0822, allowing school nurses or delegated care aides to administer undesignated glucagon through a student’s diabetes care plan if the student’s prescribed glucagon is unavailable on-site or has expired. The bill passed unanimously through the state Legislature and was signed into law on Aug. 19, 2019.

Policies such as the undesignated glucagon law represent examples of bipartisan policy solutions that can improve health care equity and access to care across states. After Illinois became the first state to pass an undesignated glucagon law, Ohio followed suit with the Allison Rose Act, HB231. Other states have since considered their own legislation.

State Executive Salaries: Regional and State-level Comparisons

By Caroline Wills and Rebecca Halpryn

The annual salaries for the five highest-ranking state-level executive positions- governor, lieutenant governor, secretary of state, attorney general and treasurer- have considerable variation. CSG’s annual publication The Book of the States is a comprehensive resource for state policymakers containing in-depth information that is comparable to all 50 states on a variety of major aspects of state government operations. Within The Book of the States, Table 4.11 “Selected State Administrative Officials: Annual Salaries” provides the annual salaries for selected state administrative officials in all 50 states. The Council of State Governments collects this data annually by surveying state executive branches.  

Overview of State Executive Positions

In state governments, governors are directly elected by constituents to head the executive branch. Governors are responsible for managing state executive branches and overseeing the implementation of state laws. On behalf of the state, governors serve as intergovernmental liaisons to the federal government. Additional powers and duties by state for governors can be found in Table 4.4 and 4.5.

The lieutenant governor serves as the second-highest executive office, is usually subordinate to the governor, and typically assumes the gubernatorial role when governor is absent from office. Arizona, Maine, New Hampshire, Oregon and Wyoming do not have a lieutenant governor position. More information about the lieutenant governor’s powers and duties are available within Table 4.14 in The Book of the States.

The secretary of state is usually the third in the line of succession and is responsible for overseeing all state and local elections within a state. The secretary of state in an executive state branch also has additional registration, custodial, publication, legislative and administrative powers and duties (The Book of the States: Table 4.17 & 4.18). In Alaska, Hawaii and Utah, the secretary of state position does not exist. In Utah and Alaska, the lieutenant governor takes on most of the duties of the secretary of state.

The state attorney general (The Book of the States: Tables 4.21, 4.22, & 4.23) serves as the chief legal officer and law enforcement within a state advocating for the public interest by representing their state legislature and agencies. In a majority of states, the attorney general has significant influence on how a state undertakes law enforcement procedures and services.

In an executive office, the treasurer (The Book of the States: Table 4.26) typically serves as a state’s chief financial officer by overseeing a state’s revenue and finances responsible for ensuring the safety and security of a state’s money. In Florida, Hawaii, Minnesota, Montana and Texas, the treasurer’s duties are taken on by other officials.  

The average annual gubernatorial salary across all 50 states in 2022 is $148,939, a 4.12% increase from 2021. At the state-level, New York has the highest gubernatorial salary at $250,000 whereas Maine has the lowest gubernatorial salary at $70,000. Computing the average gubernatorial salary by CSG region shows that governors in the East region earn the highest salary, $170,545, on average compared to the other regions, South, $149,060, Midwest, $139,520 and West, $138,487. The difference between the highest and lowest regional averages for the annual gubernatorial salary is $32,508, whereas the difference between New York and Maine is $180,000.

The average annual lieutenant gubernatorial salary across the 45 states with lieutenant governors in 2022 is $108,380, a 0.28% decrease from 2021. New York has the highest lieutenant governor salary at $220,000 compared to Texas, which has the lowest salary at $7,200. The highest-paid lieutenant governor earns $212,800 more per year than the lowest-paid lieutenant governor. The CSG East region has the highest average lieutenant gubernatorial salary at $142,922 compared to the CSG South region, which has the lowest average salary at $78,274. This is a difference of $64,648.

Across all 47 states, the 2022 average salary for the secretary of state position is $121,628, a 2.95% annual increase from 2021. Arizona has the lowest annual salary at $70,000 while Tennessee has the highest salary at $222,252 for the secretary of state position. The CSG region with the highest average salary for a secretary of state is the Eastern region at $137,041, and the CSG region with the lowest is the Midwestern region at $103,946. 

The average salary for state attorney general in 2022 is $139,075 across all 50 states, a 1.05% annual increase from 2021. Oregon has the lowest annual salary for an attorney general at $82,220 and New York has the highest salary at $220,000. The difference between New York and Oregon is $137,780. A CSG regional analysis indicates the Eastern region has the highest average salary for the attorney general position, $155,126, while the Midwestern region has the lowest at $125,841. 

The average annual salary for treasurer in 2022 across all 45 states is $126,015, a 2.15% increase from $123,358 in 2021. The state with the lowest salary for Treasurer is Arizona at $70,000 and the state with the highest salary is Tennessee at $222,252. The CSG East region has the highest average salary, $143,298, for the treasurer position while the Midwest region has the lowest, $110,124. 

Data notes:

  • Annual salaries reported do not include benefits and other compensation for selected state officeholders. General wage and salary adjustments for officials within states’ executive branches are automatically increased with the rate of inflation or must be negotiated and legislatively approved.  
  • Connecticut was the only state that did not respond to the 2022 CSG Survey of State Personnel Agencies and State Salary Databases, data from the 2021 CSG SPA&SSD Survey was used.
  • The Council of State Governments Regions are defined by the regional offices and the states as listed below:
    • West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming
    • Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin
    • South: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia
    • East: Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont

State And Local Government Associations Commend Congress for Infrastructure and Disaster Flexibility

WASHINGTON – With the enactment of the Consolidated Appropriations Act of 2023, the seven leading organizations representing state and local governments at the federal level thank Congress for providing flexibility to use American Rescue Plan Act funds for purposes of infrastructure, neighborhood revitalization, and disaster relief.

The National Governors Association, The Council of State Governments, National Conference of State Legislatures, National Association of Counties, National League of Cities, U.S. Conference of Mayors and the International City/County Management Association are grateful for the inclusion of the bipartisan State, Local Tribal, and Territorial Fiscal Recovery, Infrastructure, and Disaster Relief Flexibility Act (S. 5323), which was introduced by Senator John Cornyn and Senator Alex Padilla.

This measure provides additional flexibility under the Coronavirus State and Local Fiscal Recovery Funds that were included in the American Rescue Plan Act and will support state and local governments to continue leading America’s recovery.

Associates in Action: Hurricane Ian Relief Efforts

By Sarahi Castillo

Hurricane Ian thrashed parts of Florida’s western coast, bringing intense winds, heavy rainfall and catastrophic storm surges causing devasted damages. In the wake of Hurricane Ian, many CSG Associates have pledged to help donate and assist those in need of help. CSG is proud to highlight the excellent work that our Associates have contributed toward the relief in the wake of the catastrophic hurricane.

AARP and AARP Foundation announced a relief fund to support victims of Hurricane Ian, the relief fund will allow AARP and AARP Foundation to match contributions, dollar for dollar up to $1,000,000. All funds will be directed to organizations providing relief and assistance to those in need. To learn more, read the full story here.

Amazon and its disaster relief team have delivered supplies and basic necessities to relief organizations like Americares. Amazon has donated $1 million to Florida Disaster Fund and is providing immediate relief assistance to employees as well as deploying volunteers within the region. To read more about Amazon’s contributions click here.

American Bankers Association and its foundation have planned to collect tax-exempt contributions through its Disaster Relief Program to aid relief efforts. American Bankers Association have also pledged to donate $100,000 to the fund. The Foundation’s fundraising drive raised another $73,000 from across the banking industry. All funds raised will be directed to the Volunteer Florida Foundation to help aid and recovery efforts. Read the full story here.

The American Society of Civil Engineers’ (ASCE) Puerto Rico section is partnering with a local design firm to help deliver supplies to citizens in municipalities heavily affected by the hurricane. ASCE also continues to advise local infrastructure owner and operators on how to rebuild more resiliently to better ensure infrastructure will withstand and protect against future storms.

AT&T and the AT&T foundation are donating $400,000 to organizations supporting restoration work in the wake of Hurricane Ian. AT&T is also focusing on permanent connectivity solutions for a few cell sites that were impacted by the storm. View the full article here.

Credit Union National Association has committed $225,500 from its CUAid program, which is managing individual donations to credit union employees and volunteers in Puerto Rico, while providing financial support to those affected by it. To learn more, click here for the full story.

CVS Health has contributed $1 million in monetary donations and up to $100,000 in product donations in Florida and Puerto Rico. Contributions made by CVS Health will be made to Florida Disaster Fund, Feeding America and the World Central Kitchen.

HCA Healthcare will contribute up to $1.5 million through community organizations and colleague matching to aid in Hurricane Ian relief efforts in Florida. The contributions total $1 million to the Governor’s Florida Disaster Fund, $250,000 to the American Red Cross and up to $250,000 in colleague matching gifts to the American Red Cross. To learn more, please click here for the full story.

Hondo Motor Co Inc. is donating $500,000 in disaster relief funds to the American Red Cross to support food security and shelter issues in the areas impacted by the recent hurricanes. Honda is offering its associates an opportunity to join the hurricane relief effort through a matching fund program. View the full article on Honda Motor Co Inc. contributions here.

Pharmaceutical Care Management Association (PCMA) has provided relief effort to victims impacted by Hurricane Ian. PCMA staff and attendees have sent boxes filled with food for victims in Florida.

Procter & Gamble brings relief to residents affected by Hurricane Ian in Southwest Florida with P&G products and Tide Loads of Hope Laundry Services. P&G will also distribute free personal care kits with everyday essentials including basic hygiene needs. To learn more, read the full story here.

Target has committed $5 million to local and national disaster response partners and has also supported local first responders and nonprofit organizations in purchasing supplies. In addition, Target provided financial assistance to team members through its Team Member Giving Fund. View the full article here.

Teladoc is providing free, 24/7 general medical telehealth visits to individuals impacted by Hurricane Ian. Individuals in Florida who have been displaced or who cannot access medical care as a result of the hurricane can seek treatment from a licensed health care professional for any non-emergency illness by calling Teladoc directly at (855) 225-5032. To access the full story, click here.

T-Mobile has continued to support regional recovery through ongoing network deployments. The organization is helping residents who are working to assess damage and supporting federal, state and local organizations with addition capacity, hotspots, devices and more. Click here for the full story.

Verizon Communications has deployed its response team across the Southeast to provide mission critical communications support to public safety agencies. Verizon will also be providing unlimited calling, texting and data to their consumer and small business customers who were impacted by the storm. View the full article on Verizon Communications here.

Walgreens is supporting storm relief efforts in communities across Florida, Puerto Rico and other areas impacted by Hurricanes Ian and Fiona by contributing $1 million in aid, including $500,000 to both the Florida Disaster Fund and the American Red Cross Hurricane Fund. To learn more, visit here to read the full story.

Wells Fargo and Wells Fargo Foundation will be donating $1 million to aid four statewide organizations: American Red Cross, Feeding Florida, Florida Housing Coalition and Volunteer Florida providing urgent relief In Florida. In addition, Wells Fargo will also provide customer accommodations and employee support for those directly impacted by the storm.

Long-Term Care Policy Guide for State Policymakers

By Sean Slone

States have begun exploring a variety of strategies and policies that seem likely to transform long-term care in the years ahead. The Council of State Governments has learned from states’ success and compiled a “Long-Term Care Policy Guide” as a resource for state policymakers.

The “Long-Term Care Policy Guide” is the result of a nine-month partnership between CSG and the Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy.

The partnership involved the formation of an interbranch task force made up of state policymakers from eight states (Arizona, Georgia, Hawaii, Indiana, Minnesota, New York, Pennsylvania and Virginia). At least one state legislator and executive branch official representing an agency affiliated with long-term care from each state participated on the task force. Throughout the task force’s eight virtual meetings in 2022, as well as one state-curated conversation for each participating state, its members, subject matter experts and stakeholders examined three focus areas in long-term care that are highlighted in this guide. These focus areas include:

  • Addressing State Regulation of Long-Term Services and Supports Facilities

Long-term services and supports facilities including nursing homes and other places that care for older Americans and people with disabilities in congregate care settings experienced significant challenges during the COVID-19 pandemic. In addition to high concentrations of fatalities during the pandemic’s early days, many saw an epidemic of neglect, social isolation and loneliness among residents due to staffing challenges and restricted visitation policies.

  • Optimizing American Rescue Plan Act Spending on Home- and Community-Based Services Under Medicaid

A two-decade shift toward serving more people in home- and community-based settings was given a significant boost by the American Rescue Plan Act of 2021, which provided states an increase in the federal government’s share of total Medicaid costs. As a result, states are now deploying $12.7 billion to expand eligibility and increase access to these services.

  • Revitalizing the Direct Care Workforce and Supporting Family Caregivers

The shift toward serving more people in the aforementioned settings comes just as states are also facing an unprecedented employment crisis in the direct care workforce — the group that cares for residents across a variety of long-term care settings. There are also concerns about the burden shouldered by often-unpaid caregivers in the home who are caring for a family member or loved one.

Numerous enacted state strategies are explored throughout each focus area in the guide. In addition, the three following state initiatives are highlighted as extended case studies:

  • Illinois’ 2022 legislation to overhaul how the state assesses and reimburses nursing facilities and link future funding to staffing levels and quality of care.
  • Minnesota’s American Rescue Plan Act spending plan for home- and community-based services, which spreads $680 million across more than 50 initiatives.
  • New York’s increase to the hourly minimum wage for home health care workers.

The long-term care policy guide can serve as a roadmap of potential opportunities for state policymakers. Some opportunities may require additional discussion and further assessment on a state-by-state basis in the years ahead, especially as the lessons of the pandemic and policy goals for the future of long-term care come more sharply into focus.

School Psychologist Compacts: What You Should Know

By Grant Minix

Last spring, The Council of State Governments announced the selection of the National Association of School Psychologists for technical assistance on the development of an interstate compact for licensed school psychologists. The opportunity is a result of a cooperative agreement between CSG and the Department of Defense to develop interstate licensure mobility compacts.

The introduction of the Interstate Compact for School Psychologists will facilitate licensure mobility for the profession, which can improve access to services and care for school-age children. Schools are facing a national shortage of school psychologists. According to NASP, the recommended ratio of school psychologists to students is 1:500. However, the national ratio currently stands at 1:1,211. Some states are approaching ratios of 1:5,000. These shortages are especially evident in rural schools and historically underserved school districts.

The development of the Interstate Compact for School Psychologists also offers substantial benefits to military families by allowing for increased licensure portability for military spouse. Additionally, it increases portability for school psychologists providing care for military children which will increase continuity of care.

As part of the project kickoff, CSG and NASP hosted a compact kickoff meeting in August 2022. The meeting featured CSG, NASP and DOD officials outlining the need for increased licensure mobility for licensed school psychologists and the process to develop the compact. During this meeting, and as part of a larger stakeholder review and public comment process, participants were invited to ask questions regarding the project.

Following the kickoff meeting, CSG and NASP worked to identify individuals and organizations throughout the country to serve on the compact technical assistance group, including school psychologists, regulators, state legislators and individuals representing key organizations in education. The technical assistance group is tasked with providing recommendations on numerous aspects of the compact, such as state and licensee requirements to join the compact, the makeup of the compact commission and how to integrate telepractice into the compact, which all will be considered by the document writing team.

As of December 2022, CSG and NASP are in the process of assembling the document writing team and working with the technical assistance group to develop recommendations. In early 2023, the document writing team will meet write the model language for the school psychologist interstate compact. After an initial draft of the language is developed it will be shared with the technical assistance group and then released for public stakeholder review.

CSG, NASP and the working group will continue to work on the language until it is properly vetted and fully capable of meeting the needs of the profession and the public. Once the model compact language is finalized it will be released for state enactment. CSG anticipates the model language will be released for 2024 state legislative sessions. For more information on the Interstate Compact for School Psychologists, visit the compact web page or send an email to [email protected].

Physician Assistant Compacts: What You Should Know

In June 2019, a joint initiative by The Council of State Governments, Federation of State Medical Boards, American Academy of Physician Associates and the National Commission on Certification of Physician Assistants, was created to develop an interstate compact for the interstate practice of physician assistants (PAs). Funding support for this initiative came from the Department of Health and Human Services.

The Physician Assistant Licensure Compact (PA Compact) will facilitate the ability of licensed PAs to practice in multiple states without having to obtain an individual state professional license in each state of practice. The compact will provide for greater in-person and telehealth access to care and will significantly enhance practitioner mobility, including in times of public health emergencies. The PA Compact will also strengthen public protection by establishing a data system that facilitates information sharing and coordination on disciplinary action between participating states.

In the PA Compact licensure mobility is facilitated through a “privilege to practice” model, which allows individual licensees to seek a compact privilege in any compact member state they choose. The licensee’s application for a privilege to practice in a specific state is expedited by utilizing the compact data system to ensure the individual is eligible for that privilege by meeting the requirements in the compact.

The PA Compact includes various requirements for states to adhere to prior to enacting the model legislation. These requirements ensure there are baseline standards to be met for states to start issuing compact privileges. Some of these requirements include requiring a national exam and continuing education for all PA licensees. To obtain privileges to practice in compact member states individual licensees must also meet specific requirements laid out in the compact, such as obtaining NCCPA certification and graduating from a nationally accredited PA program.

The partner organizations met as a working group throughout the compact development process to develop the compact language. As part of the development process, the working group engaged stakeholders within the PA profession and the healthcare industry to solicit input and feedback. The working group utilized stakeholder feedback to revise the compact and respond to received concerns and suggestions.

One of the major motivations behind the desire to develop an interstate compact for physician assistants is the success of other compacts for health care professions, such as the Nurse Licensure Compact and the Interstate Medical Licensure Compact for physicians. Both compacts have been enacted in nearly 40 states. The development of interstate compacts for health care professions have been extremely popular amongst states because of their ability to strengthen state’s health care workforce and provide additional pathways to care for patients. The PA Compact working group considered and incorporated many aspects of other compacts for health care professions. While the PA Compact is similar to other compacts in how it facilitates multistate practice, each compact is unique and responds to the specific needs of the profession.

The working group approved the final version of the PA Compact in October 2022, which is being made available to states for 2023 legislative sessions. CSG and the project partners will provide educational and technical assistance for stakeholders and states interested in the compact. Supporting resources and information about the compact may be found at www.pacompact.org.