On a single January night in 2018, approximately 553,000 people in the United States experienced homelessness, either sleeping on the street or in a variety of shelters, and those numbers have been gradually increasing since 2016. The risk of homeless also looms large for many who are housing insecure, including 25 percent of renters nationwide who spend more than half their income on housing.

Many states are encouraging the development and preservation of affordable housing – often combined with health and social services – to improve the lives and health of vulnerable individuals and families.

State policymakers know it is difficult for people without safe, stable homes to become and stay healthy, as evidence shows. Studies show that housing insecurity and homelessness are associated with poor health and premature death for adults, and pose risks for child health and development.

State budgets also benefit from improving health through housing: studies show that housing with supportive services can save states money by reducing hospital utilization for some populations. Housing First policies, which remove barriers such as sobriety or treatment requirements for people entering supportive housing, have also been linked to lower emergency department use and shelter costs.

This snapshot shows how state leaders across the nation are taking executive and legislative actions to improve health through housing.

Budget and Appropriations

• Hawaii Gov. David Ige signed a number of bills related to housing, including SB471 SD2 HD1 CD1, which appropriates over $10 million for each of the next two years for homelessness services, including outreach, rapid re-housing, and Housing First programs, and the state’s rent supplement program.

• Iowa Gov. Kim Reynolds signed bill SF 608, which appropriated funds for “housing and shelter-related programs.” (Sec. 3.1.b.5)
  “Rural communities also can’t thrive without access to housing. Businesses in rural Iowa are growing and hiring, but the employees they need won’t make the move if there’s no place for their families to call home. I am therefore requesting that we double the amount of workforce housing tax credits that are set aside for rural communities.” – Iowa Gov. Kim Reynolds
  • It also appropriated $100,000 from the Iowa skilled worker and job creation fund to establish a “housing needs assessment grant program to provide small communities with hard data and housing-related information specific to the community being analyzed.” (Sec. 3.10.a)
• New York Gov. Andrew Cuomo announced that the enacted budget “continues the $20 billion, comprehensive five-year investment in affordable housing, supportive housing, and related services to provide New Yorkers with safe and secure housing.”
  • This investment creates or preserves “over 100,000 units of affordable housing and 6,000 units of supportive housing.” The funds will “support the operation of shelters, supportive housing units, and rental subsidies.”
• Oregon Gov. Kate Brown proposed $50 million of bond funding for permanent supportive housing, which was passed by the legislature in HB 5005.
• Washington State Gov. Jay Inslee signed a capital budget that appropriated $175 million for the Housing Trust Fund program. The appropriation includes funds to build or preserve affordable housing, as well as funding for supportive housing for people with chronic mental illness (Sec. 1029(1)).

Executive Order

• Iowa Gov. Reynolds issued Executive Order 3 establishing the “Investing in Rural Iowa” task force to address rural housing needs, among other priorities. The task force’s initial recommendations include helping communities conduct housing needs assessments and making the Workforce Housing Tax Credit competitive – instead of first-come-first-served – and prioritizing small cities.

Legislation

• Hawaii passed HB820 HD1 SD1 CD1, which requires the Hawaii Housing Finance and Development Corporation to study and formulate a plan for a program to “provide low-cost, high-density leasehold homes for sale to Hawaii residents on state-owned lands within a one-half mile radius of a public transit station.”
• Nevada’s AB 174, established the Nevada Interagency Advisory Council on Homelessness to Housing. Among other duties, the council will develop a strategic plan for addressing homelessness in the state. The council will include representatives from the departments of health and human services, corrections, housing, and veterans services, as well as sheriffs, judges, a state senator and assembly member, and a person who has experienced homelessness in the past.

Some states have also been taking action to protect residents from eviction, which research suggests has a negative effect on health.

• New York Gov. Cuomo signed the “Housing Stability and Tenant Protection act of 2019,” which provides fourteen days for tenants to pay their rent before being evicted, up from three days. It also prohibits landlords from evicting tenants for complaining about the need for repairs, among other provisions.
• Oregon Gov. Kate Brown signed SB 608 into law, which protects renters from no-cause evictions and limits rent increases.
• Washington Gov. Inslee signed SB 5600 into law, which provides more time for tenants to pay their rent before eviction. Previously, landlords were only required to provide three-days’ notice, but the new law increases it to 14 days.

In addition to legislation and executive action, state policymakers are using other policy tools and strategies to improve health, by helping people become and stay safely housed. For example:

• States produce Qualified Allocation Plans (QAPs) to guide the awarding of Low Income Housing Tax Credits to developers. States can award developers additional QAP points for including healthy housing features or otherwise aligning with state health and housing goals.
  • Many states award extra QAP points to developers as an incentive to create permanent supportive housing. For example, Texas provides more points for tenant services and affordable rents in supportive housing developments compared to other developments.
• While federal restrictions generally prohibit the use of federal Medicaid dollars for room and board, a number of states have incorporated tenancy supports and other housing-related services into their Medicaid waivers and State Plan Amendments.
  • Pursuant to its Section 1115 demonstration, Oregon made housing a statewide priority for its Coordinated Care Organizations (CCOs), and contractually requires CCOs to address “housing-related services and supports, including supported housing.”
  • A number of states include pre-tenancy supports and tenancy sustaining services in their Section 1115 demonstrations. For example, services in Illinois’s Behavioral Health Transformation Section 1115 demonstration provide assistance to individuals applying for housing, linkage to health and social services, and training and resources to help people manage their household and finances.
• Permanent Supportive Housing (PSH) programs combine rental assistance with supportive services for vulnerable, low-income populations. Supportive services can include help finding and securing an apartment, assistance with managing personal finances, interacting with landlords and neighbors, and facilitating connections to physical and behavioral health care.
  • In Louisiana, Medicaid and housing agencies work together to administer a supportive housing program that has reduced Medicaid acute care costs.

These executive orders, laws, and policy strategies illustrate the many levers and tools states are using to improve health through housing. These actions have the potential to control health costs while enriching the lives of vulnerable people and families.

This report is part of a series exploring how state leaders can improve the upstream factors affecting health, such as healthy environments, early childhood education, and social equity. Additional resources for state leaders can be found in the Toolkit: Upstream Health Priorities for New Governors NASHP’s Housing and Health Resources for States.

Produced in partnership with the de Beaumont Foundation