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Addressing Housing Challenges and Economic Insecurity During COVID-19

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Robert Johnson:
This is Public Health Review. I'm Robert Johnson. On this episode, stable housing as a public health strategy, making plans to bounce forward out of the pandemic.

Dr. Karyl Thomas Rattay:
Housing instability—not knowing that you're going to be able to stay in your home for another month, another two months—causes so much stress that we believe it is one of the more important determinants for pre-term birth.

Nan Roman:
I think that the pandemic has allowed us to see that maybe a little bit more clearly. It's pretty much impossible for someone to maintain good health if they don't have stable, affordable housing. It's a social determinant of health.

Denise Harlow:
I think it is incredibly important to understand that how we end up here today is not by accident and it's not going to be dismantled by accident. I think public health officials, community action agencies, health and human services need to be intentional about dismantling the structural racism in our country. If we truly want to bounce forward, we need to name it. We need to call it out, even in our own systems, when we see it.

Johnson:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Over the next several weeks, this podcast will feature conversations with experts from areas beyond public health—people who work in housing, transportation, education, and other policy realms—helping us connect the work we do and the task ahead, if we want to bounce forward, addressing the inequities laid bare by the COVID-19 pandemic.

Today, the connection between healthy people and stable housing, understanding that having a place to live isn't just an American dream—it's a public health necessity.

Nan Roman is the president and CEO of the National Alliance to End Homelessness. Denise Harlow is CEO of the National Community Action Partnership. These housing crusaders will be along shortly. First up, Dr. Karyl Rattay, director of Delaware's Division of Public Health.

Rattay:
So, we know now, more than ever before, how important having access to stable, healthy housing is to good health. I think we've known for quite some time that where you live, where you learn, where you work, where you play and pray all impact health.

But as we have really begun to delve into what we call the social determinants of health with our communities—specifically with our communities where we don't see as good of health outcomes—housing inevitably comes up as one of the most important determinants impacting the health of residents in these communities.

Johnson:
What happens if a community does not have good housing?

Rattay:
Housing instability—not knowing that you're going to be able to stay in your home for another month, another two months—causes so much stress that we believe it is one of the more important determinants for pre-term birth or for difficult outcomes for moms.

In fact, one of the things we've done here through a medical legal partnership—just providing legal access to people who are dealing with, for example, landlord issues, can do so much to decrease the stress and improve the outcomes for these pregnant mothers.

Johnson:
So, how is the state responding to the housing impact and what are you doing to ensure that you're able to bounce forward?

Rattay:
So, I'll start broadly in answering that. We're really working hard to address equity as a state, and really focus on the broader impacts, the drivers of poor health. And so, you know, our partners—such as in our housing authority both at the state and at the local levels, banks who are invested in communities, community revitalization, and the many other partners that are focused at a community level on housing—are some of our newest, favorite, and most important partners to be just really addressing overall housing and the impact of housing on health.

Now, as it relates to COVID, there's a couple of initiatives or parts to our response that I think are important to highlight. You know, I talked about the poultry plants and the outbreaks that we had in the southernmost part of our state. And what became very clear early on in this work with people who work in these plants was that not only is it important that you were assessing their health, but you're also assessing their housing stability and do they have a safe place to isolate or quarantine.

So, for every person who we would get their test results back, the next question began at that point, and we still do this was, do you have a safe place to isolate? Do you have a safe place to quarantine? Do you have a way to prevent spreading this infection to others with whom you live? And if you don't, we offer those individuals as a place to stay during their infectious period. So, we have found that to be very helpful.

On kind of a bigger scale, we have this initiative we call Healthy Communities Delaware. And with this initiative, which I'm happy to talk more about, but this is an infrastructure that we've really been able to use during our COVID response to work with the communities that we call opportunity communities identified by data, and to say, how can we help you? What do you need to do to better support your communities around COVID? And we provided a funding opportunity for these communities.

Of the 12 contracts or projects that we are doing within these communities, nine out of the 12 are implementing projects, a variety of different projects, to address housing. And this, again, is specific to COVID-19. So, they're all seeing that lack of housing or housing instability, issues related to housing, impact our ability to have a good COVID response.

Johnson:
Tell us about some of those housing projects.

Rattay:
One is doing a real assessment of affordable housing in the community. One project is around blight remediation. Another is really focused on access to housing. Another is taking on legal aid. An additional community's focusing on housing repair, and another one's even focusing on safe drinking water because some members in their community don't live in homes with safe drinking water.

All of these communities also have a COVID coordinator, who is really an on-the-ground community health worker funded by this project, who is then really helping to work with our contact tracing team to, on the ground, really help connect the dots for people.

Johnson:
Are you hoping these projects will leave those communities better than COVID found them?

Rattay:
I am hoping that these projects do leave these communities in a better place than when COVID found them. You know, that's a vision that's maybe challenging.

We know that, for a variety of reasons, COVID is really having a tremendous negative impact on our lower income and our minority communities. And. again, it's just really building on the many years of—whether it's structural racism, or educational or employment disparities, income disparities—it's really building upon centuries of inequities in these communities.

We know that communities are motivated to mobilize around COVID right now. And so, for some of the communities, especially those that are less mature in their work coalescing together, we hope that this provides an example for them to see how they can be in the driver's seat and really work to support their community and to get some things started, to catalyze some efforts that may not have gotten started if this wasn't the driving force.

So, we do hope that this helps to catalyze some action, but we know that these issues around housing certainly aren't going to be fixed overnight, and it's going to take a long-term commitment. But, maybe this will inspire some people to be and stay active.

Johnson:
You mentioned, earlier, data-driven decision-making—can you tell us how data plays a role in this process?

Rattay:
Yeah, so, we created what we call a health opportunity index, probably 18 months ago or so. We really wanted to drill down on identifying the communities in Delaware where we're we seeing the poorest health outcomes, or where we're most concerned about the social determinants of health.

And we made it relatively simple in that we used four indicators: so, life expectancy; infant mortality; child poverty; and high school graduation rates, are the four indicators that we used. We equally weighted them and then identified, by census track, the health index score. And then, we stratified these. So, we took the top quartile of those who had the worst score, and we are calling them our opportunity communities.

Now, many of them end up clustering together. So, you might have four census tracks and one opportunity community or two or another, but we want to use the data to identify geographically where we have the biggest concerns and that the community then identify kind of what their boundaries are and how they would describe their community.

Johnson:
Let's look ahead to that time. How does housing look in Delaware 12 or 18 months from now?

Rattay:
So, when we get back to a new normal or—and I'm normally a very optimistic person—but I am so concerned about the economic impacts that this pandemic is having on our communities. And so, you know, I worry that these economic impacts are going to take many years to recover from.

But my hope is that these revitalization projects—the work that has involved people coming together to really identify their greatest concerns to prioritize, to really put plans together, to address housing in their communities—is a starting point and will, you know, for some communities, hopefully they'll be on their way to more affordable housing by the end of this. In other communities, maybe repairs will be made that weren't made before.

Hopefully, we will have a much better understanding of whether it's from many years of institutional racism or just the impact of COVID itself, but hopefully more and more, as we we're all working together on this, we will better understand the housing concerns in the communities across our state, and we'll be able to continue to coalesce around addressing them.

Johnson:
Nan Roman remembers a time in the late 1970s when America had an adequate supply of affordable housing. But, as homelessness began to rise, the number of available units fell quickly. Now, Roman, the President and CEO of the National Alliance to End Homelessness, says we're more than 7 million units short—a problem that's likely to get worse given the number of people who can't pay their rent because of the pandemic.

Roman:
Housing really is health care, a health care strategy, and I think the pandemic has allowed us to see that maybe a little bit more clearly. It's pretty much impossible for someone to maintain good health if they don't have stable, affordable housing. It's a social determinant of health. Also, you often have to have good health in order to keep your housing. So, they're interconnected things and they both rely on each other.

Johnson:
You can't have one without the other, really.

Roman:
It's tough, yeah.

Johnson:
What are some of the health problems that result from not having a place to live?

Roman:
So, people who are unsheltered and don't have a place to live and don't even have shelter—which is that 37% of the homeless population at a given point in time, several hundred thousand people—that group of people has very serious health problems.

Almost 50% of them are tri-morbid—they have physical health, mental health, and substance abuse disorders. About 80% of women who were unsheltered are tri-morbid. About half of people who were sheltered became homeless because of serious illnesses in a major organ—heart, lungs, or kidneys.

So, that group of people has very serious physical and behavioral health issues, but homeless people overall suffer from a lot of stress and trauma. This causes illnesses and problems for them. They have poor nutrition generally, they lack access to quality healthcare. So, there are a lot of issues around that.

One thing, I think, also that's specific to the pandemic, that the pandemic has pointed out, is that there are also issues with people living in congregate settings, and really whether we shouldn't be learning from this, that perhaps having congregate shelter settings is not a good health strategy or a healthy strategy for people.

Johnson:
We don't even think about it—most of us, you know, the advice of stay home, don't go anywhere—but if you don't have a home, you can't really take cover from the pandemic.

Roman:
Right, absolutely. If you don't have a home, you can't stay home and protect yourself and do you're in a dangerous situation. There was a lot of guidance about social distancing in the shelters, which a lot of places did. It meant that they had to reduce their population—that, we think, ended up with more people in the street.

But, even if your bed is six feet away from someone else's bed, they're congregate hygiene facilities, they're congregate eating facilities. It's not like people lie in their beds all day long. It's not a very good situation for public health, I don't think.

Johnson:
Let's talk about funding. You know, Congress has spent a lot of money in the last few months addressing mostly the public health issues, but putting funds and do lots of programs. You've developed a framework connecting housing strategies to all of the programs that received additional funding.

Can you tell us about the framework, how you came to design it and how it's supposed to help?

Roman:
So, we started working on a framework just to say, "Here's what we've learned in our organization, which is really focused just on trying to figure out what works better than what else. Here's what we've learned about what works that you might want to try. And also, you're going to be challenged to figure out the order in which you want to do things, and here is possibly the order."

And we were joined in that by the Center on Budget and Policy Priorities, the National Low-Income Housing Coalition, and the National Healthcare for the Homeless Council, nationally. So, we all got together and we put together this framework about what to do with that ESG money.

There is also a lot of other money in the CARES Act—the community development block grant money, the coronavirus relief fund, which was money that went out to jurisdictions—$150 billion, I think it was—there's money in community services block grants, there's money in SAMHSA, there's money all over that can be used also to assist homeless people. There is also FEMA money, for example, that pays for these hotels and motels, or can pay for it. So, we tried to provide direction to people also about where they could get funding and what they should do with the money.

One of the important things to us, I think, was—and it's turned out to be important to some communities, too—is to think about the values that overlay the strategies that we proposed in there. And those values were that we should really attend first to racial and income disparities. We should be looking for those in our work and trying to remediate them and making sure that we're not advancing them, that the highest need people should be helped first.

This is an argument that goes on a lot in the homeless assistance system where people often feel we could help a lot more people with lower needs that didn't need as much help and then get them out and that would work better. But, in fact, it doesn't really work very well to reduce the number of homeless people, and helping the highest need people and getting them into housing and out of the system actually works a lot better.

Focusing on housing—so we didn't want the goal of the spending to just be getting a bunch of people into shelter, but actually getting them into housing. Partnership was an over riding value of the project as well. Housing and health have to work together, as well as employment and some other things. And, the need to act quickly. Those were kind of the overlaying values to the strategies we proposed in there.

Johnson:
How, then, would you hope that public health leaders would approach this document as they grapple with the issues that sometimes are the same everywhere and sometimes are not?

Roman:
Well, I think reaching out to the people that received the ESG money or to the continuums of care—which are kind of the local planning bodies that take on homelessness in jurisdictions—would be a good start. And, probably, working together on specific projects. Now is not maybe the time to spend a lot of time on process, on figuring out a whole process about how you're going to coordinate and work together and be best friends in the future. Maybe the best way for people to do things right now is to find something that they wanted to do.

For example, we have all these people in the hotels and motels. The homeless people that go into hotels and motels are people that need quarantine and isolation, many of them because they're older and have underlying conditions and others because they may have COVID. When they are able to leave, because of their diagnosis, those hotels and motels, we don't want them going back to the shelter. We would like to move them along into housing and ESG money can be used for that.

But, if they are high need people, they also need healthcare services attached to that. So, a good partnership would be for the housing and public health providers to work together to get those folks into—we call it permanent supportive housing, long-term subsidized housing with services attached to it.

Johnson:
The guidance is 20 pages long. It's very specific, it's so specific, I think, that it would make your head spin. I mean, there is just so much actionable detail in this framework.

What about the ideas and the connections you've made between policies and funding pots do you consider to be innovative thinking? Is there new thinking in this plan, new ideas?

Roman:
Obviously, we were trying to go really with the things that we felt we knew were really going to work—now is maybe not the time to experiment.

But innovations, I think, yes. The idea of non-congregate shelter, for example, that I brought up, that's really not something that's been discussed in this country or actually many other countries either. I think that's one.

One thing that we've learned, but hasn't been widely applied, is that the programs—shelter programs and the hotel and motel programs and the housing—need to be low barrier. That the people with the highest needs, like unsheltered people or people who have multiple diagnoses, they really want housing connected with healthcare. They don't want a lot of barriers and rules, they're just not able to deal with that. And so, there have to be low barriers to coming in and then trying to help people, you know, solve their problems once they're in housing. The idea, again, of helping the highest need people first—I don't think that's something that always gets done in our sector.

We also said in this document very clearly, which has been somewhat controversial, that we didn't think that any of the homeless money should be used on prevention strategies. The reason for that is that we have a lot of people who are already homeless that we were not serving because we don't have enough money, witness 37% of people being unsheltered, and it's very difficult to predict homelessness. So, most prevention efforts don't actually prevent all that much homelessness. They help people—the people they helped wouldn't have become homeless without the assistance. So, we've said we really feel that it's smarter to use this money for people who are already homeless to try to get them out of the system. Also, because we think that there is going to be a wave of new homelessness coming.

Johnson:
Someday the pandemic will end—we hope sooner rather than later. Is that the end of the opportunity to make lasting change on this issue?

Roman:
It's not the end at all, but I do have a lot of concerns about what's coming. Because I think we are going to see really a tsunami of evictions when the various eviction moratoria end. Those eviction moratoria are not forbearance programs, so people still are going to owe all of that rent that's been accumulating over the months that there's been a moratorium, and clearly they don't have that. If they had the money, they would have been paying the rent. So, I think we're going to see a lot of evictions. We know that unemployment is really high and that's likely to continue for a while, certainly.

So, I think that we're going to see an increase in homelessness as a result. As I said before, it probably won't be soon. And so, I think integrating housing with health care becomes even more important and we're gonna have to figure out how to help people pay rents, which there's some policy things on the table that may be able to help with that.

But, I think it's also important to recognize that providing people with housing and healthcare and merging those two things is also a racial justice issue—helping people with the highest needs has racial justice dimensions, helping the poorest people with their housing has racial justice dimensions. So, I think this is the right thing to do because it's more workable and because it's more just.

Johnson:
As public health leaders are listening to this conversation, what should they know—if they don't remember anything else from what we've discussed—about the way forward connecting public health to housing?

Roman:
What they should probably know is that they're not going to succeed with their public health goals if we have so many people who don't have secure, safe, affordable housing. And that our ambitions and goals are linked, and we need each other to succeed.

So, it's hard for these two sectors to work together sometimes. They're very different, their languages are different, the goals are different, but we need to figure it out. And maybe the best way to figure it out is that at a time like this when we have real work we could be doing together, just start doing it and building those partnerships to move ahead.

Johnson:
Community action changes peoples lives. That statement is part of the mission and promise of the National Community Action Partnership. Denise Harlow is the organization's CEO. Her advice for public health leaders? Take action.

Harlow:
Public health officials are recognizing that the housing is healthcare. I would encourage public health officials, state-level officials, to be talking with other departments. I know there's a lot of cross-collaboration.

We get very siloed, whether we're the nonprofit space or the public sector space, and we can't be siloed if we're going to bounce forward as a society and get to a place where we can ensure families have healthy access to what they need to thrive.

Johnson:
What do you think state health officials or leaders in the state and territorial agencies ought to be doing, then, to help their populations realize a healthier post-COVID-19 world?

Harlow:
I would encourage public health officials to be talking to their departments of energy at the state level, their departments of housing and community development at the state level. I would be encouraging them to talk to the human services side of the equation, as well.

In a lot of state governments, those pockets of funding and programs can be spread across very diverse state offices. And so, working with governors' offices and such to find a way to meld the health and human services sides might just take more than just two public health or public entities coming together. It might really be a myriad of state-level officials and their teams coming together.

I would encourage public health officials to find where in their state the community services block grants sits. CSBG is what gives community action agencies their designation. And in your states, as public health officials, community action agencies—there may be one, there might be four and there might be 17, there might be 52, it just varies on the state—but all of those agencies receive CSBG and are called to fight the causes and conditions of poverty and, in many cases, are already working with county health officials and maybe working with you through their state association at the state level.

Johnson:
What are some of the innovative ways states are starting to use, or at least talk about using, some of these grant and funding programs that either have existed forever or are new because of the CARES act and some of the other financing mechanisms that have come from Congress recently?

Harlow:
Certainly, COVID has just been a devastating impact across our country, certainly, and across our world. Community action agencies, they're a hub for a variety of federal and state and local funding streams that come together.

But your question brings to mind several states where the housing entity, which is receiving CARES dollars or other federal investments to help alleviate the pain on families for housing-related issues, and those are flowing through community action agencies. I think of the state of Maine where the state housing department is using community action agencies to disperse that money.

And then, I bring to mind York Community Action, which runs a federally-qualified health center in Maine. So, they're able to take the families who are coming in—for, perhaps, healthcare issues, COVID testing, even, right—and pivoting and helping those families to access, as seamlessly as possible, those other resources to help maintain stabilized housing.

Now, also what we're seeing—and we'd talked to our local agencies and public health about this—is that we see contact testing, tracing, and resource coordination as three core buckets. And, certainly, the testing piece is really fitting into the health space. Contact tracing is a blend, I think—we're seeing some of that in the health space, some of that more than the human services, or other sectors. But that resource coordination piece—working with state health officials and then county health officials, finding ways to contract with your local community action agency who can be your resource coordinator on the ground.

Families who have to self-isolate because a family member tested positive or was in contact with someone who tested positive for COVID, or a family who has been, you know, working three jobs, making the rent, paying their bills, putting food on the table—for the first time I say, "I don't have an income. I need help with my rent. I can't go to work because I'm quarantined. Who can help me?"

And the community action agencies, through the CARES act and through other dollars, can really step in and work with public health to do that resource coordination for families. So, again, they're stabilized, they maintain their housing, they have healthy food coming into the home, to keep the family as healthy as possible.

Johnson:
It sounds like it's as simple as a phone call if you're not talking already.

Harlow:
At least start with a phone call, right, a physically-distanced meeting of some sort—that's a place to start.

So much of our work, I think, in health and human services, and the way we change and bounce forward, is through relationships. And if we can build trust with one another and take some steps together—if we look two years down the road, none of us want the health and human services system to kind of be what it looked like two years ago. We want it to be different.

We want it to learn from the waivers that have been put into place, or the new partnerships that have been developed, or the new ways we're having families apply for even basic services. Those changes are happening at a rapid pace. We don't want to lose that. We want those changes to be what's real when we bounce forward two years from now.

Johnson:
Are there any barriers to doing this sort of work in the states and territories with your organizations or others?

Harlow:
There's always a limitation on resources, right—there's only so much rental assistance, there's only so much of the dollars that we have available to us. Are there limitations on what partnerships can do together? We haven't even begun to scratch that surface, I don't think—if states can leverage public dollars, if local agencies can leverage community-based dollars and other philanthropy dollars coming in the door, if we can tear down silos.

We talk a lot in human services about the human services value curve, trying to move from a regulatory environment to what we call a generative environment. And in regulatory environment, you're worried about checking the boxes—what are all the little nuts and bolts? But in a truly generative space, public health, community-based organizations, health and human services would be together always solving these complex problems.

So, there are barriers in terms of funding—limits on, you know, the regulations get in the way, right? But they're there oftentimes for a reason due from an accountability perspective. But what's a regulation because it made sense 20 years ago, not because it makes sense today? And in this expedited moment, we have a chance to figure what those are, and fix them, and move forward.

Johnson:
What about all of these grant programs? We touched on a couple of them, you mentioned earlier. What specifically could be done there? Is there anything that is just really easy to do—a low-hanging fruit, if you will—if a state's not thinking about it already?

Harlow:
So much about funding gets into that regulative space. About the community services block grant, which is, I think—one of the reasons it's been leveraged both here during COVID and during the Great Recession is because it's flexible. The more funding can be flexible for local needs is critical.

So much funding is dictated by, "With these dollars, you will provide X number of slots for childcare." Well, in my community, maybe I need dollars to do other types of coordination services, or I need to pivot for home food distribution, home food delivery for seniors, or for families with young children. The flexible dollars are critical.

Now, the community services block grant. Many people know CDBG, the community development block grants, which are a larger pot of money—critically important, also somewhat locally flexible, but more of the governmental level. CSBG is meant to be driven by local community assessments, and I know health systems are also required to do a comprehensive community assessments around healthcare issues. And we encourage health systems and community action agencies to work together on those needs assessments.

Because, again, we have a bit more flexibility in that space. That's not a large pot of money in the scheme of things, but the more funders—state funders, federal funders, and philanthropy—can do to make those dollars flexible and trust those local agencies to know their community best, the better off we are, I think, as a country.

Johnson:
What can public health do to work with your members on these issues so that, when this is all over, we're at least heading in a better direction?

Harlow:
From a policy perspective, within the housing historical construct of our country, I think, is incredibly important. To understand that how we ended up here today is not by accident and it's not going to be dismantled by accident. I think public health officials, community action agencies, health and human services need to be intentional about dismantling the structural racism in our country. If we truly want to bounce forward, we need to name it. We need to call it out, even in our own systems, when we see it.

Johnson:
If state health officials are inspired by this—maybe they're trying some of this, but they want to do more—and then they are able to actually make some of these changes to programs or policies, moving money around within the guidelines to have more of an impact, what would be the result of any of that forward leaning thought?

Harlow:
Better outcomes for families, children and seniors, and communities. We talk a lot about outputs versus outcomes, right? And we're good at counting things. It's harder to measure outcomes. They take longer.

However, if you don't start somewhere, you're not going to see those outcomes on the other side. I think that if we truly can come together as public and private systems, if we can be flexible and tear down some of these regulatory walls, we can make sure that families get what they need faster.

Johnson:
You can find links to resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you liked the show, please share it with your colleagues.

And, if you have comments or questions, we'd like to hear from you. Email us pr@astho.org. That's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.


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