 All right, it is Friday afternoon in General Housing and Military Affairs and we have a really special treat this afternoon. We're going to be talking about housing as a vaccine and we have with us and we're also going to hear a report from Dartmouth College did a report on housing and what we did in the face of the pandemic last year in terms of housing the homeless and really working on programs and they studied it and have some thoughts that they wanted to share with us and so we invited them in but first I really want to it takes me great pleasure to introduce Dr. Megan Sandel from Boston. Are you still affiliated with Boston University? Yep, Boston University, Boston Medical Center. Great college for the arts 83. So I had the pleasure of seeing Dr. Sandel when she came up to Vermont seven years ago now and I just realized as we've been discussing about the homelessness issues that no one on this committee was here except me and so when I've talked about housing as a vaccine or housing as healthcare it's become part of the language but it really had its start for me back in 2014 when I heard you speak and so I'm just going to pass the microphone to you you've been made a co-host so if you have a slide deck that you want to show us it's all yours but really just welcome you to I'm sorry to remote Vermont we were having a semantic conversation earlier today about the difference between virtual and remote and we are remote we are real we're not virtual and so welcome to welcome to our committee and please microphone is yours. Great well first thank you so much for inviting me I think for those that don't know I went to medical school at Dartmouth so I did many of my rotations in White River Junction and just have a huge amount of fond memories of being in that part of the world and then I I definitely am excited to kind of be able to kick off what is going to be a really cool hearing you guys are going to hear an amazing report and I just want to kick it off with just some overview thoughts and then I'll stick around for some questions I'm sorry I won't be able to stay the whole time but you have me until 1.30 so I am gonna share my screen if I can figure it out and start us off with just some overview let's see all right can people see my screen thumbs up yes okay great so one of the things that I think is interesting and and this is really increased a lot in the last seven years is people talking about how social factors drive health outcomes I will say that like when I first started doing this work honestly you know two decades ago I graduated from Dartmouth in 1996 from the medical school is is that this idea that a social determinant of health mattered as much as what we tend to think of as like biologic factors and I think that now you don't have to describe why housing and health are related people see the connection but I do think that it's important to just name kind of three ways in which I think we sometimes miss the nuance of how social factors drive health outcomes I think the first is we tend to separate them into individual interventions right you're doing a housing intervention or you're doing a food intervention or you're doing an educational intervention and I think that we have to understand that these social factors are interrelated that that oftentimes when you do something around housing and food together you can be more synergistic and so I do think one of the cool things that you guys did in COVID response was you were really multifactorial and I want to applaud you for that I think that that means why you were so much more effective and why your case rate and your infection rate in the state are so much lower than other states I think the second is is that we tend to think of them individually instead of system-wide and thinking about systems and policies and so again you're the ability to think beyond just an individual level intervention but starting to think about system change I do think becomes really important the last thing is that there are a lot of historical reasons why certain groups have worse housing outcomes you know histories of redlining and systematic disinvestment in certain communities and so it's going to take a while to undo those and we should put kind of an equity lens on it I'll kind of end with the kind of an equity concept but I think that idea of not splitting things apart thinking about multifactorial together thinking on a system change I think is really important the next thing is I'm just going to share with you some research I am a pediatrician but I'm also a researcher and I'm part of a network called Children's Health Watch and Children's Health Watch was founded over 20 years ago by a group of pediatricians who were really worried about a policy change that was coming which was welfare reform and we're treating already kids with failure to thrive and now we're really concerned about how was this policy going to potentially change the outcomes of young children and their families and so what started with mostly focused on food insecurity now also looks at other common hardships right like housing instability energy insecurity health care cost tradeoffs and the health and development of both kids and their parents and so what's interesting is we started to look at how three forms of unstable housing were associated with the health and development of both caregivers and their children and so this is kind of a wonky slide for those that want to get the wonky report I'm happy to send you the article in pediatrics in February of 2018 but what we looked at was we looked at three forms of housing instability the green bar you can see here is multiple moves so that's where we asked someone how many places had you lived in the past year and if you answered three or more and implied you had moved twice at least the purple bar is that we asked were you behind on your rent in the past year and then the blue bar was reporting that you had been homelessness you had been homeless in the lifetime of the young child a child zero to four and so what you'll see here is the red bar is that you answered no to all three of those and then what we did is we kind of stacked up the adjusted odds ratios like the likelihood of reporting that your child was in fair or poor health or the likelihood of reporting that the mother was in fair or poor health or that the mother was having depressive symptoms or that the family was reporting food insecurity at the household level or that you were reporting not seeking health care or avoiding purchasing medication because of fear of costs and so what's striking here is that I think we knew that homelessness was bad right that blue bar right 50% increased risk of fair or poor health 100% increased of fair or poor health and the mother 200% increase of it in maternal depression fourfold increase in food insecurity fourfold increase in health care cost tradeoffs what shocked us was the families that were behind on rent that purple bar look just as bad and so as we're thinking about this upstream approach I think it's really important for us not just to talk about ending homelessness but we have to talk about ending housing instability if we are going to be able to achieve that full kind of housing vaccine concept of being able to be healthy I think the key here is that where can we see the cost savings in the system and so I don't have to tell you guys you you already are utilizing you know University of Vermont has been utilizing being able to help homeless patients go to a respite or a housing hotel as a way to reduce health care costs this is data from Boston Medical Center where we looked at our Medicaid members in our accountable care organization and the top 3% of people that used 40% of the dollars right when we looked at that top 3% group half of them were homeless and housing unstable and so they were just cycling in and out of our emergency department and our inpatient unit and so I think it's really important to think about health care costs but I also want us to start thinking about two generational costs and that there can be ways in which we can actually look at costs not just in the individual level but for everyone living in the household and thinking about it not just in terms of avoided you know health care utilization physical health but also mental health improvement and potentially educational improvement among children and so you remember that bar graph that I showed you two slides ago we actually at Children's Health Watch took that that published paper and then tried to model what would be the avoided costs among families with young children over a 10-year time period if everyone had a stable home and so we conservatively estimate that we think there are 111 billion dollars of avoided health care costs for mothers and children related to unstable homes and we we kind of estimate that related to particularly the costs of hospitalizations ambulatory visits dental mental health care medications among the parent and then also those savings among children including special education costs and so being able to think holistically around all the because I think this is what's hard in budgets right is that you always are thinking about one side of the equation and it's harder to think about the other but I think there are ways in which you can start to think holistically as you can get upstream and so within this approach I think that we oftentimes emergently help people that's the downstream approach right with disease and injury and stabilization but what are the ways in which we can move upstream to prevent those costs what are the ways in which you can start to move from emergency stabilization to permanent supportive housing and being able to link together the capital the operating subsidies the service costs in ways that I think can be really revolutionary this is my last slide and then I'm going to unshare so that I can see everyone again and then I'm happy to answer questions but I think that oftentimes we talk about treating everyone equally and that's really important no doubt about it but I think we need to start talking about treating everyone equitably and so this is my my favorite diagram there are a lot of different diagrams about the difference between equality and equity people have seen the ones probably with the kids walk watching the baseball game or other things but I like this one because I think it's pretty simple to understand is that if you have people that start from different places they're they're different heights in this kind of diagram and you treat them all the same you give them one box to stand on only the tallest person gets to that apple of opportunity in the tree if you treat people equitably you give them what they need to be successful you give the tall person one box you give the medium high person two boxes you give the shorter person three boxes then they all get that same fair shot so the tension here is that in order to get people equitably to the same fair shot you have to treat them unequally you need to give some people more and and you have to feel okay about that because we know that people didn't start from different places by accident we know systemic racism and oppression and how our economic systems are designed are part of the issue and so in order to change that situation we have to design an equitable system not an equal system and we have to be able to think upstream and not just downstream and I really think you guys in Vermont have all the ingredients to show this is possible and so I'm really excited I'm going to stop my share and get to see everyone now and I would love to be able to answer questions I'll start by unmuting myself um thank you and when you started off you talked about the combination how it fits together and how often policy simply is trying to deal with problems that come up and I just you know just even there you see in homelessness I mean for us at homelessness affordable housing but then there's food insecurity you know I in your bar chart I don't think I'd seen maternal depression listed but of course it is you know whether it's and fatherly I mean but just the stress of being behind on rent and who that falls onto of course trying to raise children when you're in poverty is is is difficult so seeing what I'm seeing and what you're what what you're studying is just that all of it and and that's what I heard before is that but housing and you know when the when COVID hit the phrase that came to mind immediately for all of us is that if you're going to have a stay at safe home border you have to have homes to stay at safe to stay safe in and that was kind of our you know mantra when we did our work so what I would say is item that diagram I showed you at the end I say that that first box is always where you're living and it's not to suggest that that's sufficient alone right it's not in a lot of cases you need to start with a safe stable decent home that you can afford that you're not making trade-offs between food and rent or food and heat or other things so that's the foundation and then for certain people you need to build the next layer up right you need to be able to get that job with the right you know child care you need to get that right different types of access and an equitable system is able to design that I think your challenge is you've shown it's possible to create that ecosystem now how do you sustain it over time how do you use the federal government is going to send you dollars how do you create the right long-term plan to be able to have that equitable system and I think you will reap those benefits and how do you capture that over time I see that rep rip try on yep thank you thank you welcome and it's good to see you here and get this information you know I guess my my question is how do we move into this how do we take all of this information and this and everything that you're presenting and how do we move into this you comment that we are doing well but we're not there yet it's obvious and we can't build our way out of this dilemma here in Vermont we learned that as well so you know what's the transition look like in your opinion yeah I think that that is a great question I think in a lot of ways part of it is as we think about stable housing I tend to think about it as a three-legged stool and I think of it as that you need the the spaces to have it and and thinking creatively about what those spaces look like you know whether or not it's you have led the way in converting hotels into thinking about longer term housing I think office space is going to be another thing that's going to change and how what what real estate do you have available to you that could be there I think the second pillar or the second leg of the stool is is operating subsidies whether they're rental vouchers or other other opportunities how do you convert those what sometimes are shelter dollars how do you convert that to be more about a long-term operating subsidy there are certain federal subsidies that I think are underutilized called like section 811 vouchers that are designed for people with disabilities that that is the part of the federal government that's increasing section 811 has seen increases bipartisan increases in in housing along with other section 8 vouchers but then some states are doing their own voucher programs right Massachusetts has a Massachusetts rental voucher program like how do you create that operating subsidy to pay the rent and then the third piece is most people need some type of wraparound services and so what are the ways in which you look at your you know people call it like we call it Department of Children and Families some people call it Department of Social Services how do you look at that for families how do you look at other homeless services how do you look at honestly a lot of medical services are navigators community health workers how do you pool all of those services so they're not duplicating they're efficient and then how so how do you make that three-legged stool work and and I think if you can think creatively about what spaces in real estate not just residential but office how do you think through the operating subsidy how do you think about the services I that's how you create the braided funding in order to sustain this over time just one more comment quickly that trying but 45 years ago up here in the Northeast Kingdom I was a field supervisor for one of the first weatherization programs in the state and I remember I mean 45 years ago doesn't seem like that long go but it seems like an eternity because the homes that I visited were so terrible so bad the living conditions that people were living in was so bad and my recollection is they were all very unhealthy they suffered from long-term diseases they suffered from diabetes obesity I mean all these things and nutrition was bad and so you know poverty is you know at the root of so much of this and as we know mental health and substance use also plays into it but just it's just a recollection I have listening to you and recalling the ill health that people who had that people had and really poor housing yeah no that is exactly how I got interested in housing as a pediatric intern was I was treating kids in the ICU for asthma and I ended up asking a family just like what it changed and they talked about getting a cat and they got a cat because of mice and they couldn't get they couldn't make the change and I was like a eureka moment for me where I was like oh my god the prescription I want to write is for a healthier home and that's not stocked at the pharmacy right and so and that's where this idea of like housing is a vaccine it keeps you healthy now and in the future comes out and it's not that I think we should medicalize all of this language it's a little bit of like a trick around kind of getting you excited about it but but you're 100% right like let's think about all the different opportunities could you do weatherization to make a home healthier and that gives somebody a job potentially in in the community so let's use some of those job training dollars that's what they've done in North Carolina as a way to get to really badly disinvested in housing is they created job training programs that teach people how to fix houses and so then you're able to tap into other different USDA rural dollars rural housing dollars in order to make that work. Thank you. Representative Loomley. Yeah this is great. I really appreciate your your presentation Dr. Sindel and I think that I know we talk about the problems of siloing things siloing services or issue areas and we do it in the legislature we you know we do it in state government we do it as nonprofits I mean it's just it's hard it's it's hard thinking through systemic approaches to change is is very difficult and so I'm wondering where you think the biggest disconnects are systemically. Yeah it's a it's a great question. I think you know one of the things that I think is the hardest to do is to have data talk to each other because what happens is that oftentimes the family that the school is worried about the family that the Department of Children and Families is worried about the the the family that a family practitioner or a health system is worried about are the same families like what I sometimes say is like I think our knee jerk reaction is always to say let's get somebody another social worker or let's get someone another service provider when I say like the families that are the highest risk families for me they do not need another case manager they have plenty of case managers what they need is a coordinated system and so I think oftentimes we don't spend enough time on data systems so that we can create those shared case lists so that we de-duplicate a lot of effort and that's where I think some efficiencies can be found honestly we have been trying to do more like co-navigation as a way to bridge across silos in a way where like oh so for instance like we have been administering a lot of the federal dollars for back rent right because there's like actually dollars available to pay back rent but what we're finding is that typically when you just give someone the application it takes about 45 days to get the application and the check to the landlord but if we have a co-navigator somebody who's trusted by the family who knows the family helping the worker fill out the application we can get that down to 21 days right so like that's pretty real to like get someone through the system faster and so I would I would just make sure that that you have data systems that work together I think you guys have done this with sash right like where you've been able to think about some home-based services related to Medicare and regionalization like like you've actually done this like I point to Vermont as an example I wish we had sash in Massachusetts I'm trying to get sash in Massachusetts but I think this I I would focus on making sure that you find the silo efficiencies by trying to get data systems to talk to each other that's the first step before you then do the program planning before you create the quality improvement well I'm going to be mindful of your time here at 128 I do want to say I appreciate you showing that last slide about equity equity is one of those everybody looks at that picture differently and but it does really paint the picture of well everybody you know if it's a quality everybody should be able to get by with the same thing as opposed to well you know these people need a little bit more in order to make it equitable and that's that's really we could probably philosophize on that for quite some time the differences between that but I any final words for us I mean I just I wish we could have you for well listen making it virtual so I don't try five hours is awesome so I can come back anytime and then I will say I I'm sorry I can't say to listen the Dartmouth report and the Vermont legal aid report are great so like I'm excited for you guys to hear more from the authors and then yes whatever I can do to be helpful as you guys think about this journey in many ways if Vermont is successful then I get to use that in Massachusetts and in other states so please let me know how I can stay in touch air hard can obviously find me anytime and but thank you so much for the opportunity today you guys are amazing happy Friday and good luck with the rest of your hearing great thank you thank you guys thank you that story about the house you know in the mouse you know that really kind of you know gets it just keep asking that one more question and maybe you'll get a different answer is is really at the heart of what our work is so and sausage Elizabeth Carpenter song Mary Ellen Griffin and Mareto Riley welcome I don't know if you have a planned line up here so I'll just turn the microphones over to you I see that see that some of you have been named co-hosts so if you have slides that you want to show feel free to chime in but I will just let you for figure out who needs to talk next for the next little bit thanks welcome thank you so much everyone for inviting us to join you today we have slides that we'll share right now and I believe I'm not able to share yet all right it's working now okay there you go so just as Dr. Sandel said that housing is a vaccine in our work we seek to demonstrate that housing is health and we'd like to talk to you a little bit about what Vermont did and how it can build on its success in using housing policy is a tool for addressing other health challenges in this state just to introduce myself and others that are part of the team I'm Ann Sassen I'm one of the co-leads on research on COVID-19 and rural health equity along with Elizabeth Carpenter-Sung and we're joined with Mary Ellen Griffin and Mareto O'Reilly from Vermont Legal Aid today as you know Vermont has led the US in its response to the COVID-19 pandemic and use of policy has been a critical and often underappreciated component of its the state's approach in responding to the pandemic the Vermont enacted one of the country's most comprehensive eviction moratoriums provided rental relief for landlords expanded its motel voucher program to house its homeless population and has had a moratorium on utility shutoffs as Dr. Sandel has said we've known for a very long time in public health that housing is a tool for advancing population health we know that housing is a key social determinant of health and there's a really strong base of evidence linking housing to a broad range of health conditions including other infectious diseases respiratory illnesses diabetes heart disease substance use disorder and mental health we in our work also use the framing of health equity we believe that if we're going to address these persistent health disparities then we need to devote disproportionate resources into these challenges in the COVID-19 pandemic has really foregrounded the relationship between housing health in a wide range of ways we know that housing along with occupational status is one of the two key risk factors for COVID-19 across the country we see over and over again that COVID-19 has concentrated in congregate living settings including nursing homes in prisons in multi-generational houses households and in crowded housing housing household crowding is much more important than neighborhood density or urban rural status and this is something that's often under appreciated even in our rural context in Vermont housing is one of the key risk factors for COVID-19 and this comes out very strongly in early data from the state across the country there's growing evidence of the importance of housing policy and controlling COVID-19 states that maintain their eviction moratoriums after the federal moratorium lapsed had lower rates of infections than those that maintain theirs and there's also a growing recognition that housing represents a primary tool of pandemic control not something that's secondary or just useful for protecting vulnerable populations but something that's really important for controlling overall transmission rates at population levels in Vermont as you know housing support for a homeless population has been critical in protecting our most vulnerable Vermonters elsewhere across the country congregate shelters saw prevalence of up to 66 percent Vermont to our knowledge has seen less than six k that's did less than 10 cases of COVID-19 Elizabeth thank you and thank you all for the opportunity to share our work with the committee today as Anne mentioned we co-lead research and educational programs at Dartmouth that are focused on issues of health equity particularly in rural communities within the United States and as part of this work in March of last year we launched a study that aimed to examine the impacts of the pandemic on rural health systems and communities in Vermont and New Hampshire and to date we've been able to conduct interviews with over 80 stakeholders and these stakeholders represent many different sectors including health systems leaders healthcare providers members of social service organizations and housing programs mutual aid groups town and city governments and schools we really wanted to cast our net wide in terms of documenting in real time the impacts of the pandemic and throughout this process we've asked our stakeholders to describe what they saw as the key challenges and areas of need as well as their perspectives on opportunities as they look ahead in their own work and within their own communities and our goal in this work is to identify key priorities for action as well as policy next slide in and so I just want to highlight a few of the key findings that I think are particularly relevant to our discussion today and throughout the study we've heard from stakeholders that housing and homelessness are major areas of need and concern in the region and this is something that very early on the pandemic revealed the scale of housing insecurity in northern New England communities and this is something that I think largely has remained hidden particularly in many rural communities and this is something that has become much clearer as many individuals and families who had previously been doubled up with other households as a survival strategy that was no longer a tenable strategy for them given the need to social distance at that point and so what we saw and what we heard from our stakeholders is that there were many people and families who became newly homeless as this strategy of doubling up was no longer tenable for them. We've heard from our stakeholders that the expanded access to the GA Motel Program was something that was a crucial adaptation for protecting a vulnerable population and as Anne had mentioned this was noted throughout our interviews as something that was key in averting the poor outcomes that have been seen elsewhere in populations experiencing homelessness. It's also the case that within the context of some of these short-term supports and in the context of these programs this really facilitated some to access social services mental health behavioral services and to take some initial steps to achieve permanent housing security and so I think this is something that needs to be brought to light and really celebrated and as we think about it to build on this as an opportunity to think about the service connections that have been established within the context of these programs as a way to support long-term the health and social needs of vulnerable Vermonters and finally just a you know something that has emerged as a consistent refrain throughout our interviews is that there is significant unmet need for housing and so the the need for additional housing units the need for affordable housing units particularly the the need as Dr. Sandell was noting the need for supportive housing and those types of wraparound services are really crucial as well as improvements to existing housing stock and what we were just talking about in terms of thinking about weatherization and things of that nature to address some of the the poor housing that is that is a part of our communities here in vermont next slide down and so through our research we've identified three policy priorities the first is to maintain the pandemic housing protections to address the immediate needs for housing and security within vermont the second is to expand supportive housing and those wraparound services and finally the need to invest in significant expansion and improvement of affordable housing within the region and so we are delighted to have partnered with our friends in vermont legal aid to translate our findings into actionable policy recommendations and i'm going to turn things over now to Mary Ellen Griffin who will describe in more detail the policy priorities and recommendations thank you and thank you to the committee for having us it's really great to be here i also just want to say thank you for what you've been able to accomplish so far in terms of keeping vermont safe safely housed during this pandemic it is really really amazing what vermont has done in this situation and um it's just really worth taking a look at and saying thank you for that um the eviction moratorium that was enacted by the legislature has been rated very highly by all experts i think we're ranked fifth in the country for how effective our eviction moratorium has been it has worked to really reduce the rate of eviction especially eviction into homelessness the eviction filings had been at about 150 a month and they went down to 50 the eviction moratorium which i was thinking of as the eviction moratorium it also extends to foreclosure at the moment it's not addressing property tax issues which is still a problem but it's it's huge in terms of keeping people housed a crucial part of the eviction moratorium was the background program the rental housing stabilization program supported almost 10 000 households to stay housed and to keep those landlords in business the one criticism that experts make about our moratorium is that it sort of has a sudden end when the when the emergency comes to an end the eviction moratorium and the foreclosure moratorium will end there's not really a soft landing there there's just and we don't know even though the eviction filings have gone down we don't know how many people have waited to file the evictions until the moratorium ends so there is a risk that we're going to see a surge of evictions when the state of emergency ends next slide please in the other really crucial part that everybody has mentioned is the GA Motel program the short-term housing protections that this allowed brought greater stability for many people not just people who are who are facing homelessness but it meant that it kept our rates low so we almost doubled the number of people that were using emergency shelter the GA Motel program started off in March you can see on the chart on the right if you can see those tiny numbers at about 200 and it went up to almost um over 1800 households by this month by last month um the other issue that the motel program faced was that it was hard for people to move out people couldn't find permanent homes so the length of time which had already been at a record high before the pandemic went has gone even for even higher because people some people have very few people haven't able to find permanent homes to live in and next slide please um I think keeping those two main immediate housing protections in place during the pandemic are really crucial they've really worked to keep people housed or at least stably sheltered during the pandemic and we've really seen the results in terms of reduced numbers of COVID but as we keep those in place um I think as represented as Stephen said it's like a pilot project which pieces of this can we keep how can we keep some measure of this housing security moving forward um I mean there's a lot of ideas to explore there are other ways to reduce the eviction rate we have the federal money for the back rent program for the next year and that's huge but can we have a back rent program that's going to extend past there could there be other housing support programs um I think it was Dr. Sandello talked about the SASH program that's really helpful in helping people who are having conflict with their landlords figure out solutions to resolve those conflicts to stay housed the right to counsel for people to navigate through the eviction process if that happens the right to shelter the way the GA Motel program has worked is been sort of like a right to shelter everybody who needed a safe place to to stay has been able to get a safe place to stay as the state starts to talk about ending the GA Motel program and moving to a different system do we want to still say no we're going to make sure nobody sleeps outside nobody's sleeping in a tent or in a condemned building everybody who needs a bed will get one um we should also look at programs to preserve low-income home ownership the mortgage assistance program delinquent property taxes is definitely something that legal aid it's stressful to see people lose their homes over owing a relatively small amount of back taxes next slide please our second priority that Elizabeth and Anne through their research have identified is to expand supportive housing we have the roadmap to end homelessness the roadmap to end homelessness is a report that was put together by a coalition of state agencies nonprofits housing experts that mapped out how what we would do to end homelessness it's from 2017 but it's still very relevant and still provides detailed instructions as to how to end homelessness the graph on the right is um is actually from that report it's a little outdated but it is the same principles apply in terms of how much money we could save by taking people making sure that everybody who needs permanent supportive housing can get it um thanks Anne so um the the supportive services as Dr. Sandel mentioned the threes the three legs of the stool that the three legs of the stool are the bricks and mortar the subsidy for the housing and then building supportive services into the design of the housing those services especially from the research that Anne and Elizabeth have done really need to be focused on the fact that people have different needs there are different populations that were housing in the ga motel program right now and those people people have different needs so some of the different groups would be thinking of newly homeless versus the chronically homeless families with children people who have mental health or other health needs and people with substance use challenges people in those different categories with with those different challenges have different needs so the services would need to be different next slide please and then the last is that really the as as Dr. Sandel said housing is foundational and the foundation for this is that we need more affordable housing that the difference between what people can afford and what rents are being charged has just gotten further and further and further apart before the pandemic the housing needs assessment showed that there the 18,000 households in Vermont were spending more than half of their income on housing and 36,000 were spending more than 30 percent which is what the rule of thumb is to say whether it's affordable housing needs assessment said we needed 2,629 more units of affordable housing by 2025 there were new housing units created with the coronavirus relief fund i'm sure this committee knows better than me but between the Vermont Housing Conservation Board program that created 247 units and the housing recovery program which touched i think 253 units i'm hearing that was about 500 units but we still need way more units of affordable housing next slide please the research also shows sort of two important things to think about and developing the affordable housing one is that quality of affordable housing obviously matters and dr sandal spoke to this very eloquently i think this is more an issue in the private market than in the government subsidized housing but in the private market a lot of the affordable housing is really still unsafe i heard what representative tryana talked about about visiting places in the northeast kingdom and that's my service area and there still are places that are just in really really bad shape people living in condemned buildings with no heat source with an outrunning water with other people's plumbing waste coming up into their homes regularly lots of mold so addressing those issues would really move the ball forward in terms of making more safe affordable housing available the second is that the location of affordable housing also matters for health again this dr sandal spoke to this eloquently when she talked about the historic problems that we're still working through in terms of housing but in vermont i think another real issue is the rural nature of our communities and the transportation issues that are involved especially for people with low income so situating affordable housing where near jobs and services with good transportation really matters and makes it more valuable and useful to people that are exiting homelessness particularly next slide please and so i'm with dr sandal and all the other speakers that i do think vermont really has a chance to take the lead here and demonstrate to the country how to end homelessness what vermont has been able to do during the pandemic has been really incredible and i think that it's been more obvious to people outside of this room that housing is connected to health that people who weren't ever involved in these issues can see that keeping people housed really helped to keep our numbers low in covid um we have a chance to come out of this stronger and healthier by really building on the housing stability we've created through this pandemic so that's my whole presentation thank you very much representative trana yes i just wanted to mention that we had heard from the vermont housing finance agency earlier this year um to as of no to um people who are having difficulty with their financing on their homes um that property taxes were considered and that the finance agency did take on property tax arrears as part of trying to keep people in their homes so that was a good move it's fairly limited but it does exist at the last one of the last points you made um mary ellen was important in our conversation because the idea that we can create more housing or buy more motels i mean that was that was what we did last year as we bought up motels not you know however many we did but the idea of segregation is really goes against the nature of the kind of goals we've had for affordable housing for the 30 40 years that we've been really concentrating on and i'm just curious to know what you might see um i mean i appreciate that we're leaders in this so maybe we don't have comparisons per se but you know how do we avoid um how do we avoid providing i mean so much new housing in such a way that either it can be built safely and that it doesn't segregate people out like the projects of the sixties you know fifties and sixties did um where do we where do we find that conversation um to make sure that we don't so make sure we don't slip into that trap hannah elizabeth do you want to answer that i i go ahead no no please go ahead mary ellen i mean i think it's definitely a challenging issue i think one of the things that we've seen in the pandemic is that having people in the motels made it a lot easier to deliver services because people were centralized but having people centralized also created its own set of problems that we know having people spread in the community um and and sort of it's challenging because so i think part of it is what the research is showing about the need for heterogeneous to sort of address heterogeneous populations that different people are going to need different kinds of services so we need a bunch of different kinds of affordable housing some people just need affordable housing their real problem is they're poor they can't afford their rent they need a place they can afford some people needs a place that has mental health services right there on the spot or substance abuse services or different kinds of services for them there um and we're going to need different kinds of affordable housing spread across the state transportation is a really difficult issue um people a lot of people really want to stay in their home community one of my one of the places i work is a new port and i definitely hear that a lot from our continuum of care that there are people who are really bad housing situations but they don't want to come to st johnsbury they don't want to go to berry they're going to stay in their really dangerous housing situations to stay in their community so having more services spread around the state so that people can stay in their community while getting the support and housing they need is really important i don't know if anna or elizabeth you want to add to that or marae i would just add to that too in terms of you know building on you know our earlier discussions of thinking holistically and and thinking you know with with systems you know that as we're as we're thinking about the affordable housing issue to take into account location to take into account i think a principle of really thinking about building healthy communities right and so and and thinking about diversity within those communities and thinking about socioeconomic diversity within those communities um certainly what we have seen historically over time throughout the us is a move toward greater residential segregation in fact and so i think we have an opportunity here to potentially disrupt that trend you know and be thinking about the critical factors boros is a rural state of course transportation is marie ellens pointing to and and being close not only to services as we think of health and social services but other resources that all of us enjoy being close to town centers for libraries and other types of resources that are all about the health and well-being of our individuals and families represent triano do you have another i just uh thinking in terms of st john's very where you know in the 19 early 1970 or late 1960s i guess it was that what was known as moonlight ridge was built it was a low-income housing project five miles out of town and you know most of the people there had no transportation and they were you know you would see people walking that distance into town or calling cabs that they can't afford so it is actually um right now um encouraging to see that the latest project housing project in st john's very is a downtown project with the new aviola hotel rural edge is putting that in 40 units of affordable housing and it's really good to see a little bit of a turnaround in that notion that we don't want these people downtown a question that comes up when it's what we talk about housing at this um at this level i mean besides you know starting from not having housing to um perhaps transitional or safety housing to getting into affordable units and then and then above right and and we're really just stepping up the economic ladder when we try to draw it that way but when we talk about the private apartments that are available when we hear stories of mold and of of of really difficult everything that mariano described about the the description of or of these apartments that may be available unused and inhabited habitated right now um where people don't want to leave because they don't think they can find a place that's cheaper what the rehabilitation program we put into effect sort of started to address using state dollars to help private owners but how how do you inspire somebody who either can't afford or chooses not to update their apartments and make them safe and still charge the rents that they can charge because of the marketplace i mean is there is there um a magic it's not magic i know it's not magic um but has there been a conversation about how do you again how do you work with with private owners who think that their apartment is just fine perhaps well i think there's a bunch of different landlords in that category and i think it's a very very small percentage of landlords right most landlords out there are doing a really good job and are maintaining their units there are a few landlords out there who their business model is renting out substandard apartments right like that's a business model that works for them why does it work for them that's probably a complicated question but trying to disrupt that and make it less profitable to rent out substandard apartments i think that would go a long way that's a challenging task um i mean i definitely have frustrating moments where i've seen a landlord get a reduction in their property tax appraisal because the department wasn't up to code and then they're still renting it out and so that frustrates me but i it's a challenging question but i think that's a very small percentage of the landlords i think there's definitely some landlords out there who don't have the resources to fix up their units um they just don't they don't have to know how they don't have the ability i think one of the things i get from the social science research of maybe ann and elizabeth could speak more but that one of the ways to combat this is owner occupied units that people who own a foreplex and live in one of the units are more likely to keep it up um and that that could be an interesting model to pursue but it's um it's definitely a good question to ask and i don't have a full answer it's part of our dilemma period you know because you can't just have only affordable on a HUD-based system there's not enough money in the world to do that elizabeth i could make one quick plug just for the rental housing advisory board's recommendations which was to gather more data which is one of the things dr sandal said that if we had more data about where the apartments were and what condition they were in i think it would make it easier for policymakers to know how to address the problems if we knew where all these problems were right now the town health officer reports are in every town health officer across the state of ramon's offices and i can get them by emailing but it's hard for a policymaker to get a full picture of where are the problems and how widespread are they and how severe are they elizabeth i think that's that's excellent and i think that you know just thinking about building on what mariellen was saying thinking creatively about what are the with with this particular issue i think especially what are the levers of accountability you know and that can exist in terms of i think owner-occupied buildings is a really interesting one but other other things that may also exist at a community level as well in terms of creating systems of accountability and put a little pressure on you know that subset of landlords with with that as their business model we talked about sustainability again we know that the money that we were able to allocate to vhcb to help local organizations buy motels or you know and turn them into micro apartments was expensive i mean it was and that money came from the federal government and we know we have we i know we have different ways of funding things that might make it a little bit less expensive to the tax you know to our tax collection but um what again is it simply political will i mean again how do we build the resources to be sustained but we're not going to keep getting federal funding we know that i mean heartened that we have the funds that we have to maybe build a rental program for people the you know the reach-up level who can you know we might be able to help them with rent for nine months or a year um but that's not sustainable so it's it's so finding sustenance finding a way to do that how you know any words of wisdom for us or any thoughts on that and that's from the committee too i mean i'm really proud of the work we've done but i understand too that unless there's funding sources we're not going to be able to get close to that 2700 units by 2025 sorry i didn't mean to be a doggie downer here on the day when we're supposed to be hearing a report about how well we did go ahead Mariel. I think one of the interesting points that Dr Sandel made was that part of the problem is the siloing so it's hard to capture the cost savings that we see from affordable housing where we're just looking at the housing costs and i don't know how to do that i mean that might i don't even know if that's politically possible to say okay well let's look at how much we save that chart that i put up about um the cost of somebody using the emergency room in patient hospitalization if there are some way to capture those costs and say well we saved all this money from not having people be so sick and not having people have their mental health like just go down the toilet um but it's very hard to capture those costs and to try to show that actually this is cheaper it'd be much cheaper just for people to be stably housed. In that chart as you said it's a little bit out of date but not on the not on the percentage savings um i mean with the difference between the most expensive bed in the state which is in a hospital room and um and even being in a you know the what it was the bottom chart you know $40 a night or you know even in a hotel it's 73 dollars a night it's a far piece of savings from $1,600 or whatever the emergency room cost was. Short how do you how do you capture the concept of that to make the investment in the lower cost housing but at the same time still have to be able to provide emergency funding you know for the crisis of the instant and yeah that's our battle that's that's our that's our job. John you had your hand up a minute ago. Well I think we've I'm heartened by our pandemic response and I think part of the problem lies in our committee structure and what we learned in the pandemic is we worked across committees in an integrated way and I think that we just built on that and no longer think that housing is by itself and human services by itself and I think chair you kind of modeled it with with amp you in how housing and human services are like we're in the same conversation now and we have to make sure that other committees are working like that and you know I I think all the different caucuses we're in is really interesting and every caucus is looking at bills that are moving through the legislative through that caucus lens so I think there's a kind of we should take the success that we've had and I think we may have to budget differently that it may be an appropriations issue as we as we come when we do our reports and stuff but the proof is there in this eighty five million dollars we did out of our committee with human services just in the pandemic response it's been profound to see how the integrated services and last week we learned you know the motels were one part but it just can't beat up motels that had to be all these services and so I mean moving forward we cannot not include that stuff now you know uh so it's I'm I'm heartened by it I think it's like wow this crisis showed us I think a different paradigm so I'm I think it's it's up to us now you know so and you you've led it Tom so I'm I'm great about it I'm I'm actually excited further um okay can I actually go back to the beginning um with Ann and and um Elizabeth can you talk about your affiliation with Dartmouth and what the center is because I I had not I had not heard of you and so if you could just um I mean I I think looking at rural housing especially during the pandemic is is huge but as but looking at rural housing is huge regardless because of the lack of investment the lack the the changing um nature of small towns when transportation is an issue and when um you know is working from home a good thing for small town I you know all of these things where I mean there are things we're going to see out of the pandemic but if you could you just fill us in a little bit on on your organization and and how you how you came to study this not just Vermont but this whole topic. So Ann and I Ann and I come to the work Ann has a public health background I am a medical anthropologist by training and so we've we've worked as community engaged researchers for many years now what is a medical anthropologist. So I I like to say that I have one of the best jobs in the world that I the good ones of going out and spending time with individuals and families learning about their everyday lives and a lot of what I focus on um are partnering with marginalized families so families impacted by housing and security and um and mental health issues and Ann brings a background in particular with global health um Ann has recently turned her attention to issues of rural health equity and so we have come together to really try to think about how we can pull focus um and generate evidence um in terms of you know identifying areas that uh for action as well as for policy recommendations through the work that we do we're both affiliated with the Center for Global Health Equity at Dartmouth which is an umbrella organization that brings together um multiple researchers from across the institution Ann and I wear multiple hats at Dartmouth as well as have partnerships with Dartmouth Hitchcock Health the health uh system in uh in New Hampshire as well and so we're really trying to pull together um not only a network of of researchers but also community partners and other stakeholders to help us as much as we can learn about what the key needs and priorities are within our region um and we're also interested in in thinking about how we uh compare to other regions within rural regions within the U.S. as well and I would also add that this research that's focused on housing is part of a much larger body of work our work is by state in nature so we've been looking at the responses in both New Hampshire and Vermont um and the ways that um the pandemic is affecting both rural communities and health systems and housing has emerged as a very critical area of focus of this work but it's um you know we have looked much more broadly to understand what's happening across the two states and is your research I mean I again I appreciate this report and this analysis um and is this the kind of research that if we weren't in Vermont or New Hampshire we'd be able to look up and look at and learn from is there other material that you're producing that we might be able to find um nuggets of information that we can use absolutely we've we'd be happy to share with you our report that came from our initial phase of research um and we also have um some some additional updated reports as well that we'd be delighted to share with the committee yeah and I guess one more question on this for me is is um Dr. Sandel talked about again the holistic view and so do you take that I mean yes you're visiting families and you're seeing what's on the the ground but are you you know I mean I I mean I can just my brain can just go spinning at at you know what do we have for snap benefits what do we have for um food banks or you know availability what do we have for heating oil uh in our in our neck of the woods what do we have you know so seeing it holistically um yet we're still in a world that doesn't view it holistically um and and I really appreciate that and and I think that was one of the things that we in our study design tried to really be aware of um and as we thought about who we needed to connect to in the context of conducting interviews in Vermont New Hampshire we really cast our net very wide so we didn't limit ourselves even though we might be focused on world health equity we knew we needed to talk to people who were outside of the health care system outside of being health care providers and so we've had an opportunity to really connect with you know a wide cross-section of community members various health and social service organizations to try to document those different pieces of the puzzle the other thing I would say too is that uh and I think our earlier research really points to the ways in which in both New Hampshire and Vermont the success of collaborations and networks and partnerships in our region and that was something again that I think we already have some models that we can point to um in terms of breaking down some of these traditional silos um and so there I think those would be also some things that may be helpful um for the for the committee to um to to have access to some of the the research that focuses a bit more broadly than than just housing as well that's great thank you and Mary Ellen your focus is is up in you said you're based in Newport or in the kingdom I work out of the state johnsbury office of legal aid and I mostly covered um caledonia orleans and Essex counties mostly I've been doing eviction defense I do a lot of conditions cases as well but uh it's been really great to not have so many people evicted it's just it's an amazing thing um so and that's because that's not that's I mean what we've heard testimony from is that part of that is because um perhaps people aren't filing but more importantly landlords are getting their back rents so they're erasing uh up to upwards of 70 percent of all evictions are supposedly about back rent um or more um legal aid and the Veronica landlord association also started a mediation program that hopefully will keep people out of court um and you know I I guess with that with the moratorium part I mean I I mean everybody says we it kind of ends I mean it ends in 30 days um which I guess is it may not be a soft landing but it certainly is softer than than perhaps not but it's you know it's it's what we were able to um it's it's what we were able to do with with the administration and with court system um do you see oh sorry about the moratorium has saved lives in vermont it's it's amazing it's been really good it wouldn't have worked without the back rent program I don't think but the back but I think you're right a lot of problems that we were solving through eviction we figured out there are other ways we can solve these problems without making vulnerable families homeless there so it'd be great if we could continue some of that say okay these are real conflicts we need a solution to them but does it have to involve making somebody homeless I don't think it does that's not that's not to the rate that we had been doing it well and the report that we we've mentioned it and we haven't said it but something that legalated with landlord association other stakeholders was um was about the existing program basically we do have a background program tucked away somewhere in our in our emergency services division that I know several years ago we were trying to increase the funding to it before COVID and then COVID we were able to do that with the CRF funds but I think as we do our work moving forward we have to consider you know if we can fund that I mean I'm glad we had this money I'm glad we're using it but nevertheless that was $25 million in back rent in in six months that's a substantial amount of money I don't think the ongoing program would be quite as as robust but nevertheless it's almost nice to clear as many plates as we've cleared moving forward all right I am so grateful that you were able to make time for us all of you I haven't seen marae for a while so I'm assuming she's working elsewise marae do you have anything to offer I'm here I um so I was just on the call to in in case there were questions specifically about the GA program I sort of helped a little bit in in drafting the brief but primarily worked with this group in a couple of the op-eds that came out and as a medical legal partnership attorney for people with substance use disorder a lot of the work I've done in the pandemic um intersects with the GA motel program so I was just here I sort of back up in case questions came up about that um but they didn't um so it was it was nice to hear the presentation and obviously to hear from Dr. Sandel what an amazing uh partner in in this work all right well great good to see you all um and again thank you Elizabeth and and nice to meet you um and um thank you for your work I appreciate um I just appreciate the focus of your work it is really important to keep to keep knowing what's going on out there so thank you thank you so much very Ellen and marae thank you for your work and we'll see you each I'm sure at some point during the session on anything ranging from GA issues to other other landlord issues so thank you so much