Policy Topics

Across the country, people are struggling to find high-quality affordable housing in socially and economically vibrant neighborhoods. The source of the problem is complex – ranging from challenges maintaining an aging and deteriorating legacy housing stock to rising costs of construction for new homes to discriminatory zoning and financing policies and practices. Solutions must be equally multi-faceted and creative.

What 4Action funded research says:

• Affordable housing in higher-income areas has been shown to significantly improve birth outcomes, particularly for Black individuals, and foster long-term health and economic benefits. Massachusetts' Chapter 40B policy exemplifies how bypassing exclusionary zoning can create affordable housing in neighborhoods that offer greater economic mobility and better health opportunities. (See Sportiche et al., 2023). 
   
• A housing health index, developed using health insurance claims data, enables city governments to proactively identify substandard buildings and prioritize inspections. This approach shifts the focus from reactive, complaint-driven housing code enforcement to a more strategic method that addresses health risks associated with poor housing conditions, ultimately improving public health outcomes. (See Chakraborty et al., 2024).
   
• Green space goes hand-in-hand with cardiovascular health, with tree planting as a possible strategy to improve health; areas with more plants and trees (greenness) are associated with lower incidence of cardiovascular disease (See Brown et. al., 2024) and Alzheimer's Disease (See Brown et. al., 2024).
   
• Promotion of local initiatives that enhance supportive neighborhood environments and social factors are of great importance to mitigate psychological distress, particularly in times of crisis. (See Kondo et al., 2022).
   
• An asset-framing narrative that highlights the benefits of mobility vouchers has the potential to increase small-scale landlords' participation in voucher programs. By focusing on the positive impact, this approach can help expand low-income residents’ access to high-opportunity neighborhoods, offering a pathway to greater economic mobility and improved living conditions. (See Ortiz et al., 2024).
   
• Portland's N/NE Preference Policy, designed to restore housing access for displaced communities of color, has helped residents reconnect with a historically Black neighborhood and improved aspects of well-being. However, persistent challenges related to housing quality, neighborhood conditions, and affordability indicate that a more comprehensive approach is needed to fully address community development and racial equity goals. (See Thurber & Bates findings).
   
• Evictions can severely disrupt healthcare access by increasing the risk of Medicaid disenrollment, while also driving up healthcare costs due to higher rates of acute care visits. This highlights the critical intersection between housing stability and healthcare, emphasizing the need for policies that address both to ensure better health outcomes and cost efficiency. (See Schwartz et al., 2022).
   
• Most state Low-Income Housing Tax Credit (LIHTC) programs address specific health-related housing issues, such as indoor air quality, but few programs incentivize comprehensive measures needed to improve overall health outcomes. Expanding program criteria to include air quality, toxic substances, and neighborhood amenities could significantly enhance efforts to promote healthier affordable housing and better long-term health outcomes. (See Ahrentzen & Dearborn, 2020).
   
• Renovations and ownership transfers in New York City public housing under the RAD program have led to improvements in housing-sensitive health conditions, indicating that such interventions can effectively reduce the overall disease burden. This demonstrates the potential health benefits of investing in public housing improvements. (See Ellen et al., 2020).
   
• Simplifying and streamlining administrative processes for housing subsidy recipients can significantly reduce barriers to access, making it easier for low-income families to benefit from housing assistance programs. This approach enhances the overall effectiveness of these programs, ensuring that more eligible recipients can take advantage of available resources. (See Stacy et al., 2024). 
   
• Rent control policies that prioritize tenant protections, exemptions, and strong administrative capacity can result in more effective and equitable outcomes. Crafting these policies with attention to their nuanced components is essential for addressing housing affordability while minimizing unintended consequences for the housing market. (See Stacy et al., 2021).
   
• The Fair Housing Land Use Score (FHLUS) allows policymakers to more accurately assess the inclusivity of local zoning and housing plans. The tool shows that many existing land use policies may unintentionally reinforce segregation, underscoring the need for reforms to promote fair and inclusive neighborhoods. (See Monkkonen et al., 2023). 
   
• The Low-Income Housing Tax Credit (LIHTC) aims to avoid concentrating poverty and entrenching segregation by requiring states to allocate credits to projects in high-poverty locations that are part of a "concerted community revitalization plan" (CCRP). However, an analysis of Connecticut's applications over ten years reveals that nearly all lack meaningful revitalization planning. This indicates that the CCRP process may not be effectively enforced or leveraged for broader neighborhood gain, highlighting the need for reforms to better fulfill its Congressional mandate. (See Kazis & O'Regan, 2023). 
   
• Individuals experiencing homelessness face significant gaps in access to healthcare services, which leads to heavy reliance on acute emergency services and high rates of hospitalization for preventable conditions, thus increasing health care costs. (See Palimaru et al., 2020 and Davila & Buchanan, 2021).
   
• When people with complex needs are offered stable housing AND supportive services, they quickly enter housing and stay there. These individuals also experience long term benefits, like reduced jail time. The costs of providing supportive housing also reduces costs of other services, such as jail stays, court costs, police time, and local emergency services. Additionally, permanent supportive housing leads to increases in psychiatric care office visits and fewer emergency department visits.(See What We Learned from the Evaluation of the Denver Supportive Housing Social Impact Bond Initiative, Urban Institute and Hanson & Gillepsie, 2024).
   
• Federal housing support is provided to low-income families through public housing projects or subsidies (either to families or to developers or landlords). One strategy is not inherently better than another in improving housing quality or family health and well-being. Each approach has limitations and benefits recipients differently, but in general, any kind of housing support improves housing stability. There are currently insufficient resources to support all the families who are eligible. Allocating additional funding and focusing on improving surrounding neighborhood conditions could benefit millions of American families. (See Farquhar et al., 2018).
   
• Comprehensive community development efforts, such as redevelopment strategies for publicly subsidized housing communities, can increase low-income, ethnically diverse resident’s perception of safety. It can also reduce perceptions of problems with drugs, alcohol, or violent activity, as well as contribute to community social cohesion. (See E4A Project Page, Seattle's Yesler Terrace Redevelopment).
   
• Families who live in homes that have been weatherized experience improved health and are better able to afford energy bills. Expansion of weatherization programs through cross-sector partnerships with energy, healthcare and public health agencies can help improve families’ physical and financial wellbeing, and may reduce health care costs. (See Tonn et al., 2021).
   
• Remediation of abandoned lots has been the target of efforts in multiple municipalities to decrease crime and improve health. The theoretical basis of these efforts is that remediation changes the urban landscape in a way that promotes residents’ willingness and confidence to act in the service of their own security and improves neighborhood functioning which can enhance social engagement and well-being. (See Hohl et al., 2019).
   
• Policies that reduce required information on housing applications have had mixed results in the labor market and limited results in the housing market. Following the implementation of a policy that restricted the use of background checks, eviction history, income minimums, and credit history in rental housing applications in Minneapolis, discrimination against African American and Somali American men increased. (See Gorzig & Rho 2021).
   
• Opportunity Zones (OZs) were implemented by the federal government and some state and local governments to attract new investments to distressed communities in urban and rural areas in the United States, but some OZ neighborhoods can receive more investments than others.
  • Among the OZ designated census tracts, gentrifying tracts attract more investments for commercial and residential development.
  • Higher gentrification rates are associated with lower vacancy rates and the impact of gentrification on business vacancies is even stronger. This implies that gentrified neighborhoods receive a larger share of OZ investments.
  • The administrative tax and income data from the DC government shows a clear pattern between gentrification and out migration of residents with lower incomes. (See Kurban et al., 2022).
     
• Pay-for-success financing programs provide housing to individuals experiencing chronic homelessness, people with mental or behavioral disorders, and adults recently released from prison. These programs deliver a range of supportive services to address the complex psychosocial, behavioral, and medical needs of the people they are meant to benefit. Success payments to the private investors are contingent on some measure of sustained housing. (See Lantz & Iovan 2017).
   
• Evictions worsen material deprivation, sort families into lower-quality housing in more disadvantaged neighborhoods, disrupt social networks, erode mental health, and have negative impacts on healthcare utilization and health outcomes.
  • In New York City, eviction increased the likelihood of losing Medicaid coverage and decreased pharmaceutical prescription fills.
  • Among patients who generated healthcare spending, average spending was 20% higher for those who had been evicted. (See Schwartz et al., 2022).
     
• The pace of gentrification has accelerated in cities across the US, potentially displacing families and impacting quality of life for children.
  • Children who start out in a gentrifying area experience larger improvements in some aspects of their residential environment than children who start out in persistently low-socioeconomic status areas. Children moving from gentrifying areas also tend to move to lower-quality buildings. (See Dragan, Ellen, & Glied 2019a).
  • The experience of gentrification is associated with moderate increases in diagnoses of anxiety or depression—which are concentrated among children living in market-rate housing.(See Dragan, Ellen, & Glied 2019b).
     
• Source of income laws prohibiting landlords from discriminating against tenants based on their income source can help increase access to low-poverty neighborhoods for families with lower incomes. A dataset that includes details on these laws shows that source of income protections help families access low-poverty neighborhoods but these laws take five years, on average, to make an impact. (See Galvez et al., 2020).
   

Wide variance in funding for and access to education – from preschool through post-secondary school – in the United States has rendered the education system one of the most pervasive forces in perpetuating inequities. These inequities are seeded even before children enter school, due to disparities in parental leave policies and childcare options, especially for low- and middle-income families.

What 4Action-funded research says:

• Disparities in autism diagnoses among children from different racial and ethnic backgrounds in NYC’s universal pre-K programs are evident. Systemic factors such as unequal access to healthcare and cultural perceptions of developmental disorders significantly contribute to these disparities. This points to a clear need for more equitable support structures and resources in early childhood education to ensure timely and accurate diagnoses for all children, regardless of their background. (See Strassfeld et al., 2023).
   
• Storytelling has a strong evidence base in communication literature, and needs to be evaluated as part of the overall policy advocacy strategy, and tailored to where specific audiences are on the issue at that time (Access Winett & Niederdeppe, 2022).
   
• When kids age out of the Special Supplemental Nutrition Program for Women, Infants, and Children WIC program, mothers reduce their own nutritional intake to provide more food for their children, buffering the negative effects of losing program benefits. (See Bitler et al., 2022).
   
• At least 24 months may be needed to physically recover after giving birth. This is particularly true for those returning to physically demanding jobs. Returning to work before being fully recovered may mean being passed over for promotions or raises if parents can’t meet the physical demands of their jobs, resulting in a de facto financial penalty for giving birth. Parents in physically demanding careers could benefit from comprehensive parental leave and alternative job duties when returning to work. (See Healy & Heissel, 2022).
   
• Throughout the course of a child’s development, public education needs more funding. People in the early care and education workforce earn low wages and experience poor mental well-being and high rates of food insecurity. A healthy early childhood education workforce is vital to the delivery of quality childcare. (See Loh, Oddo, & Otten, 2020).
   
• When children receive early high quality education, they accrue health benefits later in life. However, these health improvements differentially benefit white families, sometimes purposefully, and sometimes unintentionally due to the way education is funded. (See Derrington, Huang, & Ferrie, 2021 and this E4A project page).
   
• While the general public supports better funding for early childhood education, elected officials are divided along party lines in their willingness to increase resource allocation. The type of information that is effective in garnering the general public’s support is not as convincing for policymakers, suggesting there may be a disconnect between the rationale and values of the electorate and the elected. (See Neiderdeppe et al., 2021).
   
• Efforts to prioritize education access and resources for families and children of color - often called affirmative action - have been deemed illegal in some places; but banning affirmative action further harms youth of color. Affirmative action bans resulted in an increase in risky behaviors like smoking and binge drinking among high school students who stood to benefit from these policies. Social policies like college-level affirmative action programs, intended to increase socioeconomic opportunity, could improve population health, wellbeing, and equity. (See Venkataramani et al., 2019).
   
• Low-income parents participating in a financial and health empowerment initiative for Temporary Assistance for Needy Families (TANF) recipients experienced sustained improvement in food security, caregiver health, employment, and savings, along with decreases in depressive symptoms. (See Weida et al., 2020).
   
• The quality and consistency of childcare arrangements affects healthy child development and are directly impacted by parent’s work schedules. Routine uncertainty is largely incompatible with formal, center-based care, and increases the likelihood of needing a complex patchwork of care arrangements. Parents’ exposure to on-call work and last-minute shift changes is associated with more numerous care arrangements with a reliance on informal care arrangements, the use of siblings to provide care, and young children being left alone without adult supervision. (See publications from Harknett, Schneider, & Luhr 2019).
   
• High quality universal pre-kindergarten (UPK) programs can generate lifetime benefits for participating children and can accelerate the rate at which conditions that could potentially delay learning and cause behavioral problems are identified.
  • The introduction of UPK in New York City increased the likelihood that a child would be diagnosed with asthma or with vision problems received treatment for hearing or vision problems, or received a screening during the prekindergarten year. UPK also accelerated the timing of diagnoses of vision problems. (See Hong, Dragan, & Glied, 2017).
     

Inflation was at a 40-year high in June, 2022. While some economists might suggest raising wages could exacerbate inflation, the “working poor” are already struggling to keep up with raising inflation (See Smialek & Casselman, NY Times). The most common (if not popular) tool for raising low-wage worker compensation is increasing the minimum wage. Other “progressive” practices include living wage policies and guaranteed income initiatives.

What 4Action funded research says:

• Reforming the tax code to address inequities could be a crucial step toward promoting racial equity in wealth distribution and ensuring more inclusive economic growth. The exacerbates racial disparities in wealth accumulation. The current federal individual income tax system’s treatment of capital income disproportionately benefits White households, which are more likely to own capital assets, further widening the racial wealth gap. (See Holtzblatt et al., 2023).
   
• Unconditional cash transfers to mothers with low incomes can lead to marked improvements in financial stability and reduced dependence on high-cost financial services. A guaranteed income program can enhance access to essential resources like nutritious food and healthcare, contribute to better health outcomes, and foster a sense of community reciprocity, further reinforcing its potential to drive broader social and economic benefits. (See Brugger et al., n.d.).
   
• Implementing a universal paid leave policy would cost less than 1% of wages but yield significant economic benefits, particularly for women, by boosting workforce participation and reducing public assistance needs. A federal program that provides at least 12 weeks of paid leave for all workers, expands family definitions to include chosen family, and guarantees job protection to prevent retaliation could reduce or eliminate access disparities for minority communities to leave benefits. (See: All Americans Deserve Paid Leave Benefits: Policy Options for Congress.)
   
• Guaranteed income appears to be one of the best tools for guarding against income volatility, leading to better physical and mental health, employment growth, and improved month-to-month income stability. Despite concerns to the contrary, guaranteed income recipients are actually MORE likely to be gainfully employed. Guaranteed income also bolsters recipient health and well-being - especially notable in decreases in anxiety and depression. At the same time, it is not a panacea – receiving guaranteed income did not improve food security, housing cost burden, or household chaos compared to non-recipients. (See West et al., 2021; West & Castro, 2023).
   
• Older women in the U.S. prioritize age-specific financial literacy programming with a focus on long-term planning, trust, and convenience (See the policy brief and full report by Yoong et al., 2023).
   
• An after-school program paired with a cash transfer intended to reduce structural barriers to participation provided enhanced opportunities for young men in families with low incomes to increase healthy behaviors and improve financial health. (See Stacy et. al., 2024).
   
• Minimum wage increases benefit some workers but these benefits are not accrued uniformly. Minimum wage policies should account for the dynamics among different fields and professions, including how higher wages will be accommodated and who will bear the cost.
  • For example, employers may implement higher standards for employment or employ fewer people. In the early childhood care setting, costs are passed along to families who may struggle to afford the added expense.
     
• Living wages seem to benefit employees - especially higher skilled workers - more universally. In addition to yielding higher wages, living wage policies also lead to better access to health insurance and better worker health.
   
• Supplemental security income (SSI) benefits are associated with better health outcomes and lower medical expenditures, suggesting that relatively small cash transfers may be a cost-effective way to improve health outcomes and reduce healthcare spending. SSI is associated with 23% lower Medicaid expenditures through age 8. Additionally, in early childhood (prior to age 6), birthweight-eligible children were significantly less likely to be diagnosed with both acute (infection, injury) and chronic (malnutrition, developmental delay) conditions, and were less likely to be admitted to the hospital (See Ko, Howland, & Glied, 2022).
   
• The Earned Income Tax Credit (EITC) is a critical component of the U.S. safety net, providing support to millions of families with potential health implications for recipients.
  • An additional $100, or a 3% increase, in the average annual EITC exposure between birth and age 18 increases the likelihood of reporting very good or excellent health, and decreases the likelihood of being obese between ages 22 and 27. (See Braga, Blavin, & Gangopadhyaya, 2020).
  • A $1,000 increase in the maximum available EITC credit is associated with a 4% reduction in the likelihood of reporting any poor mental health days in the past month for married mothers and a 4.7% reduction for unmarried mothers. (See Gangopadhyaya et al., 2020).
  • Federal EITC expansions are associated with increased employment for unmarried mothers and small reductions in employment for married mothers while state EITC expansions are associated with improved mental health for married mothers. (See Gangopadhyaya et al., 2020).
     
• Increasing in the minimum wage throughout childhood (not a one-time increase) can lead to a significant improvement in child health. Much of the benefits of a higher minimum wage are associated with the period between birth and age 5. A $1 increase in the minimum wage over the child’s early life course, between ages of 0-5 is associated with a 2.7% improvement in general health, an 8.7% increase in the probability of very good or excellent health, a 14% decrease in poor health, and 15.6% decrease in missed school days (See Wehby et al., 2020).
   
• Access to paid leave can have significant implications associated with spending, health and well-being for employers and employees, as well as for health care providers.
  • Research evaluating the effects of mandated paid sick leave shows:
    • Neither employment nor wages significantly or systematically increased or decreased after a mandate was introduced. (See Pichler & Ziebarth 2018).
    • Coverage rates increased from 66% to 79% during the first years after the mandates were implemented.
    • There is no evidence that employers decrease other benefits such as paid vacation time or paid family leave.
    • A paid sick leave mandate was significantly associated with decreases in emergency department and specialist visits, increases in primary care use, and an increased probability of receiving certain preventive health services. (See Maclean, Pichler, & Ziebarth, 2020).
       
  • Estimates of the impacts of proposed national paid family leave and medical programs developed using a simulation model show that paid family and medical leave benefits are well targeted to low wage workers, compared with moderate and higher wage workers. Workers at all earnings and income levels would gain access to new leave benefits. (See Hartmann & Hayes, 2021).
     
  • Lack of awareness of available paid parental leave benefits has negative effects on take up of the benefit.
    • Lower-income mothers report less knowledge of their maternity leave benefits than other mothers, and are 48% less likely to report receiving information from their employers.
    • Fewer than 2% of lower-income mothers had accurate information about the policy.
    • Employers are not a reliable source of information for many workers. Healthcare providers are the only source of information being used equally by low and high-income women.
    • Among women who were employed during pregnancy, only 33 percent of lower-income women were employed in jobs that were covered by paid parental leave, compared to 65 percent of higher income women. (See Goodman, Elser, & Dow, 2020).
       
  • When a new paid leave ordinance was enacted in California it expanded job protection and access to leave and improved racial and socioeconomic equity of parental leave access:
    • Extending job protection to all private firms regardless of employment size would increase the proportion of those protected to 73% for non-Hispanic Black parents and 71% for Hispanic parents.
    • The ordinance significantly increased the proportion of San Francisco employers offering paid parental leave. In 2018, 75% of San Francisco employers with 20 or more employees offered paid parental or family leave, compared to 44% in 2016.
    • Few employers reported negative impacts of changing their paid leave policies, and some reported positive impacts. However, many employers reported difficulty understanding legal requirements and responsibilities for compliance.
    • Overall, employer support for the ordinance is high. Seventy-eight percent of employers reported being supportive or very supportive of the ordinance while only 6% were opposed.
    • Before the ordinance took effect, lower-income women were less likely to take over six weeks of leave or receive pay from the government or their employer during their leave; and were offered shorter amounts of leave at a lower wage replacement rate by their employers than higher income women (See Goodman, Dow, & Elser, 2019).
       

Denial of climate change is waning as shifting weather patterns and the frequency and adverse effects of extreme climate events like heat waves, wildfires, hurricanes and flooding increase. However, discrepancy remains about how to mitigate the impact of climate change, and the systems and infrastructure that are in greatest need of shoring up - water, transportation, energy, etc. - are expensive to build and maintain.

What 4Action-funded research says:

• Targeted investments in underserved communities can simultaneously advance climate action and promote equity. By funding projects such as clean transportation, energy efficiency, and urban greening in disadvantaged areas, the California Climate Investments program provides a model for inclusive climate policy that not only reduces environmental impacts but also fosters economic opportunity and community resilience, and addresses both environmental and social inequities. (See Lim & Fahnestock, 2024).
   
• Green space goes hand-in-hand with cardiovascular health, with tree planting as a possible strategy to improve health; areas with more plants and trees (greenness) are associated with lower incidence of cardiovascular disease (See Brown et. al., 2024) and Alzheimer's Disease (See Brown et. al., 2024).
   
• Extreme heat events and unseasonably warm weather are linked with higher incidences of stress, anxiety, and depression. Low-income adults are especially vulnerable to extreme heat events, and incidence of low birth weight is negatively affected in rural areas. (See E4A Project Page: Impacts of Extreme Weather Events and Water Policy on Birth Weights and Psychological Distress in California).
   
• Weatherized homes use less energy and better protect residents from adverse effects of extreme weather events. Proactively weatherizing new buildings or retrofitting existing housing stock can contribute to the prevention of climate change and help mitigate its impacts, especially for economically disadvantaged families. (See Tonn et al., 2021).
   
• In addition to the aesthetic and functional benefits of green infrastructure, greening initiatives like tree planting have cardiovascular health benefits - leading to fewer and less severe cardiovascular conditions over time. This has been experienced first-hand by medicare recipients in Miami, FL, ground zero for climate impacts in the U.S. (See E4A Project Page: Impact of Greening on Cardiovascular Disease (CVD) in Low-Income Miami Neighborhoods).

Claims of voter fraud contrasted with concerns about voter suppression may both be contributing to eroding faith in America’s democracy.

What 4Action funded research says:

• There is a growing disconnect between voters and elected officials.
  • Although many youth still generally trust the American governmental system, young people simultaneously believe that elected officials don’t really care about their opinions and that there isn’t a good way to “make elected officials listen to them. (See E4A Grantee Page for more information).
  • Unfortunately, these beliefs prove to be true in some cases. Firearm regulations and early-childhood care and education are two issues where the politicians’ views remain relatively entrenched despite public support. (See Niederdeppe et al., 2021;Siegel & Boine, 2020; and Winett et al., 2021).
     

Public debates about the very private issues of reproductive health, including abortion access, are highly charged in the wake of the Supreme Court’s decision overturning Roe v. Wade. Systemic efforts to deny access to reproductive healthcare have serious consequences that disproportionately harm low-income people and families of color. (See statement from RWJF President & CEO for more information).

What 4Action-funded research says:

• From 2016 to 2020, 75% of American Indian and Alaska Native birthing individuals lacked access to pre-pregnancy care and were more likely to be uninsured for prenatal care than white individuals. Although the ACA improved healthcare coverage and usage among AI/AN birth givers, pre-ACA disparities remained, highlighting the need for policy interventions beyond healthcare access to address structural and systemic barriers in AI/AN communities. Similarly, perinatal care utilization and quality vary among Hispanic birthing people based on primary language and state policy environment, with states offering Medicaid expansion and immigrant Medicaid coverage showing greater equity in prenatal and postpartum care between Spanish-speaking and English-speaking Hispanic individuals. (See Gartner et al., 2024).
   
• Structural racism and neighborhood deprivation significantly impact maternal and infant health outcomes, particularly for Black mothers and infants. Policies aimed at improving maternal health equity must address systemic barriers, including economic disparities and access to high-quality healthcare, while fostering neighborhood environments that support maternal and child well-being. (See Gangopadhyaya et al., 2024).
   
• Obtaining a legal nonrestrictive abortion does not result in negative health outcomes for the vast majority of people. However, restricting access to abortion causes mental and emotional distress, most significantly experienced prior to obtaining an abortion, especially when care is not easily accessible. Furthermore, research exploring the impacts of carrying an unwanted pregnancy to term, exposed serious consequences to women’s and children’s health and well-being (See The Turnaway Project from Greene Foster et al.).
   
• Although not directly focused on abortion, studies demonstrate improved maternal and infant health outcomes when immigrants have access to reproductive health care (See Swartz et al, 2017) and other social services (See Koball & Hartig). Research also demonstrates that supportive prenatal substance use policies result in significantly better outcomes for pregnant people and infants compared to punitive policies (See Maclean et al., 2022; Meinhofer et al., 2022; and Tabatabaeepour et al., 2022). Such studies offer learnings that are applicable to this issue. Criminalizing abortion is likely to worsen physical, mental, and emotional health.
   
• Person-centered contraceptive access supports and promotes reproductive autonomy, sexual well-being, menstrual regulation, and preventive health measures, but access varies by geography. On average, state contraceptive access expanded between 2006 and 2021, but by 2021 access to contraception was markedly more limited in states in the Midwest and the South than in the Northeast and the West. (See Rice et al., 2022).
   
• Place matters: municipal budget allocations can have consequences for severe maternal morbidity (SMM). Municipalities that spend more on fire and ambulance services, transportation, public health, housing, and libraries tend to have lower rates of SMM, whereas those with higher police spending had higher rates of SMM. (See Muchomba et al., 2021).
   
• Medicaid has a long history of serving pregnant people and is associated with positive health outcomes for birthing people, but many people are not eligible for Medicaid before pregnancy or after sixty days postpartum.
  • More than one in four new mothers with Medicaid-covered prenatal care was uninsured before pregnancy, one in five became uninsured two to six months postpartum, and one in three was uninsured in either period. (See Johnston et al., 2021).
  • Pregnant people with low incomes who had access to health insurance through Medicaid expansion were more likely to take a daily folic acid supplement in the month before pregnancy, report having a preconception health conversation with a healthcare provider before pregnancy, and use effective contraception methods during the postpartum period. (See Myerson, Crawford, & Wherry, 2020).
  • About 1 in 5 uninsured new mothers reported at least one unmet need for medical care because of cost in the past year, and over half were very worried about paying their medical bills. Moreover, about one-third of new mothers who lost Medicaid and became uninsured were recovering from a cesarean section, and just over one-quarter reported being depressed sometimes, often, or always in the months after giving birth. (See McMorrow et al., 2020).
     
• Access to paid family leave increases the length of time that birthing people are able to breastfeed:
  • In California, paid family leave increased the overall duration of breastfeeding by nearly 18 days, and improved the likelihood of breastfeeding for at least six months.
  • Access to paid family leave has substantially larger effects on breastfeeding duration for some disadvantaged mothers. (See Pac et al., 2019).
     
• Medications for opioid use disorder (MOUD) improve outcomes for pregnant people and infants but access to them is not equitable among pregnant and birthing people:
  • Pregnant people with opioid use disorder (OUD) in rural areas and who are aged 35 years or older are less likely to have received MOUD.
  • Families in which the pregnant person’s primary language is English and paternity is recorded on the birth certificate are more likely to receive medications.
  • Regardless of high school degree attainment, non-Hispanic Black people were less likely than non-Hispanic white people to receive medications.
  • Hispanic pregnant people without a high school degree were less likely to receive medications. (See Henkhaus et al., 2021).

Debates about how to address crime and policing range from a focus on police training and practices, to community-level interventions to disrupt interactions with the criminal-legal system.

What 4Action-funded research says:

• Mental health diversion holds the potential to reduce racial disparities in incarceration in California. However, to effectively reduce racial disparities and connect underserved communities to vital mental health resources, mental health diversion programs must be accessible to these communities. Creating standardized policies at the state and county level to minimize barriers to participating in mental health diversion, ensure the provision of culturally responsive services, and monitor the demographics and outcomes of program participants, can improve equitable access to mental health diversion. (See Sizemore et al., 2024).
   
• Three strikes and truth-in-sentencing policies worsen birth outcomes, particularly for Black infants, with significant drops in birth weight, especially among those born to less-educated individuals. These policies not only exacerbate racial health disparities but also indirectly harm population health through stress and stigma, suggesting the need for reforms that consider broader social determinants of health when addressing criminal justice policies. (See Boen et al., 2023).
   
• Growing evidence indicates that policy around policing needs to focus on the relationship between frequent police interactions and health and violence outcomes. (See Theall et al., 2022).
   
• In efforts to more adequately address mental health crises with the appropriate resources, cities across the country are experimenting with alternative first responder models. Characteristics of these approaches often include co-development with community members, differential triaging by dispatchers, partnerships between police and social workers, and independent crisis intervention teams, among others. (See E4A projects: Transforming Public Safety to Address Structural Racism and Reduce Health Inequities and Exploring Alternative Models of 911 Response to Behavioral/Mental Health Crises).
   
• Housing first models, which connect individuals and families experiencing homelessness to permanent housing without preconditions and barriers to entry, can successfully interrupt cycling through the criminal justice system. This is because people who are unhoused often cycle in and out of jails due to the criminalization of activities like loitering. (See Hanson, Gillespie, & Oneto, 2022).
   
• Remediation of abandoned lots has been the target of efforts in multiple municipalities to decrease crime and improve health. The theoretical basis of these efforts is that remediation changes the urban landscape in a way that promotes residents’ willingness and confidence to act in the service of their own security and improves neighborhood functioning which can enhance social engagement and well-being. (See Hohl et al., 2019).
   
• How we measure impacts of these efforts matters.
  • For example, while vacant property remediation may impact collective efficacy, 311 data may not provide adequate information absent broader context about various forces that shape neighborhood conditions. (See Theall et al., 2021).
  • Additionally, work is underway to develop and validate new ways to measure racism-based police violence. (See E4A project page: Measuring the Impacts of Exposure to Racism-Based Police-Involved Interactions for Emerging Adults).
     
• Stronger connections between law enforcement and local health and social service organizations may help to build cultures and practices that promote health, safety and social justice. (See findings from the S4A Using Network Science to Explore Pathways for Reducing Policing-Attributable Health Problems And Inequities Evidence Brief project).
   
• Coordinated supportive services can help break a negative feedback loop wherein people who have uncontrolled medical or behavioral health issues have increased contact with law enforcement, leading to arrests and incarceration, which adds additional stress and trauma and perpetuates their risk of future negative outcomes.
   
• Delivering screening and care coordination services on-site at county probation offices significantly increases access to and utilization of primary care among justice-involved adults in the probation system, providing a strong mechanism for addressing unmet health needs. (See findings from the S4A Testing the Impact of a Referral Program to Link Probationers to Primary Care Evidence Brief project).

U.S. Immigration policy is ever-evolving - rules regarding who is eligible and by what means have changed over time and continue to fluctuate. Overarching immigration laws are set by the federal government, but states have the ability to regulate more nuanced aspects of immigrants’ experiences, like access to some social supports and services.

What 4Action-funded research says:

• State preemption laws, like North Carolina's H.B. 318, limit the positive impact of municipal sanctuary policies on immigrant health and well-being. These laws create confusion, deter immigrants from accessing essential health services, and contribute to an overall negative climate. Despite these challenges, community strategies such as the use of community IDs can help mitigate some of the detrimental effects of these restrictive laws. (See Mann-Jackson et al., 2022).
   
• Supportive immigrant policies can improve health and wellbeing for individuals, children, and families, whereas punitive policies lead to worse health outcomes and reduced access to care for immigrants.
  • For instance, social policies and programs like Deferred Action for Childhood Arrivals (DACA), sanctuary policies, and issuance of drivers licenses all resulted in better health outcomes for immigrants (See Koball & Hartig, 2020). Whereas enforcement of punitive policies and programs, such as the U.S. Immigration and Customs Enforcement (ICE) 287(g) Program, resulted in worse health outcomes at birth and a large reduction in the utilization of adequate prenatal care (See Tome et al., 2021).
  • DACA, specifically, improved psychological health and wellbeing for eligible individuals; and children whose mothers were eligible for the program were more likely to participate in the Women, Infants, and Children program (WIC). (See A. Venkataramani et al., 2017 and M. Venkataramani et al., 2018).
     
• Expanding prenatal care coverage to immigrant women, regardless of documentation status, is a cost-effective strategy that improves maternal and child health - during pregnancy, immediately following birth and into early childhood, increasing well-child visits and vaccination rates among children during the first year of life. (See Rodriguez et al., 2019 and Daw & Summers, 2017).
   
• The positive impacts of municipal sanctuary laws and policies are limited by preemption and other state and federal actions. These preemptive laws and policies are confusing for the communities impacted, have a chilling effect on health services use, and make life harder overall for Latine communities. Evidence shows they likely increase the climate of hostility and fear that adds to stress and reluctance to seek services. (See Hall, Mann-Jackson, & Rhodes, 2021 and Mann-Jackson et al., 2022).
   

In the wake of the first federal legislative action related to firearm regulation in nearly three decades, efforts to curb gun violence continue at the state and local levels, with heightened focus on enforcement as well as greater attention to providing resources for mental health services.

What 4Action-funded research says:

Broader adoption and stricter enforcement of effective firearm regulations and increased investments in and availability of mental health resources are both necessary.

Related to messaging and communication:

• Messages using respectful and transparent language in gun violence prevention advocacy efforts are the most likely to encourage gun owners to support those policies advocated by public health professionals. (See Boine et al., 2022).

Related to firearm regulations:

• There isn’t a “one-size-fits-all” approach – different policies work better in different places.
  • While permit requirements are generally effective in lowering firearm homicide rates across the board, universal background checks and “may issue” laws seem to be most effective in large cities, while laws prohibiting gun possession by people convicted of a violent misdemeanor are more effective in suburban and rural areas. (See Siegel et al., 2019).
     
• The nuances of policy provisions are important.
  • Providing law enforcement officials greater discretion when issuing firearm permits tends to be more effective at curbing gun violence. (See Siegel et al., 2017).
  • Including enforcement provisions to guarantee that people prohibited from possessing firearms do not have access to weapons is a critical component of effective firearm regulations. (See Diez et al., 2017).
     
• Although laws banning assault weapons or large capacity ammunition magazines may seem like an appropriate response, especially in the context of mass shooting events, there is no significant relationship between these laws and homicide rates. The same is true for stand your ground laws, one gun per month laws, and prohibitions on gun trafficking. (See policy brief from Siegel & Boine).
   
• The strongest single predictor of a state’s youth suicide rate is the prevalence of household gun ownership in that state. The availability of firearms is contributing to an increase in the number of suicides, not just leading youth to substitute other means of suicide for guns. (See Knopov et al., 2019).
   
• The presence of state firearm-related laws varies across states, but with the exception of “punitive preemption” the number of gun-control, gun-rights, and preemptive measures remained consistent in most states from 2009 through 2018. As of 2018, a majority of states had preemptive measures on almost all gun-control policy topics without enacting substantive gun-control measures. (See Pomeranz, Silver, & Lieff, 2021).

Related to mental health resources:

• School-based mental health services may help prevent youth suicide attempts.
• Students make better use of mental health resources when services are embedded in schools.