Overview of Funding: Meeting the Health-Related Social Needs of Low-income Persons
National Housing Trust Fund (HTF)
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| State Agency or Entity | State housing departments or housing finance agencies |
| Population served | Very low and extremely low-income households, including homeless families |
| What it pays for | Primarily buying and developing affordable rental housing; some relocation costs, such as moving expenses. 10% can be used to promote homeownership. |
| What it cannot pay for | Transitional housing; counseling services (except for housing counseling paid for as an administrative cost); some costs for projects already underway when the HTF is implemented; (See p. 5208 of the Federal Register, Section 92.730 of the Preamble to the Interim Rule) |
| Strings attached | Cannot require tenant to accept supportive services.All HTF-assisted units will be required to have a minimum affordability period of 30 years. (See Section 93.304 of the interim rule)Aligned with the HOME Investment Partnerships program regulationsNo state match is required, although the state allocation plan must consider the availability of non-federal funding as a priority factor for determining allocations. (See Section 92.220 of the interim rule) |
| Accountability | States prepare an annual allocation plan (See Section 91.220 of the interim rule)Annual audits |
| Magnitude | HUD expects to award funds by summer 2016. HUD is required to grant each state and DC a minimum allocation. |
HOME Investment Partnerships Program Block Grants
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| State Agency or Entity | Localities or State Housing and/or Community Development Authorities |
| Population served | Very-low and low-income people90% of occupants of HOME-supported rental units generally must have incomes at or below 60% of area median income. (Section 92.216 of final rule) |
| What it pays for | Tenant-based rental assistance, including rent and security deposits;Grants, loans or loan guarantees for construction or rehabilitation of rental housing, rehabilitation of owner-occupied housing, and assisting homebuyers and tenants. 60% to localities; 40% to states. (Section 92.205–92.212) |
| What it cannot pay for | Modernizing public housing, providing tenant-based rental assistance under theSection 8 program, supporting ongoing operational costs of rental housing, paying back taxes or fees on properties that are or will be assisted with HOME funds, and providing non-federal matching funds for any other federal program. (Section 92.214) |
| Strings attached | Most HOME grantees must match 25% of their grant with non-federal funds (Section 92.218 of Final Rule)Participating jurisdictions must reserve part of their HOME funding for Community Development Housing Organizations. (Section 92.300 of Final Rule) |
| Accountability | To be awarded funds, submit Consolidated Plan covering a 3- to 5-year period describing housing needs and HOME funds will be used to meet those needs and attract non-federal funds for affordable housing.Annually, submit a performance report describing the year’s activities, progress to date, and use of funds. |
| Magnitude | $1 billion appropriated nationwide in FY2014, according to the Congressional Research Services (CRS).According to HUD, “HOME is the largest Federal block grant to state and local governments designed exclusively to create affordable housing for low-income households.” |
Emergency Solutions Grants
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| State Agency or Entity | State housing and/or community development authorities; localities |
| Population served | The homeless and those at risk of homelessness (The definition of “homeless” for different purposes is codified in statute.) |
| What it pays for | Emergency shelter, including costs associated with maintaining and operating an emergency shelter;Services associated with emergency shelter, including physical and mental health, employment, substance abuse and other services;Homelessness prevention and rapid re-housing, including rental assistance and utility and security deposits;Street outreach;Homeless Management Information Systems (HMIS) |
| What it cannot pay for | Services unrelated to street outreach emergency shelter, homelessness prevention, rapid re-housing assistance, HMIS, and administrative activities. (See Section 576.100 of Interim Rule) |
| Strings attached | States are required to match grant funds awards above a certain threshold |
| Accountability | Grant recipients submit a Consolidated Plan and annual performance reports |
| Magnitude | $250 million nationwide appropriated for FY2014, according to CRS |
Continuum of Care Program
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| State Agency or Entity | Applicants generally apply collectively by geographic area; state participants include State Housing and Finance Agencies. State and local governments and nonprofit organizations can apply. |
| Population served | Homeless individuals and families |
| What it pays for | Permanent housing, transitional housing, permanent supportive housing, rapid rehousing, supportive services, outreach, homelessness prevention, and Homeless Management Information Systems.Covers property acquisition, rehabilitation, construction, leasing costs, and rental assistance (42 USC 11383). |
| What it cannot pay for | Services not meeting the required criteria for reducing homelessness |
| Strings attached | Grantees must match 25% of funds, except for leasing funds.Housing units acquired, built, or rehabilitated must be operated for the specified purpose for 15 years |
| Accountability | Annual Report to Congress |
| Magnitude | Total allocation for 2014 nationwide: $1.8 billion |
Low Income Home Energy Assistance Program (LIHEAP) Block Grant
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| State Agency or Entity | State housing, health and human services, community and economic development agencies |
| Population served | Low-income households, including renters |
| What it pays for | Home heating and coolingWeatherization: replacing or repairing furnaces or air conditioners; installing insulation; fixing leaks in doors and windowsEnergy needs resulting from a natural disaster or emergency(See the Low-Income Home Energy Assistance Act) |
| What it cannot pay for | Water bills (unless used for air conditioning) or energy for other uses such as lightingPurchase of real estate |
| Strings attached | |
| Accountability | Grantees report annually |
| Magnitude | $3.4 billion appropriated for the block grant nationwide in FY2014; $3.36 billion for FY2015 |
Low Income Housing Tax Credit
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| State Agency or Entity | State housing finance agencies |
| Population served | Low-income households |
| What it pays for | Construction and rehabilitation of affordable rental housing that has a certain percentage of affordable units. |
| What it cannot pay for | |
| Strings attached | Credits are allocated to states, who allocate them to developers, who sell them to investors, who finance low-income housing developments |
| Accountability | Tax credit documents are filed with the IRS |
| Magnitude | It gives the equivalent of $8 billion in tax credits annually. According to HUD, “The Low-Income Housing Tax Credit (LIHTC) is the most important resource for creating affordable housing in the United States today.” |
Mortgage Revenue Bonds
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| State Agency or Entity | State housing finance agencies |
| Population served | Lower-income first-time homebuyers |
| What it pays for | Low-cost mortgages for first-time homebuyersThe federal government authorizes state or local governments, or their housing finance agencies, to sell Mortgage Revenue Bonds to investors. The proceeds of the sale finances mortgages to eligible homebuyers |
| What it cannot pay for | Mortgages for those who are not first-time home buyers, or who earn more than the area median income (with an adjustment for large families) |
| Strings attached | There is an annual cap on the amount of bonds a state can issue |
| Accountability | Subject to IRS requirements |
| Magnitude | The National Council of State Housing Agencies estimates that Mortgage Revenue Bonds make first-time homeownership possible for approximately 100,000 families each year |
Medicaid (U. S. Centers for Medicare & Medicaid Services) |
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| State Agency or Entity | Medicaid agencies |
| Population served | Lower income individuals |
| What it pays for | For most beneficiaries, states must cover medically necessary services, including hospital, lab, physician, non-emergency medical transportation, and other services. Services must generally be offered statewide, and adequate in amount, duration, and scope. |
| What it cannot pay for | Expenditures not allowable under federal rules.Waivers and state plan amendments can provide states with some flexibility. |
| Strings attached | States pay for a portion of their Medicaid expenses. The state share varies from state to state based on per capita income and other factors. |
| Accountability | States report budget and expenditure data |
| Magnitude | The federal government’s share of Medicaid expenditures totaled $299 billion in FY2014, according to CRS. |
Title V Maternal and Child Health Services Block Grant
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| State Agency or Entity | State health departments |
| Population served | Women and children, especially those with low income |
| What it pays for | A wide range of health care and related activities, including preventive and primary health care services for children, some child care services, and assistance applying for services. |
| What it cannot pay for | Cash payments to beneficiaries; purchase of medical equipment or real estate; most inpatient services (See 42 USC 704) |
| Strings attached | States must match every $4 of Title V funding with at least $3 in non-federal funds |
| Accountability | Annual reporting on outcome and performance measures, and narrative of program impact. |
| Magnitude | $630 million appropriated nationwide in FY2014, according to CRS |
Community Mental Health Services Block Grant
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| State Agency or Entity | State health departments |
| Population served | Adults with serious mental illness and children with serious emotional disturbances |
| What it pays for | Comprehensive community mental health services, including screening, outpatient, and emergency services |
| What it cannot pay for | Financial assistance to private for-profit entities |
| Strings attached | Grantee states must have a mental health planning councilState maintenance of effort requirement |
| Accountability | Annual reporting; federal monitoring visits to some states |
| Magnitude | FY2014 appropriation was $480 million nationwide, per CRS |
Substance Abuse Prevention and Treatment Block Grant
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| State Agency or Entity | State health departments |
| Population served | Pregnant women, women with dependent children, IV drug users, those in need of TB and HIV services |
| What it pays for | A range of activities to prevent and treat substance abuse, including primary prevention services for those at high risk for substance abuse |
| What it cannot pay for | Financial assistance to private for-profit entities |
| Strings attached | State maintenance of effort requirementSpecified percentages of grant funds must be used for primary prevention; early HIV intervention; administration; and a SAMHSA “set-aside” for data collection, evaluation, and TA |
| Accountability | Annual reporting, including reporting on national outcome measures |
| Magnitude | FY2014 appropriation was $1.8 billion, per CRS. SAMHSA writes that this block grant accounts for roughly 29% of public funds spent on substance abuse services. |
Preventive Health and Health Services Block Grant
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| State Agency or Entity | State health departments |
| Population served | Varies by state |
| What it pays for | A range of public health topics, including social determinants of health. The grant has funded walking trails, bicycle helmets, and water fluoridation, among other activities.The grant supports the priorities of Healthy People 2020 |
| What it cannot pay for | Prohibited uses include inpatient care, cash payments to beneficiaries, real estate or construction, as a source of non-federal matching funds, and financial assistance to a private for-profit entity. |
| Strings attached | Maintenance of effort requirement |
| Accountability | Annual reporting requirements |
| Magnitude | $160 million appropriated for FY2014 |
State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (U. S. Centers for Disease Control and Prevention) |
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| State Agency or Entity | State and local health departments award |
| Population served | Population-wide |
| What it pays for | Chronic disease prevention programs, focused in four areas: Epidemiology and surveillance; environmental strategies to promote healthy behaviors; health systems interventions, and community and clinical linkages. |
| What it cannot pay for | Prohibited uses include gun control promotion, needle exchange programs, dealings with corporations with felonies or tax debts |
| Strings attached | States sub-award half of the funds to 4-8 local communities |
| Accountability | Annual reporting, including the Prevention and Public Health Fund reporting requirements |
| Magnitude | $33 million in new funds for 2014. Financed by the Affordable Care Act’s Prevention and Public Health Fund |
Ryan White HIV/AIDS Program (Part B)
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| State Agency or Entity | State departments of health |
| Population served | Those testing positive for HIV; generally lower-income or uninsured people. Some states establish additional criteria. |
| What it pays for | Medication to treat HIV/AIDS; medical and support services and services to support HIV/AIDS treatment |
| What it cannot pay for | Prohibited uses include real estate, construction, or cash payments to recipients of services |
| Strings attached | Some state must provide non-federal matching funds |
| Accountability | Annual reporting requirements |
| Magnitude | Funded at $2.32 billion as of October 2014 |
Community Development Block Grant (CDBG)
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| State Agency or Entity | State community and economic development agencies generally administer grants for smaller cities and counties which do not receive funds directly from HUD |
| Population served | Low- and moderate-income people70% of funds go to cities and communities; 30% to states for use in smaller communities |
| What it pays for | A variety of activities related to economic development, neighborhood revitalization, housing rehabilitation and blight prevention.At least 70% of funds must benefit low- and moderate- income people. |
| What it cannot pay for | Ineligible activities generally include construction of new housing (with exceptions), some income payments, political activities, buildings to house “the general conduct of government” |
| Strings attached | States generally may not use the funds to directly undertake community development activities. States are pass-through agents that distribute funds to communities. |
| Accountability | Uses the HUD consolidated planning process. Annual action plan and a performance evaluation report detailing its progress toward the goals identified in the action plan. The evaluation report must include information on the racial, ethnic, and income status of people benefiting from the funds. |
| Magnitude | According to CRS, over $3 billion was allocated nationwide in FY 2013. In that year, the CDBG was the largest source of federal funding for community development, and the 20th largest source of federal assistance to state and local governments. |
Community Services Block Grant (CSBG)
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| State Agency or Entity | State community and economic development agencies |
| Population served | Low-income communities |
| What it pays for | A range of poverty reduction and community development activities, based on community needs assessments. Examples can include emergency shelter and food programs, employment counseling, transportation programs, and activities for senior citizens and youth. |
| What it cannot pay for | Real estate or construction; political activities |
| Strings attached | States must pass at least 90% of CSBG funds to local entities. |
| Accountability | Annual state assessments; monitoring visits to some states |
| Magnitude | According to CRS, $709 million was appropriated for FY2014. TheFY 2015 White House budget proposed $350 million for CSBG nationwide |
Child Care and Development Block Grant
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| State Agency or Entity | State human and social services agencies |
| Population served | Lower-income (income not exceeding 85% of state median) working (or attending school or training) families with children younger than age 13. |
| What it pays for | Subsidies for child care; child care program improvements |
| What it cannot pay for | Prohibited uses include:Administrative costs exceeding 5% of a year’s allocationMost real estate purchases or constructionSectarian worship or instruction |
| Strings attached | Health and safety requirements for providersMost families contribute child care co-payments on a sliding scale. |
| Accountability | States must make electronically available the results of monitoring and inspection results for child care providersQuarterly, annual, and biennial reporting requirements |
| Magnitude | $2.36 billion discretionary funding appropriation and $2.9 billion in mandatory appropriation for FY2014, per CRS. |
Social Services Block Grant (SSBG)
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| State Agency or Entity | State community and economic development agencies, and state human services agencies |
| Population served | At state’s discretion. The program aims to promote economic self-sufficiency |
| What it pays for | A wide range of activities in 29 service categories that promote self-sufficiency, prevent child abuse, and support “community-based care for the elderly and disabled (CRS).” Examples:
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| What it cannot pay for | Prohibited uses include:Land or capital improvements (may be waived)Room and board (with certain exceptions)WagesMost medical care (with some exceptions for family planning, rehab/detox, and medical care provided as an “integral but subordinate component of a social service”),Social services for people in institutionsEducational services available in public schools |
| Strings attached | No matching requirement for states |
| Accountability | States submit an annual intended use plan and post-expenditure report |
| Magnitude | $1.57 billion appropriated for FY2014, according to CRS |
Temporary Assistance for Needy Families (TANF) Block Grant
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| State Agency or Entity | State departments of health and human services or social services |
| Population served | Needy families with children |
| What it pays for | Cash assistanceWork programsChild care & transportation aid for nonworking parentsPrograms, activities, and services “reasonably calculated” to achieve TANF’s four-fold purpose, per HHS ACF:(1) provide assistance to needy families so children can be cared for in their own homes; (2) Reduce the dependency of needy parents by promoting job preparation, work and marriage; (3) Prevent and reduce the incidence of out-of-wedlock pregnancies; and (4) encourage the formation and maintenance of two-parent families. |
| What it cannot pay for | TANF block grant “assistance” has some limitations, such as a prohibition on payment for medical services in most cases.However, non-assistance aid can fund a broad range of services related to TANF’s four-fold purpose |
| Strings attached | States contribute their own funds in a maintenance-of-effort (MOE) requirementWork requirements for some adult recipients60 month time limit for adults |
| Accountability | States submit three quarterly reports and an annual report |
| Magnitude | FY2014 appropriation was $17.3 billion nationwide, according to CRS |
Child and Adult Care Food Program
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| State Agency or Entity | State departments of education or departments of health or human services |
| Population served | Children in day care and adults in adult day care |
| What it pays for | Meals meeting nutritional guidelines served to participants meeting income requirements for free or reduced-price meals |
| What it cannot pay for | The program will not approve reimbursement to state agencies for:Food served to someone not enrolled for adult or child careMeals not approved in the agreement or out of compliance with the approved meal pattern |
| Strings attached | |
| Accountability | Annual reportingUnannounced site visits at least once every three years |
| Magnitude | $3 billion obligated for FY2014, according to CRS |
Supplemental Nutrition Assistance Program (SNAP)
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| State Agency or Entity | State departments of health and human services |
| Population served | Low-income households |
| What it pays for | Food for home preparation and consumption; seeds and plants to grow food at home |
| What it cannot pay for | Hot food ready to eat (with some exceptions), alcohol, tobacco |
| Strings attached | SNAP benefits may only be used at certain retailersMost able-bodied recipients must meet work or training requirements |
| Accountability | Included in annual Schedule of Expenditures of Federal Awards (SEFA) |
| Magnitude | According to CRS, in 2014, more than 46 million individuals participated in SNAP, and the federal government spent more than $70 million on benefits nationwide |
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
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| State Agency or Entity | State health departments |
| Population served | Low-income pregnant and postpartum women, and children up to age 5 at nutritional risk |
| What it pays for | Food, nutrition education, breastfeeding support, health and social service screening and referrals |
| What it cannot pay for | Food items that are not WIC-eligible |
| Strings attached | States participating in the Farmers Market Nutrition Program must pay for at least 30% of the program’s administrative costs |
| Accountability | Annual reporting and evaluation requirements |
| Magnitude | $6.6 billion as of September 2015 |
Surface Transportation Program
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| State Agency or Entity | State departments of transportation |
| Population served | The general public |
| What it pays for | Highways, transit infrastructure, bicycle transportation and pedestrian walkways |
| What it cannot pay for | Some projects on non-federal, local or rural minor roads |
| Strings attached | States and localities generally pay for the 20% of a project not covered by the federal share. States and localities generally pay 10% of interstate projectsNote: states also contribute significantly to transportation funding through gas and vehicle taxes and other sources. |
| Accountability | |
| Magnitude | $10 billion appropriated nationwide in FY2014, according to CRS |
The role of the state in the below programs varies. However, the programs listed below have the potential to align with and support state health goals and initiatives.
Federal Reserve Banks: Pay for Success Programs and Social Impact Bonds |
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| State Agency or Entity | State community development, housing finance agencies, or other agencies could be involved |
| Population served | Varies by project |
| Purpose | Social Impact Bonds address social services or social issues. The specific project and criteria for success are outlined in the contract between parties.Government contracts with an entity to provide services, and pays the entity based on their performance. The entity raises private and philanthropic capital for operations. Investors are paid back with the entity’s pay for performance funds, if any. |
| Accountability | Based on the terms of the program |
Hospital Community Benefit Requirements |
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| State Agency or Entity | Hospitals must comply with both federal and state (if any) community benefit requirements in order to maintain their tax exemptions. |
| Population served | The communities served by the hospital |
| Purpose | Services and activities to support the health or safety of the communities served by the hospitals. “Community building activities” can include child care services; housing rehabilitation; the provision of housing for certain patients after discharge; construction or maintenance of parks and playgrounds; economic development activities; public health emergency readiness activities; environmental improvements, such as addressing pollution and garbage.The ACA also requires tax-exempt hospitals to conduct a community health needs assessment once every three years and plan a strategy to implement it.IRS requirements for tax-exempt hospitals describe the activities and services that satisfy the hospital community benefit requirements.Hospitals can count the uncompensated and charity care as community benefit activities. |
| Accountability | Annual reporting to IRS on Schedule H of Form 990 to maintain tax-exempt status |
Community Development Financial Institutions (CDFIs) |
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| State Agency or Entity | Can include credit unions and non-regulated private-sector financial institutions |
| Population served | Low-income individuals and communities |
| Purpose | Mortgage financing, bond funding and commercial loans in low-income communities |
| Accountability | |
Community Development Financial Institutions Fund (Treasury) |
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| State Agency or Entity | Funds credit unions, CDFIs, and other “mission-driven financial institutions,” not states |
| Population served | Primarily low income populations |
| Purpose | Financing for affordable housing services, economic development services, consumer credit counseling and financial education |
| Accountability | |
New Markets Tax Credit Programs
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| State Agency or Entity | State NMTC programs are administered by state finance authorities or development agencies |
| Population served | Low-income communities or populations |
| Purpose | Permits individual and corporate taxpayers to receive a federal income tax credit for making Qualified Equity Investments (QEIs) in qualified community development entities (CDEs).Cannot pay for things outside the scope of the Treasury programLegislation is pending to indefinitely extend the federal NMTC program.$3.5 billion in NMTCs allocated for CY2014 |
| Accountability | Community Development Entities certify their status with Treasury’s CDFI fundNMTC grantees report to IRS |
Note: Other CDC support is available to states and localities, often targeted at specific conditions. Such support includes state-based tobacco control programs, the National Asthma Control Program, and a number of HIV–related demonstrations.
