This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h1609c.HCA
DATE: 1/29/2024
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: HB 1609 Pregnancy Support Services
SPONSOR(S): Stevenson
TIED BILLS: IDEN./SIM. BILLS: SB 1442
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY
CHIEF
1) Healthcare Regulation Subcommittee 16 Y, 0 N Osborne McElroy
2) Health Care Appropriations Subcommittee 14 Y, 0 N Aderibigbe Clark
3) Health & Human Services Committee
SUMMARY ANALYSIS
Social determinants of health are the external factors of a person’s life that impact their health. These are the
conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a
wide range of health, functioning, and quality-of-life outcomes and risks. Housing is an important social
determinant of health.
The United States is in the midst of a housing affordability crisis. Income growth has not kept up with rising
housing costs, and the overall housing market has not responded adequately to the need for affordable
housing. The national crisis is being acutely felt in Florida, with low-income renters being especially vulnerable
to the rising cost of housing.
In 2022, there were 224,403 recorded births in Florida. Healthy pregnancies and childbirth are foundational to
healthy families and communities. Nonetheless, pregnancy remains an essential but often dangerous
experience with the potential for many avoidable complications. Maternal and infant health outcomes are an
important marker of the overall health of a society. Florida’s expecting mothers are not exempt from the state’s
affordable housing crisis. While the long-term effects of housing instability are detrimental to all who
experience it, the impact on pregnant women is especially acute. Homelessness during pregnancy poses
significant health risks for mothers and infants.
The bill creates that it is the Florida State Maternity Housing Grant Program within the Department of Health
(DOH). The bill states that it is the intent of the Legislature to provide housing resources to resident women
and families during the prenatal period, regardless of age or marital status, whose financial resources have
been determined inadequate to meet residential costs.
The bill outlines expenses which grant funds may be allocated toward, and directs DOH to make rules for the
implementation of the grant. The bill specifies that the total amount of grants awarded by DOH may not exceed
the funding appropriated for the grant program.
The bill grants DOH rulemaking authority to adopt rules necessary for the administration of the program.
The provisions of the bill are subject to an appropriation. The bill has no fiscal impact on local governments.
The bill provides an effective date of July 1, 2024. STORAGE NAME: h1609c.HCA PAGE: 2
DATE: 1/29/2024
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Social Determinants of Health
Social determinants of health (SDOH) are the external factors of a person’s life that impact their health.
These are the conditions in the environments where people are born, live, learn, work, play, worship,
and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
There are five main categories of SDOH:
1
Economic stability;
Education access and quality;
Health care access and quality;
Neighborhood and built environment; and
Social and community context.
SDOH influence a persons’ health in several ways. Some SDOH have causal relationships that are
clear and relatively direct; for example, the presence of mold, or poor air and water quality, are part of
the built environment that a person lives in and while consequences may be delayed, the causal
relationship is easily established.
2
Living in such environmental conditions are often influenced by other
SDOH, such as economic stability and community context where the connections to health outcomes
are evident, but less easily conceptualized.
3
Some aspects of health are especially sensitive to the environments that a person find themselves in.
Housing Insecurity
Housing is an important social determinant of health. The lack of housing, or poor-quality housing,
negatively affects a person’s health and well-being. Tangible housing defects resulting from damp and
mold, unregulated indoor temperatures, overcrowding, and safety factors have a clear impact on
physical and mental health. There are also pronounced psychosocial benefits to the concept of “home,”
which are tied to the social values of housing as reflecting stability, control, autonomy, status, and
empowerment. Such qualities have a significant impact on a person’s mental health and long-term
stability.
4
The US is in the midst of a housing affordability crisis.
5
Income growth has not kept up with rising
housing costs, and the overall housing market has not responded adequately to the need for affordable
housing. The national crisis is being acutely felt in Florida, with one survey showing that 25 percent of
Floridians identifying “housing costs,” as the most important problem facing Florida today.
6
1
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Social Determinants of Health.
Available at https://health.gov/healthypeople/priority-areas/social-determinants-health (last visited January 21, 2024).
2
Braubach, M., Jacobs, D.E., & Ormandy, D. Environmental burden of disease associated with inadequate housing: a method guide to
the quantification of health effects of selected housing risks in the WHO European Region. (2011). World Health Organization. Regional
Office for Europe. https://iris.who.int/handle/10665/108587
3
Braveman, P., & Gottlieb, L. The social determinants of health: it's time to consider the causes of the causes. (2014) Public health
reports, 129:2, 19–31. https://doi.org/10.1177/00333549141291S206
4
Rolfe, S., Garnham, L., Godwin, J. et al. Housing as a social determinant of health and wellbeing: developing an empirically-informed
realist theoretical framework (2020). BMC Public Health 20, 1138. https://doi.org/10.1186/s12889-020-09224-0
5
Desmond, M. Unaffordable America: Poverty, Housing, and Eviction (2022). American Journal of Sociology. In The Affordable
Housing Reader (pp. 389-395). https://doi.org/10.4324/9780429299377-34
6
University of North Florida, Public Opinion Research Lab, Florida Republican Presidential Primary Polling (2023). Available at
https://www.unfporl.org/uploads/1/4/4/5/144559024/unf_mar_statewide_2023_ada.pdf (last visited January 21, 2024). STORAGE NAME: h1609c.HCA PAGE: 3
DATE: 1/29/2024
The precise cause of the shortage of affordable housing is complex and multi-faceted, but it is an issue
felt by would-be homebuyers and renters alike. In Florida, the median single-family home prices are
approaching the boom-era costs of the mid-2000s; between 2011 and 2022, the median home price
has risen 91 percent. Meanwhile, the situation in the rental market is dire for low-income renters. The
state has added hundreds of thousands of rental units in the last decade, but simultaneously lost
“affordable”
7
rental units.
8
Many low-income renters pay more than 40 percent of their income for
housing, and there are only 26 affordable and available rental units for every 100 households with an
extremely low income.
9
As a result, more families and individuals are finding themselves in precarious housing situations.
10
Nationally, 5.52 million renter households reported being behind on their rent payment, with 1.87 million
fearing imminent eviction in August 2023.
11
While the majority of people experiencing homelessness are men, women and families constitute the
fastest-growing segment of the homeless population.
12
Black and Hispanic women, particularly single
mothers with children, are at the highest risk for housing insecurity. Women experiencing housing
insecurity report barriers to health care generally, and as such tend to lack access to adequate
contraceptive methods.
13
Pregnancy Outcomes
In 2022, there were 224,403 recorded births in Florida.
14
Healthy pregnancies and childbirth are
foundational to healthy families and communities. Nonetheless, pregnancy remains an essential but
often dangerous experience with the potential for many avoidable complications.
15
Maternal and infant
health outcomes are an important marker of the overall health of a society.
Maternal Health Outcomes
Maternal mortality refers to deaths occurring during pregnancy or within 42 days of the end of
pregnancy, regardless of the duration of the pregnancy, from any cause related to or aggravated by the
pregnancy, but not from accidental or incidental causes.
16
In 2021, more than 1,200 women died of
maternal causes in the United States compared with 861 in 2020 and 754 in 2019.
17
The national
maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births.
18
Racial and ethnic gaps exist
between non-Hispanic black, non-Hispanic white, and Hispanic women. The maternal mortality rate of
these groups is 69.9, 26.6, and 28.0 deaths per 100,000 live births, respectively.
19
7
“Affordable” rental units mean those renting for $1,000 or less per month.
8
University of Florida, Shimberg Center for Housing Studies. Florida Affordable Housing Trends (2022). Available at
http://www.shimberg.ufl.edu/publications/FL_presentation_121422.pdf (last visited January 22, 2024).
9
Id.
10
Greene, S., Richardson, T., Bryon, J., & Cho, R. Rise in homelessness averted amidst worsening housing needs in 2021. What does
this tell us about how to end homelessness in the U.S.? (2023). HUD User. Available at https://www.huduser.gov/portal/pdredge/pdr-
edge-frm-asst-sec-082223.html (last visited January 22, 2024).
11
Id.
12
Welch-Lazoritz, M.L., Whitbeck, L.B., & Armenta, B.E. Characteristics of mothers caring for children during episodes of
homelessness. (2015). Community Ment Health J. 51(8):913-920. doi: 10.1007/s10597-014-9794-8
13
Kozlowski, Z., Sanders, J.N., Panushka, K., Myers, K., Millar, M.M., & Gawron, L.M. "It's a Vicious Cycle": A Mixed Methods Study of
the Role of Family Planning in Housing Insecurity for Women (2022). Journal of Health Care for the Poor and Underserved 33(1), 104-
119. https://doi.org/10.1353/hpu.2022.0009
14
FL Health Charts, Birth Counts Query System. Available at https://www.flhealthcharts.gov/FLQUERY_New/Birth/Count (last visited
January 9, 2024).
15
Hernandez, L., Thompson, A., & Burch, D. Florida’s Pregnancy-Associated Mortality Review 2015 Update (2017). Florida Department
of Health. Available at http://www.floridahealth.gov/statistics-and-data/PAMR/pamr-2015-update.pdf (last visited January 22, 2024).
16
U.S. Dep’t of Health and Human Services, The Surgeon General’s Call to Action to Improve Maternal Health (2020). Available at
https://www.hhs.gov/sites/default/files/call-to-action-maternal-health.pdf (last visited December 5, 2023).
17
Donna L. Hoyert, Ph.D., Division of Vital Statistics, National Center for Health Statistics, Maternal Mortality Rates in the United
States, 2021, (March 2023). Available at https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-
2021.pdf https://www.cdc.gov/reproductivehealth/maternal-mortality/index.html(last visited January 8, 2024).
18
Id.
19
Id. STORAGE NAME: h1609c.HCA PAGE: 4
DATE: 1/29/2024
2013201420152016201720182019202020212022
Florida Total 17.919.120.217.018.017.218.020.423.823.6
Non-Hispanic White14.115.615.613.314.514.315.015.919.319.1
Non-Hispanic Black28.028.332.028.027.226.326.431.035.635.3
Hispanic 15.718.219.115.816.915.417.519.722.222.0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Although Florida’s maternal mortality rate is lower than the national rate, it has been increasing in
recent years. As of 2021, the maternal mortality rate in Florida is 28.7 deaths per 100,000 live births, an
increase from a low of 12.9 deaths per 100,000 live births in 2016.
20
Similar to the national trend, racial
and ethnic disparities exist in the maternal mortality rates in Florida as evidenced in the following chart:
For every maternal death, 100 women suffer a severe obstetric morbidity, a life-threatening diagnosis,
or undergo a lifesaving procedure during their delivery hospitalization.
21
Severe maternal morbidity
(SMM) includes unexpected outcomes of labor and delivery that result in significant short- or long-term
consequences to a woman’s health. SMM has been steadily increasing in recent years.
22
The consequences of the increasing SMM prevalence, in addition to the health effects for the woman,
are wide-ranging and include increased medical costs and longer hospitalization stays.
23
From 2013 to 2022, there were 51,454 cases of SMM among delivery hospitalization in Florida.
24
Similar to maternal mortality rates, rates of SMM are higher in racial and ethnic minority women.
25
The following figure shows the trend over time for SMM rates in Florida per 1,000 delivery
hospitalizations:
26
20
Presentation by Kenneth Scheppke, M.d., F.A.E.M.S., Deputy Sec’y for Health, DOH, before the Senate Committee on Health Policy
(Nov. 14, 2023), available at https://www.flsenate.gov/Committees/Show/HP/MeetingPacket/5979/10504_MeetingPacket_5979_4.pdf
(last visited January 8, 2024).
21
Elizabeth A. Howell, MD, MPP, Reducing Disparities in Severe Maternal Morbidity and Mortality (2018). CLINICAL OBSTETRICS AND
GY NECOLOGY, 61(2). Available at
https://journals.lww.com/clinicalobgyn/abstract/2018/06000/reducing_disparities_in_severe_maternal_morbidity.22.aspx (last visited
January 8, 2024).
22
Id., and CDC, Severe Maternal Morbidity in the United States (2023). Available at
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html (last visited January 8, 2024).
23
CDC, Severe Maternal Morbidity in the United States (2023). Available at
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html (last visited January 8, 2024).
24
Presentation by Kenneth Scheppke, M.D., F.A.E.M.S., Deputy Sec’y for Health, DOH, before the Senate Committee on Health Policy
(Nov. 14, 2023). Available at https://www.flsenate.gov/Committees/Show/HP/MeetingPacket/5979/10504_MeetingPacket_5979_4.pdf
(last visited January 8, 2024).
25
Supra, note 21.
26
Id.
2012201320142015201620172018201920202021
Florida Total 18.825.116.016.912.915.716.319.521.028.7
Non-Hispanic White9.518.713.220.013.312.712.919.812.912.4
Non-Hispanic Black60.537.929.325.125.035.332.038.950.075.1
Hispanic 1.725.48.1 6.3 4.6 7.510.68.916.321.8
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Florida Total Non-Hispanic White Non-Hispanic Black Hispanic STORAGE NAME: h1609c.HCA PAGE: 5
DATE: 1/29/2024
The consequences of maternal death and severe maternal morbidity are felt throughout a community.
High rates of maternal death are associated with infant and child mortality, loss of economic
opportunities, and cycles of poverty extending from the family into the broader community.
27
Infant Health Outcomes
Infant mortality is the death of an infant before the first birthday. The infant mortality rate is the number
of infant deaths for every 1,000 live births. DOH reports annually on fetal and infant deaths through the
Florida Vital Statistics Annual Report.
28
This report provides the number of fetal deaths per 1,000 live
births, the number of deaths by race, and compares that data to national figures. Florida ranks 19
th
in
the nation in infant mortality with a rate of 5.9 deaths per 1,000 live births (1,275 in 2021).
29
In Florida, the leading causes of infant mortality, per 1,000 live births, are:
30
Birth defects;
Preterm and low birth weight;
Unintentional injuries;
Maternal complications of pregnancy;
Complications of placenta, cord, and membranes; and
Sudden Infant Death Syndrome.
The relationship between infant health outcomes and adequate prenatal care is well established.
Adequate prenatal care received regularly throughout a pregnancy can help to detect risks before they
manifest dangerously, and can help women to manage both pregnancy and non-pregnancy related
health conditions. This is especially important for marginalized populations for whom access to health
care services before pregnancy may have been limited.
31
Adequate prenatal care is closely associated
with improved birth weight and reduced rate of preterm births.
32
Housing Insecurity and Pregnancy Outcomes
Florida’s expecting mothers are not exempt from the state’s affordable housing crisis. While the long-
term effects of housing instability are detrimental to all who experience it, the impact on pregnant
women is especially acute. Homelessness during pregnancy poses significant health risks for mothers
and infants.
Extreme housing insecurity, in the form of homelessness or threatened eviction, among pregnant
women is tied to significant pre-birth risk factors. This population is significantly more likely to have
comorbidities and higher-risk pregnancies, including higher rates of substance use disorder and major
mental health disorders.
33
The need for adequate perinatal health care is heightened for women with
high-risk pregnancies, but pregnant women experiencing homelessness report barriers to prenatal
27
Miller, S., & Belizán, J. M. The true cost of maternal death: individual tragedy impacts family, community and nations (2015).
Reproductive Health, 12(1), 56–56. https://doi.org/10.1186/s12978-015-0046-3
28
Florida Department of Health, Florida Vital Statistics Annual Report 2020. Available at
http://www.flpublichealth.com/VSbook/PDF/2020/Fetal.pdf (last visited January 22, 2024).
29
Id. See also Centers for Disease Control and Prevention, Infant Mortality Rates by State (2019). Available at
https://www.cdc.gov/nchs/pressroom/sosmap/infant_mortality_rates/infant_mortality.htm (last visited Jan. 12, 2022).
30
Presentation by Shay Chapman, BSN, MBA, Deputy Division Director, Community Health Promotion, Sept. 21, 2021 meeting of the
Professions and Public Health Subcommittee. Available at
https://www.myfloridahouse.gov/Sections/Documents/loaddoc.aspx?PublicationType=Committees&CommitteeId=3093&Session=2022
&DocumentType=Meeting+Packets&FileName=pph+9 -21-21.pdf (last visited January 22, 2024).
31
Shah, J. S., Revere, F. L., & Toy, E. C. Improving Rates of Early Entry Prenatal Care in an Underserved Population (2018). Maternal
& Child Health Journal, 22(12), 1738–1742. https://doi-org.proxy.lib.fsu.edu/10.1007/s10995-018-2569-z
32
Alexander, G.R. & Kotelchuck, M. Assessing the Role and Effectiveness of Prenatal Care: History, Challenges, and Directions for
Future Research (2001). Public Health Reports (1974-), 116(4), 306.
33
Huang, K., Waken, R.J., Luke, A., Carter, E., Lindley, K., & Maddox, K. Risk of Delivery Complications Among Pregnant People
Experiencing Housing Insecurity (2023). American Journal of Obstetrics & Gynecology, 5:2,
https://doi.org/10.1016/j.ajogmf.2022.100819 STORAGE NAME: h1609c.HCA PAGE: 6
DATE: 1/29/2024
health care, and lower rates of adequate prenatal care utilization, further increasing their risk of adverse
birth outcomes.
34
Women experiencing extreme housing insecurity experience worse birth outcomes than their securely
housed counterparts, with higher rates of preterm birth and severe maternal morbidity.
35
Infants born to
mothers experiencing homelessness or threatened eviction are at a significantly higher risk of being
born preterm or with a low birth weight, require stays in neonatal intensive care units, and extended
hospital stays after delivery.
36
More complex births and extended hospital stays lead to higher delivery-
associated costs for this financially insecure population.
37
Effect of the Bill
HB 1609 establishes the Florida State Maternity Housing Grant Program within DOH. The bill states the
intent of the Legislature to provide housing resources to resident women and families during the
prenatal period, regardless of age or marital status, whose financial resources have been determined
inadequate to meet residential costs.
The bill outlines the types of expenses for which grant funding may be used, including:
Housing in an authorized living arrangement for a period of time determined by the mother’s
due date;
Services recommended by DOH to encourage economic independence and positive health
outcomes;
Staffing and reimbursements for housing providers; and
All other costs related to the administration of the program, not to exceed 5 percent of the total
grant funds.
The bill specifies that the total amount of grants awarded by DOH may not exceed the funding
appropriated for the grant program.
The bill grants DOH rulemaking authority to adopt rules necessary for the administration of the
program. The bill does not restrict the rules that DOH may adopt to administer the program, but
provides that DOH may adopt rules pursuant to the following:
A framework for the payment or reimbursement for expenses related to the “authorized living
arrangement;”
Eligibility criteria for expecting mothers and families seeking maternity housing services;
Requirements for maternity housing grant applications; and
Guidelines for assessing the appropriateness of living situations and the determination of
approval.
The bill provides an effective date of July 1, 2024.
B. SECTION DIRECTORY:
Section 1: Creates s. 381.97, F.S., relating to the Florida State Maternity Housing Grant Program.
Section 2: Provides an effective date of July 1, 2024.
34
DiTosto, J., Holder, K., Soyemi, E., Beestrum, M., & Yee, L. Housing Instability and Adverse Perinatal Outcomes: A Systematic
Review (2021). American Journal of Obstetrics & Gynecology, 3:1, https://doi.org/10.1016/j.ajogmf.2021.100477; see also, Bloom, K.C.,
Bednarzyk, M.S., Devitt, D.L., Renault, R.A., Teaman, V., & Van Loock, D.M. Barriers to prenatal care for homeless pregnant women
(2004). J Obstet Gynecol Neonatal Nurs. 2004;33(4):428-435. doi: 10.1177/0884217504266775
35
Leifheit, K.M., Schwartz, G.L., Pollack, C.E., Edin, K.J., Black, M.M., Jennings, J.M., & Althoff, K.N. Severe Housing Insecurity during
Pregnancy: Association with Adverse Birth and Infant Outcomes (2020). International Journal of Environmental Research and Public
Health. 2020; 17(22):8659. https://doi.org/10.3390/ijerph17228659
36
Id.
37
Yamamoto, A., Gelberg, L., Needleman, J., Kominski, G., Vangala, S., Miyawaki, A., & Tsugawa, Y. Comparison of Childbirth
Delivery Outcomes and Costs of Care Between Women Experiencing vs Not Experiencing Homelessness (2021). JAMA network
open, 4(4), e217491. https://doi.org/10.1001/jamanetworkopen.2021.7491 STORAGE NAME: h1609c.HCA PAGE: 7
DATE: 1/29/2024
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
See Fiscal Comments.
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
None.
D. FISCAL COMMENTS:
As written, the bill has no fiscal impact. The bill creates a framework for a grant program administered
by DOH, but does not provide any funding. Implementation of the bill provisions are subject to an
appropriation.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not applicable. The bill does not appear to affect county or municipal governments.
2. Other:
None.
B. RULE-MAKING AUTHORITY:
The bill provides sufficient rulemaking authority for DOH to implement its provisions.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES