Poverty is a strong predictor of poor health. According to the 2021 American Community 1-Year Survey (ACS), the median household income was $66,474 in Idaho compared to $69,717 nationally.[i] Similarly, per capita income was less in Idaho at $33,841, compared to $38,332 nationally. All racial and ethnic groups measured in the ACS had lower household and per capita incomes in Idaho than their counterparts nationally. Despite lower incomes, Idaho’s overall poverty level of 11 percent is lower than the national average of 12.8 percent and has been decreasing.[ii] Within Idaho, poverty has decreased from 2016 to 2021 in all racial groups and among the Hispanic and Latino population (2016 & 2021 5-year ACS). Regardless of the overall improvements, disparities do still exist among demographic groups and within certain areas. For instance, 24.6 percent of Black or African Americans, 25.8 percent of Native Americans and 16.6 percent of Idaho’s Hispanic or Latino population is estimated to live at or below the poverty level in comparison to 10.6 percent of the white population who do not identify as Hispanic or Latino. Geographic disparities exist across the state with poverty measured at the county level ranging from 24.3 percent in Madison County to 5.2 percent in Clark County [iii]. Access Limited Income Constrained Employed (ALICE) – in Idaho, ALICE identifies and defines those households who fall within the “gap” – though they have income above the Federal Poverty Level (FPL), they are ineligible for state or Federal benefits programs and struggle to make enough to support their families. According to UnitedforALICE.org, ALICE families are often forced to make difficult decisions when they don’t have enough income to afford basic needs - housing, food, transportation, childcare, and health care. These decisions mean a family must decide between paying the rent or paying their childcare provider, or between buying groceries and filling a prescription. In 2021, the most recent ALICE data available, 11 percent of Idahoans fell under the FPL, while another 32 percent were ALICE. As Idaho’s cost of living rises, driven by the skyrocketing growth in housing prices outpacing growth in wages, more households are finding their financial stability jeopardized.[iii] Idaho’s low wages coupled with rising costs of living across the state has resulted in many wage-earners struggling to get out of poverty. The economic impact of COVID-19 on Idaho’s economy and people is still being realized. [i]. U.S. Census Bureau. American Community Survey. 2021 American Community Survey 1-year Estimates Subject Tables. Retrieved from: https://data.census.gov/ [ii]. U.S. Census Bureau. American Community Survey. 2016 and 2021 American Community Survey 5-year Estimates Subject Tables. Retrieved from: https://data.census.gov/ [iii]. Alice In the Crosscurrents: COVID and Financial Hardship in Idaho. 2023 Idaho Report. United Ways of the Pacific Northwest. Retrieved from: https://www.unitedforalice.org/state-overview/idaho

Education and income go hand-in-hand. “A quality education is the best predictor of professional and financial success in the U.S., and the earliest years of a child’s education lay a critical foundation for this success.” Quality early education increases the likelihood of children who are prepared for kindergarten, graduate from high school, achieve higher education degrees and future career success. Additionally, people with more education tend to have higher incomes and better health outcomes. College graduates are often able to secure better paying jobs with fewer safety hazards and income from these jobs can be used on higher quality housing as well as other health enhancing resources.[i] A greater percentage of Idahoans over the age of 25 have graduated from high school (91.2 percent) than the national average of 88.9 percent.[ii] Yet, the rate for those who go on to higher levels of education are lower in Idaho across most demographic groups. Nationally, 33.7 percent of the population over the age of 25 hold a bachelor’s degree or higher, while 29.1 percent do in Idaho. Educational attainment disparities are also seen among various racial and ethnic groups. For Idaho’s Hispanic and Latino population, 67.5 percent are high school graduates or higher compared to 71.2 percent nationally.[ii] Also, 13.4 percent of Idaho’s Hispanic and Latino population holds a bachelor’s degree or higher compared to 18.4 percent across the U.S. Within Idaho’s rural and remote counties, a smaller percentage of adults over the age of 25 have gone on to receive at least some post-secondary education than those living in urban counties, 55.4 percent compared to 67.6 percent.[ii] Quality and affordable early childhood education is a vital component necessary to support a child’s lifelong educational attainment and future earnings. In turn, access to affordable childcare supports a healthy economy as it allows parents to go to work and earn a better living. The most recent United for ALICE report, released by the United Way in 2023, highlights the crisis in child care availability and cost that was brought to the forefront in the pandemic. Many childcare providers went out of business during the pandemic and 35 percent of that workforce has an income below the ALICE threshold. While childcare providers are struggling to stay afloat families are also challenged with cost as a family of four in Idaho can expect to spend $1,137 on childcare each month. [iii] [i]. Zajacova, Anna and Lawrence, Elizabeth, The Relationship Between Education and Health: Reducing Disparities Through a Contextual Approach, Annual Review of Public Health, Vol. 39: 273-289, April 2018. [ii] U.S. Census Bureau. American Community Survey. 2021 American Community Survey. 2017-2021 American Community Survey 5-year Estimates Subject Tables. Retrieved from: https://data.census.gov/ [iii] Alice in the Crosscurrents: COVID and Financial Hardship in Idaho. 2023 Idaho Report. United Ways of the Pacific Northwest. Retrieved from: https://www.unitedforalice.org/state-overview/idaho

Community design and the quality of our built environments directly affect human health. The built environment refers to the physical spaces where we live, recreate and work. It is comprised of our homes, businesses, cultural institutions, parks, public spaces, roads, environmental conditions, utilities and other infrastructure. These neighborhood or community attributes have a profound impact on our health by promoting or restricting access to physical activity, transportation options, healthy foods, safe housing, and even social interactions. Research has shown that people living in more affluent neighborhoods tend to have better access to health promoting attributes like parks and safe connected sidewalks and pathways that are buffered from automobile traffic.[i] In contrast, people living in lower income neighborhoods tend to be exposed to unhealthy attributes such as higher levels of pollution from nearby freeways or industrial land uses. Emerging climate research also shows that residents living in lower income urban neighborhoods are exposed to higher summertime temperatures due to built environment conditions that include greater expanses of asphalt and concrete with fewer trees or green spaces.[ii] FOOD SECURITY Food security means “access by all people at all times to enough food for an active, healthy life.” Food insecurity indicates a limited ability to secure adequate food due to insufficient resources.[iii] Prior to COVID-19, Idaho was seeing improvements in the number of food insecure households. Data from Feeding America reported 8.7 percent of Idaho’s population faced food insecurity in 2020.[iv] According to the Idaho Food Bank and Idaho’s Map the Meal Gap report, released in July 2022, national food insecurity did not increase in 2020 largely due to a strong public and private response to the pandemic. The economic downturn resulting from the pandemic did highlight and exacerbate disparities among populations who experience food insecurity. In Idaho, 17 percent of the Hispanic and Latino population faced food insecurity in 2020 compared to 8 percent of the white, non-Hispanic population.[iv] Among children enrolled in Idaho public schools during the 2021-2022 school year, 27.26 percent were eligible for free or reduced-price lunch, a reduction from the previous year when 36.11 percent were eligible.[v] Idaho’s most rural counties tend to experience higher rates of food insecurity and limited access to healthy foods.[iv] Shoshone County is estimated to have the highest food insecurity rate, with 15.7 percent overall, and 20.7 percent among children in the county. As a comparison, Jefferson County had the lowest food insecurity rate, at 6 percent. Food insecure households often rely on low cost, low nutrient foods resulting in a greater risk of obesity for this under-resourced population.[vi] Adults with obesity are at increased risk for many diseases and health conditions including type 2 diabetes, stroke, and heart disease. TRANSPORTATION AND ACCESS TO PHYSICAL ACTIVITY OPPORTUNITY Maintaining a robust transportation system with safe options for all people regardless of age, income or ability to drive improves health. Transportation connects people to employment, healthcare, food, recreation and all the other places people need to access to live full and healthy lives. Without reliable and safe transportation, people are less likely to receive preventative healthcare and less able to participate in health promoting activities like healthy eating and physical activity.[vii],[viii] While only 3.9 percent of Idaho households do not have access to vehicles, 23.7 percent of households only have access to one vehicle, thereby increasing their reliance on alternative modes of transportation.[ix] Many Idahoans also face difficulties paying maintenance costs for the vehicles that they own, and others drive less as they age. Although rural areas have different needs than urban areas, an equitable and health promoting transportation system that works for all Idahoans would include safe and ADA accessible walking routes, safe and connected bicycle infrastructure, street connectivity, public transportation or shuttle options and diverse land uses so people have the opportunity to live within walking distance to key destinations. In 2021, approximately 35 percent of Idaho adults making less than $15,000 per year reported no physical activity outside of work, compared to 11.8 percent of those who make $75,000 or more per year.[x] Neighborhood design may help to explain this discrepancy, as people who live in neighborhoods where it is safe and enjoyable to walk, or bike are more likely to participate in these activities. At a national level, the 2022 Dangerous by Design report by Smart Growth America, found that while lower-income neighborhoods (those with a median household income of $2,500-$43,000) make up 17 percent of the population, they account for more than 30 percent of all pedestrian deaths.[xi] Communities that invest in active transportation options like sidewalks, protected bike lanes and public transportation not only help to protect the environment, but they also increase transportation equity and improve health.[viii] HOUSING Housing costs started to decrease in 2022, although not at a rate commensurate with the rapid increases seen in recent years. Purchase prices for homes in the state increased 115.87% percent over the past 5 years (Period ended 2022 Q3).[xii] Statewide, the median rent reportedly decreased 5.39 percent from December 2021 to 2022, down from a 58.0 percent increase from 2020 to 2021.[xiii] While slowing, the recent increase in the cost of housing without a comparable increase in income has resulted in many households struggling to meet living expenses. Many studies have shown that housing instability contributes to poor health and, as a result, increased healthcare costs. People who rent housing comprise 28.1 percent of Idaho’s occupied housing units, and of those who rent housing, 46.7 percent are cost burdened, meaning they pay 30 percent or more of household income toward their rent. For homeowners with a mortgage, 25.8 percent are cost burdened.[ix] According to the National Low Income Housing Coalition there is a shortage of 24,486 rental homes affordable to low-income households whose incomes are at or below 30% of the area median income in Idaho. Among these extremely low-income renter households, 66 percent are severely cost burdened meaning they spend more than 50 percent of their income on housing.[xiv] Housing cost burdened families are unable to afford other necessities and essential services, leading to poor downstream consequences, such as missed medical or dental check-ups. These decisions are often the determining factor turning acute health issues into costly chronic health conditions. The US Department of Housing and Urban Development (HUD) estimates that Fair Market Rent for a two-bedroom apartment in Idaho is $981.[xv] To afford this level of rent without paying more than 30 percent of income on housing, a household must earn $3,272 monthly or $18.87 per hour for a 40-hour work week. However, the average wage for those who rent their housing in Idaho is $16.10. People who make the minimum wage would need to work 104 hours per week to afford a two-bedroom rental home. Based on the estimates, certain areas of the state require much higher wages to afford a two-bedroom apartment, $21.50 per hour in Boise and $21.46 per hour in Blaine County.[xv] [i]. Do All Children Have Places to Be Active? Disparities in Access to Physical Activity Environments in Racial and Ethnic Minority and Lower-Income Communities. Active Living Research. Research Synthesis November 2011. Accessed September 15, 2021. Retrieved from: https://activelivingresearch.org/sites/activelivingresearch.org/files/Synthesis_Taylor-Lou_Disparities_Nov2011_0.pdf [ii]. The Effects of Historical Housing Policies on Resident Exposure to Intra-Urban Heat: A Study of 108 US Urban Areas. Climate 2020. Accessed October 14, 2021. Retrieved from: https://www.mdpi.com/2225-1154/8/1/12/htm [iii]. SA Anderson, Core indicators of nutritional state for difficult-to-sample populations, Journal of nutrition, 1990. Accessed January 9, 2023. Retrieved from: https://doi.org/10.1093/jn/120.suppl_11.1555 [iv]. Feeding America, Map the Meal Gap 2022 -Online. Accessed January 25, 2023. Retrieved from: https://map.feedingamerica.org [v]. Idaho State Department of Education, CNP Lunch Eligibility Reports, 2021-2022 - Online. Accessed January 25, 2023. Retrieved from: https://apps.sde.idaho.gov/CnpEligibility/Report [vi]. Pan L, Sherry B, Njai R, Blanck HM. Food Insecurity is Associated with Obesity among US Adults in 12 States. J Acad Nutr Diet. 2021 Sep; 112(9):1403-1409. doi: 10.1016/j.jand.2012.06.011. PMID: 22939441; PMCID: PMC4584410. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4584410/ [vii]. Transportation and the Role of Hospitals. American Hospital Association. November 2017. Accessed October 14, 2021. Retrieved from: http://www.hpoe.org/Reports-HPOE/2017/sdoh-transportation-role-of-hospitals.pdf [viii]. Healthy Places. Centers for Disease Control and Prevention. Accessed October 21, 2021. Retrieved from: CDC - Healthy Places - Transportation and Health [ix]. U.S. Census Bureau. American Community Survey. 2021 American Community Survey 1-year Estimates Subject Tables. Retrieved from https://data.census.gov/ [x]. Idaho Behavioral Risk Factor Surveillance System Demographic and Public Health District Results (2021). Retrieved from: https://www.gethealthy.dhw.idaho.gov/idaho-brfss [xi]. Smart Growth America. Dangerous By Design 2022. Accessed January 10, 2023. Retrieved from: https://smartgrowthamerica.org/wp-content/uploads/2022/07/Dangerous-By-Design-2022-v3.pdf [xii]. Federal Housing Finance Agency House Price Index Quarterly Report, September 2022 – Online. Accessed January 25, 2023. Retrieved from: https://www.fhfa.gov/AboutUs/Reports/ReportDocuments/HPI_2022Q3.pdf [xiii]. Rent Report January 2023. Online. Accessed January 25, 2023. Retrieved from: Rent. January 2023 Rent Report - Rent. Research [xiv]. National Low-Income Housing Coalition – Housing Needs By State -Online. Accessed January 11, 2023. Retrieved from: https://nlihc.org/housing-needs-by-state/idaho [xv]. National Low-Income Housing Coalition – Out of Reach 2022 Report – Online. Accessed January 25, 2023. Retrieved from: https://nlihc.org/oor/state/id

HEALTH PROFESSIONAL SHORTAGE In 2022, 100 percent of Idaho was a federally designated mental health professional shortage area, 98.7 percent of Idaho was a federally designated shortage area in primary care and 95.7 percent of Idaho was a federally designated dental health professional shortage area.[i] Primary care and dental health shortages areas increased in Idaho from 2021 to 2022. In 2022, the Idaho Hospital Association reported 51 hospital members throughout the state. Twenty-seven of these hospitals are critical access hospitals, located in Idaho. These small, rural hospitals also own primary and specialty care clinics and may be co-located with the hospital or operate as remote clinics.[ii] Prior to 2018, there were no medical schools (either allopathic or osteopathic) in the state. In 2018, the first college of osteopathic medicine began operating in Idaho for the purpose of training and developing physicians. The Idaho College of Osteopathic Medicine (ICOM) is a private, for-profit school which received pre-accreditation status while it continues working towards establishing full accreditation status from the Commission on Osteopathic College Accreditation. ICOM’s mission is to train competent and caring physicians prepared to serve persons in Idaho, Montana, North and South Dakota, Wyoming, and beyond with an emphasis on rural, underserved areas within this five-state region. IDAHO MEDICAID In SFY 2022, on average 414,7330 Idahoans were enrolled in Medicaid, a 48 percent increase from SFY 2019 average enrollment. The growth is due to the Medicaid expansion program.[iii] Medicaid serves individuals from birth to end of life, provided they meet eligibility criteria. In SFY 2022, 43.8% of Medicaid enrollees were children from birth to 18 years of age, another 6.6% are comprised of children with developmental disabilities up to age 21.29 Medicaid enrollment typically fluctuates depending on the state’s economy: When the economy is strong, more people are working and have access to healthcare coverage through their employers; however, when the economy is not performing well, more Idahoans seek healthcare assistance through Medicaid. In November 2018, voters passed a ballot proposition to expand Medicaid in Idaho. The goal of Medicaid expansion is to provide Medicaid coverage to individuals with incomes up to 138 percent of the Federal Poverty Level. “Prior to 2020, there were an estimated 78,000 Idaho residents in the coverage gap – ineligible for subsidies in the exchange and also ineligible for Medicaid.”[iv] The state implemented Medicaid expansion January 1, 2020. Estimates prior to the COVID-19 pandemic expected that an additional 91,000 people would be covered. As of January 2023, around 145,000 Idaho residents were enrolled in Medicaid expansion. These are individuals who have a monthly income of $1,563 or less, or are a family of four with a monthly income of $3,192 or less. Idaho hospitals report spending $42 million less on charity care and had $61 million less bad debt since Medicaid was expanded from 2019-2021.[v] IDAHO KIDS HEALTH COVERAGE According to a 2021 Idaho Kids Covered report, a project of Idaho Voices for Children, “Idaho had the highest increase in the rate of uninsured children in the entire country between 2017 and 2018.” The report emphasizes the critical importance of prioritizing health coverage for children, as they are “more likely to do better in school and grow up healthy.” As of 2021, 5 percent of children in Idaho are uninsured. This equates to 24,000 kids who do not have health coverage. The report also illustrates disparities that exist across income, age and geography, confirming that a child’s zip code impacts their health and access to care. Hispanic children are more likely than White children to be without coverage.[vi] Half of Idaho’s children (51 percent) are covered by their families’ employer-sponsored health insurance, while 35 percent are covered by Medicaid/CHIP, another 8 percent are covered through health insurance exchange, and 5 percent are uninsured. [i]. Rural Health and Underserved Areas Bureau of Rural Health and Primary Care, Division of Public Health, Idaho Department of Health and Welfare. Accessed January 19, 2023. Retrieved from: https://healthandwelfare.idaho.gov/providers/rural-health-and-underserved-areas/rural-health-and-underserved-areas [ii]. Idaho Hospital Association. Hospitals 101 A guide to Idaho’s Community Hospitals 2023 edition. Accessed January 19, 2023, Retrieved from: https://teamiha.org/policy-advocacy/ [iii]. Facts, Figures and Trends: 2022-2023. Idaho Department of Health and Welfare. Accessed January 19, 2023, Retrieved from: https://publicdocuments.dhw.idaho.gov/WebLink/DocView.aspx?id=24088&dbid=0&repo=PUBLIC-DOCUMENTS&cr=1 [iv]. Norris, Louise, Health insurance & health reform authority, July 18, 2021. Retrieved from: Idaho and the ACA’s Medicaid expansion - healthinsurance.org [v]. Idaho Department of Health and Welfare. An FAQ about Medicaid Expansion and continuous enrollment, January 27, 2023 – Online. Accessed January 30, 2023. Retrieved from: An FAQ about Medicaid Expansion and continuous enrollment | Idaho Department of Health and Welfare [vi]. Idaho Kids Covered, Idaho Kids Health Coverage Snapshot – Online. Retrieved from: Idaho-Kids-Health-Coverage-Snapshot-FINAL-.pdf (idahokidscovered.org)