HomeMy WebLinkAboutAgenda 12-01-2025; 12-6 - Information Item - Memorandum - Board of Health Resolution Promoting the Development of Adequate Affordable Housing 1
ORANGE COUNTY
HEALTH DEPARTMENT
Improving health.Inspiring change.
MEMORANDUM
TO: Board of County Commissioners
Jamezetta Bedford, Chair
Jean Hamilton, Vice Chair
Marilyn Carter
Amy Fowler
Sally Greene
Earl McKee
Phyllis Portie-Ascott
FROM: Jean Phillips-Weiner, Board of Health Strategic Plan Manager
DATE: November 10, 2025
RE: Board of Health Resolution Promoting the Development of Adequate Affordable Housing
Purpose
The purpose of this memorandum is to 1) recognize the lack of affordable housing in Orange County as a threat
to public health and 2) recommend fourteen items that will help improve the affordable housing supply and benefit
public health for consideration in the Orange County Land Use Plan.
Background
During the March 2024 Annual BOH Retreat, the Board adopted three Priority Areas to align with the 2023
Community Health Assessment Priorities. These priorities included Access to Care, Behavioral Health and
Connections to Community Support. The Board created committees to do additional work to support these
priority areas. The Connections to Community Support Committee has a focus on access to adequate affordable
housing. Members of the Connections to Community Support Committee have researched the issue and heard
presentations from Housing Department staff, local organizations working to address affordable housing access,
and subject matter experts in land use planning and zoning.
As a result of all the information gathered, the Board drafted a resolution over the Summer and Fall of 2025, to
recognize housing as a public health issue and recommend certain health-promoting policies for the Board of
County Commissioners to consider for the forthcoming Land Use Plan.
This item supports County Strategic Plan Goal #3, Housing for All.
919 245 2405 300 West Tryon Street Hillsborough, NC 27278 orangecountync.gov
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ORANGE COUNTY
HEALTH DEPARTMENT
Improving health. inspiring change.
ORANGE COUNTY BOARD OF HEALTH
RESOLUTION PROMOTING THE DEVELOPMENT OF ADEQUATE AFFORDABLE HOUSING
WHEREAS, housing is a human right, not a commodity', because humane and adequate housing' is necessary for all
humans to live their best lives and to rise to their full potential2; and
WHEREAS, Orange County is experiencing a housing crisis:
• County residents identified a lack of affordable, humane housing as a top concern, both in the 2023 Community
Health Assessment3 and the countywide assessment for the Orange County Strategic Plano;
• The county has 13,689 fewer units5 than we need, and this deficit disproportionately affects individuals earning
less than 50% of the area median income, with a deficit of 9,555 units6;
• National data show that 16% of Orange County residents spend at least half of their income on housing, a
proportion that is considered severely housing cost-burdened. This greatly exceeds the proportion in neighboring
and peer countiesa which ranges from 9% to 13%7. The annual income to afford a two-bedroom in Orange
County is $74,880, exceeding earnings for teachers ($51,740), childcare providers ($33,000), and firefighters
($36,230), so our civil servants cannot live where they work8; and
WHEREAS, unstable housing significantly harms individual health:
• Living unhoused disrupts access to sanitation and supplies9, increases social isolation and stigma9, impedes
access to healthcare9,10,11, and increases exposure to hazards such as heat, cold, and physical and sexual
violence9,10,11. These effects accelerate aging, with premature onset of chronic medical conditions, functional and
cognitive impairments, and increase mortality12,13Individuals who are unhoused have 7 times the mortality rate
from all causes and 14 times the overdose mortality rate compared with their housed counterparts14;
• Children who move frequently are more likely than stably housed children to experience chronic health conditions,
poor physical health, and to have less consistent health insurance coverage15, and efforts to improve housing are
one of the most promising interventions to prevent adverse childhood experiences16; and
WHEREAS, lack of housing causes significant adverse impacts to public health for communities:
• Communities lacking adequate housing experience disproportionate levels of incarceration 17,18,19,20,21 increased
levels of drug use'4,22,23,24and overuse of hospitals and emergency medical services, straining medical providers
and increasing wait times'0,25,26,27,28,29,30,31,32•
• Investments in permanent supportive housing decrease emergency room visits by 70%33 and annual healthcare
utilization costs by an average of$48,510 per person34;
• Failure to house community members costs more than providing adequate housing due to the expense of
supplementing emergency healthcare and incarceration costs20,35,36,37. "housing first" strategies save $900 to
$29,400 per person housed per year38, returning $1.80 for every $1.00 invested34; and
WHEREAS, zoning and land use policies profoundly shape our built environment:
• Deficits in affordable housing reflect longstanding zoning policies39,40 that have had an exclusionary effect,
including limits on small-scale multifamily housing41, commonly known as "Missing Middle" housing42;
• Best practices such as APA's Equity in Zoning Policy Guide43 can help correct these harms;
• Orange County and the Towns of Carrboro, Chapel Hill, and Hillsborough are engaged in the process of
developing new land use plans and/or zoning ordinances.
NOW, THEREFORE, BE IT RESOLVED on this 29th of October, 2025, that we the Orange County Board of Health
recognize the lack of affordable housing in Orange County as a threat to public health. To address this, the Board of
Health recommends that the Orange County Board of County Commissioners and the governing bodies of Carrboro,
Chapel Hill, and Hillsborough incorporate the following in their land use plans and zoning ordinances:
a Peer counties are other NC counties with similar population size,age distribution,racial composition,income,and education levels as compared to Orange County.
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ORANGE COUNTY
HEALTH DEPARTMENT
Improving health.inspiring change.
1. Ensure that policies, ordinances, and administrative practices do not unduly restrict the development of adequate,
affordable and attainable housing, recognizing that land use plans and zoning ordinances can redress
generational harms created by historic discriminatory policies.
2. Reduce minimum lot sizes, minimum setbacks, and other dimensional requirements to reasonably allow more
compact development footprints and higher density.
3. Implement incentives for developments that incorporate desirable residential characteristics such as:
a. clustering of units to preserve natural lands
b. mixed housing types or sizes
c. dedicated affordable housing units
d. reservation of adequate lot area and wastewater system allocation for Accessory Dwelling Units (ADUs)
e. commitments that Home Owners Association (HOA) documents will permit and accommodate ADUs with
no unreasonable restrictions
f. support for multi-generational living
g. cooperative housing initiatives
h. preservation of high-quality open space such as wetlands and floodplains
i. connection to public sewer systems
4. Identify and evaluate ways to incentivize development of affordable and "Missing Middle" housing types such as
by streamlining the permitting processes and reducing permit fees where practical.
5. Re-evaluate development standards to ensure that they do not create excessive constraints on housing
production. Examples include regulations that require development to include transitional buffers, a minimum
number of off-street parking spaces, and high amounts of open space.
6. Where onsite wastewater systems are utilized, consider basing residential density on number of allowed
bedrooms instead of number of units, as this is a more precise measure of development intensity and impact.
7. To reduce vehicle miles of travel, eliminate home-based business restrictions that are not related to the impact
those businesses may have on the residential neighborhood.
8. Allow in residential areas supportive uses such as childcare and appropriate commercial uses that support
families and provide important neighborhood services.
9. Develop a significant portion of the jointly owned Greene Tract with affordable and "Missing Middle" housing
options, both for rent and for purchase.
10. Permit and encourage appropriate types of non-traditional or innovative housing that are less expensive to build
and may provide greater affordability, such as manufactured (mobile) homes, modular homes, cottages, tiny
homes, pop-up homes, container homes.
11. Re-visit interlocal agreements with other jurisdictions as needed to implement the above.
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A AL- ')r
ORANGE COUNTY
HEALTH DEPARTMENT
Improving health. Inspiring change.
12. Work collaboratively with the City of Mebane to optimize residential development with municipal utility services in
and near Mebane's extraterritorial jurisdiction, where located within Orange County.
13. Consider implementing Naturally Occurring Affordable Housing Overlay Districts41 to preserve areas of Naturally
Occurring Affordable Housing, especially those with high density or in historically disadvantaged communities.
14. Explore the potential for new developments to utilize community onsite wastewater systems in lieu of individual
wastewater systems for areas unserved by public wastewater. For these community systems, incentivize
enhanced design standards and treatment criteria.
Alison Stuebe, MD, MSc Quintana Stewart, MPA
Chair, Orange County Board of Health Orange County Health Director
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ORANGE COUNTY
HEALTH DEPARTMENT
Improving health.inspiring change.
REFERENCES AND RESOURCES:
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2"Unlocking Human Potential through Adequate Housing." Habitat for Humanity, Home Equals Campaign, www.habitat.org/home-
equals/unlocking-human-potential-through-adequate-housing.Accessed 24 July 2025.
3 Orange County Health Department, 2024, 2023 Community Health Assessment,
https://www.orangecountync.gov/DocumentCenter/View/27392/Orange-County-2023-CHA.Accessed 24 July 2025.
4 Orange County Government,2024, Orange County North Carolina Strategic Plan FY2025-2029,
https://www.orangecountync.gov/DocumentCenter/View/31371/Orange-County-Strategic-Plan.Accessed 24 July 2025.
5 NC Chamber Foundation, 2024, Housing Supply Gap Analysis, https://ncchamber.com/wp-
content/uploads/Housing Supply Gap Analysis.pdf.Accessed 24 July 2024.
6"Consolidated Planning/CHAS Data."Consolidated Planning/Comprehensive Housing Affordability Strategy(CHAS) Data, U.S. Office
of Housing and Urban Development, www.huduser.gov/portal/datasets/cp.html.Accessed 24 July 2025.
"Consolidated Planning/CHAS Data."Consolidated Planning/Comprehensive Housing Affordability Strategy(CHAS) Data, U.S. Office
of Housing and Urban Development, www.huduser.gov/portal/datasets/cp.html.Accessed 24 July 2025.
8 North Carolina Housing Coalition, 2025, The 2025 Housing Need in Orange County, https://nchousing.org/wp-
content/uploads/2017/01/NCH-CountyProfile-Orange.pdf.Accessed 24 July 2025.
9 Baxter,Andrew J, et al. "Effects of housing first approaches on health and well-being of adults who are homeless or at risk of
homelessness: Systematic review and meta-analysis of Randomised Controlled Trials."Journal of Epidemiology and
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10 Fazel, Seena, et al. "The health of homeless people in high-income countries: Descriptive Epidemiology, Health Consequences, and
clinical and policy recommendations."The Lancet,vol. 384, no. 9953, Oct. 2014, pp. 1529-1540,
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homelessness, 2011-20." Health Affairs,vol.43, no. 2, 1 Feb. 2024, pp. 226-233, https://doi.org/10.1377/hithaff.2023.01039.
12 Baggett,Travis P et al. "Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period."JAMA internal
medicine vol. 173,3 (2013): 189-95. https://doi.org/10.1001/Iamainternmed.2013.1604.
13 Brown, Rebecca T et al. "Geriatric Conditions in a Population-Based Sample of Older Homeless Adults." The Gerontologist vol. 57,4
(2017): 757-766. https://doi.org/l 0.1093/geront/gnw011.
14 Fliss, Michael Dolan, et al. "People Experiencing Homelessness in NC Have Increased Mortality, Including High Overdose, Violence,
Injury, and Chronic Disease Death Rates: Published in North Carolina Medical Journal." North Carolina Medical Journal,
NCIOM,The Duke Endowment, 1 Sept. 2022, https://ncmedical'ournal.com/article/55415.
15 Busacker,Ashley, and Laurin Kasehagen. "Association of Residential Mobility with Child Health: An Analysis of the 2007 National
Survey of Children's Health."Maternal and Child Health Journal,vol. 16, no. S1,Apr. 2012, pp. 78-87,
https://doi.org/l 0.1007/sl 0995-012-0997-8.
16 Courtin, Emilie, et al. "The role of socioeconomic interventions in reducing exposure to adverse childhood experiences:A systematic
review."Current Epidemiology Reports, vol. 6, no.4, 8 Nov.2019, pp.423-441, https://doi.org/10.1007/s4O471-019-00216-2.
1' Diamond, Pamela M., and Steven B. Schnee. Hogg Foundation for Mental Health, 1991, Lives in the Shadows: Some of the Costs
and Consequences of a"Non-System"of Care, httt s://repositories.Iib.utexas.edu/server/api/core/bitstreams/9e3O8239-48f6-
4f5f-a889-c9b95b474ec2/content.Accessed 24 July 2025.
18 Lebovits, Hannah, and Andrew Sullivan. "Do criminalization policies impact local homelessness? Exploring the limits and concerns of
socially constructed deviancy."SSRN Electronic Journal, 2024, https://doi.org/10.2139/ssrn.4716230.
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ORANGE COUNTY
HEALTH DEPARTMENT
Improving health.inspiring change.
19 Rountree, Janey, et al. California Policy Lab, Health Conditions Among Unsheltered Adults in the U.S.,
https://www.capolicVlab.org/wp-content/uploads/2023/02/Health-Cond itions-Among-Unsheltered-Adults-in-the-U.S..pdf.
Accessed 24 July 2025.
21 Shinn, Gregory A. The Central Florida Commission on Homelessness, 2014,THE COST OF LONG-TERM HOMELESSNESS IN
CENTRAL FLORIDA, https://shnnV.org/uploads/Florida-Homelessness-Report-2014.pdf.Accessed 24 July 2025.
21 Slevin, Peter. "Life After Prison: Lack of Services Has High Price."The Washington Post, 24 Apr.2000,
https://www.washi ngton post.com/arch ive/pot itics/2000/04/24/1 ife-after-prison-lack-of-services-has-hig h-price/b75a3e9l-ec40-
4399-90ed-d87ce52d360c/.Accessed 24 July 2025.
22 Austin,Anna E., et al. "Associations of housing stress with later Substance Use Outcomes:A systematic review."Addictive
Behaviors, vol. 123, Dec.2021, p. 107076, https://doi.org/l0.1016/'.addbeh.2021.107076.
23 Bradford, W. David, and Felipe Lozano-Rojas. "Higher rates of homelessness are associated with increases in mortality from
accidental drug and alcohol poisonings." Health Affairs,vol. 43, no. 2, 1 Feb.2024, pp. 242-249,
https://doi.org/10.1377/hlthaff.2023.00951.
24 Coombs, Thomas, et al. "Understanding drug use patterns among the homeless population: A systematic review of
Quantitative Studies." Emerging Trends in Drugs, Addictions, and Health, vol. 4, Dec. 2024, p. 100059,
https://doi.org/l 0.1016/i.etdah.2023.100059.
26 Hanson, Devlin, and Sarah Gillespie. "`Housing First' Increased Psychiatric Care Office Visits and Prescriptions While Reducing
Emergency Visits." Health Affairs, vol.43, no. 2, 1 Feb. 2024, pp. 209-217, https://doi.org/10.1377/hlthaff.2023.01041.
26 Kushel, Margot B., Sharon Perry, et al. "Emergency department use among the homeless and marginally housed: Results from a
community-based study."American Journal of Public Health,vol. 92, no. 5, May 2002, pp. 778-784,
https://doi.org/l 0.2105/aiph.92.5.778.
27 Kushel, Margot B., et al. "Factors associated with the health care utilization of homeless persons."JAMA,vol. 285, no. 2, 10 Jan.
2001, p. 200, https://doi.org/10.1001/'ama.285.2.200.
28 Larimer, Mary E., et al. "Health Care and public service use and costs before and after provision of housing for chronically homeless
persons with severe alcohol problems."JAMA,vol. 301, no. 13, 1 Apr. 2009, p. 1349, https://doi.org/10.1001/'ama.2009.414.
29 Martell, Jon V., et al. "Hospitalization in an urban homeless population:The Honolulu Urban Homeless Project."Annals of Internal
Medicine,vol. 116, no.4, 15 Feb. 1992, pp. 299-303, https://doi.org/10.7326/0003-4819-116-4-299.
30 Martinez, Tia E., and Martha R. Burt. "Impact of permanent supportive housing on the use of acute care health services by homeless
adults." Psychiatric Services, vol. 57, no. 7,July 2006, pp. 992-999, https://doi.org/10.1176/ps.2006.57.7.992.
31 Peng, Yinan, et al. "Permanent supportive housing with housing first to reduce homelessness and promote health among homeless
populations with disability:A community guide systematic review."Journal of Public Health Management and Practice, vol. 26,
no. 5, Sept.2020, pp.404-411, https://doi.org/10.1097/phh.0000000000001219.
32 Salit, Sharon A., et al. "Hospitalization costs associated with homelessness in New York City." New England Journal of Medicine,vol.
338, no. 24, 11 June 1998, pp. 1734-1740, https://doi.org/10.1056/ne'ml99806113382406.
33 Thomas, M. Lori, et al. UNC Charlotte, NC, 2014, pp. 1-42, Moore Place Permanent Supportive Housing Evaluation Study-Year 1
Report. https://shnny.org/images/uploads/Charlotte-Moore-Place-Study.pdf Accessed July 24, 2025.
34 Thomas, M. Lori,et al. UNC Charlotte, NC, 2015, pp. 1-93, Moore Place Permanent Supportive Housing Evaluation Study-Final
Report. https://www.roofabove.org/wp-content/ul)loads/2021/12/Moore-Place-Evaluation-Project Final-Report 4-28-15.pdf.
Accessed July 24, 2025.
36 Gillespie, Sarah, et al. Urban Institute, Denver, CO, 2021, pp. 1-49, Costs and Offsets of Providing Supportive Housing to Break the
Homelessness-Jail Cycle Findings from the Denver Supportive Housing Social Impact Bond Initiative.
https://www.urban.org/sites/default/files/publication/104499/costs-and-offsets-of-providing-supportive-housing-to-break-the-
homelessness-jail-cycle O.pdf.
36 Jacob,Verughese, et al. "Permanent supportive housing with housing first: Findings from a Community Guide Systematic Economic
Review."American Journal of Preventive Medicine,vol. 62, no. 3, Mar.2022, https://doi.org/10.1016/'.amei)re.2021.08.009.
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HEALTH DEPARTMENT
Improving health.inspiring change.
37 Ly,Angela, and Eric Latimer. "Housing first impact on costs and associated cost offsets:A review of the literature."The Canadian
Journal of Psychiatry, vol. 60, no. 11, Nov. 2015, pp.475-487, https://doi.org/l 0.1177/070674371506001103.
38 Brennan, Kevin, et al. Blue Cross&Blue Shield of Massachusetts, 2020, THE PREVENTIVE EFFECT OF HOUSING FIRST ON
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12/Housing%20First report FINAL.pdf.Accessed 24 July 2025.
39 Gray, M. Nolan.Arbitrary Lines: How Zoning Broke the American City and How to Fix It. Island Press, 2022.
40 Rothstein, Richard.The Color of Law:A Forgotten History of How Our Government Segregated America. Liveright Publishing
Corporation, a Division of W.W. Norton&Company, 2018.
41 Brennan, Maya, et al. Urban Institute, 2020, Housing for North Carolina's Future: Policy Tools That Support Rural, Suburban, and
Urban Success, https://www.urban.org/sites/default/files/publication/102473/housing-for-north-carolinas-future 0.1Ddf.
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