Access to Affordable Housing Promotes Health and Well-Being and Reduces Hospital Visits

Abstract

Clinical interventions can only partially mitigate homelessness and housing insecurity, which are threats to health and well-being. Clinicians have several opportunities to address these problems: They can refer patients who are homeless or housing insecure to support services, advocate for their employer or care group to commit resources to end homelessness and housing insecurity, and/or work with government and private sector community organizations to address and eliminate these problems. Citing examples from around the US, we will illustrate how clinics, hospitals, health plans, and public health organizations work to engage in initiatives to end homelessness and housing insecurity.

INTRODUCTION

In 2013, the lack of affordable housing was the leading cause of homelessness in America’s 25 largest cities,¹ and 10% of low-income renters lived in units that lacked complete plumbing or kitchen facilities, experienced frequent breakdowns in major systems, or had to address other physical housing defects.² In 2014, 7 million people in poor households (2.2% of the total US population) were living with family and friends, and the number of households paying more than 50% of their income toward housing increased to 6.6 million, a 27.7% increase since 2007. On the night of the 2015 homelessness census, 1 of every 567 Americans was sleeping outdoors, in an emergency shelter, or in transitional housing.³

The Family Options Study reported that it costs $4800 per family per month to house a family in an emergency shelter.⁴ Homelessness and housing insecurity create a vicious cycle that destroys well-being and can be fatal: Adults who are homeless or housing insecure are less likely to have goal-oriented thinking and more likely to experience psychological distress, substance use, intimate partner violence, and symptoms of trauma.⁴ Children who are homeless or housing insecure exhibit more antisocial behavior, less prosocial behavior, more sleep problems, and difficulty advancing in school.⁴

Homeless people die at about four times the rate of housing-secure people in the general population,⁵ and housing-insecure individuals are likely to delay medical care because of costs.⁶ Lack of health insurance and the inability to follow through on the treatment of chronic conditions can exacerbate illnesses that would normally respond to medical intervention. Without affordable, accessible health care, illness or injury can interfere with employability that, in turn, increases the likelihood of poverty and homelessness.

HEALTH PROMOTION THROUGH AFFORDABLE HOUSING

Increased access to affordable housing promotes health and well-being.⁴ Housing can improve the effectiveness of care for patients whose coverage is capitated through Medicaid or similar programs. Promoting health through housing will become increasingly important as health care payments transition from volume-based to value-based models. Investments that reduce homelessness are a good value relative to many clinical services that are offered as a matter of course.⁷ These initiatives also can stabilize neighborhoods surrounding health care facilities and increase the comfort levels of patients, families, employers, and others who visit a health care organization.

Benefits to Patients

Stable housing for homeless patients, especially those with mental illness and/or people fleeing domestic violence, can reduce Emergency Department visits and hospitalizations.⁸ Stable housing also can improve the management of chronic medical conditions.⁹ Children are more likely to meet developmental milestones when raised in stable and healthy housing in which they are not exposed to lead, mold, vermin, or other threats.^10,11 Children spend more time in school when they spend less time in hospitals or in Emergency Departments. They also learn more when stable housing allows for classroom continuity.^12,13

Benefits to Employees and their Families

The increase in worker productivity that is associated with improved housing can benefit health care organizations as employers.¹⁴ For health care organizations located in older areas of cities in which the housing stock has deteriorated below current standards, housing initiatives can provide attractive, yet affordable, housing that reduces the need for employees and their families to commute long distances between home and work and between home and school.

Housing and Community Development Resources

Policies that regulate banks and the financial services industry have stimulated investments in affordable housing for more than 40 years. The 1977 Community Reinvestment Act¹⁵ and the Low-Income Housing Tax Credit are two examples.^16,17 Since 1999, the Healthy Homes Initiatives at the US Department of Housing and Urban Development (HUD) has been leading a federal effort to address lead and other toxins in existing housing stock.

Nearly 1000 private-sector community development financial institutions work at local, regional, and national levels. These institutions are financial intermediaries that have community development as their primary mission. For example, the Local Initiatives Support Corporation (LISC) is a national community development intermediary that was established by the Ford Foundation on the heels of Community Reinvestment Act passage.¹⁵ LISC, community development financial institutions, and other intermediaries provide capital and support capacity building to fuel production and preservation of high-quality affordable rental housing; supportive, service-enriched, mixed-income, and senior rental housing; and affordable home ownership. As a result, the community development sector—with its deep bench of thousands of community development corporations, regional and national nonprofit housing developers, socially minded private developers, and investors—provides the track record, expertise, and resources to create synergy when partnering with private health care systems and public health agencies to advance coordinated projects.

Affordability is created or preserved through a number of avenues including publicly owned housing maintained by a local public housing authority, housing privately owned by nonprofit and for-profit developers, limited-equity programs, and community land trusts. Low-Income Housing Tax Credits, HUD mortgages, the Community Development Block Grant Program, and similar programs support nonprofit and for-profit developers. Because these government programs are limited in scale, “naturally occurring” affordable housing—housing that becomes available within the private market when landlords keep rents relatively low, accept subsidy vouchers from eligible tenants, or own aging properties that cannot command market-level rents—is a helpful complement to new construction. Strategies to improve and to preserve this housing stock have come into favor among local jurisdictions, philanthropists, community residents, organizers, and those working in community development. One example of naturally occurring affordable housing is described in the following paragraph.

EXAMPLE OF MODEL PROGRAMS

Clinics

On the east side of St Paul, MN, the Federally Qualified Health Center, East Side Community Health Services, is collaborating on a housing initiative with Rolling Hills Apartments to serve recent immigrants and refugees with naturally occurring affordable housing.¹⁸ These 2 populations have unique needs because many have experienced trauma and torture. They also tend to lack experience with and trust in Western medicine. Rolling Hills is a renovated 108-unit “housing of last resort” complex. During renovation, space was added for health services, immigration services, and social/community-building activities. The Federally Qualified Health Center provides preventive services on site and primary health care services at its nearby East Side Family Clinic. The project was made possible by the Healthy Futures Fund, a $200 million initiative formed by the LISC, Morgan Stanley, and The Kresge Foundation.

In Washington, DC, catalytic investments of $14 million to finance a clinic and $22 million for affordable housing from The Healthy Futures Fund allowed the not-for-profit So Others Might Eat and the provider of clinical services Community of Hope to develop the 320,000-square-foot Conway Center.¹⁹ This project brings affordable housing, primary care services, employment training, and economic development opportunities together in one location. In addition to living adjacent to a Metro stop, residents and community members will have access to outreach and health education programs designed to promote healthy lifestyles.

Hospital Systems

A premier example of the “anchor institution” strategy is the Phillips Partnership in South Minneapolis.²⁰ Initiated by Allina Health and the Abbott-Northwestern Hospital in the 1990s, public partners, community developers, and Allina leaders developed strategies to improve investments in surrounding single-family homes for affordable home purchase and multifamily apartment building quality. An employer-assisted housing strategy complements these physical improvements by helping hospital system employees find quality affordable nearby housing.

In Indianapolis, IN, Eskenazi Hospital is improving community quality by serving as an anchor institution and by placing community health workers in neighborhoods.²¹ These activities are all part of LISC’s Great Places 2020 initiative. Because 79% of its patients live in neighborhoods that Eskenazi Hospital serves, the hospital is considering assuming an even larger role in its surrounding community.

In New York City, Mount Sinai Hospital is supporting the evaluation of the Two Shades of Green program. Two Shades of Green is a partnership that applies green (energy efficient and low impact), healthy (free of mold, toxins, and vermin), and cost-effective measures to property maintenance and the rehabilitation of existing affordable housing.²² To reinforce program delivery, LISC New York City mobilized a range of affordable housing, community health, and building science stakeholders. These partners include the New York City Department of Health and Mental Hygiene, New York City Department of Housing Preservation and Development, Steven Winters Associates, Mount Sinai Hospital, and Community Development Corporation. Since 2013, Two Shades of Green has stimulated housing renovation and property maintenance in more than 1500 affordable apartments. Owners of these properties have reduced asthma risk for their residents through property management practices that minimize exposures to pests, tobacco smoke, and harsh cleaning products. Such practices also reduce operating costs, particularly for green cleaning, with several properties experiencing a cost savings as high as 50%. It was critical to collaborate with New York City’s Department of Health to bring technical expertise to owners regarding more effective pest control methods to reduce asthma risks through active design and program evaluation.

Health Plans

A Minnesota Accountable Care Organization, Hennepin Health, comprises 4 organizations (Hennepin County Human Services and Public Health Department, Hennepin County Medical Center, Metropolitan Health Plan, and NorthPoint Health & Wellness Center) to provide integrated medical and social services to low-income Medicaid patients in the county that includes Minneapolis.^23,24 Data sharing and community health workers are critical to the success of this program, which offers housing and social services navigation, job placement supports, Emergency Department triage, and intensive case management. The health plan was started in January 2012 and by December 2014 had enrolled nearly 10,000 members, many of whom were nonwhite middle-age men with unstable housing and significant mental health and substance abuse needs. During the second year of operation, the number of outpatient visits increased by 3.3%, and the rate of Emergency Department and inpatient admissions decreased by 9.1% and 3%, respectively. Quality scores for patients with diabetes, asthma, and vascular conditions improved, and 87% of enrollees expressed satisfaction with their care experience. Hennepin Health’s influence on county health and social services costs is not yet known but generally is regarded as positive.

In St Paul, MN, HealthPartners collaborated with Catholic Charities and other community organizations to raise $100 million for the Higher Ground Shelter, which opened in 2016.²⁵ The Opportunity Center, an adjacent 6-story building in which clients will be able to receive job resources and training, access to veterans’ programs, and basic health care services, opens in 2018. The new complex is integral to HealthPartners’ Hospital to Home Program because it will provide permanent housing for patients who were homeless when they were admitted to Regions Hospital.²⁶

United Health Group, with home offices in Minnetonka, MN, invested $20 million in Chicanos Por La Causa in Phoenix, AZ, to support its integrated health and human services programs within its affordable housing properties.²⁷ United Health Group also has committed $50 million to the Greater Minnesota Housing Fund to support Low-Income Housing Tax Credit investments in supportive housing.²⁸

Public Health and Other Organizations

The Rhode Island State Health Department, in collaboration with the Centers for Disease Control and Prevention, has created 10 Health Equity Zones.²⁹ Each Health Equity Zone has a work plan that focuses on ideas to improve population health and approaches for investment in local communities. Community engagement is a priority in reaching these public health goals.

Paseo Verde in Philadelphia, PA, demonstrates the accomplishments that can be achieved when a private investor partners with a community organization.³⁰ This $48 million green and transit-oriented development was created through a partnership between community-based Asociación Puertorriqueños en Marcha³¹ and private developer Jonathan Rose Companies. The Paseo Verde complex has a health center and pharmacy on site.

Since 2008, the Baltimore-based Green and Healthy Homes Initiative has led national efforts to integrate lead abatement, healthy homes programs, weatherization, and energy efficiency work.³² The Green and Healthy Homes Initiative promotes integrated methods to create a whole-house approach to reducing toxins and other contaminants and improve energy efficiency in Baltimore, MD, and other US cities. The Initiative has worked in partnership with numerous health departments and health systems to measure the impact of these interventions on rates of asthma, lead poisoning, injuries, and other respiratory illnesses.

An Uncertain Future

Even with existing government and private initiatives in place, the affordable housing crisis persists for low-income families. The current political climate puts existing funding mechanisms at risk at a time when new partnerships and new perspectives are needed. President Trump’s Fiscal Year 2018 budget features substantial cuts to nondefense domestic discretionary programs.³³ As housing costs continue to rise, an increasing portion of the HUD budget is being used to maintain the supply of affordable housing units and rental subsidies, which means that fewer HUD dollars are available for housing production.³⁴ HUD’s HOME Investment Partnerships Program,³⁵ which provides formula grants to states and municipalities, has seen its budget reduced by more than 50% from its fiscal year 2010 watermark and was threatened with elimination as recently as last year.

These funding mechanisms must be protected if the US is to address the severe affordable housing shortage. In addition to directly participating in the construction of housing or supporting individuals and families, health care organizations can play an important role by advocating for the value of affordable housing and its related health and well-being benefits.

CONCLUSION

Despite the nation’s financial recovery since the Great Recession, low-income families remain at high risk for homelessness and housing insecurity because wages are not keeping up with rent inflation.³⁴ Changes in federal policy are exacerbating the problem. Homelessness and housing insecurity not only reduce the effectiveness of health care and increase its cost; these problems serve as barriers to well-being for adults and children.

Clinicians help patients when they can 1) recognize homelessness and housing insecurity during encounters with patients and refer them to supportive resources, 2) advocate for their health care organizations to become involved in ending homelessness and housing insecurity, and 3) work with government and private sector community organizations to eliminate these problems. Clinic groups, hospital systems, health plans, and public health organizations can promote this “triple aim” by engaging in initiatives to end homelessness and housing insecurity. Although some approaches necessitate a long-term investment, each approach mitigates an aspect of housing insecurity, which threatens health and well-being and cannot be eliminated even when clinical services are enhanced.