Building Up Housing to Break Down Health Disparities

When the foreclosure crisis struck the United States in 2007 to 2008, millions of homeowners lost their homes, greatly limiting economic opportunity and wealth-building potential.¹ Subsequently, a new calamity arose: the affordable housing crisis. As the availability of affordable apartments declined by more than 50%, the search for affordable housing led many middle- and upper-income individuals to migrate to low-income communities where rents were more reasonable. This trend, gentrification, placed low-income communities at further risk for residential displacement.² With stagnant wages and diminished housing affordability, many could no longer meet costly rent requirements and were faced with a sobering and precarious reality—homelessness.

HOUSING AS A FUNDAMENTAL CAUSE

Substandard housing and the lack of housing are associated with high rates of respiratory infections and tuberculosis. In addition, chronic diseases such as asthma and cancer have been linked to poor housing and the absence of housing in general. It is expected then that individuals who are homeless are at disproportionate risk for a variety of health disparities in comparison with the general population. Without a consistent and adequate nighttime residence, other ailments such as physical disability are also frequently observed in individuals who are homeless. While the compounded impact of poverty and health issues may precipitate homelessness, the experience of homelessness can also worsen health or introduce illness, attributable to novel hurdles in accessing health care.³

Reducing resource inequality is a health policy implication tied to Link and Phelan’s fundamental cause theory. The role of housing as one of the fundamental causes of homelessness and poor health cannot be ignored and should be recognized as a health-relevant policy.⁴ If the public health field is to address the fundamental causes of illness in populations who are unstably housed and homeless, health disparities in these communities can no longer be perceived as irrevocable norms but rather as a reflection of improper and inconsistent shelter and an indicator of a failing housing system.

EXPANDING THE SCOPE OF PUBLIC HEALTH

Housing is a foundational human right. As such, it belongs in the forefront of the research, policy analysis, and intervention development undertaken by public health practitioners. Housing First is a promising programmatic model that prioritizes permanent housing instead of standard emergency shelter for individuals who are homeless. The Housing First approach can serve as platform for developing innovative social policies and has already demonstrated great potential in places including New York City, California, Pennsylvania, and Washington. Housing First does not require that individuals who are homeless address behavioral health–related problems before “graduating” through a series of programs or services to obtain shelter. Instead, this model shifts the paradigm by recognizing that housing is a human right that should not be withheld from anyone.⁵ Importantly, evidence of its impact can be found across a plethora of studies and has been associated with positive residential and health-related outcomes, including improved housing retention rates, decreased criminal justice system involvement, fewer psychiatric hospitalizations, less emergency department utilization, and fewer costs incurred over time to hospitals.⁶

Hospitals and health care organizations are uniquely positioned to engage in this housing-centered work. Precipitated by the housing crisis and perhaps inspired by the core values of Housing First, some hospitals and health systems are beginning to prioritize the provision of adequate and stable places to live as essential to patient health. The Better Health Through Housing project at the University of Illinois Hospital, for example, conducted a three-year experiment investigating the effects of providing housing for patients who were unstably housed and homeless who frequented the emergency department with severe and chronic health problems. The program resulted in less health care costs for the hospital, more consistent visits between patients and primary care providers, and increased use of more preventive health measures.⁷ When housing is recognized as a fundamental cause of health, the impact is measurable.

Despite the obvious potential of Housing First, the framework has not been immune to critique, as efforts to evaluate long-term health impacts of Housing First models have been sparse. While many of the short-term indicators for Housing First are promising and relevant, particularly with respect to housing retention and hospitalization rates, the field has yet to determine whether there are significant and lasting changes in residents’ health.⁶ Public health research is critically needed to address this void. By expanding the evidence base for Housing First, public health researchers can generate more support for this approach. This can prompt endorsement from various stakeholders, including policy-makers and social service providers.

The most significant gap, however, is that the standardization of the Housing First model has not been completed. The fundamental values of the framework are often inconsistently defined and applied. There is a crucial need to unify the core principles of the model, such that Housing First is consistently advantageous across a variety of settings. Naturally, the housing needs of each community may differ, especially those comprising diverse populations. It is important that Housing First is aligned not only with the needs of local populations but also the regional policies and available social services in the areas targeted by this intervention.⁶ The emerging field of dissemination and implementation science within public health is directly equipped to meet this challenge. Through a more unified Housing First approach, cohesiveness may be achieved in its use, which enhances the reliability of this promising housing intervention.

Although the involvement of hospitals and health systems in housing-centered efforts is innovative, action to address housing must extend beyond social service agencies and health care organizations. The affordable housing crisis is far too substantial to be met with limited effort. The public health field must work with policy-makers to design affordable housing opportunities that yield cost-saving benefits to other sectors, ranging from the criminal justice system to real estate development.⁷ Moreover, the use of Medicaid funding for affordable housing might be achieved by framing particular health ailments as “housing-sensitive conditions” that can be improved with the provision of stable and adequate housing. These housing-centered efforts require the advocacy of public health practitioners and policy-makers alike.

The impact of the housing crisis placed millions at greater risk for unstable housing and even homelessness. Because of the persistence of the housing crisis and the now mounting crisis of homelessness, there is substantial opportunity for the field of public health to intervene. Housing First, hospital-based housing programs, the creation of cost-saving incentives across various sectors, and the enlistment of Medicaid in this housing effort, should be just the beginning.

It is essential that intervention and prevention are both emphasized to put an end to this current crisis. However, a unique tension often exists between the efforts required to address homelessness and those required to prevent it. When the acute needs of a community are vast, intervention may inadvertently eclipse advantageous prevention efforts. Thus, it is important that public health practitioners also pay close attention to individuals who are unstably housed, but not yet homeless, as they represent a unique opportunity for prevention. Surely, shifting the status quo to a focus toward the appreciation and provision of housing will contribute to our ongoing efforts to promote health and prevent disease. There are few issues for public health practice that deserve greater concern than working to eliminate this preventable dilemma.