Writing a Prescription for Housing
by Aaron Shroyer
Research estimates that behaviors, social circumstances, and environment—broadly known as social determinants of health—determine approximately 60 percent of our overall health, outweighing the importance of health care and genetics. In other words, our zip code is more important than our genetic code.
Housing is one of the underlying and critical components of these social determinants of health. Even though housing and health occupy separate policy worlds and often are discussed differently, evidence proves their intrinsic interrelatedness. To frame housing in health terms, we must understand that although housing can be a cause of illness, it can also be used as a treatment or a vaccine. This begs the question: how can we adopt a medical framework to diagnose problems with housing and write a prescription to address them?
Research about people experiencing homelessness most clearly highlights the connection between housing and health outcomes. Young children who experienced prenatal or postnatal homelessness had significantly higher risk of negative health outcomes and developmental delays. Roughly half of all homeless people had their first points of contact after becoming homeless with health care providers, including emergency departments, detox centers, or mental health facilities. These interactions are not only a missed opportunity to engage and provide resources to address the root cause of these people’s health problems, but they are expensive. In part to prevent costly contact with the health system, the Housing First model of care has emerged as a cost-effective mechanism to provide housing and services for homeless individuals.
Housing First is an evidence-based program that provides permanent housing to people experiencing homelessness. It is coupled with access to supportive services that residents can use to address mental health, employment opportunities, or issues with substance abuse. Provision of supportive housing through these programs reduces health care expenditures for homeless individuals and families. Although supportive housing programs cost money, they can reduce health care spending. These savings have led to the integration of these interventions into pay for success projects.
But the importance of integrating housing and health is not limited to homeless individuals. There is a link between stable, decent, and affordable housing and positive health outcomes. Housing plays into social determinants of health in several different ways:
- Families lacking affordable housing options are at higher risk of lead poisoning and exposure to mold and other allergens, which can trigger asthma. Green housing retrofits improve general and respiratory health by removing harmful indoor air allergens.
- As Matthew Desmond wrote in Evicted: Poverty and Profit in the American City, the rent eats first. When a large portion of a family’s income goes toward rent, there is little leftover for food and health care expenses. Cost-burdened adults are less likely to fill prescriptions and follow health care treatments.
- Place matters for economic outcomes, and moving to high-opportunity areas is associated with an 11 percent decrease in adult obesity, reductions in the prevalence of diabetes, and lower rates of mental health problems. Clustering in high-poverty neighborhoods exacerbates stress and leads to lower social cohesion, both of which negatively affect health.
- Frequent moves can disrupt health care services, especially for people with chronic diseases. Children lacking stable housing are more likely to use costly emergency services instead of visiting a regular health care provider. Housing loss can contribute to job loss, which has further health implications. The number of years spent in one’s residence—an indicator of stability—is connected to residents' behavioral and mental health.
With evidence building about the inextricable ties between housing and health, some programmatic changes and ideas are emerging that resemble a policy prescription. Health impact assessments, which take environmental, social, and economic factors into account, help policymakers minimize health risks when weighing the impacts of proposed policies and projects. Other programmatic changes, such as giving states more flexibility to use Medicaid dollars to support housing-related health programs, would help address the underlying cause of the problems. These shared project missions, whether programmatic or between health care and housing organizations, are important factors in breaking down barriers between the two fields.
One of the best programs to combine housing and health is the US Department of Veterans Affairs’ (VA) initiative to end veteran homelessness. Because of this initiative, estimated veterans’ homelessness was halved from 74,000 in 2010 to 39,000 in 2016. One of the critical programs that contributed to the decrease was the US Department of Housing and Urban Development VA Supportive Housing (HUD-VASH) voucher program, which allows veterans to access permanent housing and other services to address their needs. Doctors can be part of the referral network for veterans to obtain HUD-VASH assistance—effectively prescribing housing.
What if all medical professionals—not just VA doctors—could be empowered to ask about housing conditions and provide resources to address those problems? Doctors are aware of underlying factors that contribute to their patients’ conditions, but they may be unaware of resources that could help them, or these resources are insufficient for their patients to get better housing even if it were doctor prescribed. Any policy prescription to address housing’s contribution to health problems would have to do more than activate the medical community as a referral source. A complete solution would need to increase the supply of and access to more suitable housing, addressing quality, affordability, location, and stability. And to address those issues, all levels of government would need to prioritize changes that enable a more sufficient housing supply and provide more resources to tenants.