Image of a hand holding up a cutout of a small house to a sunset, with light streaming through the house and creating a shadow.

The Need to Improve Housing to Improve Health

Housing is a central social determinant of health, and there is extensive evidence of the negative impacts on health from a lack of access to affordable and stable housing. In March 2019, the County Health Rankings & Roadmaps program, (CHR&R) a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, released its 2019 County Health Rankings, this year highlighting the impact that secure and affordable housing has on how well and long people live.

The report discussed how the location of homes—such as proximity to good schools, jobs, grocery stores, and parks—quality of homes—such as the presence of mold or lead—and cost burdens and opportunities to accumulate wealth associated with different housing conditions—such as renting versus homeownership—all influence the health of individuals and communities.

Homeownership paves the way for many benefits, such as building wealth and accumulating savings to pay for education, among other opportunities that enable better health. Unfortunately, racial disparities in homeownership are widening, with households headed by whites owning homes at rates 20-30% above households headed by people of color in large urban and smaller metro counties (see chart below). According to the CHR&R report, “[i]n large urban and smaller metro counties, the vast majority of households headed by Whites own their home, while more than half of households headed by Blacks are renters.” Accordingly, opportunities for better health associated with homeownership are disproportionately available to whites. The report noted that income tends to be lower among renters than homeowners, and that renters often have very little wealth and savings, resulting in renters disproportionately facing housing cost burdens. And while the rate of housing cost burdened homeowners has declined over the last decade, that trend hasn’t been similarly experienced by renters.

Residential segregation—which is reinforced through “discrimination and institutional racism in the form of long-standing, deep-rooted and unfair systems, policies and practices such as redlining, restrictive zoning rules, and predatory bank lending practices”—is associated with higher rates of severely housing cost burdened residents (households that spend more than half of household income on housing are defined as severely housing cost burdened). But while this is true for households headed by both white and black residents, households headed by black residents are still disproportionately severely housing cost burdened: on average, 12% of households headed by whites and 26% of households headed by blacks are severely housing cost burdened in the 10% of counties with the greatest measures of residential segregation, in contrast to 9% and 18%, respectively, in the 10% of counties with the lowest measures of residential segregation.

Needing to spend such a high percentage of income on rent, severely cost burdened families don’t have much to spend on other needs. A study from the Joint Center for Housing Studies of Harvard University found that in 2011, for example, families who lived in affordable housing spent close to five times the amount that their severely cost-burdened peers spent on healthcare, and 1/3 more on food.

And a recent survey found that of renters who pay over half their monthly income on housing, 45% reported that because of affordability, they didn’t follow a treatment plan from health care professionals and 31% delayed a routine checkup because of affordability (versus 34% and 23% of all renters surveyed, respectively).

The survey also interviewed 500 medical providers, every one of which reported that at least some of their patients have indicated concerns regarding affordable housing. For providers who treat many lower-income patients, a greater percentage of their patients expressed such concerns.

The survey results also pointed to ways in which housing cost burdens negatively impact renters’ mental health. As Brian Rahmer, Vice President of Health and Housing with Enterprise Community Partners, Inc., said, chronic stress associated with economic burdens imposed by housing costs “has a wearing effect, a weathering effect.”

Homelessness also impacts costs to the healthcare system. For example, emergency room costs are much higher for homeless individuals than average Medicaid recipients, and homeless people who are admitted to the hospital are likely to stay longer and have a greater chance of being readmitted after discharge.

Investors and health plans are also working to address the interrelated effects of health and housing. UnitedHealthcare, for example, began an initiative in 2011, through which they’ve invested money to help build eighty new affordable-housing communities throughout the U.S. According to Ron Falkenberg, CEO of UnitedHealthcare of California, “[e]ighty percent of what influences a person’s health happens outside the doctor’s office,” and innovative solutions to enable on-site support and access to affordable housing are critical.

Kaiser Permanente has also recognized the value of investing in housing, reflecting its expanding definition of what qualifies as preventive care. According to Bernard J. Tyson, Kaiser Permanente’s CEO and chairman, “[a]s we began to prioritize how we were going to focus our community health agenda, [affordable housing] clearly was one of the critical areas that surfaced to the top floor.” Kaiser’s taken innovative steps to address health, recognizing that even “more than medical care,” social and economic conditions—with affordable housing especially pressing among those—increasingly impact people’s health.

Many changes are needed to improve accessibility to housing and opportunities for health, made all the more urgent by troubling racial disparities in both the health and housing spheres. The CHR&R report closes with recommendations for effective approaches to creating and preserving stable and affordable housing that can enable greater economic and social well-being. These included:

  • Improving inclusivity and connectedness of communities—such as through civic engagement and access to quality healthcare and living wage jobs;
  • Facilitating access to critical resources for low- to moderate-income families in particular to obtain affordable housing—such as Housing Choice Vouchers
  • Addressing capital resources necessary for creating and preserving affordable homes, especially for low- to moderate-income families—such as tax credits, and acquisition, management, and financing of land dedicated to affordable housing; and
  • Increasing housing stability and aiming to reduce the risk of homelessness by improving access to services and supports to meet basic needs—such as supportive housing, rental assistance, and strategies to prevent eviction.


Rebecca Friedman is a 2018-2019 Petrie-Flom Center Student Fellow. 

Rebecca Friedman

Rebecca Friedman graduated from Harvard Law School in 2019. Prior to becoming a Student Fellow, she participated in the Health Law and Policy Clinic with HLS' Center for Health Law and Policy Innovation. At the time she completed her Fellowship, Rebecca planned to work at Charlotte Center for Legal Advocacy in Charlotte, North Carolina as an Equal Justice Works Fellow sponsored by Kilpatrick, Townsend & Stockton LLP. There, Rebecca will provide direct representation to Medicaid beneficiaries experiencing legal challenges as North Carolina transforms its Medicaid system to managed care, and will work to ensure that Medicaid beneficiaries facing legal issues as a result of social determinants of health receive appropriate support. As a Petrie Flom Center Student Fellow, Rebecca studied the potential for Medicaid to cover doula services and analyzed how racial and socioeconomic disparities in prenatal care and childbirth could be mitigated as a result. The current title of Rebecca’s paper is “The Feasibility and Potential Impact of Broader Medicaid Coverage of Doula Services on Racial and Socioeconomic Disparities in Birth Outcomes.”

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