Improving Value

Social Determinants of Health – Housing

There are many factors that affect a person’s health beyond clinical care. A person’s neighborhood, education, access to food, level of poverty and housing situation all significantly impact individual- and population-level health.¹ These factors are considered to be social determinants of health (SDOH) – “conditions in the places where people live, learn, work and play.”²

Housing is a basic necessity – a prerequisite for meeting a person’s physiological and psychological needs.³ As such, unmet housing needs can have a profound effect on people’s physical and mental health outcomes. As described below, evidence-based housing interventions can lower costs, improve the health of entire communities and remove barriers to health equity. 

How Housing Affects Health

There are four major ways in which housing issues can undermine health:⁴ 

• Substandard Housing: safety hazards within the home,
• Housing Instability: not having a stable home,
• Housing Affordability: financial burdens related to housing, and
• Neighborhood: characteristics of the places in which people live

Substandard housing has been shown to contribute to health conditions like respiratory infections, asthma, lead poisoning and other mental and physical health conditions.⁵ Children who are raised in stable, healthy housing without exposures to environmental toxins are more likely to meet developmental milestones than children who are not raised in these conditions.⁶

Housing instability, another housing factor that influences health, is associated with not having a usual source of healthcare, postponing medical care and not taking necessary medications.⁷ Adults who live in stable housing situations are able to better manage chronic illnesses and have increased productivity at work compared to adults who do not live in stable housing conditions.8 Housing instability is also a risk factor for becoming homeless,⁹ which is associated with higher rates of life-threatening illnesses and problems with access to care.¹⁰ 

Housing issues are a major contributor to health inequities.¹¹ Low-income people are over twice as likely to occupy homes with severe structural problems, to live in overcrowded homes and less likely to have proper insulation in their homes compared to the general population.¹² Black populations are 1.7 times more likely to occupy substandard homes – this inequity remains even after controlling for income and other demographic factors.^13,14,

Strategies to Address Housing Needs and Improve Health Outcomes

As described in our issue brief, a key approach to improving health outcomes for vulnerable populations is to ensure their housing situation is safe and stable.¹⁵ When appropriately targeted, providing supportive housing to patients with high healthcare costs can “pay for itself“ in health care cost reductions.^16,17 Interventions to help families improve the condition of their housing or move to healthier neighborhoods also show promise to improve people’s health status. 

Strategies to address housing insecurity that feature a role for the health system include:

• Screenings for unmet housing needs,
• State and local community housing support,
• “Housing First” interventions and
• Broad public health interventions

Social needs screening tools can help providers to identify patients’ non-medical needs and connect them to social supports. Federal and state governments can encourage social needs screenings by requiring (and paying) providers to use evidence-based screening tools as a condition of participation in government-sponsored health plans. Characteristics of a high-quality screening tools and best practices can be found in Health Leads’ comprehensive Screening Toolkit.¹⁸

Another strategy states can use to is maximizing the benefits available through the Medicaid program. The Medicaid program does not cover direct housing costs (like rent) but, through waivers like the 1115 waiver, Medicaid can fund house-related supports, like screening for housing instability, assisting with the housing search process and minor home modifications.¹⁹

The “Housing First” movement prioritizes providing immediate housing to people experiencing homelessness, guided by the belief that people need a place to live and other basic necessities before they can be successful in other aspects of life.²⁰ This model, which involves providing a person with permanent housing, has been shown to be cost-efficient²¹ and has been particularly effective at ending homelessness in high need populations.²²

Public health interventions that address housing include fixing substandard housing through policies like the US Department of Housing and Urban Development’s (HUD) HOME initiative, which gives state and local municipalities grants to use in partnership with community nonprofits for a variety of housing-related activities.²³ Other public health interventions include creating “mixed income” developments to improve the health- and economic-status of people who have low income when they move into high-income areas.²⁴

Notes

1. Statistics vary, but research demonstrates that around 80 percent of health is determined through these health-related behaviors, socio-economic and environment factors broadly called Social Determinants of Health. https://nam.edu/social-determinants-of-health-101-forhealth-care-five-plus-five/

2. Centers for Disease Control and Prevention, “Social Determinants of Health: Know What Affects Health” (January 29, 2018). https://www.cdc.gov/socialdeterminants/index.htm

3. Maslow’s Hierarchy of Needs indicates humans need to have their physiological needs met from food, water, warmth, and rest, and psychological needs met from security and safety in order to be a productive member of society and work towards “self-actualization.” McLeod, S., “Maslow’s Hierarchy of Needs,” Psychology Today (2018). https://www.simplypsychology.org/maslow.html.

4. Taylor, Lauren, “Housing and Health: An Overview of the Literature,” Health Affairs (June 7, 2018). https:// www.healthaffairs.org/do/10.1377/hpb20180313.396577/full/

5. Diaz, Stephanie, “The Effects of Housing Insecurity on Health Outcomes and Costs,” Healthify Blog (March 1, 2018). https://www.healthify.us/healthify-insights/theeffects-of-housing-instability-on-health-outcomes-andcosts

6. Sandel, Megan, and Richard Sheward, Compounding Stress: The Timing and Duration Effects of Homelessness on Children’s Health, Center for Housing Policy (June 2015). www.issuelab.org/resources/21731/21731.pdf

7. Kushel, Margot, “Housing Instability and Food Insecurity as Barriers to Health Care Among Low-Income Americans,” Journal of General Internal Medicine (January 2006). https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC1484604/

8. Kottke, Thomas, “Access to Affordable Housing Promotes Health and Well-Being and Reduces Hospital Visits,” The Permanente Journal (Nov. 15, 2017).

9. Ibid.

10. Health and Homelessness, National Alliance to End Homelessness, https://endhomelessness.org/homelessness-in-america/what-causes-homelessness/health/

11. Centers for Disease Control and Prevention, “Social Determinants of Health: Know What Affects Health” (January 29, 2018). https://www.cdc.gov/socialdeterminants/index.htm

12. Krieger, James, and Donna Higgens, “Housing and Health: Time Again for Public Health Action,” American Journal of Public Health (May 2002). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447157/

13. Ibid.

14. Mundra, K, and Amarendra Sharma, “Housing Adequacy Gap for Minorities and Immigrants in the U.S.: Evidence from the 2009 American Housing Survey,” Journal of Housing Research, Vol. 24, No. 1: 55-72 (2015).

15. Maynard, Christopher, “Study suggests hospitals invest in housing to improve patient outcomes,” Consumer Affairs (Nov. 2, 2011). https://www.consumeraffairs.com/ news/study-suggests-hospitals-invest-in-housing-toimprove-patient-outcomes-110217.html

16. Anirban Basu et al., “Comparative Cost Analysis of Housing and Case Management Program for Chronically Ill Homeless Adults Compared to Usual Care,” Health Services Research, Vol. 47: 523-543 (November 2011) https://www.researchgate.net/publication/51812631_Comparative_Cost_Analysis_of_Housing_and_Case_Managem  

17. Tsega, Mekdes, Corinne Lewis, Douglas McCarthy, Tanya Shah, and Kayla Coutts, “Review of Evidence for Health-Related Social Needs Interventions,” The Commonwealth Fund (July 1, 2019) https://www.commonwealthfund.org/sites/default/files/2019-07/COMBINED_ROI_EVIDENCE_REVIEW_7.15.19.pdf

18. The toolkit is available for download at: https:// healthleadsusa.org/resources/the-health-leadsscreening-toolkit/

19. Medicaid’s Role in Housing, MACPAC (October 2018) https://www.macpac.gov/wp-content/uploads/2018/10/ Medicaid%E2%80%99s-Role-in-Housing-.pdf

20. Rapid Rehousing Fact Sheet: Housing First, National Alliance to End Homelessness. http://endhomelessness.org/wpcontent/uploads/2016/04/housing-first-fact-sheet.pdf

21. National Alliance to End Homelessness, “Housing First,” https://endhomelessness.org/resource/housing-first/

22. Gulcur, Leyla, et al., “Housing, Hospitalization, and Cost Outcomes for Homeless Individuals with Psychiatric Disabilities Participating in Continuum of Care and Housing First Programmes,” Journal of Community and Applied Social Psychology (April 9, 2003).

23. Home Investment Partnership Program, U.S. Department of Housing and Urban Development, https:// www.hud.gov/program_offices/comm_planning/ affordablehousing/programs/home/ (accessed on Feb. 28, 2019).

24. Levy, D, et al, Effects from Living in Mixed Income Communities for Low Income Families, Urban Institute (November 2010). https://www.urban.org/sites/default/ files/publication/27116/412292-Effects-from-Living-inMixed-Income-Communities-for-Low-Income-Families.pdf

More on this Topic

• Healthcare Value Hub, Research Brief No. 36: Housing Interventions to Improve Health Outcomes
• Healthcare Value Hub, Research Brief No. 41: Social Determinants of Health: Food Insecurity in the United States