The pandemic has shone a stark light on structural and systemic inequities and their downstream effects on health in Rhode Island. After a year like few others, the hardest hit families are struggling to regain some kind of equilibrium in the face of unparalleled health and economic trauma that has left them with too few resources in a whirlwind of challenges.
As non-profits and community leaders race to provide what supports they can, and communities recover and look to implement changes to address key learnings of 2020, housing advocates are turning to research done over the past 10 years that underscores the importance of safe, affordable housing to the health and wellbeing of residents. Many have identified housing as the key foundational social determinant of health, on which all other programs can build greater success and actually achieve a transformative impact.
“Without safe, affordable housing as a basic entry point, many of our workforce development programs, education reform, early learning and childcare efforts don’t have the opportunity to succeed,” says Jeanne Cola, Executive Director of Local Initiatives Support Corporation (LISC) Rhode Island. LISC, one of the nation’s largest Community Development Financial Institutions, provides financial support, program development and technical assistance to local non-profits engaged in workforce development, health equity, early education and childcare, and other aspects of a healthy community. “We are woefully behind in addressing the housing crisis, and the impact is being clearly seen in a variety of metrics – from health equity, wealth creation, educational outcomes, as well as violence and addiction rates. Much, much more needs to be done.”
Many are now pointing to the research done by the Robert Wood Johnson Foundation and the National Center for Healthy Housing, both of which have been investigating the link between safe and affordable housing and health equity for the past decade. The undeniable correlation between having stable housing and improved health outcomes makes addressing housing an important priority. Housing security can be a powerful tool to address rising Medicaid expenses, as well as improving job retention, education outcomes and overall community success.
Quality and Safety
The National Center for Healthy Housing, which has created healthy housing profiles for each state, has been working to improve the health of housing since 1992, and during those early years, focused on lead abatement. Lead is a widespread problem still today, including in RI, where more than 70% of our housing stock was built before 1978 when lead was removed from the paint formulary.
According to Rhode Island’s senior Senator Jack Reed, “Lead poisoning remains a real problem that affects too many kids, and it’s taken a great deal of effort to create and fund these kinds of grants.” At the time, Senator Reed was the ranking member of the Appropriations Subcommittee on Transportation, Housing and Urban Development, and awarded $12.4 to Rhode Island to help address this issue. Even though the problem of lead poisoning was first identified nearly 40 years ago, Rhode Islanders are still dealing with the crisis in real time.
While lead poisoning has been linked to irreversible brain damage, as well as damage to the kidneys and nervous system, it is not the only link to healthcare reflected in the data. There is strong evidence characterizing housing’s relationship to health through its impact on family stability, quality and safety, affordability, and even the environmental conditions of the surrounding neighborhood.
Stability
One study showed the impact of foreclosure and eviction during the Great Recession in 2007-2009 on both physical and mental health. Given the economic crisis our country is facing as we emerge from the Coronavirus, the data is particularly compelling. The stress of personally experiencing foreclosure was associated with worsened mental health and adverse health behaviors, which were in turn linked to poorer health status; at the community level, increasing degradation of the neighborhood environment had indirect, cross-level adverse effects on both health and mental health. The Toxic Stress and trauma experienced by the whole family from the lack of housing stability cannot be overstated.
While the impact from the 2009 foreclosure crisis elevated the importance of housing in the public discourse, efforts from community development organizations have not met the pace of the growing need due to inadequate funding and resources. The broader affordability crisis has continued to worsen during the intervening years and in the wake of COVID-19, housing has emerged as a foundational key to understanding the social determinants of health and their impact on healthcare costs.
The Robert Wood Johnson Foundation has been making the healthcare case for safe, affordable housing for many years. In an issue brief published in 2011, the foundation reported that in 2004 alone, the cost of preventable hospitalizations for asthma was $1.4 billion, and represented a 30% increase from 2000. Each year, accidents in the home contribute to an estimated 4 million emergency room visits and 70,000 hospital admissions. Contributing factors include steep staircases, balconies, and lack of safety devices such as window guards and smoke detectors.
Housing the homeless has consistently been shown to improve health outcomes. A randomized controlled trial of interventions to address homelessness had a positive effect, improved health and decreased health care costs. For this population, the Housing First model, in which chronically homeless people receive supportive housing has been shown to be particularly cost-effective, with one study finding that the provision of housing generated cost offsets of up to $29,000 per person per year – after accounting for housing costs.
Stable housing can reduce health care costs. Within a population of nearly 10,000 people in Oregon with unstable housing, the provision of affordable housing decreased Medicaid expenditures by 12 percent. At the same time, use of outpatient primary care increased by 20% and emergency department use declined by 18% for this group. The health impacts of other means of stabilizing housing, including rental and foreclosure assistance, have been rigorously studied in relation to mental health outcomes, and show clear benefit.
Residential crowding has been linked to physical illnesses, including infectious diseases such as tuberculosis and respiratory infections, as well as a contributing factor for psychological distress among both adults and children. According to a study, children who live in crowded housing may have poorer cognitive and psychomotor development or be more anxious, socially withdrawn, stressed or aggressive. All of these contribute to decreased learning, and set up the children for a lifetime of ongoing challenges.
Overcrowding due to the high cost of housing has contributed to the increased rate of spread of the Coronavirus as well. In Rhode Island, urban and overcrowded communities have borne the brunt of serious disease and death. Rhode Island leads the country in population density, behind only New Jersey, and the community of Central Falls in northern Rhode Island is its most dense. With many multi-generational homes, the virus has devastated this community. Early in the pandemic, Central Falls had the highest test positivity rate in the state at well above 20%. It dipped down to an average of 8 % during the summer months and then rebounded to a high of 23%. A targeted vaccination plan is currently underway to help mitigate this explosive tragedy.
The shortage of housing that is affordable limits a families’ choice about where they live, and often consigning lower-income families to potentially substandard housing in overcrowded neighborhoods with higher rates of poverty and fewer resources to improve their health, like parks, bike paths, recreation centers and community activities. According to HousingWorks 2020 Housing Factbook, Central Falls remains the only municipality in the state where a household earning an annual income of $50,000 could afford to buy a home. For families earning the state’s median renter income of $34,255, and looking for a two-bedroom apartment, there is no municipality that offers affordable housing. Even with an income of $50,000, there are only three municipalities for affordable rent. Currently, Rhode Island’s “housing wage” to afford a fair market rent apartment with two bedrooms is $21.16 /hr – which is more than twice the state’s current minimum wage.
Affordability
The affordability of housing has clear implications for health. Housing is “affordable” when a family spends less than 30% of its income to rent or buy a residence. An estimated 17 million households in the United States pay more than 50% of their incomes for housing. In Rhode Island, across all income categories, 37% of households - more than 145,000 families are considered cost burdened. The Housing Fact Book data show that of the lowest income renter households, more than 80% are cost burdened, with 60% considered severely cost burdened and pay more than 50% of their income on housing. The excessive financial burden of unaffordable housing can prevent families from meeting other basic needs including nutrition and health care, and is particularly significant for low-income families.
With the correlation between high housing costs and the resulting lack of disposable income, it is easy to see how it could easily affect a family’s health. High housing payments relative to income, along with rising food and utility costs, force some families to choose between heating, eating, and filling prescriptions. One study found that low-income people with difficulty paying rent, mortgage or utility bills were less likely to have a usual source of medical care and were more likely to postpone treatment and to use the emergency room for treatment. Without a primary care doctor to provide ongoing care, families would wait until the problem became too big to ignore. Severely cost-burdened renters are 23% more likely to lack a sufficient supply of food and to go without prescribed medications.
The Role of Healthcare within the State
The evidence of the relationship between housing and health is compelling. The health care sector, businesses, community-based organizations, foundations and government must all work together to find solutions to the underlying issues of housing security in Rhode Island.
Given the shift toward accountable care models and other value-based payments, the financial incentives for health care systems to take broader responsibility for social determinants of health — particularly housing — are likely to increase.
A study done by the Center for Health Care Strategies in 2017 found that using Medicaid resources to pay for health related supportive services had a profound effect. According to the brief, investing in supportive services, and other non-medical interventions that address the social determinants of health, can improve outcomes and reduce health care spending. Consequently, several states are testing models that incorporate non-medical interventions – including housing – into their Medicaid state plans as part of broader delivery system reform efforts.
In New York, for example, supportive housing benefits were included as part of a larger Medicaid Redesign Team effort in 2011. This plan, drawing on input from a group of more than 40 housing advocates, agencies that operate housing programs, developers and providers, focused on creating lasting ways to provide housing services for Medicaid beneficiaries. The state launched a two-year, $10 million pilot project to provide capital funding for services such as expanding housing units for high-cost Medicaid populations and home modifications to enable individuals to remain in their homes. It included rental subsidies, tenancy advocacy, counselling, case management, job development, and clinical supervision.
The program was a success, and in 2014, New York City reported that the supportive housing program saved taxpayers a net average of $10,000 per person per year – after subtracting housing and service costs. The report’s analysis confirms similar findings nationwide that showed how supportive housing can significantly reduce costly public expenses.
In fiscal year 2015-2016, funding grew to $47 million of state-share Medicaid funding to expand supportive housing units for high-cost Medicaid populations, $38 million in rental subsidies and related supportive services, and $24 million for new supportive housing pilot programs as well as $2.5 million for tracking and evaluation.
The Role of Healthcare Providers
Massachusetts has seen several large, non-profit health systems using community benefit dollars and money from community investment funds to help address social determinants of health. A number of hospitals have gone beyond their standard community benefit dollar allocation used to treat Medicaid patients and have devoted a portion of their revenues and investment portfolios in innovative ways intended to address the upstream determinants of health, including lack of access to healthy food and safe housing. The hospitals that have ventured into this area do so in part recognition that health is the product of much more than health care, with factors like poverty and education playing an outsized role.
LISC has worked with ProMedica, a health system with 12 hospitals in Ohio and Michigan, to develop a $100M program to reduce food insecurity in Toledo, OH, where poverty rates are as high as 40% in some neighborhoods. The health system created a grocery store in Toledo’s Uptown area that brings fresh and healthy food to the neighborhood, and also provides residents with job training and employment opportunities. ProMedica opened a Financial Opportunity Center, a LISC program that connects low- to moderate-income families with the financial and labor market mainstream, to help families gain financial literacy, improve their credit and build assets. ProMedica worked with LISC Toledo to create a loan pool for impact investing in the community. Through these and other efforts, ProMedica is working to improve the factors that are at the root of health and well-being.
Dignity Health, a San Francisco–based health system that operates 39 hospitals and hundreds of care centers in 21 states, has used both community investment and grant dollars to address social determinants of health, and has made housing development one of its key focus areas. Dignity Health has donated unused buildings and vacant land for the development of affordable housing and provided low- and no-interest loans to Community Development non-profits to develop housing for families, seniors, and individuals experiencing homelessness. In some cases, the Dignity Health model uses supportive housing coupled with medical and social services for residents.
Since 1990, Dignity Health has given a total of $62 million in grants and made $166 million in loans and equity investments in nonprofit organizations that provide access to food, housing, health, and education in low-income and minority communities. In 2015, it established a “social innovation partnership grant program” that offers grants to organizations to pursue or promote new models of care and other strategies for improving access, care coordination, and health outcomes for disadvantaged populations.
Lastly, in the study that examines the benefits of pairing affordable housing and health care access in Oregon titled Health in Housing: Exploring the Intersection between Housing and Health Care, Megan T. Sandel, MD, MPH and Associated Professor of Pediatrics at the Boston University School of Medicine writes that housing is a critical vaccine. Her prescient title highlights the critical need that so many housing advocates see every day.
“As a physician,” Sandel writes. “Health in Housing speaks to what I see in my work every day: far too many low-income people who lack access to primary care and as a result seek treatment for chronic conditions at emergency rooms. For many of my patients, concerns about keeping up with doctor appointments and medications are far outweighed by trying to pay their rent on time or finding safe and stable housing.”
As Rhode Islanders, non-profits and healthcare providers must collaborate to support our local communities. Safe, affordable housing should be the top priority as we work together to address health equity for our neighbors.