What causes poor health? Lack of access to consistent good medical care can play a role. Genetics play a role.
But in fact when researchers look in to it, those things together account for only 30–40 percent of causes of premature death.
The rest comes from because some combination of environment, social and economic factors, and behavioral choices, which are often strongly influenced and constrained by the other two (e.g. it’s hard to eat fresh food if there’s nowhere to buy it, or get kids exercising if there’s nowhere safe to play outside, or kick an addiction with when under intense economic stress). These are called the “social determinants of health.”
Safe and affordable housing has emerged as one crucial factor affecting people’s health. We have come to realize, certainly, over the past several decades that housing full of lead paint, toxic mold, or pests can harm our health. Doctors get incredibly frustrated, for example, with having to send asthma patients home to living conditions they know will send them right back to the ER. So much so that hospitals and clinics have started employing tenants rights lawyers (plus lawyers who can provide other needed services) on site. Today the National Medical-Legal Partnership supports this smart, outcome-oriented kind of approach to health care.
But it’s not only quality of housing that affects people’s health. It’s also how expensive it is. Research presented in Housing Policy Debate last year found that “Housing cost burden is equally or more important than other physical housing characteristics in explaining the variation in self-reported general health status and health care postponement.”
In other words, as Matthew Desmond writes in Evicted (which everyone should read), “The rent eats first.” The effects of unaffordable housing on nutrition, medication, health care, and overall stress levels—all of which of course in turn affect health—are dramatic. Unaffordable housing (and the presence of children in a household) also markedly increases the risk of housing instability and eviction, which have been shown to have incredibly negative effects on children’s development and education.
Housing affordability may seem like an issue primarily for booming places like New York and San Francisco, but of course housing cost is only one part of affordability. The other part is income. And as Amanda Fries explained in the Times Union last week, when you consider income-to-cost ratio, we have a housing affordability problem right here at home too. Using the common affordability standard that a household should not pay more than 30 percent of its income on housing, Fries calculated that Albany has “an estimated deficit of 6,591 affordable units for households receiving less than $24,999 per year.” (This probably understates the problem, given that at very low incomes, having even 70 percent left for other expenses isn’t enough.)
All of those households who are struggling to pay the rent and keep themselves in a stable home is a public health crisis.
And across the country, the health care world has been figuring this out. That’s why public health agencies in the Bay Area, and statewide health-focused foundations, supported ballot measures to increase funding for affordable housing construction. And, in one of the rare bright spots of last November’s elections, several of them passed!
It’s why Cincinnati Children’s Hospital took the medical-legal partnership one step further and helped tenants whose landlord went into foreclosure organize a tenant association and fight to save their homes. It’s also why both Cincinnati Children’s Hospital and Nationwide Children’s Hospital in Columbus, Ohio, have started investing millions of dollars in local community development organizations to build and rehab affordable housing in their cities.
And they aren’t alone. Major hospital chains like Trinity Health, and even insurers like United Healthcare, are starting to act on the recognition that stable, affordable housing is a crucial component of public health. This sea change was partially driven by components of the Affordable Care Act that strengthened nonprofit hospitals’ obligations to serve their surrounding communities in ways beyond charity care.
But no one seems to expect it to go away even if the ACA comes to harm—once you stare down the fact that if you stand for healthy communities, you need to care about where people live as much or more as how often they go to the doctor, you can’t look away.
“We are in a Galileo moment,” Frank Woodruff, director of the National Association of Community Economic Development Associations, heard a hospital explain recently, “where hospitals are not the center of the universe anymore. Community is.”
Especially in this political moment, we can’t afford to stay in our narrow lanes and pretend that public health and affordable housing are not linked or can pursue their overlapping goals without each other. We have numerous excellent health care institutions in the Capital Region, as well as numerous talented affordable housing organizations. It’s time for them to become partners in advancing health outside the doctor’s office.