The relationship between housing and health is intuitive and multifaceted. Causal pathways linking housing and individual health include everything from environmental health concerns (lead poisoning in old homes, for an example) to neighborhood characteristics (walkability, safety, access to affordable supermarkets) to the psychosocial stress of financial instability.
The latter is of particular interest to public health researchers because the health effects of financially-related housing instability are so far reaching. Rent burdened households — i.e. households that spend more than 30 percent of their monthly income on rent — suffer profound health consequences as a direct result of their housing status. As more and more American households become rent-burdened, the downstream health consequences experienced by these households need to be articulated and addressed, preferably by upstream solutions.
A rent burdened household is less likely to be able to afford sufficient food, to have a usual source of medical care, or to seek needed medical treatment. In fact, a rent burdened household is more likely to ultimately use the emergency room for medical treatment, potentially at a later, more severe, less treatable point in the disease course.
Housing stability in the U.S. is threatened by rising rents, inadequate housing stock, and poor access to legal resources to fight evictions. (The NYC Right to Counsel Coalition estimates that half of evictions wouldn’t have occurred if residents had had an attorney). Housing instability itself — which can be broadly defined as falling behind on rent, moving frequently, or experiencing a period of homelessness — is associated with enormous health consequences: poorer self-reported health and more frequent hospitalizations for both parents and children.
The actual experience of losing one’s home also has a litany of associated negative health outcomes. In a systematic review of scientific literature on home foreclosures and health, researchers noted significant associations between foreclosures and higher body mass index, higher systolic blood pressure, a greater frequency of psychological distress queries, poorer reported health, a higher number of positive depression screens and self-reported anxiety attacks, an increased number of service calls about domestic violence, higher rates of suicide, increased number of emergency visits and hospitalizations, higher rates of alcohol dependence, lower rates of health insurance, higher rates of cost-related unmet health needs, and higher rates of cost-related prescription non-adherence.
In one study, the authors found that an outbreak of West Nile Virus in California was likely related to a rise in the number of abandoned swimming pools because there were so many foreclosed homes in the area.
The distribution of housing instability also falls more heavily on people of color: 54.7% of Black households were categorized as rent burdened in 2015, while only 42.7% of White households were. Racial health disparities (chronic disease burdens, cancer rates and mortality, geographic access to health care, to name just a few) have been studied for more than half a century but still remain stable, and some researchers have speculated that persistent residential segregation is one of the common threads that links many of these disparities together.
The health problems associated with housing are very well documented, and they are also often very expensive. Health care delivery systems, eager to save money by decreasing hospitalizations and decreasing emergency room utilization, are keenly aware of potential solutions. In Oregon, Massachusetts, New York, and Vermont, state Medicaid programs have sought waivers allowing them to spend Medicaid funds on more broadly defined social services, including providing permanent shelter for patients experiencing homelessness. Hospitals in Illinois have partnered with the Department of Housing and Urban Development to fund permanent supportive housing for homeless patients. Doing so is ultimately much cheaper than paying for the emergency care that homeless and unstably housed patients often seek.
Another approach involves intervening earlier by providing financial support to families so that they can move out of high-poverty neighborhoods. A randomized controlled trial conducted in five cities in the mid-1990’s demonstrated that when residents of low-income neighborhoods were provided with vouchers to move to high-income neighborhoods and provided assistance facilitating that move, they had significantly lower rates of diabetes, obesity, and psychological distress. Participants in this trial who were children at the time of the move were more likely to attend college, had higher average earnings, and lower rates of single parenthood. Another study showed that children who experienced a period of homeless in utero were more likely to have fair or poor health and to be at risk for developmental delays.
Among the many social determinants of health, housing is of particular interest to both public health researchers and community activists alike. The need for stable and affordable housing is felt urgently by communities, and this emergency is manmade: municipal politics that serve the interests of the wealthy have led to decisions that have drained our cities of affordable housing and drastically exacerbated rates of homelessness in many American cities. There’s no shortage of research that demonstrates the health consequences this will have, but it remains to be seen whether there will be a shortage of political will to meaningfully address these issues.