Want to improve public health? Start with housing

Article by Irv Lichtenwald

A well-worn axiom says that “hope is not a plan.” Indeed, hope alone is such a hands-up abdication of planning that editor Thomas Mowle was inspired to use the phrase as the title of his 2007 book of essays on the war in Iraq, which says something.

Still, if we play with syntax and add a few words, we can say that every successful plan should offer a measure of hope—hope for success, an improved reality, greater opportunity.

With the twin American scourges of homelessness and addiction, hope starts with a plan that includes housing—a refuge, even if it’s just a 50-square-foot wooden box.

“Housing is one of the best-researched social determinants of health, and selected housing interventions for low-income people have been found to improve health outcomes and decrease health care costs,” writes Lauren Taylor in Health Affairs.

Perhaps, then, housing is a key component in the overall explanation for why health and life expectancy have been declining in America the last few years. When workers making minimum wage—more than 20 million people and roughly 30 percent of all hourly, non-self-employed workers over 18—can afford a modest one bedroom home in only twelve counties in the country, it’s near impossible to argue that the gap between wages and housing costs does not create profound desperation and instability.

That despair, in turn, worsens public health in myriad ways. People with no hope turn to drugs and alcohol, battle depression, eat poorly, work three jobs to exhaustion and injury, battle chronic pain with no viable options, sleep too little, etc. And in worst case scenarios, they end up on the street with few if any possible good outcomes.

Is it the housing as an end that creates better public health outcomes? Not really. No one who lacks adequate housing or has to move frequently is clamoring for a 7,000-square-foot home.

Instead, it’s the benefits housing provides that support a healthier, more sustainable life. As an essential social determinant of health, well-built and well-conceived housing is one corner of foundation supporting four interconnected quality of life pathways: stability, quality and safety, affordability, and community. If any of these pathways are lacking in the housing options available, housing potentially becomes a negative social determinant of health.

For example, consider the tiny homes many cities are now building to try and grapple with the problem of homelessness. Initially, it seems like any kind of lockable structure is an improvement on doorways, park benches and even shelters. But in some cities, tiny houses don’t come with heat, electricity and plumbing, effectively making clusters of houses a small step up from homeless encampments. As social determinants of health, they still register a negative, leaving America far from realizing the goal of housing as net positive for all citizens.

Of course, housing is only one social determinant of health, which collectively are generally lumped as social and environmental factors (20 percent), genetic fortune or misfortune (30 percent), and individual behavioral choices (40 percent).

The final 10 percent is healthcare, and maybe that percentage seems a little light, given how much attention we pay to the healthcare system. Still, think about the ability of healthcare to balance all other social determinants—diet, housings situation, employment status, mental status—when they’re decidedly or even predominantly negative.

It’s not hard to see why clinicians resent being held responsible for the fire after the house is engulfed in flame.

And what, if anything, can healthcare do about these social determinants over which they have no control? In short, look for solutions and shortcuts.

Comprehensive medical records, interoperable systems, healthcare data exchanges and the like can together enable hospitals and clinicians to circumvent the complications created by a transient life. But healthcare providers and organizations can also address social determinants of health more directly.

“The health care sector should continue to explore the extent to which home interventions, such as the well-studied community asthma initiatives, can make financial sense among other patient populations,” says Health Affairs writer Taylor. “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 (including housing) are likely to increase.”

And that’s the added factor that may motivate healthcare organizations as much as anything else. Housing makes communication with patients more reliable, which cuts down on the costs of care and lends stability that enables accountable care. Really, all social determinants on the positive side of the ledger decrease healthcare costs, but stable housing makes the others that much more likely.

The social determinants of health are also lurking in the national discussion of universal healthcare. At times, the nation and the industry seem caught up in discussions of payment models, insurance deductibles and technological advancements. Maybe we miss the fact that having affordable healthcare is better than not having it in the same way that having a 200 square-foot house with locks is better than living on the streets, even if we can agree that such basic standards are not enough.

Using social determinants, we could improve the health of many Americans without ever specifically addressing a medical record or length of stay. And until we do see patients as a complex amalgamation of influences, we can’t be surprised that specific therapies out of context have negligible impact on overall public health.