Americans are less healthy than their peers in other developed countries. On most measures—chronic illness, maternal mortality, longevity—Americans lag their international counterparts despite leading the world in health care spending per capita by a wide margin.
For years, researchers have sought to explain this discrepancy by pointing not only to the absence of universal insurance coverage, which consistently leads to a healthier population, but also to social determinants such as education, transportation, and eating habits.
While these factors all contribute to the relatively poor health of Americans, choosing among them is a bit like identifying the culprit in Agatha Christie’s Murder on the Orient Express. If they’re all to blame, who’s accountable?
As in the murder mystery, there is no single answer.
Increasingly, however, those who study, finance, and deliver health care are focusing on housing, a subject formerly absent from most health-related discussions. Among funders and physicians, a consensus is emerging that stable and affordable housing, though no panacea, must be the starting point for improving people’s overall health.
Rich Besser, the president of the Robert Wood Johnson Foundation, the country’s largest health foundation, took the unusual step of devoting his recent annual message entirely to the links between housing and health.
Calling housing a “key part of the health equation,” his report pointed out that 1 in 10 households, and fully half of low-income renters, spend more than 50% of their income on rent or mortgages, leaving less for other essentials, including health care itself. An estimated 4.6 million asthma patients attribute their illness to damp or moldy housing, and approximately 6,300 Americans are evicted from their homes each day.
Eviction is particularly drastic in its effect on health. When people lose their homes, their health plummets, as they become much harder to treat.
According to Mercy Housing, the national affordable-housing nonprofit, people who are chronically homeless have a life expectancy that is 25 years less than the general population.
People living on the streets face constant physical and psychological stress. Managing chronic conditions such as diabetes or mental illness is challenging under any circumstances. Without a home, it’s all but impossible.
The health costs of homelessness are staggering.
Destination: Home, a Bay Area organization working to reduce homelessness, analyzed 15 million public records that detailed the cost of services to 100,000 homeless people in Santa Clara County.
Its researchers found that the county spent $520 million per year between 2007-2012 on this population. The single largest component? Medical diagnoses and associated health care services. Roughly a quarter of the nation’s unsheltered homeless live in California. Los Angeles County alone is home to 55,000 homeless people.
Oakland-based Kaiser Permanente, the country’s biggest integrated health system, sees the connection between homelessness and health crises every day: of the 10 U.S. cities with the biggest homeless populations, six are in Kaiser’s service areas.
Kaiser has put the housing crisis at the center of its reform efforts, pledging to invest up to $200 million in affordable and accessible housing in the Bay Area. The health care giant is working to find sustainable homes for 500 people with chronic illnesses now sleeping on the streets of Oakland.
Sustainable housing is expensive, but not as expensive as emergency room visits.
Likewise, Sutter Health, a large non-profit health system based in Sacramento, has made recent major commitments to affordable housing.
As a part of the Whole Person Care Pilot launched in 2016 by the California Department of Health Care Services, Sutter has given $2 million to Placer County to deliver care to those who are homeless and need complex medical and social services.
This contribution is part of a broader Sutter initiative to combat homelessness; the health system says it has funded housing for more than 1,000 people over the past three years.
California is in the unenviable situation of confronting two huge, self-reinforcing crises: a very large homeless population and a dramatic shortage of housing.
According to the Public Policy Institute of California, the state has the lowest number of housing units per capita in the country and is near the lowest rung on any measure of housing affordability.
And despite Gov. Gavin Newsom’s campaign pledge to add 3.5 million housing units by 2025, some recent indicators suggest housing is heading the wrong way. For instance, residential permits for new multi-family units, which are key to solving the state’s affordability crisis, sank 23%, annualized, in the first quarter of 2019.
The need for affordable housing scarcely requires more justification. But now that the state’s largest health care providers and reform advocates are backing affordable housing initiatives, it brings new momentum and ideas to debates in Sacramento.
These include holding back gas tax revenue from cities that build too little housing, challenging restrictive zoning, making it harder to evict tenants, and curbing rent increases.
While Senate Bill 50 – which aims to change zoning restrictions near transit centers to encourage denser housing – has been stymied by local opposition, it points the way toward the kind of political response that will be needed if these twin crises are to be resolved.
Leslie Teicholz, former senior vice president at Arnhold and S. Bleichroeder, an investment firm, writes on state and local issues. Leif Wellington Haase is the past director of the New America Foundation’s California office and president of LWH Consulting. They wrote this commentary for CalMatters, a public interest journalism venture committed to explaining how California’s Capitol works and why it matters.
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