Health care institutions are recognizing that housing stability leads to better health outcomes. Photo by flickr user Taber Andrew Bain, CC BY 2.0
“Housing is health care” has become something of a mantra for housing advocates in recent years. A growing number of health care institutions have started to recognize the well-established link between housing stability and health outcomes as well, with many directing their community investment dollars into affordable housing development to boost housing stability, and thus health, in the communities they serve.
While more affordable housing is needed, investing in policy changes to bolster tenant protections can often have a broader and more immediate impact on community health than the same money spent on affordable housing development. A $25,000 investment wouldn’t go far toward new construction, for instance, but one Oregon health funder was able to leverage that sum to help fund a campaign that advanced legislation limiting no-cause evictions and rent increases for every tenant in the state.
In the age of COVID, the link between housing policy and health outcomes is even more grimly apparent. Home is where people isolate to avoid infection with the deadly disease. Without that refuge, they’re forced to double up with other households or congregate in shelters. In October, when landlord groups in Georgia, North Carolina, South Carolina and Virginia mounted a legal challenge to the CDC’s temporary eviction moratorium, health institutions, including the American Academy of Pediatrics, the American Medical Association, Children’s HealthWatch and others, filed an amicus brief defending the moratorium and its role in protecting public health during a pandemic.
“The consequences of eviction (such as overcrowding, homelessness, and housing instability) increase contact with others and hinder compliance with the key strategies to contain COVID-19, including social distancing, self-quarantining, and hand hygiene,” the brief says.
While rent relief funds have helped some distressed tenants avoid eviction, they don’t come close to the $100 billion that the National Low Income Housing Center estimates is needed to stem an expected tidal wave of evictions.
Meanwhile, simple policy changes could have saved thousands of lives from the effects of eviction during a pandemic. One study published by UCLA in November 2020 estimated that 10,700 COVID-19 deaths could have been avoided if states had delayed lifting their eviction moratoriums.
Even outside of a pandemic, housing policy is often a matter of life and death. The homeless and unstably housed have higher rates of overall mortality, and increased rates of depression, anxiety, substance abuse, and suicide. Any policy that expands affordable housing and prevents homelessness and evictions may avert dire health consequences down the line.
“Rent controls, incentives, and taxes to ensure the creation of affordable housing, that’s the long-term solution,” says Brian Castrucci, president and CEO of the de Beaumont Foundation, a community health funder focused on policy change. “We have to make a decision in this nation if we’re going to continue to apply Band-aids, or if we’re going to start looking to some cures.”
The foundation’s CityHealth initiative ranks cities across the country each year on their adoption of nine policies that have been shown to boost community health. Among those policies is inclusionary zoning for increased affordable housing, which the foundation notes can reduce urban sprawl, improve air quality, support mental health, and leave families with more in their budgets to pay for food and health care.
Ideally, local governments would take it upon themselves to adopt policies like inclusionary zoning, Castrucci says, which target economic and social issues that are far beyond the traditional purview of medicine. Failing action from lawmakers, local health systems—anchor institutions and major employers in most cities—can provide the needed political push.
“We fully know how to solve all these problems, we just lack the political will to do so,” says Castrucci. “But health care can be a real engine for political wealth. So the way that health care is going to help this world get healthier is much less about their clinical services and much more about their power in politics and advocacy.”
Some hospitals and health funders have started to recognize their roles as engines of social change by supporting the more “political” aims of housing work. That means putting their community investment dollars to work toward advancing tenant protections that can lead to greater housing stability, and better health, for entire communities.
Boston Hospitals Back Anti-Displacement Policies
Some Boston housing groups have secured a steady stream of funding for their policy work in the coming years thanks to Massachusetts’s “Determination of Need” public health law, which requires health care facilities embarking on major capital projects to reinvest a portion of their budgets in community health.
Beth Israel Deaconess Medical Center (BIDMC), a teaching hospital of Harvard Medical School, announced $6.6 million in funding in 2020 for 17 local groups focused on jobs and financial security, behavioral health, and housing affordability.
The Innovative Stable Housing Initiative (ISHI), a community health initiative that pools funds from Boston Medical Center, Boston Children’s Hospital, and Brigham and Women’s Hospital, is investing $3 million over three years into housing stability in Boston.
Both the ISHI and the BIDMC initiatives are unique in that they’re not only funding service providers, but also campaigns to strengthen tenants’ rights in Boston and across the state. Such campaigns can have an impact on displacement, which itself is detrimental to health, according to Dr. Shari Nethersole, a pediatrician and executive director of community health at Boston Children’s.
“A lot of our families who still need to come here for care have actually been displaced and are now outside of the city. They’re having difficulty with their continuity of care because they’re so much farther away,” says Nethersole. “So as you think about … the things that help stabilize children and families in particular, [funding housing policy work] makes sense.”
Fenway Community Development Corporation is one group that received such funding. The organization was named the lead agency for a $500,000 “focused investment” grant from the BIDMC initiative in December 2020. Along with four partner groups, Fenway CDC will use the grant to “organize and campaign at the city and state level to move legislation, budget items, and policies that will increase funding for affordable housing and rental subsidies, further fair housing, and improve tenants’ rights.”
Richard Giordano, director of policy and community planning at Fenway CDC, called the funding “groundbreaking.”
“This is a hospital saying, we recognize that housing affects health, and we’re going to pay people to work on policy change. This is not like, ‘Let’s give money to the food bank and make sure people eat well,’” says Giordano, adding that such programs are also important. “They’re saying, there’s a laundry list of housing policies that we think could be improved and would affect, ultimately, health.”
Among the policy priorities for Fenway CDC and its partner groups is revising and reintroducing the state Tenant Opportunity to Purchase Act (TOPA), which would require landlords to notify tenants if they plan to sell their building, giving them a chance to purchase it collectively, often with help from local nonprofits. The bill passed the state legislature in early January, but Massachusetts Gov. Charlie Baker vetoed it just before the legislative session ended, meaning it will have to be reintroduced. Fenway CDC and its partners are hoping a new TOPA bill will pass this legislative session.
The organization is also working to help shape the implementation of Boston’s recently passed amendment, which requires that developers take active steps to address historical housing discrimination and mitigate displacement from their projects.
Boston Tenant Coalition, which received funding from both the $500,000 BIDMC grant and part of a $150,000 grant from the ISHI, plans to hire a full-time senior organizer to help accomplish these goals, something made possible thanks to the grant funds, according to Kathy Brown, the group’s coordinator.
“I can count on my hands the number of funders normally funding policy work,” says Brown. “The grants are incredible.”
Another priority for Brown and Giordano’s groups is campaigning for a stronger Inclusionary Development Policy (IDP) in Boston. The Massachusetts state legislature passed a Home Rule petition in early January that granted the city the authority to alter its IDP, which governs zoning policy, including the minimum number of affordable housing units that developers must include in projects that require zoning variances.
The city’s IDP was originally established by a mayoral executive order, leaving it vulnerable to legal challenges, and meaning it could in theory be rescinded by a future administration. According to Giordano, the next goal is changing that.
“The Home Rule petition gives the city the authority to actually put [the IDP] in the zoning code, which would be a much stronger thing,” Giordano says. “And then while we’re at it, we would have the option of strengthening and improving it.”
The city’s current policy requires developers to set aside 13 percent of units in projects that need zoning relief as affordable units, at 70 percent of the area median income (AMI). The AMI in Boston is $113,300 for a family of four, a figure that factors in the incomes of the surrounding suburbs, including Brookline and Newton, named two of the most affluent communities in Massachusetts in recent years.
According to Giordano, the current affordability requirements aren’t close to sufficient in Greater Boston, where nearly half of all renter households are cost burdened, spending more than 30 percent of their incomes on housing. Among extremely low-income renter households, earning 30 percent of the AMI or less, about 75 percent were cost burdened in Boston as of 2016.
“If you’re making 15 percent of the units affordable to people at 70 percent of the area median income, that’s a drop in the bucket as to what the city really needs,” Giordano says.
Along with its partner groups, Fenway CDC wants to push the city council to update Boston’s IDP and set a range of affordability tiers averaging 40 percent of AMI, or $45,300 for a family of four. They’d like to see the policy apply to 33 percent of units, and for the affected units to be made permanently affordable.
Health and Affordable Housing
When it comes to affordability, research has confirmed what common sense tells us: where rents rise faster than incomes, spikes in homelessness follow.
According to Dr. Megan Sandel, a pediatrician at Boston Medical Center (BMC) who helped develop the ISHI, between 30 to 40 percent of the families with young children visiting the hospital’s pediatric emergency room are homeless or housing unstable.
Aside from being a human tragedy, homelessness puts a financial strain on health systems. The homeless are more likely to have chronic health conditions, substance use disorders, and mental illnesses, and they’re more likely to be the victims of violent crime, all factors that contribute to their requiring three to four times more emergency health care than the general population.
Many states, including Massachusetts, are reforming their Medicaid programs to base reimbursement on patient outcomes, rather than on the volume of services providers deliver. Along with the state’s Determination of Need obligation, this value-based payment system gives hospitals like BMC a strong financial incentive to help address the root causes of poor health, including homelessness and housing instability.
“When we look at our highest utilizing patients, half of them are homeless and housing unstable. These are people that will cost us and our health plan over $100,000 a year,” says Sandel.
Families who’ve experienced an eviction within the last five years often suffer poor health outcomes as well, according to Sandel, who’s also a principal investigator at Children’s HealthWatch. She sees “unbelievably high” rates of maternal depression among these patients, and higher rates of health problems and developmental delays among the children in these families, she says.
“Anything that can be done to prevent evictions is like preventing the toxic exposure,” says Sandel. “We can do a lot of mitigation after the fact, but it’s always better to prevent it in the first place.”
Oregon Health Funder Backs Rent Control and Just Cause Evictions
In Oregon, a grant from the Northwest Health Foundation (NWHF), a nonprofit community health funder, supported a campaign to limit no-cause evictions and cap rent increases across the state.
The Community Alliance of Tenants received a $162,000 grant from NWHF in 2017-2018 and another $25,000 grant from NWHF in 2018 to campaign at the state and local level for just cause eviction laws and laws banning unreasonable rent increases, and to advocate for and help establish local agencies to enforce landlord-tenant law.
The group helped lead the Stable Homes for Oregon Families Coalition, which advanced a bill passed by the Oregon State House of Representatives in 2017 to bar landlords from terminating month-to-month leases within 60 days of tenants requesting certain repairs.
The first bill died in the state Senate, but it paved the way for a second bill that prohibits Oregon landlords from terminating month-to-month leases without cause after 12 months of occupancy, limits rent increases to one per year and caps them at 7 percent above the rate of inflation. That bill was signed into law in 2019.
Prior to its passage, Oregon landlords were able to evict month-to-month tenants for no legal reason with 30 days’ notice, no matter how long they’d been in the rental. They could also hit tenants with massive, unforeseen rent increases.
Oregon’s Medicaid Advisory Committee identified housing stability and affordability as top social determinants of health for the state’s Coordinated Care Organizations to address in 2017, noting that children who experience housing instability are more likely to use drugs at a younger age, experience depression, and become pregnant as teenagers. Families who struggle to afford housing are also more likely to be food insecure, and to delay medical treatment, resulting in more emergency room visits, the committee noted.
According to Jen Matheson, director of programs at NWHF, health funders backing improved housing policies makes sense for other reasons as well. Tenant protections like just cause eviction and rent control are necessary supports for “healthy housing” laws, like those requiring landlords to remediate lead paint or toxic mold.
“We can think all day about really important interventions when it comes to making sure housing is healthy, but then you need policies to protect renters from retaliation and no-cause evictions to back that up,” says Matheson.
Without strong tenant protections, renters may be forced to choose between demanding the repairs they’re entitled to under the law—and risking backlash in the form of rent increases or no-cause evictions—or tolerating health hazards in their homes.
While it’s long been illegal for Oregon landlords to use rent hikes, harassment, or eviction to retaliate against tenants for asserting their legal rights, that doesn’t necessarily keep it from happening, Matheson says. Laws that require a reason for an eviction and limit how much rents can be raised take away part of the threat.
“Even though the laws stated there were protections around retaliation, we knew that the families who spoke up for what they needed were often the families that saw an eviction without cause,” says Matheson. “Having some predictability and not having to worry about getting kicked out, that supports the health, mental health, and emotional health of families.”
Organizing Against ER Visits in the Bronx
When two hospital systems in New York City’s Bronx borough wanted to prevent asthma-related emergency room visits, they turned to tenant organizers for help.
Montefiore Medical Center and St. Barnabas Hospital both have campuses in the Bronx’s Mott Haven neighborhood, dubbed “asthma alley” because its majority Black and Hispanic residents require hospitalization for the condition at five times the national average, and 21 times the rate of other New York City neighborhoods.
In an effort to cut Medicaid costs, the state of New York announced in 2014 that it would spend $8 billion over five years to prevent avoidable emergency room visits, in part by investing in community health initiatives. The Bronx has the highest number of potentially preventable hospitalizations in New York City, according to St. Barnabas’s application for the funds, with chronic conditions like asthma accounting for the bulk of these admissions.
Montefiore and St. Barnabas came together to form Bronx Partners for Healthy Communities in order to claim and disburse a portion of the state Medicaid reform funds. Through that partnership, the hospitals helped support the Bronx Healthy Buildings Initiative, a program that sought to convince landlords to retrofit their buildings via grants from the Department of Energy’s Weatherization Assistance Program (many weatherization measures also improve indoor air quality and reduce asthma triggers), then use the savings to finance other asthma-improving upgrades, like pest management, green cleaning, and mold remediation.
The initial funding for the program came from the BUILD Health Challenge, a funding collaborative project by the de Beaumont Foundation that provided a grant for the coordination work for the first two years. The initiative also helped landlords access New York City-funded grant and loan programs for needed retrofits.
Although federally funded energy upgrades that can also prevent asthma attacks sound like a win-win for both renters and landlords, it wasn’t always easy to get property owners on board, according to Edward Garcia, lead community organizer at the Northwest Bronx Community and Clergy Coalition (NWBCCC). His group has been organizing tenants in the borough since 1974, and they brought those skills to bear to lead the Bronx Healthy Buildings Initiative.
“We wanted to leverage our existing tenant organizing work, and we knew there was a clear connection. The tenants that were going into the emergency room were living in buildings where landlords were not investing in upgrading the major systems that were enabling a lot of the asthma triggers, like mold, or not investing in integrated pest management,” Garcia says.
Part of the reason that Garcia and other organizers could see the connection between hospital admissions for asthma and where renters lived was clinical data shared by Montefiore Medical Center, which helped NWBCCC target the borough’s “sickest” buildings. Garcia’s group would then organize the residents, helping them form tenant associations to pressure their landlords to make the needed repairs.
Prior to the asthma program, NWBCCC was already administrating weatherization grants, which allowed the Healthy Buildings Initiative to piggyback on that funding and push landlords to do more than just retrofit their buildings for energy efficiency.
“We kind of had the stick and the carrot,” says Garcia. “We would approach the landlord with our organized tenant association and say, ‘This is happening in the building and it’s making us sick. We have available resources that we want to offer you, like this free grant to upgrade a building system.”
The weatherization grant would come on the condition of other health upgrades, Garcia says, like addressing infestations and other asthma triggers.
“In a lot of cases it worked, but in other cases we had to go the traditional tenant organizing route, to build a strategy that was often confrontational, either through court or through direct action, to pressure the landlord to do what was needed to keep people safe and away from the hospital,” Garcia says.
In some cases, Montefiore and St. Barnabas Hospital disbursed state Medicaid reform funds to provide community health workers and pest management to the targeted buildings.
While funding for the Healthy Buildings Initiative is now on indefinite hiatus, NWBCCC is looking for new ways to continue making the case to local hospitals to invest in tenant organizing to keep residents healthy and out of the hospital.
And it’s not just about preventing asthma attacks, Garcia says.
“It’s also the level of stress, and the trauma people have lived through due to landlord harassment or being rent burdened that’s making our communities sick,” he says. “You can exercise and eat well and do all the things that people believe are important to be healthy, but still be unhealthy because you don’t have access to an affordable, safe home.”
Editor’s Note: This article was updated to correct the spelling of Shari Nethersole’s name.
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Thanks for your article on this important topic. One sentence made me curious and I am wondering if you know of other states with a determination of need public health law similar to what is in Massachusetts? “Some Boston housing groups have secured a steady stream of funding for their policy work in the coming years thanks to Massachusetts’s “Determination of Need” public health law, which requires health care facilities embarking on major capital projects to reinvest a portion of their budgets in community health.” Adoption of DoN public health laws might be a great initiative for other states as well as a national housing advocacy group to work on in collaboration with national health advocacy allies to create a federal law.
As a housing provider, this article was actually one of the scariest things I’ve read. And just when I thought there might have been a good idea, the section about the Bronx hospital fighting asthma cases by helping housing providers fund improvements to their buildings, it took the usual turn of “confrontational” and “pressuring landlords to do what was needed”.
The Oregon group didn’t spend $25,000 on creating new housing, or paying overdue rent for residents or paying for security deposits to help secure housing for thousands of families. No, they gave it to lawyers, and lobbyist, and politicians to increase renter protections.
I agree that stable housing is important to social, emotional and medical health. However, these programs never seem to work WITH housing providers. Did the Bronx group ask why the owners hadn’t made improvements to the buildings? Are those buildings under rent control? Are they filled with HCV residents and the rates are restricted? Has the owner’s property taxes risen in the past decade to extreme levels while their profit margins have shrunk? And even when there were funds offered for improvements “the weatherization grant would come on the condition of other health upgrades”. There are always additional strings attached.
Absolutely use these funds to go into communities and make serious, no strings attached offers to help housing providers provide better housing! That is a great program idea! Stop spending this money to make it harder for housing providers to do their job. All that will do is run out providers from your area.