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Connecting Housing and Health: Investing to Avoid a Crisis

By Topic: Medicaid ACOs Delivery of Care Social Determinants Equity of Care Disparities Disparities in Care By Collection: Blog


A growing body of research shows social determinants of health have a significant impact on health outcomes and the cost of care delivery. The root causes of many disparities in patient outcomes can be traced back to social determinants of health, with many stemming from generations of de jure racism and segregation.

Among these factors, the quality, location and cost of housing can deeply impact overall health in both children and adults. High housing costs often require households to cut back on other necessities such as nutritious food, utilities and healthcare services. In addition, the stress of housing insecurity negatively impacts mental health for people of all ages.

Patients and their families are considered “housing burdened” when housing costs exceed 30% of the household income. According to an Out of Reach study from the National Low Income Housing Coalition, there is no state in the country in which a 40-hour work week at minimum wage is sufficient to afford a modest apartment. Meanwhile, increases in rental costs continue to outstrip wage growth—meaning the problem is likely to worsen.

Unemployment and reduced hours/wages during the COVID-19 pandemic has exacerbated these problems. Temporary eviction protections implemented at the start of the pandemic at the federal level and in many states are beginning to expire even as the most recent wave of infections hampers recovery, setting up large portions of the population for an imminent housing crisis.

Increasingly, healthcare leaders and other experts are recognizing that investing in safe, adequate and affordable housing can support positive health outcomes and reduce patient care costs. Individually and collectively, providers are supporting the creation of affordable housing for their most vulnerable patient populations.

Among single entities that have made the largest housing investments is Kaiser Health, which announced a $200 million investment in affordable housing in 2018. Through their Thriving Communities Fund, Kaiser Health works to reduce homelessness by increasing access to supportive housing and preventing displacement of lower- and middle-income households. Funds are used for a combination of community programs that reach individuals in need directly, as well as for lending and financing options that help developers create and preserve healthy, accessible and affordable housing.

Coalitions can boost the impact of individual organizations’ contributions. In 2015, the University of Illinois Hospital in Chicago partnered with a community group called the Center for Housing and Health to launch a $250,000 pilot program to locate and subsidize housing for homeless ED “super-utilizers.” In addition to receiving an apartment with rent paid up to $1,000 a month for one year, patients were assigned a case worker. This partnership grew into Better Health Through Housing which, in the years since, has added resources from the city’s flexible housing pool and other healthcare providers. To date, they’ve housed 91 patients, with a 57% reduction in inpatient stays and 67% decrease in ED utilization among program participants. This infographic summarizes how the partnership works and its impact.

According to ACHE research, healthcare CEOs continue to rank financial challenges among their organizations’ top issues. Especially in the wake of the losses form COVID-19, many organizations will not have the budget to provide housing directly, no matter their commitment to population health. Identifying opportunities to advocate for supportive services and programs, and educate patients on available options, can also make an impact on outcomes.

Some states are leveraging Medicaid reimbursement options under CMS State 1115 waivers for housing-related activities. While it’s prohibited for Medicaid dollars to be used for rent payments or other direct housing costs, states are utilizing accountable care organization dollars to provide ancillary services. Utah’s Medicaid program has enlisted four managed care organizations as ACOs, giving them flexibility to pay for home improvements and housing support. In 2018, North Carolina established the Healthy Opportunities program, authorized to spend up to $650 million over five years on services that impact health outcomes and healthcare costs, including housing, food and transportation.

COVID-19 may impact these plans for better or worse. Many states have applied for new CMS Section 1115 waivers, but resources may be spread thin. In North Carolina, the Healthy Opportunities pilot evaluation has been put on hold to put all available energy behind fighting the pandemic.

U.S. hospitals, health systems and even payers continue to trend toward including social determinants of health in plans to advance the health of our patients and communities. Finding sustainable, long-term solutions—such as addressing housing needs and other social determinants of health—will create better, more equitable outcomes.