Health Care Meets the Voting Booth: Why Housing Policies Determine Wellness

New candidates and incumbents seeking election in the midterms and beyond have made access to health care a key issue. A recent poll from the Kaiser Family Foundation states that 71 percent of voters consider health care a “very important” issue when choosing a candidate.

Around the country, several of these congressional candidates are vowing to ensure coverage for those with pre-existing conditions, while other candidates vow to save Medicaid and Medicare. New initiatives to frame health care needs and costs around the social determinants of health — and housing in particular — are necessary additions to the debate.

Experts at the Center for Health Policy Research and Ethics and Harvard Business School note in a recent paper that some of the poor health outcomes have been attributed to the lack of investments in interventions that address the social needs of some of the country’s most vulnerable populations.

Data from 2016 ranking health by counties shows that the social determinants of health account for approximately 80 percent of health care outcomes. Traditional medical care accounts for 20 percent of health outcomes.

Factors such as housing, education, employment, access to food and poverty are strong predictors of health outcomes. If addressed, there is potential for improving the nation’s health.

As a nurse with expertise in health care for these populations, I know firsthand how challenging it is to expect a diabetic patient to properly manage his or her diabetes without access to stable housing, adequate supply of nutritious food and other vital resources.  

While it may be easy to label someone non-compliant, an assessment of the social determinants of health may provide valuable information needed to plan an appropriate program of care. The influence of these factors is particularly significant for communities of color and other underserved communities. Yet, the social policies aiming to address these social needs are far from adequate.

Federal funds to support these efforts are frequently on the chopping block. According to the Center on Budget and Policy Priorities, the 2019 budget proposes substantial cuts in health care, nutrition support, supplemental education funding, housing and energy assistance. The proposed budget will adversely impact low- to moderate-income people including children, seniors and people living with disabilities. This would be catastrophic for millions.

Housing is one of the strongest predictors of health outcomes causing some to categorize “housing as health.” According to Health Affairs, individuals without stable housing live 27.3 years fewer than the average housed person. Also, individuals ages 25-44 who are homeless have a mortality rate 8.9 times higher than the general population.

The 2019 proposed budget seeks unprecedented cuts to housing assistance and, if enacted, will constitute the largest cut back of federal support since the U.S Housing Act was enacted in 1937.

Affordable housing is so critical to health that some public health leaders have challenged us to consider housing to prevent disease and disability. Hospitals and health systems are beginning to invest in housing as a means to reduce the high cost of uncompensated care driven by high readmission rates and frequent emergency room visits for those lacking stable housing.

Municipalities across the country consider housing a key factor in public health.  

The University of Illinois Hospital, along with the Department of Housing and Urban Development, launched the “Better Health Through Housing” initiative to provide housing and counseling services for the chronically homeless population who visit the emergency room. Researchers say the benefits of the program outweigh the $3,000 a day bill for the chronically homeless that frequent the emergency room.

In Missouri, tax credits have been instrumental in ending veteran homelessness in Kansas City, Missouri.  

In St. Petersburg, Florida, foundation research underscores the impact of housing on health and health equity and provides a road map for future planning including policy advocacy.

In 2017, Hawaii senator and physician Josh Green (D) introduced legislation that would classify homelessness as a medical condition citing medical costs as much as $120,000-$130,000 per year for each homeless individual. If passed, providers would be able to write prescriptions for housing for those experiencing homelessness for six or more months and have mental health illnesses or drug addiction.

Since the passage of the Patient Protection and Affordable Care Act, candidates across the country have been debating the merits of this legislation and continue to search for solutions to ensure access to health care and reduce health care costs.

The United States continues to spend more on health care than other high income countries. Health care costs exceeded $3.5 trillion in 2017 and continue to rise in the United States. According to researchers reporting in the Journal of the American Medical Association, despite these high expenditures, the United States has the lowest life expectancy and highest infant mortality compared to similar countries.

The issue of affordable housing is poised to continue as a prominent theme past the midterms and into the 2020 presidential race. Candidates and lawmakers could now seize the opportunity to consider housing as health care in the policy-making process.

As Americans head to the voting booth to usher in a new legislative session and welcome newcomers to Congress, it would be ideal to intensify efforts to fully embrace “the health in all policies” framework as a strategy to reduce disparities and achieve health equity.

Where people live and how they live affect every American and the health of a nation.


Janice Phillips, Ph.D., RN, CENP, FAAN, is the director of nursing research and health equity at Rush University Medical Center and associate professor of nursing at the College of Nursing, and she is also a public voices fellow through The OpEd Project and a former Robert Wood Johnson health policy fellow.

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