Urban Strategies Promotes Housing Security as Health Care

The greatest form of love is healthy, safe, and thriving communities. The
best way to ensure that is to secure adequate, safe, and affordable housing for
all.

At its core, health care is about helping people live healthy lives.
Clinical care is only one piece of the puzzle, however. Research shows that
medical services contribute some 10 percent to overall health outcomes. Whereas
genetics account for another 30 percent, 40 percent comes from behaviors such
as diet, exercise, and substance use. The remaining 20 percent arises from
social and environmental conditions. These “social determinants of health,”
which include our jobs, neighborhoods, access to food, education, and community
support, shape our well-being to a greater extent than our work inside clinics
and hospitals. Among these social determinants of health, housing is
foundational.

Without safe, stable housing, the rest falls apart. Housing is the literal
and figurative basis of health: a place to sleep, store food and medicine,
recover from illness, and feel safe. Without stable housing, it is difficult to
prioritize or receive health care. Families and individuals without it face
cascading challenges that no amount of clinical care can solve.

The Weight of Housing Costs

For decades, Americans have faced a growing gap between incomes and housing
costs. Families that spend more than 30 percent of their income on rent are
considered “rent burdened.” Today, nearly half of US households fall into that
category, and more than one-quarter spend more than 50 percent of their income
on housing (“severe rent burden”). Many of these families are forced to make
impossible choices: rent or food, rent or medicine, rent or transportation to
work.

The math is unforgiving. According to the National Low Income Housing
Coalition, the United States faces a shortage of 7.1 million affordable and
available rental homes for extremely low-income households. For each 100 such
families, only 35 units exist. No state in the country has an adequate housing
supply, and there is no city where someone working full time at the federal
minimum wage can afford a modest two-bedroom apartment. This is not an urban or
coastal crisis but a national one, encompassing everything from rural towns to
major cities, and it is getting worse.

Housing and Health Outcomes

The absence of safe, stable, and affordable housing has profound health
effects. Substandard housing exposes families to mold, pests, and lead, and
exacerbates asthma and other chronic illnesses. Poor insulation and heating
systems leave residents vulnerable to extreme heat and cold. Overcrowded units
worsen stress and poor sleep and accelerate the spread of infectious diseases,
a problem laid bare during the COVID-19 pandemic, when household density proved
a major driver of viral transmission.

For people struggling to balance rent payments with other expenses, and for
those living on the edge of eviction, constant stress takes a toll. Researchers
have linked housing stressors to depression, anxiety disorders, and poorer
control of chronic conditions such as diabetes and hypertension. Children in
unstable housing experience developmental delays, worse school performance, and
higher rates of hospitalization.

Homelessness sits at the extreme end of this continuum of housing
insecurity. On any given night, more than 770,000 Americans face
homelessness—it’s a public health emergency. People without homes experience
rates of chronic illness that greatly exceed that of the general population,
and their life expectancy is decades shorter. Exposed on a regular basis to
violence, extreme weather, and the psychological strain of living without
safety or privacy, unhoused individuals endure much higher rates of hospitalization.
Discharges are fraught. Patients are often sent “home” to a shelter cot or the
street, undermining recovery and setting the stage for readmission.

Providers face impossible decisions. Sometimes patients are admitted not
because they require hospital-level care, but because they have nowhere safe to
go. Medications are lost or stolen. Patients without phones or addresses miss
follow-up appointments. The system strains under the weight of treating
symptoms that stem not from biology, but from the absence of shelter.

Structural Inequities in Housing

These crises are compounded by structural inequities that are baked into US
housing policy. For generations, discriminatory practices such as redlining,
mortgage denials, predatory lending, and exclusionary zoning locked Black,
Indigenous, and other people of color out of stable housing opportunities.
These policies denied individuals access to homes but also denied families the
chance to build wealth, stability, and health across generations.

The consequences are visible today. Black families are more likely to be
rent burdened and more likely to experience eviction or homelessness. Native
communities face extreme housing shortages and overcrowding. Latino families
disproportionately live in substandard housing with environmental exposures.
These inequities reverberate in health statistics: higher rates of asthma,
hypertension, maternal mortality, and life expectancy gaps that span decades.

Housing insecurity is not evenly distributed and neither are the health
impacts. If we want to achieve health equity, we must confront housing equity
head on.

Housing as Health Care

What does it mean to say that housing is health care? It means recognizing
that prescriptions and procedures cannot compensate for the absence of a home.
It means understanding that rent subsidies, eviction prevention, and affordable
housing production are as vital to health as flu shots and cancer screenings.
It means that if health systems are serious about improving outcomes, they must
step outside the clinic and invest in housing stability.

Some hospitals and health systems are beginning to invest in affordable
housing, partnering with developers, leveraging their land, or providing
capital to stabilize housing for vulnerable populations. Medicaid waivers in
some states now allow funds to be used to support housing navigation services
and short-term rental subsidies. Philanthropic and public-private partnerships
are expanding permanent supportive housing, providing stable housing, and
ending homelessness for individuals with the most significant behavioral health
challenges. But these efforts pale in comparison to the scale of need. While
pointing the way forward, they cannot substitute for comprehensive policy
solutions.

The Path Forward

We know what works. Universal rental assistance would dramatically reduce
rent burdens and prevent homelessness. Expanding the Housing Choice Voucher
program, strengthening eviction prevention services, and investing in
affordable housing construction and development are essential. Inclusionary
zoning and fair housing enforcement can chip away at structural inequities. We
must scale permanent supportive housing for those with complex health needs. 

For health systems, the imperative is clear: move from pilots to permanence.
Partner with housing authorities, community-based organizations, and policy
makers to address housing as a core determinant of health. Reframe “return on
investment” as not only dollars saved on avoidable hospitalizations but also
healthier, more resilient communities.

Instead of an abstract debate, this is about whether families can afford
groceries without skipping rent. Whether an older adult can safely recover from
surgery inside a warm home. Whether a child can grow up free from the trauma of
repeated evictions.

The highest form of love is healthy, safe, and thriving communities. To
achieve it, we must guarantee safe, stable, and affordable housing for all.

Read more stories by Marc Dones & Margot Kushel.