Housing Agencies Eye Healthcare

7 min read

Rewards for in-home care in affordable housing   

Substandard, unaffordable housing can damage the health of its residents – potentially causing problems like asthma or exacerbating ailments like hypertension.

“Vulnerable occupants — young children, older adults, the infirm — are particularly susceptible,” says Sherry Ahrentzen, Shimberg Professor of Housing Studies at the ME Rinker School of Construction Management at the University of Florida.

Housing agencies have taken notice. In many states, housing officials are more likely to provide funding, like Low Income Housing Tax Credits (LIHTCs), to affordable housing developments that would provide features and services that are correlated with better health. The surprise is all of the different ways that housing can link to better health.

The competition for tax credits in Massachusetts offers a four-point advantage to planned developments with excellent indoor air quality.  Developments that offer stable housing that will be affordable in the long-term have a 52-point advantage in California. And applications to build homes with services, including primary health, dental and preventative health service have a five-point advantage in New Jersey, to name just a few.

Better buildings linked to better health
Residents of communities built with LIHTCs often benefit from the high standard of construction demanded by many state housing agencies.

Simply removing toxins from homes often has a powerful effect. A 1984 report by the World Health Organization (WHO) found that up to 30 percent of new and remodeled buildings had excessive indoor air quality problems due to inadequate ventilation or chemical contaminants.

“We all know that living in quality affordable rental housing can significantly reduce asthma in kids – one of the leading reasons children visit the ER and miss school,” says Eileen M. Fitzgerald, president of Stewards of Affordable Housing for the Future.

Newer sustainable design standards go further to make sure living spaces have fresh air and avoid building materials, like plywood and carpeting that give off unhealthy gases. Twenty states now integrate the Enterprise Green Communities Criteria into their competition for LIHTCs, according to a count by CSH.

“In most states, green building has been increasingly required or incentivized,” says Ahrentzen.

State housing officials are also tailoring their LIHTC competitions to promote good health. For example, the preferences and point system in Georgia’s qualified allocation plan were heavily influenced by a health impact assessment (HIA) conducted by the Georgia Health Policy Center. As a result, applications to build affordable housing in Georgia get extra points in the LIHTC competition if they have features, such as locations within walking distance of services and amenities.

“Agencies’ interests in and use of HIAs to inform housing decisions have grown in recent years,” comments Robert Friant, managing director of communications for CSH. Between 2012 and 2014, 17 housing Health Impact Assessments were completed or underway, up from just one completed between 2002 and 2004.

“We anticipate an increase in the number of states adopting and awarding incentives to developers with proposals that emphasize health services, amenities and attributes,” says Friant.

Affordability is a health issue
Housing can also be healthier for residents simply by being less expensive relative to their income. People who can’t reasonably afford the cost of their housing can be forced to scrimp on other basic needs, such as food and healthcare.

Many states, including New York and California, reward properties that target people earning very low incomes.

“When families pay 50, 60 or 70 percent of their incomes for rent, they can’t afford healthy food and medicines, but they also are under tremendous stress every day that often results in poor health outcomes,” says Fitzgerald.

Residents who struggle to pay rent may also be threatened by eviction or forced to move.

“You are going to have better health outcomes if you have stable housing,” affirms Jennifer Schwartz, assistant director for tax policy and advocacy for the National Council of State Housing Agencies.

Housing and services help residents stay healthy
The services that low-income residents receive at their affordable housing communities can also have a significant effect on their health.

Dozens of states now recognize the clear benefit of providing services and permanent supportive housing to chronically homeless people who struggle with issues that can include addiction and mental illness.

“Supportive housing is having an impact because it is getting people off the street. We all know that living on the street, people have higher health care costs,” says Amanda Saul, senior program director for Enterprise Community Investments.

However, affordable housing paired with health services also provided health benefits to low-income people who had less intensive needs.

“It was a little bit of a surprise,” says Saul. “It’s about prevention and learning to use the right kind of care.”

“My theory is that when you have stable housing that you can afford, it gives you the space so that you can plan that doctors appointment and think about what your kids need, instead of reacting to emergencies,” says Saul.

For example, health services paired with affordable housing can significantly increase access to primary care and reduce emergency department visits, according to a study by Enterprise Community Investments and the Center for Outcomes Research and Education (CORE).

The study examined Medicaid reimbursement for 1,600 new residents at service-enriched affordable housing communities in the Portland, OR, metropolitan area.

These residents used their primary care physicians 20 percent more and they used the emergency room 18 percent less in the year after they moved into affordable housing, compared to the year before.

“People in affordable housing are more likely to use their primary care doctor and less likely to use the emergency room,” says Saul, author of the study for Enterprise.

The Medicaid health care costs for these residents also dropped an average of 12 percent in the year after they moved in, compared to the year before.

“It’s about people using the right kind of medical care, which is often cheaper than waiting until they have an emergency,” comments Saul.

State health officials in a few states, like Oregon, recognize the savings that housing combined with health services can provide.

“We do have the ability to use Medicaid funds more flexibly in Oregon to cover the cost of providing community health workers and some of the nurse practitioner visits to affordable housing sites,” says Saul. “It has to do with having services on-site or having intentionally coordinated services offsite.”

Savings for seniors healthcare
The benefits of health services are especially clear for elderly residents.

“Enabling seniors to live independently in affordable housing with some services significantly reduces the time, if at all, that they will spend in nursing homes,” says Fitzgerald. “That saves many taxpayer dollars since the cost of housing with services is substantially less than nursing homes.”

For example, Vermont’s SASH program connects seniors with healthcare services in their homes. The annual Medicare costs of affordable housing residents in the program for three years slowed by more than $1,500 per resident on average, according to an analysis by the Center for Applied Research at LeadingAge.

“That’s real money,” says Linda Couch, director of housing policy for Leading Age. “Soon, the federal government will no longer be able to ignore the massive savings potential on the health side to providing and coordinating services within the affordable housing platform.”

LeadingAge research also found an 18 percent decrease in hospitalizations when the senior affordable housing property has a service coordinator.

Easing the strain of high housing costs can also improve the health of seniors. For example, severely cost-burdened households aged 50 and over in the bottom expenditure quartile spend 43 percent less on food and 59 percent less on healthcare compared with otherwise similar households living in housing they can afford, according to the Harvard Joint Center for Housing Studies.

More than half of all state housing agencies offer extra points in the competition for LIHTCs or set-asides of LIHTCs to applications to build affordable housing for seniors, according to LeadingAge. A smaller, but significant, number of states also give extra points to applications for seniors developments that would include health services.

Most state and municipal housing agencies post the qualified allocation plan for their funding competitions online: https://www.ncsha.org/housing-help.