Q&A with Rebecca Morley on How HIAs are Changing Affordable Housing

The Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts, is a national initiative designed to promote the use of health impact assessments (HIAs) as a decision-making tool for policymakers. HIAs help identify and address the health impacts of policies and decisions in non-health sectors. For instance, how might building a major roadway affect the health of area residents? Or how might how the site of an affordable housing development be influenced by health considerations?

Rebecca Morley, the former head of the National Center for Healthy Housing, recently became the director of the Health Impact Project, bringing her expertise in housing to this important area of work.

How Housing Matters spoke with Morley about how HIAs can improve housing and health in the United States. Her comments were edited for length and clarity.

How Housing Matters: Tell us about your background in housing and how that perspective influences your work and thinking at the Health Impact Project?

Rebecca Morley: What I bring is a window into how people in sectors outside of health view the tool of HIA, and how we can make that tool more practical, more affordable and more accessible to more people in order to really ramp up its use.

HHM: What are some of the HIAs applied on housing issues that are beginning to move the needle?

Morley: There are 345 completed HIAs in the United States. A recent analysis by the National Center for Healthy Housing, found that 40 of these HIAs were in the housing space—less than 10 percent. It’s not the most developed of all of the sectors for which HIAs have been done, but it’s definitely emerging.

A housing HIA that is a really good example is one from the Bay area. Developers were building an affordable housing complex near a highly polluted traffic area. Without the HIA, the windows and ventilation system would have ended up on the traffic side of the building. With a small tweak to the design, they ended up putting the windows and system facing the courtyard in the interior space, which resulted in residents facing green space while being exposed to less noise and pollution. So this particular HIA changed the way that the development was done, but even almost more importantly it changed the way that the developer thought about health.

HHM: Is it a relatively new strategy for developers to look at housing from a health perspective?

Morley: “Housers” and community developers have, for a long time, thought that they were delivering a health benefit by providing shelter. It’s just not been explicitly discussed that way. The emergence of HIAs as a tool has finally given them some recognition for that work, but also let them know that there’s much more that can be done, such as job training, resident empowerment and resident engagement. They can also look at the quality of housing materials being used and whether residents have access to green parks and services. Housers have been good public health practitioners for a long time, and now we’re expanding that role and naming it.

HHM: The country doesn’t have enough affordable housing, or adequate funding, to help all those in need of a safe, permanent home. Can HIAs change that?

Morley: The housing community is constantly asking how to increase the overall pie for affordable housing, and there’s always a tension about if you do more to housing with respect to health, are you actually decreasing available funds for the actual homes? It’s a real concern. Developers are concerned that if we put in a more expensive ventilation system, for example, or add more amenities, that’s going to mean the construction of fewer units. So the question is where can we find more resources to do the health piece? Do you make the health piece more integrative so that it doesn’t cost more?

This is where developers see the Affordable Care Act as a possible opportunity that’s untapped, though it’s unproven so far. Demonstration projects have shown some decreases in spending, such as Medicaid costs when you house chronically homeless people. We need more of those demonstrations, but we also need to be thinking not just about how we’re treating sick people with the housing intervention, but how we promote preventive health.
That piece has not been fully developed. It might mean a hospital investing in neighborhood revitalization as part of their community benefits requirement under the ACA, or investing in some of the nice amenities that we need as part of having a complete neighborhood. Maybe it’s energy efficiency, which we know helps people save money and provides a more comfortable home — too hot and too cold are stressors that can contribute to poor health. And we do see hospitals beginning to rethink their community investments.

HHM: What are the elements of the strongest HIAs?

Morley: You’ve got to have great stakeholder engagement. You’ve got to have a very ripe decision and a decision-maker that’s actually interested in the report. If you’ve got a decision-maker that says, “Don’t bother doing this, we’re not going to take it no matter what you do or say,” you’ve got a problem at the front end. To get to a great HIA, the practitioners also have to make sure that the recommendations are evidence-based. Having science to support the HIA is everything to us because we are selling this to decision-makers as a piece of evidence. It’s a piece of data for them, and if it’s not robust then we’ve really failed.


Correction, 5/1/15: The original post listed the HIA analysis as having been completed by the Center for Community Health and Evaluation with support from the Robert Wood Johnson Foundation. The analysis was actually done by the National Center for Healthy Housing.