What’s Bad for your Wallet Might Be Bad for your Health: The Negative Health Consequences of Spending Too Much on Housing

by Martha Fedorowicz

In May 2018, Kaiser Permanente, the largest private integrated care system in the US, announced that it would invest $200 million through its Thriving Communities Fund to address the affordable housing crisis in California’s Bay Area. Then in 2019, Kaiser announced that it used the fund to purchase an apartment building in a diverse but quickly gentrifying neighborhood in Oakland with the express purpose of making repairs and upgrades to improve health in the building and to ensure affordability to current residents. If Kaiser wanted to improve health, why wouldn’t it focus solely on housing upgrades, which research shows can produce positive health outcomes (PDF)? Why would it include maintaining affordability in its mandate?

Although we’ve known that poor housing quality can have negative impacts on a person’s health, a growing body of evidence also ties housing unaffordability to negative health outcomes. A few hospitals and health systems are reorienting their investments around this new evidence by funding affordable housing, hoping to improve outcomes of the people and communities they serve.

While Kaiser’s large housing affordability investments may seem far removed from its health focus, it is part of a growing movement by hospitals, health systems, and other anchor institutions to invest in improving social determinants of health—like housing and neighborhoods—by rehabilitating housing and by increasing the supply of below-market rents.

So how does unaffordable housing affect health?

• Inability to pay rent each month can force families to have high rates of residential mobility. Frequent moves and housing instability have been linked to gaps in insurance coverage among children, not having a usual source of care, postponing needed medical care and medications, increased emergency department usage, and increased hospitalizations. It is also associated with poor health among young children, increased use of illicit drugs before age 16, higher levels of behavioral and emotional problems among children, increased teenage pregnancy rates, and adolescent depression.
• Families who spend a higher proportion of their income on housing costs spend less on other needs. This can cause food insecurity and can lead families to decrease expenditures (PDF) on health-promoting activities, such as healthy eating, exercise, and preventative care, and to postpone medical or dental care. A recent survey by Enterprise Community partners found that among severely cost-burdened survey respondents who spend more than 50 percent of their monthly income on rent, 83 percent prioritize paying rent before anything else, compared with 1 percent who prioritize health care costs.
• Not having enough money to pay rent or being behind on payments can also have negative mental health outcomes. A 2012 study by Burgard, Seefeldt, and Zelner found that people who were behind on their rent or mortgage payments or who were in foreclosure were more likely to meet the criteria for depression, had a higher likelihood of reporting fair or poor health on self-reported surveys, and were more likely to have had a recent anxiety attack.
• Unaffordable housing means that people will look to rent or purchase whatever housing they can afford, which is often poorly maintained, of lower quality, or in neighborhoods with fewer opportunities. Poor housing quality is associated with poor respiratory health and high rates of asthma, morbidity among the elderly, lead poisoning among children, increased risk of cardiovascular disease, and injury. (To learn more about the links between neighborhood physical environments and health, see Where We Live Matters for Our Health: Neighborhoods and Health (PDF).)

This growing body of evidence linking unaffordable and poor-quality housing and negative health outcomes is shifting how hospitals and health systems see their roles in improving community health. Not only are more hospitals starting to invest in housing, they are also looking beyond housing rehab and upgrades to maintaining affordability for low-income residents.

For more information on what hospitals and health systems can do to invest in housing, stay tuned for the Urban Institute’s forthcoming Health Systems, Hospitals, and Housing Investment Toolkit to be released summer 2019.

Photo by Wondervisuals/Shutterstock