How healthcare delivery organizations are moving upstream to tackle housing justice

Imagine you’ve been sick for a while and then your doctor finds a medicine that will help you get better. But when you arrive at the pharmacy, the medication is out of stock. It’s actually out of stock at every nearby pharmacy because of policies that intentionally distributed the drug to other communities instead of yours. 

For many people, that’s the reality of safe, affordable housing in the United States. It’s critical for good health, but because of historical and contemporary housing policies that perpetuate racial and economic inequities, it is perpetually out of stock for a large percentage of Americans.

Given this reality, healthcare delivery organizations increasingly screen patients for signs of unsafe housing, eviction risk, and difficulty paying rent. They also build referral networks with community-based organizations to connect patients with housing navigation and other tenant support services. Navigating housing insecurity at an individual level is important. However, health care has an opportunity—and an imperative—to deepen its health equity impact by going beyond housing support for individuals to advance housing justice for whole communities.

The Urban Institute defines housing justice as “ensuring everyone has affordable housing that promotes health, well-being, and upward mobility by confronting historical and ongoing harms and disparities caused by structural racism and other systems of oppression.” In other words, housing justice involves addressing the root of the problem by changing the unjust policies and systems that led to housing inequities in the first place. And according to the Right to the City Alliance, housing justice requires solutions that are community controlled, affordable, inclusive, permanent, and sustainable.

Housing justice isn’t only about stocking the existing affordable housing pharmacy. It is about re-building what that pharmacy looks like and how it works so that it is equitable for everyone. As anchor institutions in their communities, healthcare delivery organizations wield a lot of economic power and influence and thus have the ability to help reshape the future of housing in their communities by addressing issues at the structural level. But to ensure changes don’t deepen existing inequities, it’s critical that healthcare delivery organizations work alongside and follow the lead of community groups working to achieve housing justice.

Keeping those principles in mind, here are four ways healthcare delivery organizations can move upstream to work at a structural level to improve the quality, availability, and accessibility of safe, healthy, affordable housing.

• Work with power-building community groups that are leading locally to advance just housing policies. People closest to a problem are best positioned to inform and design solutions, and an important part of working toward housing justice is shifting power toward groups that have been historically marginalized. Healthcare delivery organizations can do this by following the lead of local community groups and providing them with funding, sharing de-identified healthcare utilization trend data, amplifying organizers’ stories and issue-framing, participating in local housing coalitions, and advocating for policy changes initiated by those community groups. For example, the Cottage Grove Collaborative in Greensboro, North Carolina, worked to map and rehabilitate more than 175 substandard housing units in the city, successfully reducing emergency department admissions for childhood asthma. For its part, Cone Health, a local health system, contributed critical data that allowed asthma admissions to be mapped against city housing data. Cone Health’s participation in this community-led work as well as in local coalition meetings led to more trusting relationships and continued partnership between the community and the health system. See Human Impact Partner’s primer on Power, Housing Justice, and Health Equity for strategies that healthcare delivery systems can use to successfully engage with community organizers. 
• Invest in place-based solutions. Communities and neighborhoods have different histories of investment and disinvestment in resources like transportation, public parks, schools, and housing. As a result, inequities are often geographically distributed, so solutions must be too. One way to do this is through Health Equity Zones (HEZs). Every HEZ is a designated geographic area where a community identifies and eliminates specific health inequities, working with a coordinated set of institutional partners—including healthcare delivery organizations—to effectively broaden and deepen their impact in a specific place. Because problems and solutions are identified by communities themselves, HEZs shift power and resources to those communities and de-emphasize historical systems of power. The Rhode Island Department of Health, where the HEZ model originated, currently supports 15 HEZ collaboratives with more than $30 million in public health funding. These collaboratives choose to tackle a wide range of issues, many of which relate to housing justice. A HEZ in Newport, Rhode Island, conducted a racial-justice and economic inclusion audit of the city’s proposed land use and economic development plan in its North End neighborhood. It launched a project to work with residents to develop an equitable development plan for the community to address multiple public- and private-sector development projects that threaten the North End with gentrification and displacement. Healthcare delivery organizations looking to do place-based housing work can learn from the HEZ model. 
• Partner with local legal aid organizations to address housing issues from ‘patients-to-policy.’ Many of the problems that make housing unsafe or unhealthy to live in or that put people at risk of losing their housing altogether can be addressed with help from a lawyer. For example, a landlord might refuse to make a legally required repair to a rental unit or provide a tenant with a disability accommodation. A landlord could also illegally threaten to evict a tenant from their home. In each of these situations, a lawyer might be able to enforce a tenant’s rights and improve or protect their housing. Nearly 500 healthcare delivery organizations have medical-legal partnerships (MLPs) where legal aid lawyers work upstream as part of the healthcare team to address health-harming legal issues. This includes Kaiser Permanente, which, in 2021, invested in housing-focused MLPs in five markets, and is poised to deepen its commitment to building legal aid’s capacity for this work. Medical-legal partnerships often bridge individual- to structural-level interventions by identifying trends in the health-harming legal issues that patients face, tracing the problems to a specific policy failure, and addressing it directly. For example, after seeing many patients with lead poisoning blocked from transferring their federal housing assistance to a new home, the MLP at Erie Family Health Centers in Chicago, Illinois, built a multi-state coalition that got the U.S. Department of Housing and Urban Development to update its federal lead regulations. 
• Directly build or rehabilitate local affordable housing units. Housing is considered affordable when a household spends no more than 30% of its income on it, but only 34 affordable and available rental homes exist for every 100 extremely low-income renter households in the United States. Housing assistance programs, like Section 8, along with federal low-income housing tax grants, help with affordability, but neither program has enough funding to help everyone who qualifies. Healthcare delivery organizations can be well-positioned to construct and rehabilitate housing units in their communities, and can fill in the financing gap by donating or swapping land with housing developers, providing direct loans for construction or renovation costs, or enhancing credit. There are several examples of healthcare delivery organizations doing this. Since 2008, Nationwide Children’s in Columbus, Ohio, has done full-gut renovations, new builds, and provided residents with home repair grants on more than 703 homes. In 2016, six healthcare providers in Portland, Oregon, invested $21.5 million to construct three buildings in the city with almost 400 living units for people who were homeless or at risk for homelessness. Each of the three buildings was designed with a different population in mind, including one for people displaced by gentrification. And the Healthcare Anchor Network, a national coalition of more than 70 health systems, invested $450 million in affordable housing projects between 2017 and the end of September 2022. The Urban Institute released a guide to help nonprofit hospitals and health systems understand the benefits of investing locally in affordable housing and how to plan for it.

Kate Marple is a Boston-based writer who specializes in helping nonprofit, health care, and legal services organizations develop practices to ensure that the stories they tell are shaped by and benefit people directly impacted by the issue(s) those stories are about. Her website is https://whotellsthestory.org. 

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