Author: Heather Wallace, Erin Georgen, and Elizabeth Swenson
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Better Health Together supports housing-first approaches to solving homelessness. We understand that safe and affordable shelter is fundamental to achieving health equity.
The Housing First approach (Heading Home, 2021) prioritizes establishing access to decent, safe, and permanent housing for people experiencing homelessness to ensure the needed stability for improving health, reducing harmful behaviors, and increasing income. Housing is prioritized, but ongoing support and community integration are crucial to success.
The core principles of this framework are that people must have immediate access to permanent housing without housing readiness requirements, the right to some choice and self-determination over where they live and what support they receive, access to recovery orientation that provides them individualized support, and community integration.
Within this model, people in need have:
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Immediate access to permanent housing without housing readiness requirements
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Self-determination over where they live
and what support they receive -
Individualized support for recovery orientation and community integration
Health Impacts of Housing Instability
Stable Housing
Providing stable housing over temporary housing services is vital because of the related health benefits that go along with it. Stable housing ensures a secure, predictable place of their own without restrictions on family makeup, pets, or access to visitors. It also ensures a place to cook and store food, access the Internet, and an address to send/receive mail. Often, homeless services do not provide these types of stability resources for those who need them. Studies have shown that all people need access to stable housing in order to decrease their risk of poor health and health outcomes, especially in the case of young people. Some of these outcomes include the increased risk of teen pregnancy, early drug use, and depression.
Unstable Housing
In contrast, the stress of unstable housing disrupts employment, access to social service benefits, and community (Desmond, 2016), (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services, n.d.). Chronic stress and trauma related to housing insecurity, financial stress, and lack of safety impact the mental health of adults and children (Cutts, et al., 2011). Low-income children who switch schools or residences frequently due to housing instability or homelessness had lower math and reading achievement over time and were less likely to graduate from high school. Residency mobility is a better predictor for children dropping out of school than school mobility or living in poverty. (Voight, Shinn, & Nation, 2012)
Supportive Stable Housing Improves Social Determinants of Health
Quality and Safety
Housing conditions are safe and healthy. Beyond just stability, housing conditions must also be safe and healthy as poor housing conditions can increase healthcare costs and contribute to rehospitalizations (Laphear, Kahn, & Berger, 2001). Environmental and safety issues inside homes such as lead, water leaks, poor ventilation, mold, dirty carpets, and pest infestation all increase health risks for both children and adults. Particularly among elderly populations, exposure to high or low temperatures are correlated with adverse health events, including cardiovascular events. A study showed that children from families In federal programs providing home heating or cooling were at a healthier weight and at less of a nutritional risk than those who were not in the program (Taylor, 2018).
Affordability
Covering monthly housing costs consistently leaves enough discretionary spending. Those who are burdened by rent or housing costs have less discretionary income to spend on healthy food, medical care, medications, which can negatively impact health. They also have less to spend on education, which may allow them to increase their wages and build social mobility. In New York City, families with affordable rent payments were able to increase their discretionary spending by 77% (Taylor, 2018). In Spokane County, approximately 31% of households are rent burdened, meaning they are paying 30% or more of income on housing costs (Federal Reserve Bank of St. Louis, 2022).
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40% of American renters (19 million households) are cost-burdened with rent, paying more than 30% of income on housing costs (United States Census Bureau, 2022).
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18.8 million households were “severely cost-burdened” meaning that they spent more than 50 percent of their income on housing, with much of this burden falling on renters rather than owners.
A lack of affordable housing negatively impacts mental health. The psychological impact of poverty, financial stress, and housing insecurity can increase cortisol and other stress hormone levels. This also affects physical health, as it impacts the health of the heart, digestive, sleep, and other brain functions. (Carrere, Vásquez-Vera, Pérez-Luna, Novoa, & Borrell, 2022)
Residual-income Approach to Measuring Housing Affordability
Accurately understanding the housing cost burdens of each family is essential to determining the scope of housing needs and ensuring that families can afford other nondiscretionary costs, but defining affordability in terms of a percentage of household income creates challenges. The conventional measure of affordable housing (30% of household income) may underestimate the number of households who are burdened by combined housing and transportation costs as well as the number of households in need of quality affordable housing. (Office of Policy Development and Research, 2017)
The residual income approach starts by identifying key categories of essential spending. This includes food, health care, transportation, child care, and a small allowance for other necessary expenses, such as clothing and household goods. This measure incorporates estimates of income taxes owed and tax credits received. This approach recognizes that the necessary basic level of consumption for a household differs according to the number and type of people living in a given household. For example, households with large numbers of young children often have higher costs for health care, food, and child care. The estimated cost of these necessities is subtracted from a household’s income. This calculation produces the amount (and percent) of income that the household members can consistently spend on housing and still have enough left over to cover other necessities. If households spend more on housing than the residual income approach indicates is feasible, they may cut back spending on other essential items. (Herbert & McCue, 2018)
Community
Location facilitates access to social, economic, and health resources. Community impacts health and well-being. Ease of access to a job, grocery stores with nutritious foods, and safe spaces to exercise. Segregation, crime, and social capital also have an impact on a community’s stability (Taylor, 2018).
Benefits of Supportive Stable Housing
Reduces Health Care Costs and Redirects Health Spending
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Housing First Models show improved physical and behavioral health, reduced healthcare costs, and an average net cost offset of $29,000 per person/year for people in stable housing (Taylor, 2018)
Healthcare costs for people experiencing homelessness or in unstable housing are significantly higher than for those with stable housing. Chronic homelessness leads to higher morbidity of physical and mental health, higher mortality rates, and increased risk of trauma. The costs are most prevalent for urgent outpatient care. Housing insecurity is associated with poor health, lower weight, and developmental risk among young
children, which can increase the cost burden of health care over the course of a person’s life (Cutts, et al., 2011).
Access to affordable housing reduces healthcare costs and moves spending from emergency care to primary care for more efficient resource use and overall cost savings (Taylor, 2018). Providing stable housing decreases Medicaid expenditures and emergency room use.
Reduces Criminal-Legal System Involvement
The relationship between homelessness and criminal justice involvement is bi-directional. Being homeless increases the likelihood of criminal legal involvement, and entanglement with the legal system increases the likelihood of a person becoming homeless or experiencing housing insecurity (Augustine & Kushel, 2022). Formerly incarcerated people in the United States are almost ten times more likely than the general public to experience homelessness (Couloute, 2018). This is influenced by many policies and structures in place that make finding long-term housing post-incarceration incredibly difficult. Many people with criminal records face barriers that block them from affordable housing programs, and certain parole and probation association conditions block people from accepting stable housing options with family or friends, even when the family or friend is willing to house them. Criminal record screening policies and stigma trigger stereotypes and discrimination in the rental process, making it less likely that people with criminal records will be considered for tenancy (Evans, Blount-Hill, & Cubellis, 2012).
In the other direction, homelessness increases the likelihood of contact with police and recidivism, making it a risk factor for reincarceration, violations of supervision, and failure to appear. “Anti-homeless” or “Quality of life” policies increase the likelihood that basic survival behaviors of those without housing, such as sleeping, sitting, or lying in certain public places, are criminalized (O’Brien, Farrell, & Welsh, 2019). Criminal and civil punishment of behaviors related to homelessness serves no constructive purpose. Arrests and unaffordable fines make it more difficult for people to regain stable housing. (Tars, 2021)
Improves Psychological Wellness
Why does having a stable, safe, affordable community to call home matter? The conception of “home” is often defined within four separate categories: the environmental psychology it brings about, how it provides for people with their hierarchy of needs, how it builds attachment and memory, and how it supports a sense of identity or community.
Environmental psychologists documented the qualities that homes expose people to, such as noise levels, toxins, emotional climates, and crowding (or its absence). These factors impact all aspects of people’s living experience, from the personal (biological, cognitive, emotional, behavioral) to the social. Stable housing also provides for individuals’ hierarchy of needs, including shelter, nutrition, hygiene, safety, work, and play, as well as their interpersonal needs for contact, communication, companionship, and belonging. This belonging is also initiated by the third category, attachment and memory. Home, for many, is where they forge and nourish human attachment bonds. “Home” also includes primary locations where early memories and emotions result in attachment scripts and their consequences. Finally, “home” is a place where people build and shape their identity and sense of self. Home is a context for imagining possible selves and expressing personal identity. It is a place to practice boundaries, connections, and communication. Home is a physical and metaphorical place where small groups develop and people express and implement values. (Tower, 2021)
Works Cited
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Augustine, D., & Kushel, M. (2022, September 14). Community Supervision, Housing Insecurity, and Homelessness. The ANNALS of the American Academy of Political and Social Science, 701(1), 152-171.
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Carrere, J., Vásquez-Vera, H., Pérez-Luna, A., Novoa, A. M., & Borrell, C. (2022, April). Housing Insecurity and Mental Health: the Effect of Housing Tenure and the Coexistence of Life Insecurities. J Urban Health, 99(2), 268-276. Retrieved from www.ncbi.nlm.nih.gov.
3.
Couloute, L. (2018). Nowhere to Go: Homelessness among formerly incarcerated people. Prison Policy Initiative. Nothhampton, MA: Prison Policy Initiative.
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Cutts, D. B., Meyers, A. F., Black, M. M., Casey, P. H., Chilton, M., Cook, J. T., . . . Frank, D. A. (2011). US Housing Insecurity and the Health of Very Young Children. American Journal of Public Health, 101, 1508-1514.
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Desmond, M. (2016). Evicted: Poverty and Profit in the American City. New York: Crown.
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Evans, D. N., Blount-Hill, K.-L., & Cubellis, M. A. (2012). Examining housing discrimination across race, gender and felony history, Housing Studies. Housing Studies, 34(5), 761-778.
7.
Federal Reserve Bank of St. Louis. (2022, December 8). Burdened Households (5-year estimate) in Spokane County, WA. Retrieved 2023, from FRED: https://fred.stlouisfed.org/series/DP04ACS053063
8.
Heading Home. (2021, February 16). Housing First Model: An Evidence Based Approach to Ending Homelessness. Retrieved 2023, from Heading Home: https://www.headinghomeinc.org/housing-first-model/
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Herbert, C., & McCue, D. (2018, September 26). Is There a Better Way to Measure Housing Affordability?. Retrieved 2023, from Joint Center for Housing Studies: https://www.jchs.harvard.edu/blog/is-there-a-better-way-to-measure-housing-affordability
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Laphear, B., Kahn, R., & Berger, O. (2001). Residential exposures to asthma in U.S. children. Pediatrics, 107(3), 505-511.
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O’Brien, D. T., Farrell, C., & Welsh, B. C. (2019, May). Broken (windows) theory: A meta-analysis of the evidence for the pathways from neighborhood disorder to resident health outcomes and behaviors. Social science & medicine(228), 272-292.
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Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. (n.d.). Housing Instability. Retrieved 2023, from Healthy People 2030: https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/housing-instability
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Office of Policy Development and Research. (2017, August 14). Defining Housing Affordability. Retrieved 2023, from HUD User: https://www.huduser.gov/portal/pdredge/pdr-edge-featd-article-081417.html
14.
Tars, E. S. (2021). Criminalization of Homelessness. Retrieved February 2024, from National Low Income Housing Coalition: https://nlihc.org/sites/default/files/AG-2021/06-08_Criminalization-of-Homelessness.pdf
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Taylor, L. A. (2018). Housing and Health: An Overview of the Literature. Retrieved 2023, from Health Affairs: https://www.healthaffairs.org/do/10.1377/hpb20180313.396577/
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Tower, R. B. (2021, November 4). The Meaning of “Home”: Four approaches to studying “home” show how home affects our experiences. (Sussex Publishers, LLC) Retrieved 2023, from Psychology Today: https://www.psychologytoday.com/us/blog/life-refracted/202111/the-meaning-home
17.
United States Census Bureau. (2022, December 8). More Than 19 Million Renters Burdened by Housing Costs. Retrieved 2023, from United States Census Bureau: https://www.census.gov/newsroom/press-releases/2022/renters-burdened-by-housing-costs.html#:~:text=DEC.,by%20the%20U.S.%20Census%20Bureau.
18.
Voight, A., Shinn, M., & Nation, M. (2012, December 1). The Longitudinal Effects of Residential Mobility on the Academic Achievement of Urban Elementary and Middle School Students. Sage Journal, 41(9), 385–392.
