Looking Toward the Future: Healthy Parnerships Pay Off

By Gail Gonzales for Texas Affiliation of Affordable Housing Providers

When families spend 30-50 percent of their income on rent and utilities, they’ll make sure food is on the table and a roof is over their heads. Typically, they’ll also forego doctor visits, dental care, medicines, and more. This housing insecurity creates a constant, toxic stressor for a growing number of families. Constant worry about providing the basics for living creates a cascading effect producing more emergency room visits, dire health crises, and a vicious cycle of uncertainty for home budgets, steady work, and family health. A 2017 study by the National Bureau of Economic Research found that "increasing access to housing subsidies led to reductions in hospitalizations and emergency room visits for children” and also found a link between stable housing and improved mental health. Hospitals and taxpayers ultimately pay the financial price for failure to manage acute and chronic care effectively.

Healthy housing is high quality, achieves affordability by design and not by age, and includes proximity to parks, grocery stores, transportation, and many other amenities and services. Much of this is achieved thanks to a significant change to affordable housing development pioneered by President Reagan in 1986 through the introduction of housing tax credits. As a result, today's

affordable housing is a far cry from the public housing of the 1960s, ’70s, and ’80s. Tax credit developments built today are beautiful, well-maintained properties that residents are proud to call home. Housing that serves the needs of working families, retirees, and the elderly is now not just a goal but a mandate by the state. Unfortunately, the current affordable housing shortage in Texas means that only 25 of every 100 extremely low income residents in need can secure affordable housing, and an even smaller percentage end up in ideal, healthy housing communities.

Quality Housing Is a Social Determinant of Health

Privately owned housing that is affordable due to its age, insufficient management, investment, and oversight is rife for lead poisoning, respiratory illnesses, cancer, and unintentional injuries or death. These conditions result in poor school attendance and performance, missed workdays for parents, and the loss of loved ones disproportionately affecting communities of color and low-income families. Still, some don’t understand or believe there is a direct link between health and housing or that it can’t be proven – unless they work in healthcare.

There are four pathways where housing and health intersect, and the former affects the latter: housing stability, affordability, the quality and safety of the home, and the neighborhood. The National Center for Healthy Housing (NCHH) noted that 37 percent of Texas housing was built before 1978 and, to this day, may contain leadbased paint causing neurological deficits, anemia, abnormal vitamin D metabolism, nephropathy, hypertension and reproductive abnormalities. As recently as 2019, nearly 5,000 Texas children tested had elevated blood lead levels. The Panhandle and western areas of Texas continue to represent the highest risk for Radon levels averaging twice the EPA action level. Radon gas typically enters a home through the foundation, causing lung cancer.

Those in the Lowest Income Quintile Have Nearly 3X Greater Risk of Heart Disease

These conditions where people are born, live, learn, work, play, and age are social determinants of health. Statistics on Social Determinants of Health reveal:

+ Individuals in the lowest income quintile have nearly three times greater risk of developing heart disease than those in the highest income quintile.

+ Lack of access to transportation can result in missed medical appointments, difficulty accessing healthy food options, and limited job opportunities.

+ The landmark federal mobility program Moving to Opportunity demonstrated that adults who used vouchers to move to better-resourced neighborhoods experienced a lower prevalence of diabetes, extreme obesity, physical limitations, and psychological distress versus those who did not move.

Creating Vitality and Community

Keep Building and Provide More Opportunities: Redefining "high-opportunity" areas to focus on essential amenities rather than cost-driving factors would help provide more much-needed healthy housing in Texas. Lawmakers could let cities with robust affordable housing policies make the final decisions on their planning and eliminate regulations such as the "two-mile, same year" and "census tract rules" that discourage high-quality affordable housing where it is needed. Supplementing the Housing Tax Credit by offering subsidies through federal programs like HOME Investment Partnership, a Community Development Block Grant, or the National Housing Trust Fund can help build more quality affordable housing in these areas and reduce regulatory costs. Streamlining the application process for these programs would make it easier for developers to participate. Additionally, affirmative marketing policies are needed to promote the availability and educate income-eligible families about high-opportunity homes and encourage them to apply.

In an interview with healthcare and development leaders, CVS Health Associate Vice President & Head of Impact Investment Strategy Keli Savage noted that she has "been hoping Congress will soon provide incentives or a special bonus for developers who incorporate a healthy housing component.” Austin-based, Megan Lasch, president of O-SDA Industries, LLC, shared that, “Texas just passed a bill creating a new state tax credit, and the buyer for those would mainly be insurance companies. It’s the third time the bill has been presented, and while it just gets our toe in the water with a $25 million credit, it’s a start.”

A national housing study suggests that, as an easy first step, housing providers could “look up the local tax-exempt hospital’s Community Health Needs Assessment (CHNA). Its CHNA will illuminate how much the hospital has thought about housing as a social determinant of health and serve as a useful benchmark to guide initial conversations.”

Follow the Model of Successful Mobility Programs: The Housing Choice Voucher Program in Dallas is notable for helping families find rental units in high-opportunity areas and helping pay moving costs and security deposits. The Dallas Housing Authority Dallas has reported significant success in moving substantial numbers of families to higher-opportunity neighborhoods. Families say their children are doing well in school, and their neighborhoods are more peaceful. However, it’s often the case that vouchers expire before high-opportunity relocations become available. Extending voucher deadlines per typical waiting lists, source of income protections, and pay-to-stay policies could help.

The Future of Health & Affordable Housing: Encouraging Healthcare and Developer Partnerships

Healthcare organizations are increasingly looking for ways to reduce medical claims, and affordable housing stands out as ripe for investment. That's why some of the largest organizations like Aetna, United Health Group & Elevance (formerly: Anthem) have invested more than $2.5B in the past two decades and have increased their annual investment volumes over the past few years. Other healthcare companies like Humana are taking notice and building out their own affordable housing investment platforms.

CVS Health: Leading By Example: CVS Health recognizes the direct link between housing, improved health outcomes and lowered healthcare expenditures. Since 1997, CVS Health and Aetna, a CVS Health company, have invested more than $1.5 billion in affordable housing and community initiatives. Aetna has invested nearly $150 million in affordable housing in Texas (more than half of that in the last four years) and provides numerous programs and services to residents to address other social determinants of health such as food insecurity, lack of transportation and barriers to accessing quality healthcare.

Home-based care partnerships between healthcare companies and developers are more important than ever. Project Health, a free mobile CVS Health program, offers blood pressure, cholesterol, glucose level and body mass index screenings for early detection of chronic conditions such as diabetes, hypertension, and heart disease to affordable housing communities nationwide. Recently, assessments were added to help identify people requiring additional evaluation for depression. Following these screenings, participants meet with a nurse practitioner for low or no-cost treatment referrals and advice on follow-up care. Walter D. Woods, Vice President of Philanthropy at CVS Health said they are “addressing social determinants of health at the community level, which is where we can make a meaningful and lasting impact.”

In addition, CVS Health has an entire team within its Workforce Initiatives Program partnering with state and federal workforce agencies as well as developers to provide innovative employment services and training to underserved communities. The Workforce program has taken more than 120,000 people off of public assistance, breaking the cycle of poverty which often spans generations. Recent data on Aetna Medicaid members in Texas revealed those living in affordable housing experienced a 42 percent decrease in per member/per month costs, a 400 percent increase in mental health outpatient visits (over hospitalization), and a 20 percent decrease in emergency department per member/per month costs. Many other case studies have shown similar statistics. CVS Health’s Keli Savage hopes that over time, they can, “connect all the vast amounts of data to look at prescription adherence, shopping habits, primary care usage, and chronic disease management over a five-year period and be able to show how much that adds up in tax savings.”

AETNA HAS INVESTED NEARLY $150 MILLION IN AFFORDABLE HOUSING IN TEXAS

Housing providers have a key role to play in data collection too, but becoming HIPAA compliant and tracking sensitive health data is not an appropriate role or expectation. If affordable housing providers report resident move-in dates, a health insurer could conduct a cost study analysis to compare the pre- and post-move-in healthcare claims data. For example, their data may indicate a reduction of emergency room visits and increased primary care visits. Likewise, healthcare players new to affordable housing may not care to learn the complexities of tax credit financing and architecture and need to partner with qualified consultants or non-profit organizations.

Megan Lasch of O-SDA Industries noted that, "CVS Health was a stellar partner who went out of their way to provide resources for residents like mobile health checkup buses and wellness checks at the properties in addition to the equity that they provided for the development."

Health Advocate Led Programs

In 2017, Nurses Transforming Healthcare in Spicewood, Texas, providing clinical intake services, conducted a survey and found that 41 percent of patients had significant housing concerns. The survey has continued, and the figure has climbed to 64 percent due to the shortage of affordable homes. Seventy-six percent said they did not go to the doctor as needed due to cost. These findings spurred a pilot program for creating an ecosystem of connected care, community assessment, outreach, education, and programs. The group will publicize success stories from the program to generate public funding support. Community Nurse Navigators will then pull together a wide array of resources into an app the public can easily access.

Anthem, Inc., the parent company of Amerigroup Texas, has invested millions in affordable housing in Texas as part of Anthem and Amerigroup’s commitment to improving lives and communities. The funds, established through investments made to the federal Housing Tax Credit program, and Amerigroup Texas played an important role in helping to direct funds to Texas initiatives. In Kyle, Texas, $55 million of this funding is helping to finance the Balcones Trails complex, a housing development that will feature onsite healthy living resources supported by Amerigroup.

Funding and incentivizing healthy communities by building more high-quality, affordable homes is just a first step. No single entity can tackle the challenges around health and housing alone, but meaningful progress can be made by sharing strengths and resources. Building relationships takes time and the vision of leaders to get people excited about the benefits for everyone. Small collaborations, like data-sharing, are one way to build trust and learn to communicate effectively across industries. If Texas legislators can streamline the process, ease the regulations put in place over the last decade, and consider additional funding mechanisms, health care and housing organizations can house more citizens in need, meaningfully impact their physical and mental health, reduce expenditures and produce better outcomes and cost savings for all Texans.