Social Welfare to of the housing choice policy.
Making (and Framing) the Connection Between Housing Affordability and Health
Follow-up on: Fenelon A, Mayne P, Simon AE, et al. Housing assistance
programs and adult health in the United States. Am J Public Health. 2017;
107(4):571–578.
In 2017, Fenelon et al. dem- onstrated significant health im- provements among low-income adults receiving housing assistance from the Department of Housing and Urban Development (HUD). Using multivariate models, the investigators examined self- reported health status and levels of psychological distress among adults who were currently receiving HUD housing assistance (including public housing, housing choice vouchers,andmultifamilyhousing) and adults who were scheduled to receive housing assistance within the next two years.1 Adjusting for all other factors, the authors found that housing assistance was associ- ated with improved health status and psychological well-being amongcurrent public housing and multifamily housing residents relative to those who were on a waitlist.1 Notably, their findings indicate the high value of HUD housing assistance programs with respect to recipients’ physical and men-tal health.
Such evidence helps reify the link between housing afford- ability and health, a link that recent research suggests may be recognizedbythepubliconlywhen it is explicitly communicated.2
Because the public more readily perceives housing as an essential good,similartofoodandclothing, robust communication strategies are needed to help make the connection between housing and health more salient in the public’s
mind. Framing housing afford- ability as a fundamental contrib- utor to health may be central to overcoming public resistance to inventive and targeted solutions that increase housing affordability.
Furthermore, espousing the connection between housing and health may offer key stake- holders, such as policymakers, developers, and landlords, new and productive ways of thinking about the collective effects of reduced housing burden. Given their magnitude, how might the findings of Fenelon et al. be operationalized within a message frame generating awareness about the housing–health con- nection as well as garnering support for housing affordability policies and interventions?
USE OF EVIDENCE AND FRAMING IN DECISION- MAKING
Research shows that the use of evidence alone in messaging is ineffective in moving public opinion and that policymakers tend to rely more heavily on values and personal anecdotes than available evidence.3 The evidence emerging from the Fenelon et al. study should be especially perti- nent to today’s decisions regarding support for existing housing in- vestments in the United States. Yet, the White House’s recently proposed fiscal year 2020 HUD budget calls for severe cuts to programs that serve our nation’s most vulnerable communities, including millions of low-income individuals, elderly people, families
with children, people with dis- abilities, and veterans.
Overall, recommended fiscal year 2020 funding for HUD is 18% lower than what Congress allocated to HUD in 2019.4
More specifically, the proposed budget recommends the elimina- tion of the public housing capital fund,4 which oversees the devel- opment, financing, and moderni- zation of public housing, a housing assistance program that Fenelon et al. showed to be significantly associated with better health.
The White House’s proposed budget does recommend a slight funding increase for the Office of Lead Hazard Control and Healthy Homes. However, it is important that the public un- derstand, and that we effectively convey, the entirety of how housing functions to affect health. Although eliminating lead exposure is a pressing con- cern, so too is the need to increase the stock of affordable housing to minimize the adverse health effects of housing burden and to repair deteriorating housing conditions that contribute to illness and neighborhood disadvantage; such concerns are difficult, daresay impossible, to remedy without financial guarantees. Policymakers and advocates who are committed
to safeguarding the nation’s housing safety net would be re- miss to overlook or only partially acknowledge the housing–health connection in their opposition to the proposed budget.
HOUSING AFFORDABILITY AS A DETERMINANT OF HEALTH
Fenelon et al. also noted that their findings may be of special interest given the recent attention on improving health by targeting “community, social-structural, and environmental factors.”1(p578)
Indeed, some large health initia- tives are now focusing on housing affordability and availability as a core program component. Kaiser Permanente, for instance, recently launched Thrive Local, a network of community care services that address the social determinants of health, including access to afford- ablehousing.5 Themessagebehind Kaiser’s initiative is relatively straightforward: the network’s comprehensive services are intended to achieve total pa- tient health.
Another initiative comes by way of the Centers for Medi- care and Medicaid Services (CMS). In its recognition of the housing–health connec- tion, CMS offers Medicaid re- imbursement to support states’ efforts to provide supportive housing services for populations living with disabilities, chronic conditions, substance use disor- ders, and mental health issues.6
ABOUT THE AUTHOR The author is with the Department of Health Policy and Administration, Pennsylvania State University, University Park, and is a fellow with the FrameWorks Institute, Washington, DC.
Correspondence should be sent to Selena E. Ortiz, PhD, MPH, Department of Health Policy and Administration, Pennsylvania State University, 604N Ford Building, University Park, PA 16802 (e-mail: seortiz@psu.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
This editorial was accepted June 8, 2019. doi: 10.2105/AJPH.2019.305227
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1168 Editorial Ortiz AJPH September 2019, Vol 109, No. 9
One of the guiding principles undergirding this initiative is in- novation, a term that signals growth, creativity, and big ideas.
REINFORCING THE HOUSING–HEALTH CONNECTION
Despite these considerable endeavors, adopting purposive communication strategies to widen public support for policies and interventions that aim to decrease housing burden—as well as public support for repealing or discarding those that stymie progress—remains a priority. Recently, the FrameWorks In- stitute embarked on an extensive undertaking to develop and test a number of strategic framing techniques that could be deployed to advance housing affordability efforts. The institute’s work reveals a number of communication ap- proaches built upon a “fairness frame” that may help avoid triggering unproductive ways of thinking about housing affordabil- ity (e.g., “not in my backyard”).7
Oneapproach,forexample,isto developmessagesthatcontextualize housing affordability as a societal
issue instead of an individualized problem. Because concern re- garding affording one’s home is ubiquitous, the FrameWorks In- stitute found that the public can more easily coalesce around the idea that affordable homes are something that everyone should be abletoobtain.7Anotherapproachis to construct messages focusing on the positive benefits that re- sult from expanding housing affordability (e.g., health and well- being and more stable communi- ties) rather than messages that focus only on the negative consequences of inaction.7 As Fenelon et al. posit (and recommend as an area for future research), the improved health status and decreased stress experienced among residents in public and multifamily housing units may have resulted from the presence of social networks of support, a mechanism that could potentially be highlighted in future communication.
CONCLUSIONS Ensuring effective oversight and
support of evidence-based policies and interventions that reduce or eliminate housing burden (e.g.,
HUD’spublichousingprogram),as well as the success of endeavors that integrate patients’ housing needs within their care plans (e.g., Thrive Local), essentially depends on co- gent understandings about the housing–health connection. The findings of the Fenelon et al. study underscore the critical role that HUD programs play in reducing the physical and psychological harms and stress that accompany uncertainties about housing.
Communicating these findings in ways that make the housing– health connection clear to the public—such as incorporating storytelling to highlight the health advantages experienced by hous- ing residents, integrating universal values (e.g., fairness), and calling attention to the collective benefit of housing affordability—may help build policy support and counter political attempts to de- stabilize housing programs. To be sure, raising consciousness and appreciation of the housing– health connection must be a public health priority if all of our communities are to have fair and equal opportunities to attain healthy and secure lives.
Selena E. Ortiz, PhD, MPH
CONFLICTS OF INTEREST The author declares no conflicts of interest.
REFERENCES 1. Fenelon A, Mayne P, Simon AE, et al. Housing assistance programs and adult health in the United States. Am J Public Health. 2017;107(4):571–578.
2. Ortiz SE, Johannes BL. Building the case for housing policy: understanding public beliefs about housing affordability as a key social determinant of health. SSM Popul Health. 2018;6:63–71.
3. Gollust SE, Kite HA, Benning SJ, Callanan RA, Weisman SR, Nanney MS. Use of research evidence in state policy- making for childhood obesity prevention in Minnesota. Am J Public Health. 2014; 104(10):1894–1900.
4. National Low Income Housing Co- alition. Analysis of President Trump’s FY2020 budget request. Available at: https://nlihc.org/resource/analysis- president-trumps-fy2020-budget- request. Accessed June 23, 2019.
5. Kaiser Permanente. Kaiser Permanente launches social health network to ad- dress needs on a broad scale. Available at: https://permanente.org/kaiser- permanente-launches-social-health- network-to-address-needs-on-a-broad- scale. Accessed June 23, 2019.
6. Cassidy A. Medicaid and permanent supportive housing. Available at: https:// www.healthaffairs.org/do/10.1377/ hpb20161014.734003/full. Accessed June 23, 2019.
7. O’Neil M, Sweetland J. Piecing It Together: A Framing Playbook for Affordable Housing Advocates. Washington, DC: FrameWorks Institute; 2018.
Population Health Science Bearing Witness: A Public Health of Consequence, September 2019
See also Himmelstein, p. 1243; Kobayashi et al., p. 1236;
Siegler et al., p. 1216; Muldoon et al., p. 1280; and Rodrigue
et al., p. 1273.
Science is concerned with studying the world through ob- servation and experiment. The data that emerge from science lead to knowledge about our physical and social world. That knowledge is, in and of itself, a worthwhile
pursuit—it elevates us as humans, creates an understanding of the forces around us, and frees us from superstition and magical thinking. Some of the knowledge that comes from our scientific enter- prise also leads directly to action,
suggesting interventions that we can implement to improve the human condition.
Population health science is anchored in a universal human value—health—that is, itself, a foundational human condition that we wish to improve. As such, population health science is in- timately linked with its opera- tional arm—public health—and is more concerned with the pragmatic implications of its
ABOUT THE AUTHORS Sandro Galea is with the School of Public Health, Boston University, Boston, MA. Roger D. Vaughan is with The Rockefeller University, New York, NY, and is an AJPH associate editor.
Correspondence should be sent to Roger D. Vaughan, DrPH, MS, The Rockefeller Uni- versity, 1230 York Ave, Box 327, New York, NY 10065 (e-mail: roger.vaughan@ rockefeller.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
This editorial was accepted June 13, 2019. doi: 10.2105/AJPH.2019.305234
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September 2019, Vol 109, No. 9 AJPH Galea and Vaughan Editorial 1169
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