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Affordable housing is one of the main social drivers of health – the social, economic, and physical conditions that affect how well and how long people live. The U.S. Department of Housing and Urban Development defines affordable housing as housing for which the occupant pays no more than 30 percent of gross income for housing costs, including utilities.

“We well know that affordable housing can make as much of a difference to an individual’s health and their overall community health as having access to a doctor,” said Robin Hacke, co-founder and Executive Director of the Center for Community Investment (CCI), an organization that supports hospitals and health systems to deepen their investments in the social drivers of health with an emphasis on affordable housing. “Housing is the bedrock of community strength and stability,” she said, “and what we're seeing right now is that the pressure on housing prices and housing costs is causing many families to experience housing instability or even homelessness. And that is a social driver of health that needs to be addressed.”

Healthy Home, Healthy Community

CCI serves as a conduit between funding partners, like the Robert Wood Johnson Foundation and Kresge Foundation, and dozens of community organizations across the country, many with a hospital system — or two or three — as one of its anchors.

One of its partnerships, with Accelerating Investments for Healthy Communities (AIHC), includes six leading non-profit hospital systems, including Nationwide Children’s Hospital, that invest upstream in the health of the communities that they serve by developing and preserving affordable housing.

Since 2009, Nationwide Children’s (NC) in Columbus, Ohio has been revitalizing local housing in two communities around its campus through its Healthy Homes initiative. “We realized if we were going to be a world-class hospital, we had to be a world-class neighbor and that meant becoming involved in housing,” said Gretchen West, Executive Director. Starting with the purchase of vacant buildings in 26 blocks around the hospital, Northwest Children’s now supports community housing with several programs:

  • Purchasing vacant homes, making them lead- and asbestos-free and energy efficient, and selling these homes below market value to community members in need, primarily older adults
  • Providing $20,000 exterior home improvement grants to keep homes from falling into disrepair or vacancy
  • Rehabbing and building new homes for affordable rental opportunities

Over the past 15 years, NC and its funding partners have bought, renovated, and sold 500 homes.

Tri-Hospital Partnership

The Innovative Stable Housing Initiative (ISHI) involves three Boston-area hospitals — Boston Medical Center, Boston Children’s Hospital, and Brigham and Women’s Hospital — and is managed by Health Resources in Action, a non-profit consulting organization devoted to creating healthy communities. Together, the partnership provided $3 million over a three-year period to support expanding housing options for the most vulnerable populations in Boston. Rather than serving as developers or property owners, the health systems collaborate with community groups and housing agencies to help ensure that more affordable options exist for residents.

“We have been intentional so that we're working as a collective, not as individual institutions,” explained Megan Sandel, MD, MPH, co-leader of the Housing Initiative at Boston Medical Center and a nationally recognized expert on housing and child health. “Setting up a collaboration with a collective-impact approach has been really critical, making us more effective because we were not doing this in isolation.” For example, during the COVID-19 pandemic, the partnership worked together to help enact one of the strongest eviction moratorium policies in the country. They also achieved other new policy wins in the Boston area such as more effective distribution of rental assistance. ISHI has also invested in coalition-building efforts geared toward protecting tenants from discrimination or eviction.

“The hardest part about housing is that there's still a very dominant narrative, that it is your individual responsibility and if you are housing unstable or homeless, it is your individual failing,” added Sandel. “It’s not; it is a systemic and structural outcome and we have shown we can improve housing access if you attack it at that level.”

Who Foots the Bill for Expanded Housing Access?

A variety of funding sources are key for successful community housing programs:

  • Local city or state funding
  • Federal funding through neighborhood stabilization programs
  • Hospitals and health systems (some states require hospitals to invest in community health)
  • Health insurers
  • Private philanthropy: individuals, foundations, or organizations like the United Way

“We look to create a ‘capital stack’ for the programs we are involved with,” said Hacke. The bottom layer usually supplies the base funding through a grant or guarantee. Second would be a middle layer of foundations, health systems, health plans, and other people who are motivated by mission. At the top: banks, insurance companies, or other institutions motivated by financial incentive. “That layer cake brings together the different players and they all invest in the same thing, but they have different terms, conditions, and incentives in the deal,” added Hacke.

Starting Blocks: Teamwork and Trust

Programs designed to expand access to housing must be designed for the community they are looking to impact. “This work really has to center around people in the community and what they want,” said West. “Hospitals or anchor institutes who are considering starting a program should work hard to engage partners on the team who have already built trust with residents in the area.”

To get started, West advises identifying the key community organizations — such as community development or neighborhood-based organizations, religious institutions, and others — that bring residents together in an effective way. Then identify potential funding sources.

Other Lessons:

  • Each community is different: become familiar with the local needs and politics since they are a huge driver of what gets done and does not.
  • Don’t go it alone: Build a team of community organizers, healthcare professionals, housing experts, local and state legislators, and funding organizations.
  • Plan with a large-scale vision but start with a smaller series of deals or programs to build incremental success, gain awareness and trust, and generate more funding sources.

“To be effective, you have to have patience and persistence,” added Hacke. “Finding the right mix of partners, locking arms, and learning to work together is essential.”

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