Even before the COVID-19 pandemic, housing instability and homelessness were linked to poor physical and mental health outcomes for children and adults. But the COVID-19 pandemic and subsequent economic crisis highlight the critical intersection between where you live and health in myriad ways. Solutions that respond to the complex nature of these interlocking issues are needed more than ever and offer a way forward to reset our future post pandemic.

Home Is Where The Health Is, Both Physically And Mentally

New models of linking housing, health and social service resources are needed to drive a new foundation for health. Our recently published study in Health Affairs may provide critical insight into the need for responding to housing instability and homelessness among families during and after the current crisis. The study was a randomized trial that examined the effect of a multifaceted housing intervention—which integrated health, housing, social, legal, and financial services—on family health and stability. Those in the intervention group received intensive case management, financial counseling, legal services, and priority status on the public housing waitlist through partnerships with community-based agencies.

Within the first six months of the study, child overall health and parent mental health improved among those in the intervention group compared to those in the control group. These positive results suggest that a model which integrates services may be effective in improving health for multiple family members and can set families on a better trajectory toward well-being.

Our study, along with others, documents the importance of integrated housing and health interventions for improved outcomes. The study results show encouraging and arguably predictable outcomes. It demonstrates what is possible for families with low incomes when they are provided with tangible opportunities that enable them to thrive. As an additional benefit for families when there is mitigation of housing instability and associated distractions, families are able to prioritize their health and the health of their children.

What If There Isn’t Enough Housing To Fill The Prescription?

Stories from across the country highlight the urgent and immediate concerns of people living in shelters and unstable situations, including couch surfing, doubling up, and living in overcrowding conditions during this pandemic. As people’s incomes decrease due to infection and quarantine requirements, increased childcare responsibilities, and business closures, families struggle to afford rent and mortgage payments. While the CARES Act passed by Congress provides eviction and foreclosure protections for some households and enables those with federally backed mortgages to apply for up to 12 months of forbearance, payment arrearages will still accrue. According to National Multiple Family Council, a third of renters didn’t pay rent on time in April 2020. Those bills will continue; we need new action to help lower-income families pay rent to ensure a healthy recovery.

Although these solutions are critical to ensuring people remain in their homes during the pandemic, without further action this crisis will have a ripple effect on housing instability once the protections lift and people are unable to afford back payments. While the number of families and individuals at risk of losing housing following the crisis is currently unknown, data on unemployment rates and reports documenting families’ inability to afford basic needs during the crisis indicate the potential for widespread hardship. The impending increase in housing instability and homelessness will have further downstream effects on health outcomes and health care use and costs.

Inequalities Playing Out In COVID-19 Pandemic Are Structural Inequities At Work

Systemic racism and policies that promote inequity—from redlining and exclusionary zoning to systematic disenfranchisement from economic prosperity—have meant that families of color and immigrant families have been disproportionately affected by housing instability and homelessness. These disparities in housing and homelessness contribute to racial and ethnic health inequities across the lifespan. This reality is currently manifesting in COVID-19 disparities. States have begun documenting an alarming trend in COVID-19 cases: people of color are contracting the virus and being hospitalized at much higher rates than whites. Your race, ethnicity, immigration status, and neighborhood should not predict how you do in the COVID-19 pandemic, but the effects of redlining continue to play out decades later.

These disparities, however, are not limited to infection and treatment rates. They are also reflected in who is at greatest risk of housing instability and homelessness as a result of the economic crisis created by the pandemic. Unlike other recessions, the current economic downturn has been marked by large-scale shocks to service industries, including retail and restaurants, which disproportionately employ immigrants, people of color, and women. For families, the closure of businesses is further compounded by child care issues; even if a parent is not furloughed or laid off, school and child care closures make it extremely difficult for them to continue to work.

When families lose income, they often have to rely on savings to continue to afford basic needs like housing. For most families with low-incomes, however, this is not possible. Further, well-documented wealth disparities across race/ethnicities place female-headed households and families of color at high risk of severe financial instability when they lose pay, even if temporarily. As a result, millions of families with children are likely to experience housing instability, evictions, and homelessness.

Lessons learned from decades past are helpful to create a different future. Structural systems of community disinvestment created barriers to standard opportunities for thriving in America. This dynamic resulted in the emergence of distinct socioeconomic classes and has led to the predictable cascade of racial and ethnic COVID-19 data. In a future built on a foundation of equity, low-income families would have risk-free opportunities to improve their economic status and move beyond the necessity for subsidies. They could achieve financial stability and self-sufficiency. In turn, these families would reap the benefits of access, and be able to break the cycle of generational poverty.

Imagine A New Status Quo With Housing As Foundation For Health

Our status quo cannot be our future. The efforts across the country to respond to the urgent needs of homeless individuals are essential during this crisis, but families cannot be left behind. Currently 2.5 million children in the US are homeless and even more experience some form of housing instability. Research by Children’s HealthWatch shows these forms of housing instability can have enormous impacts in caregiver and child health.

But imagine a future where the number of housing unstable families doesn’t grow but is eliminated. Solutions that respond to the intersection of housing and health exist and should be leveraged during and after the immediate COVID-19 crisis. Although the Housing Prescriptions intervention described in Health Affairs was not designed to respond to a global pandemic, the benefits afforded to families through this intervention highlight the importance of putting families on a road toward stability and health.

Interventions developed and tested prior to the COVID-19 pandemic highlight the need for cross-sector collaboration that recognizes the unique needs of different populations for developing solutions. These include, but are not limited to:

• Urgent federal and state investments in affordable housing and rental assistance. The Urban Institute is calling for $100 billion dollar investment in universal vouchers to fill the gap, which would put us on the right trajectory to health.
• Systemic solutions that reduce racial and ethnic disparities and set families on a path toward well-being. Addressing the asset gap through scaling the Family Self Sufficiency program by funding financial coaches is one example of building health and wealth across racial lines.
• Identification of high-risk populations in need of short and long-term resources.
• Incentivizing braiding of housing, health, and social services funding streams to effectively respond to underlying conditions that exacerbate poor health and make people more vulnerable to infections among other health conditions.
• Long-term solutions that stabilize families and individuals before they become homeless in order to reduce individual and population-level health risks.

Without large scale policy change that addresses the root causes of housing instability including a lack of affordable housing, discriminatory policies, and inequitable access to financial stability, it will be difficult for health systems to adequately respond to housing needs during this crisis and beyond. Now is the time to move families toward stability, but as health systems we cannot do this alone. As leaders across levels of government and within multiple sectors from around the country grapple with how to respond to the survival needs of people experiencing homelessness and housing instability during a global pandemic, we cannot lose sight of the urgent need to implement changes that promote housing instability, health equity, and family well-being.

Authors’ Note:

Megan Sandel is an unpaid board member for Enterprise Community Partners, a nonprofit charitable organization promoting affordable housing.