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Excerpted from: Dayna Bowen Matthew, Health and Housing: Altruistic Medicalization of America's Affordability Crisis, 81 Law and Contemporary Problems 161 (2018) (174 Footnotes) (Full Document)


DaynaBowenMatthewThis article argues in favor of responding to the lack of affordable housing in America as a public health crisis. The “medicalization” frame adopted here responds to epidemiological evidence of the nexus between health and housing, invites collaborative and integrated solutions to improve health outcomes, and points to innovative financing streams to pay for policy recommendations. Harkening to the theme of this conference, the article is organized into three parts. Part II lays groundwork for the conclusion that contemporary housing policy should reflect historic notions of altruism in order to efficiently and effectively lower the public health costs imposed by a widespread lack of affordable housing. Part III identifies defects that make market solutions as poor a substitute for public health interventions today, as they were during nineteenth century America, when national housing policy began. The focus of this discussion points to the impact that housing affordability has on population health outcomes. Part IV identifies the communities that suffer when the public health burdens imposed by markets that lack affordable housing. This part advances the view that housing policy informed by a population health perspective could improve health outcomes not only in low-income communities, but also in the working-class and middle-income communities. The article concludes with a summary of the benefits and limitations of viewing housing affordability crises through a public health lens.

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Evidence of the association between housing affordability and health outcomes reviewed here supports the view that a medicalized approach to the current crisis has significant advantages. Five benefits have been highlighted in this article. First, a public health framework would encourage rebalancing societal investments to ensure affordable housing for all populations, regardless of income, geography, disability, age, gender, or race. This would encourage abandoning the selective, conditional altruism that has informed policies that identify some but not other populations as worthy recipients of housing assistance. Instead, a public health framework will advance health equity. Second, a public health framework will provide justification for blending currently siloed sources of funding for housing and health programs. This approach is supported by evidence that social interventions are strongly correlated with better health outcomes. For example, researchers have shown that countries that spend a higher proportion of public dollars on health care, relative to social interventions, have demonstrably worse population health outcomes. In other words, a higher ratio of social spending to dollars spent on Medicare, Medicaid, and other health care programs, is associated with better health outcomes. Elizabeth Bradley replicated this positive relationship between social spending and health care spending among the American states. Figure 7 shows that states with the highest ratios had better outcomes in adult obesity, asthma, mental health, lung cancer, heart attack, and type 2 diabetes than states with lower social to medical spending ratios.

Third, a public health framework would focus housing policy around shared, measureable objectives, to promote interventions that help low, modest, and middle-income families achieve positive health outcomes, rather than policies that cause these groups to compete for scarce housing resources in a zero-sum fashion. Currently, although the U.S. government spent $190 billion in 2015 to help Americans buy or rent homes, the majority of America's public spending on housing targets higher income households, and pays less attention to low-income families that are at greatest risk for the homelessness, housing instability, and over-crowding problems frequently associated with poor health outcomes. Fourth, a public health approach to housing policy would reorganize housing benefits to achieve a greater good but will also advance better individual outcomes. Finally, and perhaps most importantly, the evidence that children are severely disadvantaged by current U.S. housing policy, leaving them behind in dilapidated public housing, and excluded from affordable neighborhoods when economic circumstances change, argues in favor of a strategy that will not repeatedly impose high health costs on American medical and systems indefinitely. National altruism, markets, and communities are inextricably linked in American housing policy. Policies that focus on the public health impacts of housing affordability will reflect the communal altruism that has historically motivated American housing policy, while also being more effective, efficient, and equitable than current approaches.

William L. Matheson and Robert M. Morgenthau Distinguished Professor of Law, F. Palmer Weber Research Professor of Civil Liberties and Human Rights, University of Virginia Law School.