How clinicians can address housing insecurity

Guidelines increasingly recommend screening for housing insecurity with questions like, “In the past year, was there a time when you were not able to pay the mortgage or rent on time?” The problem of housing insecurity is enormous: over 11.3 million renter households in America spent more than half of their income on rent and utilities in 2023.  The impact on health and healthcare is well documented: people who spend more money on their housing spend less on their food and healthcare. It’s not that these individuals are less hungry or less sick. They have less money because, as sociologist Matthew Desmond describes, “The rent eats first.”

Federal housing assistance, in the form of public housing, housing vouchers, and other programs, are designed to limit a household’s spending on rent and utilities, but only a quarter of households eligible for housing assistance receive it. In August 2023, the Housing Authority of Baltimore City opened their wait list for public housing for two weeks: 28,000 people applied.

When patients “screen positive” and we talk about their housing situation, I sometimes feel powerless. I cannot write a prescription for housing. Yet, there are many ways to try to help patients facing housing insecurity. Screening itself can create the space to talk about these issues during patient encounters. With this comes opportunities to plan for the impact of housing insecurity on medical advice and treatment. There’s also the chance to provide assistance, including connecting patients with legal counsel, working with clinic social workers, and identifying other community-based organizations and local resources. For those lucky enough to practice in settings with medical legal partnerships, these can offer tremendous support for patients in addressing housing needs.

At the same time, there’s the need for innovation and advocacy, recognizing that community resources for housing are often few and far between. On the innovation front, several states’ Medicaid programs, under Section 1115 waivers, are testing approaches that integrate housing counseling. Some are even starting to provide short-term housing assistance.

For advocacy, clinicians can support and advocate for policies that make a difference. For example, in my community in 2016, voters in Baltimore passed a referendum to establish the Baltimore Affordable Housing Trust Fund to increase the supply of affordable housing. Maryland voters also passed the HOME Act in 2020 that made it illegal for landlords to deny housing to prospective tenants solely because they were paying for rent with a housing voucher or other forms of federal assistance. Policies in some states range from zoning ordinances, to just cause eviction, from expanded childhood tax credits, to testing universal basic income.

As more of our patients face housing insecurity, we need to continue working together to address their basic needs while supporting policies that make access to safe, stable, and affordable housing a possibility for all.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.