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January 24, 2022
Social determinants of health
John E. McDonough
May 23, 2022
Nov 10, 2021
Nov 3, 2021
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Back in my 20s, in early 1980s Massachusetts, I was a tenant organizer and advocate. I learned quickly that the landlord-tenant space was zero-sum, dog-eat-dog, and take-no-prisoners. Health policy, with which I first engaged in 1985, seemed more collegial and dynamic than the fraught world of rent hikes, evictions, condominium conversions, security deposits, code violations, lead paint, gentrification, and much more. If economics is the “dismal science,” housing felt to me like the “dismal policy.”
Well, good news is here today from the rental housing world, news that ties housing with the social determinants of health in smart and positive ways. A Boston-based, for-profit real estate company is showing that working proactively and positively with renter households that are behind on rent can produce eye-popping drops in tenant evictions. Averting evictions can prevent homelessness and mental and physical health problems, as well as deep disruptions to family stability, employment, and education. It also produces positive financial returns for landlords, public and private. What?!
A December 2021 article by Shelby King in the housing journal Shelterforce tells the story. WinnCompanies, one of the largest rental property owners in Boston, with 106,000 housing units in 23 states and Washington DC, many of them federally and state-subsidized, had among the highest number and rate of evictions in the city. “It wasn’t a list we wanted to be on,” observed Trevor Samios, senior vice president of Winn’s resident services office, Connected Communities, in the Shelterforce article.
Lawyer Jay Rose brought an idea and a plan to Gilbert Winn, the company’s CEO. In 2019, Rose had just retired from 33 years as a tenant’s rights attorney at Greater Boston Legal Services. Over many years, he had locked horns and broken bread with Winn personnel. “I knew Boston was starting to grade landlords for their tenant eviction rates,” he recalled. “I said to them, ‘You should hire me as your eviction prevention consultant. You’ll win awards, outdo your competitors with access to city money, and do the right thing. You’ll make money, too.”
Rose, together with Winn’s Samios and Kendra Hudson, developed a 9-step “Housing Stability Program” emphasizing four key strategies: 1) Resident education and engagement; 2) Upstream intervention, communication, and coordinated financial assistance; 3) Integrated payment plans and structured, interactive mediation; and 4) Strategic, accountable housing stabilization goal development.
“Long before any state or federal moratorium occurred, we set a goal to reduce our eviction rate for financial hardship by 50% over five years,” Samios said. “We ended up reducing it to 0% in two years.” The company also made some compelling financial discoveries. “It costs Winn between $4,000 to $8,000 to evict a tenant,” Rose said. Their estimate of the cost of managing the eviction prevention initiative is $2,000 per involved tenant household. On top of this, the City of Boston now requires real estate developers to submit an “eviction prevention plan” to qualify for any housing development assistance from the city.
WinnCompanies’ 106,000 housing units include military housing, federal- and/or state-subsidized housing, and market rate rentals. Their new approach has special relevance for low-income subsidized households because more tools are available. These include updating household income information to qualify for increased subsidies and lower rents, a common occurrence. Samios and Rose both affirm that the Winn approach yields good outcomes even in their unsubsidized market rental portfolio.
Here’s another surprise. Rose and Winn did not invent this model. They adapted it from “Housing First” advocates who have been honing the notion since the 1990s in Boston’s Roxbury and Dorchester neighborhoods. A Boston housing advocacy non-profit called HomeStart began focusing on eviction prevention in Boston public housing in the early 2000s. HomeStart, according to its executive director, Matt Pritchard, showed so much success that in 2013, the Boston Housing Authority (BHA) began paying them for their services. According to Pritchard, BHA records show that three years after prevented evictions, 97% of those families are still stable in their homes. Now, HomeStart’s Renew Collaborative is working to bring this model to smaller landlords who own and manage a large proportion of the nation’s rental housing stock and lack the financial resources available to firms such as WinnCompanies.
Though evictions are hardly the only symptom of the need to address the nation’s affordable housing crisis, the threat of eviction is a hard reality for millions of vulnerable renters each year. Matthew Desmond’s 2016 best-selling book, Evicted, shows the consequences through the eyes of eight Milwaukee households going through the wringer. Desmond notes that “the majority of poor renting families in America spend over half their income on housing, and at least one in four dedicates over 70 percent to paying the rent and keeping the lights on.” A 2010 study estimated that in many housing courts across the nation, 90% of landlords have legal representation, but 90% of renters do not. Just preventing the original court filing of an eviction action can avoid a permanent, damaging mark on a renter’s record.
Moreover, Boston Medical Center’s Dr. Megan Sandel and colleagues produced jaw-dropping research in the Journal of Pediatrics showing the adverse health consequences of being behind on rent:
“Households behind on rent had increased adjusted odds of fair and/or poor caregiver health (adjusted odds ratio [aOR]: 1.91; 95% confidence interval [CI]: 1.77–2.05), maternal depressive symptoms (aOR: 2.71; 95% CI: 2.51–2.93), child lifetime hospitalizations (aOR: 1.19; 95% CI: 1.10–1.27), fair and/or poor child health (aOR: 1.41; 95% CI: 1.28–1.56), and household material hardships.”
Tying this issue to the social determinants of health is not a stretch. Indeed, further research might show the Centers for Medicare and Medicaid Services whether this could be a cost-effective way to reduce Medicaid medical costs and align with CMS’s new social determinants agenda. It’s on the federal radar screen. Last June 30, a White House summit on evictions featured WinnCompanies’ CEO Gil Winn on one of its virtual panels, with Jay Rose, Trevor Samios, and Matt Pritchard all in the online audience.
Unsurprisingly, racial and ethnic inequities abound in this space. According to the Pew Research Center, 58% of households headed by African Americans and 52% headed by Latinos rent their homes, while just 27.9% of non-Hispanic white households rent; and whites hold 75% of all US owner-occupied units. Renting your home is reality for lower-income, disadvantaged populations, and is essential to consider when grappling with social disadvantages.
And, while we’re at it, Congress ought to extend emergency aid to renters beyond its original $46 billion appropriated in 2020. This COVID-19 relief program has provided essential benefits to needy households and families, and is now running out of funding.
As a former hard-boiled tenant advocate, an innovation that puts tenants, landlords, and governments all on the same side of a table feels magical, in fact, better than magical. Folks working on the social determinants of health would do well to pay attention to preventing tenant evictions, and to learn and propagate these powerful innovations.
John E. McDonough, DrPH, MPA, is a professor of public health practice at the Harvard University TH Chan School of Public Health in the Department of Health Policy and Management. Between 2008 and 2010, he served as a senior adviser on national health reform to the US Senate Committee on Health, Education, Labor, and Pensions, where he worked on the writing and passage of the Affordable Care Act. Between 2003 and 2008, he was executive director of Health Care For All, a Massachusetts consumer health advocacy organization, where he played a leading role in the passage of the 2006 Massachusetts health reform law. From 1985 to 1997, he was a member of the Massachusetts House of Representatives where he cochaired the Joint Committee on Health Care. His articles have appeared in the New England Journal of Medicine, Health Affairs and other journals. He has written several books including Inside National Health Reform in 2011 and Experiencing Politics: A Legislator’s Stories of Government and Health Care in 2000, both by the University of California Press and the Milbank Fund. He holds a doctorate in public health from the University of Michigan and a master’s in public administration from the Kennedy School of Government at Harvard University.
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