The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
The Fund identifies and shares policy ideas and analysis to advance state health leadership, strong primary care, healthy aging, and sustainable health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is is a foundation that works to improve population health and health equity.
October 23, 2023
Social determinants of health
Ashley A. Meehan
Joshua M. Sharfstein
May 23, 2022
Jan 24, 2022
Nov 10, 2021
Back to The Milbank Quarterly Opinion
It is no longer novel to point out that housing has substantial impacts on health. Housing quality influences exposure to health harms like lead, mold, and asbestos. Where housing is located within a community shapes our social networks, access to food and health and social services, and risk for violence, all of which are known to impact health. Housing costs that increase disproportionately to wages means that more people are facing housing insecurity and homelessness than in recent decades. The current housing crisis is leading to infectious and non-infectious adverse health outcomes at a population-level, which means greater strain on emergency departments and crisis response services.
As a result of the legacy of racist zoning and redlining policies, Black, brown, indigenous, and other people of color continue to bear the brunt of the housing crisis. Racial and ethnic minorities experience housing instability at significantly higher rates than their White, non-Hispanic counterparts, and are overrepresented among people experiencing homelessness.
In recent years, greater appreciation of the impact of social and structural drivers of health in clinical settings have resulted in the use of social needs screening. The National Academies in 2016 highlighted social needs screening as a promising practice for improving care, and in 2019 recommended five core activities for health care systems to strengthen integration of social needs screening in their systems. The American Academy of Family Physicians (AAFP) currently provides tools to screen patients for social needs, identify available resources to support patient needs, and develop action plans with patients to address their social needs. The Centers for Medicare and Medicaid Services (CMS) have also developed a 26-item social needs screening tool that can be used by providers.
Currently, social factors can be tracked in patient electronic health records using ICD-10-CM codes for the social determinants of health. These codes, also referred to as Z Codes, are billable but not yet reimbursable or standardized. In August 2023, CMS put forth a 2024 proposed rule that would require social needs to be recorded in patient health records and allow primary care facilities to be reimbursed for supporting patient social needs.
Screening is a major step forward for attention to housing. Electronic health records can now include health information on housing or homelessness status, which are often missing in traditional public health surveillance systems. During COVID-19, social needs screening in clinical settings helped fill a critical gap in knowledge about hospitalizations for COVID-19 for people experiencing homelessness and incarceration.
For some social needs, such as food assistance and tax credits, resources are available that are underutilized. Clinical engagement can make a major difference, with one clinic reporting helping families receive $14 million in tax benefits.
Housing, however, is a particularly difficult challenge. Clinicians who screen for housing issues face the herculean task of having to link their patients to meaningful resources. In many places, such resources are few and far between, if they exist at all. From 2020 to 2022, the number of people experiencing chronic homelessness increased by over 15%; the sheltered population experiencing chronic homelessness increased by over 32%; and the unsheltered population experiencing chronic homelessness increased by 7%. More people are experiencing homelessness, and for longer durations, than ever before.
Moreover, the pipeline to homelessness is expanding. The number of households with high housing cost burden — meaning they spend more than 30% of their income on housing — continues to climb. The US Census Bureau estimates that from 2017-2021, over 40% of renter households experienced high housing cost burden. At the same time, exiting homelessness is complicated by the limited number of housing vouchers — a mechanism used by the federal government to support housing payment— and growing shortages in the workforce that help people navigate the housing system. Even when people can access vouchers, they then compete for a small pool of available housing units that align with their needs and preferences and with landlords that accept housing vouchers.
This has created a conundrum — screen, then what?
One approach is for health care to create housing resources on its own. For example, in 2022, Baltimore’s Health Care for the Homeless collaborated with the Episcopal Housing Corporation to open 70 housing units with onsite clinical care for people exiting homelessness and people under certain income thresholds. Similar programs have been reported in Denver, St. Louis, and Sacramento.
A review of public information during 2017 through November 2019 found that health care systems across the United States committed over $2.5 billion to screening and programming for the social drivers of health, with housing programs receiving the largest portion of the funds. The authors noted that housing programs ranged from building more affordable housing to reserving funds for covering health care services utilized by patients experiencing homelessness.
Unfortunately, no matter how impactful housing programs are for individuals, the health care system will not be able to create enough housing resources to fill the housing gaps. The need for stable housing is estimated to affect 3.7 million people.
This enormous gap means that health care organizations committed to their patients must recognize that policy solutions are also needed. This relates to the fifth and perhaps least cited recommendation from the 2019 NAS report, which noted: “improving health and reducing health disparities is likely to depend — at least in part — on improving social conditions and decreasing social vulnerability.”
Here are three ways that clinicians and health care organizations can become involved in housing policy to improve social conditions and reduce health disparities.
First, they can advocate for efforts to increase the supply of affordable housing. Such policies include modifying zoning and land-use policies to allow for multi-family or multi-home lots and smaller lot sizes, increasing the number of housing units available in a geographic area.
Second, they can support efforts to control the costs of available housing. This includes backing expansion of housing voucher programs, extending deadlines for low-income housing tax credits, and establishing local housing trust funds to supplement state and federal housing assistance.
Third, they can advocate to increase funding for supportive housing programs that address the root causes of homelessness. This includes housing programs that focus on recovery from substance and alcohol use, support community reintegration after incarceration, and provide general wrap-around services that help people remain in housing. Rather than pursuing such programs as a community benefit supplement to core operations, hospitals and other health care systems can embrace these efforts as a business line that makes a profound difference in their communities.
Addressing the US housing crisis requires sustained, multi-sector investment and collaboration. Social needs screening in health care settings has been an important step to understand how social factors influence health. Now, the health care sector must engage with housing policy to help many more patients and their communities.
Ashley A. Meehan is a PhD student at the Johns Hopkins Bloomberg School of Public Health. She currently coordinates the National Health Care for the Homeless Council’s Homeless Mortality Working Group and provides technical assistance on public health and homelessness to grantees of the U.S. Department of Housing and Urban Development. Previously, Meehan was a Health Scientist focused on health and homelessness at the Centers for Disease Control and Prevention. She received her Bachelor of Applied Health Science degree from Bowling Green State University and her Master of Public Health degree from Emory University’s Rollins School of Public Health.
Joshua M. Sharfstein is associate dean for public health practice and training at the Johns Hopkins Bloomberg School of Public Health. He served as secretary of the Maryland Department of Health and Mental Hygiene from 2011 to 2014, as principal deputy commissioner of the US Food and Drug Administration from 2009 to 2011, and as the commissioner of health in Baltimore, Maryland, from December 2005 to March 2009. From July 2001 to December 2005, Sharfstein served on the minority staff of the Committee on Government Reform of the US House of Representatives, working for Congressman Henry A. Waxman. He serves on the Board on Population Health and Public Health Practice of the Institute of Medicine and the editorial board of JAMA. He is a 1991 graduate of Harvard College, a 1996 graduate of Harvard Medical School, a 1999 graduate of the combined residency program in pediatrics at Boston Medical Center and Boston Children’s Hospital, and a 2001 graduate of the fellowship program in general pediatrics at the Boston University School of Medicine.
Get the Latest from the Milbank Memorial Fund
An endowed operating foundation that engages in nonpartisan analysis, collaboration, and communication, with an emphasis on state health policy.