For Dr. Robert Ratner, the connection between housing and health is more than a concept. It is the focus of his work in California’s Santa Cruz County, where he serves as director of housing for health.
In a region consistently ranked among the nation’s most expensive housing markets, the lack of affordable homes can have profound consequences for residents’ health and increase the risk of homelessness. As the county’s director of housing for health, Ratner works at the intersection of these challenges and solutions.
In this Q&A, Ratner discusses his role, the health consequences of housing instability, and why housing providers should think more broadly about resident well-being.
Tell us about your role as director of housing for health. What are your responsibilities and goals?
Santa Cruz County in 2020 authorized the creation of a new unit to focus on coordinating housing, health, and human services resources more effectively. This was specifically coming up in the context of the challenges many communities face around homelessness, but it’s broader than that. I think homelessness is a manifestation of multiple breakdowns in the healthcare, human services, and housing sectors. We were created with this charge of trying to bring the community together and help people work across our system silos to combine housing with supportive services. The term that has been around for decades is supportive housing; pairing deeply affordable housing for seniors and people with disabilities with services and supports in the broader community.
Our name reflects that commitment of pairing housing with health in the broadest sense. In California government, we often split people into different categories to fit our separate systems. You have behavioral health, that splits mental health and substance use services into different funding categories and services. You have human services for public benefits, child welfare, and older adult services. Our unit was created to fill gaps and increase coordination between these systems to be more effective in supporting people with homelessness and housing instability. For example, a senior may call adult protective services because they’ve lost money due to fraud or abuse, and now they can’t pay their rent. That then uncovers some other issues or areas of needed support. There are also people currently on the streets who need someone to build a connection with to help them navigate into housing with the right mix of supports.
Housing is first in our division’s name because of its importance for individual and community well-being. It’s the major reason why so many people struggle not only in Santa Cruz County, but across the country, The cost of housing and the quality of housing is such a stressor for many people, particularly those with lower or fixed incomes.
Are you working with developers and in affordable housing developments? Or, are you working more with clients?
Both. Our agenda calls for our team to develop a housing pipeline and preservation network. That means looking at opportunities for more affordable housing developments, including supportive housing units in our county. We are also looking at our existing stock. There might be units at risk of closing or losing affordability or housing sites struggling to support their tenants’ well-being and housing stability. We also play a major role in directly providing and funding supportive services within the county.
From your perspective as a public health professional, what are the most significant health consequences of housing instability?
There are so many. The No. 1 issue I see is stress. Stress has an impact on many different health conditions: from mental and emotional wellness, to diabetes, hypertension, and your risk for infection. The stress that goes with housing instability, in and of itself, can create health problems or exacerbate them.
If you don’t have stable shelter, are dealing with the weather, and do not have access to basic hygiene and food storage facilities, those can have major health impacts. Rates of infection and poor nutrition are much higher among people with unstable or unsafe housing. Research has shown that folks who’ve been homeless for a year or more have significantly decreased life expectancy of 20 to 25 years compared with the national average.
Here are some other examples:
- If you’re someone who needs to refrigerate medication to get the best treatment, but you don’t have a place to stay with access to refrigeration, you’re not getting the best treatment for your condition.
- Managing your day-to-day life and schedule is challenging with disrupted sleep, maintaining your belongings, and navigating multiple competing survival needs. If you don’t have stability of place, accessing care is very difficult.
- If you’re living in public places, you’re often asked to move from one place to another by law enforcement. It’s hard for care providers to stay in touch with you and hard for you to stay in touch with care providers.
So there’s a long list of public health-related challenges associated with homelessness and unstable housing.
How does housing instability affect the larger community, including people who have stable housing?
There are several ways. Families with young people in their household are very concerned their children won’t be able to afford to live in their community. There’s a concern about the next generation. How can they live here?
Another concern is having higher rates of overcrowding and sometimes unsafe living conditions. When there are so many people without shelter, it has public health implications for everyone. There have been examples in Santa Cruz and other communities where infectious disease outbreaks can occur among unsheltered people. These outbreaks strain local health systems and can have impacts on housed and unhoused people.
The Housing First approach has also been shown to save the public money because if people are stably housed, they’re less likely to use the emergency room and other public services.
My experience of the research and data on this indicates that for a small segment of unhoused people touching multiple systems, Housing First can save public dollars. A problem with focusing on cost alone is that the expenses are borne by many different systems working with separate budgets and leadership. No one system feels the full cost so it’s hard to get the systems to shift their funding to pay for supportive housing.
Public systems end up spending on crisis response rather than long-term stability for people. Rather than continually paying for emergency room visits, short stays in jails and detox facilities, and repeated shelter stays, investing in supportive housing offers a much wiser long-term investment.
There’s some recent information about how Finland really committed to ensuring everyone had a home. The positive impacts there have been significant. It’s challenging to build the political will and the consensus for people to see the long-term benefits of supportive housing like MidPen Housing’s new Jessie Street Terrace.
Can you share any evidence that bringing health and housing together is working and producing the desired outcomes?
We have a lot of data that shows our best intervention is the Jessie Street Terrace-type supportive housing intervention, where we combine permanent affordable housing with services. Typically, 90% to 95% of people that we refer stay in housing for at least a year. By contrast, in programs that combine short-term shelter with services, only 30% to 40% exit to some kind of permanent housing.
There is data showing once people have housing stability their incomes go up and their access to care shifts from crisis and institutional services to more stable long-term outpatient services.
What concerns you today?
Under the current federal administration, the idea of linking housing and health has gotten much more difficult. There have been decades of Republican and Democratic administrations promoting “social determinants of health,” with housing as a critical determinant. The current administration is rewriting some of the rules and saying that healthcare needs to be just for traditional medical care, and we can’t mix housing and health together. I have experienced in my professional and personal life that’s the wrong direction. We’re living through an era of rising healthcare costs, reduced health insurance coverage, and rising housing costs and instability. I’m deeply concerned about these trends.
How should affordable housing providers think differently about resident health and well-being?
If you focus on building community and the wellness of your tenants, your housing project and organizational finances will improve over the long run. I read a study recently related to the number of evictions and unit turnover in buildings with and without on-site support services and community building activities. Sites with investments in services had fewer evictions and less unit turnover. Tending to the well-being of your tenants leads to greater stability at the individual unit level but also in the entire building community. Incorporating supportive services resources into your operating budget can pay off in the long run.
For developers who make a living creating new projects, the types of projects that are run well, with these kinds of partnerships and supports, are generally more well accepted and appreciated by local community residents. That’s because of a built-in commitment to community health and well-being, including the area around the development. It creates more of a good neighbor, and that means you, as a developer, are more likely to be wanted in the community. The next time you propose a development, instead of getting opposition, you’re more likely to get support if you have a reputation of having that broader focus on well-being.
I’ve found in my career that more integrated and diverse developments tend to have better outcomes for the building community as a whole and the tenants in designated supportive housing units. I prefer developments that keep their number of set-aside supportive housing units at 25% or below the total number of units. There are projects with higher percentages of supportive housing units that are great and work well. The ones that seem to have the longest-term positive impact on the supportive housing tenants, other tenants, and surrounding community are the ones with a more diverse unit mix with varying income levels, household sizes, age ranges, and supportive and non-supportive units.