Building Healthy Communities through Health Care and Affordable Housing Synergies Front Range Case Studies, 1219 COBJ, Vol. 48, No. 11 Pg. 40

• Author: BY Y. MELINDA PASQUINI AND ROBERT M. MUNROE.
• Position: Vol. 48, 11 [Page 40]

48 Colo.Law. 40

Building Healthy Communities through Health Care and Affordable Housing Synergies Front Range Case Studies

Vol. 48, No. 11 [Page 40]

Colorado Lawyer

December, 2019

REAL ESTATE LAW

BY Y. MELINDA PASQUINI AND ROBERT M. MUNROE.

This article discusses how various organizations are striving to create safer, healthier communities for all by meeting the housing and health care needs of the most vulnerable populations. It focuses on Front Range case studies.

Colorado, along with the rest of the United States, is experiencing record numbers of mass shootings and suicides, and homelessness is on the rise.^[1] These issues impact everyone, regardless of socioeconomic and cultural backgrounds. Solutions for these problems can only be created by building healthy communities.

Building Healthy Communities

Healthy communities are filled with healthy residents. Some developers view healthy communities as those with structurally safe homes free of lead, asbestos, and other environmental contaminants. Other developers focus on access to good schools, restaurants, movie theaters, public transportation, and healthy foods, and offer amenities that encourage physical activity. Most market-rate developers prioritize features and amenities that will help them gain a competitive edge or increase their return on investment.

But building healthy communities involves more than constructing homes and offering amenities; it requires looking at the interactions with larger communities and setting development priorities accordingly. Healthy communities are holistic; they meet an individual's basic needs so each person has the opportunity to contribute to and integrate in to the community in a positive way. Affordable shelter and permanent housing are imperatives in satisfying basic needs, and health care is essential to meeting an individual's physiological and safety needs. However, housing and health care are often viewed as separate needs and priorities within the communities, when meeting these basic needs is fundamental to physical and mental health. Access to affordable housing and health care are thus key to creating healthy communities.

Housing as a Public Health Crisis A MacArthur Foundation study that followed 2,400 children, teens, and young adults aged 2 to 21 in Boston, Chicago, and San Antonio found that poor housing quality is one of the strongest predictors of emotional and behavioral problems in low-income children.^[2] Residential instability adversely affects peer and school networks, impeding both the academic and behavioral success of children.^[3]When families cannot afford housing, other basic necessities such as food and medical care are also limited, and this lack of basic necessities is linked to lower emotional and behavioral functioning in young people.^[4]And housing instability is not limited to homeless children and families; as many cities become less affordable, the population of hidden homeless (i.e., those who temporarily live with others and lack prospects for accessing permanent housing)^[5] increases. Those lacking secure housing are characterized by multiple moves, overcrowding, and doubling up.^[6]

Results from a six-year Children's Health-Watch study of 22,324 families in Baltimore, Minneapolis, Boston, Little Rock, and Philadelphia found that unstable housing is associated with adverse health conditions in both children and adults.^[7] Specifically, 34% of the individuals experiencing adverse health conditions in this study were behind on rent, had experienced multiple moves, or had a history of homelessness.^{[8] [9]} By closely following these families, the study found that there is a strong connection between adverse health conditions and housing instability.

Hospitals and Health Care Organizations Take Notice

Linking health care dollars and political capital with affordable housing development efforts is one tactic for providing stable housing to individuals, families, and children.

A 2015 study of 9,000 adults found that the availability of an on-site service coordinator such as a social worker at federally subsidized senior housing reduced hospital admissions by 18%.^[10] Accordingly, hospitals and health care providers around the country are starting to invest in housing projects and supportive services provided by housing developers by donating land and other financial resources to housing projects and participating in social impact funds.

In Massachusetts, Boston Medical Center committed to invest $6.5 million in affordable housing to improve community health and patient outcomes while reducing medical costs.^[11] In Oregon, six health care organizations contributed $21.5 million to three housing projects designed to address Pordand's pressing affordable housing, homelessness, and health care challenges.^[12] And as described in the case studies below, Colorado affordable housing developers are collaborating with hospitals and health care organizations to provide co-located housing and services.

Public-Private Partnerships

Just as hospitals and health care organizations are starting to take notice of the benefits of investing in affordable housing, public-private partnerships (PPPs) are making a resurgence. Another vehicle for financing affordable housing PPPs vary in structure, but generally are a collaboration between government and the private sector to finance, build, and operate large-scale construction projects that benefit the community.^[13] While PPPs have been touted in political circles as a financing solution to aging infrastructure, they have been used to develop affordable housing since 1986 when Congress enacted the low-income housing tax credit (LIHTC) program. The LIHTC program creates an indirect subsidy to finance the construction and rehabilitation of low-income affordable rental housing by providing investors a matching dollar reduction in federal tax liability in exchange for such financing.^[14]

When used solely as a financing tool, PPPs tend to be less beneficial to governments, because government can usually borrow money at a lower cost than private developers can.^[15] But when used for financing affordable housing, PPPs are highly successful for two reasons.

First, federal and state subsidized LIHTCs provide a financing structure that injects equity into a private housing development and lowers the debt on any given project, rather than financing the project entirely through a costly debt structure.^[16] Since their inception, LIHTC transactions have leveraged federal tax credits with private dollars to build or preserve more than 37,727 low-income rental housing projects and an estimated 2.3 million low-income rental housing units.^[17]

Second, various other state and federal funding programs, such as state tax credits, Medicaid, and Community Development Block Grant (CDBG) and Home Investment Partnerships (HOME) funds available through programs administered by the U.S. Department of Housing and Urban Development (HUD), can all be leveraged with private funds to provide ongoing services to affordable housing recipients in connection with the affordable housing development. Such "permanent supportive services" (PSS) are discussed below in connection with specific case studies.

Social Impact Bonds

Social impact bonds are an example of new and innovative PPPs that provide returns for private investors who partner with local and state governments to deliver statistically proven results. Developers of affordable housing projects financed by social impact bonds either provide, or partner with local organizations to provide, PSS such as access to health care and addiction and psychiatric counseling to homeless individuals and families.

In Denver, investors in social impact bonds (including the Denver Foundation, the Colorado Health Foundation, The Piton Foundation, and the Ben and Lucy Ana Walton Fund of the Walton Family Foundation) have invested in programs such as the Denver Social Impact Bond Program (the Denver SIB).^[18] Investors can earn a positive return on their investment if they meet specific goals measured by metrics set in their Denver SIB contract with the City and County of Denver.^[19]

As part of the Denver SIB, organizations such as the Colorado Coalition for the Homeless and the Mental Health Center of Denver team up to provide housing and Health care to Denver's most vulnerable populations, who repeatedly burden the jail and hospital systems by their repeat, but mostly preventable, visits. The Denver Crime Prevention and Control Commission estimated that these frequent users of societal resources spent an average of 59 nights in jail each year and visited detox facilities over 2,000 times in a given year.^[20]

In addition to the social and societal costs of crime and unsanitary conditions in communities, users who frequently interact with jails, detox facilities, and emergency care cost...