Dear John,

Access to care is not the sole determinant of health. In fact, research suggests other variables, including health behaviors and social and economic factors, play a larger role in determining health outcomes. In Northern Virginia, this is evidenced by differences in life expectancy at the neighborhood-level of up to 18 years.

There are many ways in which neighborhoods and the built environments where we live affect our health, from proximity to major roads to walkability and access to fresh foods, green space and public transit. Housing supply and affordability can be barriers for lower income households excluding them from neighborhoods with health promoting amenities. At the same time, the legacy of racist land use policies and discriminatory lending practices contribute to racial disparities in health outcomes today.

Limited supply of quality affordable housing in neighborhoods with ample health-promoting resources, and limited investment in the built environment in lower income neighborhoods forces low-income households into overcrowded living conditions or poorly maintained housing. Frequently, residents who are housing cost-burdened must choose between medical care, food or paying the rent. Given the relationship between housing and health, one would expect healthcare institutions and health insurers to invest in solutions that promote access to housing for all.

The Affordable Care Act requires tax-exempt hospitals to conduct community health needs assessments (CHNAs) every three years, complete with implementation strategies to improve the health of the communities they serve. CHNAs ensure that hospitals have the information they need to make impactful investments in community benefits, and to coordinate these investments with external efforts to improve community health and well-being. By statute, CHNAs must take into account input from “persons who represent the broad interests of the community served by the hospital facility.”

In Northern Virginia, the 2019 CHNAs Inova Health System produced for the neighborhoods surrounding its Alexandria, Fair Oaks, Loudoun and Mount Vernon Hospitals and Fairfax Medical Campus indicated that housing affordability significantly impacts the health of these communities. In each of the five reports, “affordable housing” was residents’ most common response to the question: “What would most improve the quality of life for our community?”

Despite this overwhelming community response, affordable housing and other concerns related to neighborhood and the built environment were left unaddressed in the implementation strategies that accompanied each needs assessment. Inova determined these needs were “beyond the scope of the hospital” and that “the hospital has insufficient resources to make a meaningful impact.”

The notion that investing in affordable housing and other improvements to the built environment is “beyond the scope” of the hospital’s mission “to provide world-class healthcare” is undermined by the demonstrated link between housing and health. Truly world-class care requires the foundation of a healthy living environment and adequate access to resources in order to adhere to treatment protocols and engage in health-promoting and preventative behaviors.

Limited resources is a poor excuse to ignore the need for affordable housing, particularly as hospitals across the country are showing how much can be accomplished with differing levels of financial investment. The following are examples of strategies that Inova could consider to make a meaningful impact on community health through a modest investment in housing affordability:

Donate vacant land. The high cost of acquiring land can drive up the cost of a new development making it impossible to serve residents at the lowest end of the income spectrum. Hospitals can donate vacant land or buildings to mission-driven developers making it economically viable to serve very low-income households. In Paterson, New Jersey, St. Joseph’s Hospital is partnering with the New Jersey Housing Finance Agency and the Corporation for Supportive Housing to develop 71 units of affordable housing on hospital-owned land.
Leverage funds in a capital stack. When multiple stakeholders layer their investments into what is called a “capital stack” it enables each partner to assume a different level of financial risk. Hospitals can partner with community development financial institutions (CDFIs) or non-profit developers to identify other investors with complementary levels of risk-tolerance. A regional example for Inova to follow is the partnership between Bon Secours Baltimore and Enterprise Community Development. Together, these institutions secured financing from multiple investors to fund the development of over 800 affordable units.
Guarantee a loan. Hospitals can support affordable housing development without an upfront financial investment by providing a loan guarantee. A loan guarantee leverages a hospital’s strong financial position to secure more favorable terms for borrowers. In Columbus, Ohio, Nationwide Children’s Hospital provided a loan guarantee for a fund established by a local CDFI, enabling the CDFI to provide below-market loans to mission-driven developers.

As these strategies demonstrate, a significant monetary investment is not necessary for healthcare institutions to help move the needle on our region’s affordable housing goals. What is necessary is a willingness to think creatively, build relationships and engage in cross-sector collaboration. The impact of Northern Virginia’s housing affordability crisis on community health is undeniable. Inova should be a leader in promoting regional discussions with affordable housing developers, the public sector, financial institutions and philanthropy – community stakeholders who are eager to collaborate to respond to the question, “What would most improve the quality of life for our community?” COVID-19 has demonstrated the importance of safe, quality housing, and we need all hands on deck to answer the call. We hope Inova will follow the example of other world-class healthcare institutions by making an investment, financial or otherwise, in affordable housing.