By Kylie Valluzzi and Scott Merrill, Granite State News Collaborative

New Hampshire’s housing crisis is about a lot more than having a roof over your head. It also involves economic growth, job creation and tax revenue. 

And now, a new awareness is developing: the profound impact of housing on well-being and health care. There’s a growing realization that making affordable housing more available could be a key to enabling Granite Staters to lead healthier lives.

Housing is one of several “social determinants of health” that some researchers believe have a greater influence on people's well-being than traditional health care.

In New Hampshire, 40.7% of residents have at least one social risk factor known to affect health outcomes and 15.6% have three or more factors, according to the Census Bureau’s 2021 Community Resilience Estimates for Equity. 

Risk factors include poverty, age, disability, access to health insurance, housing security and race. 

In Hillsborough County, New Hampshire’s largest county, 61,974 people have three-plus risk factors, the report says; that’s 14.7 percent of all the residents of the county. Of New Hampshire residents between ages 35 and 64, 41,000 have no health care coverage.

Across the state, a network of researchers, policymakers and health care providers is working to address how these risk factors affect health outcomes for New Hampshire residents.

At the University of New Hampshire, the Carsey School for Public Policy is setting up a community loan fund to improve health conditions; plans are to address affordable housing and other social determinants of health. 

The fund is being modeled after a program at the University of Vermont, said Michael Swack, director of community development at the Carsey School’s Center for Impact Finance. 

Patients with housing insecurity — that is, people unable to pay rent or utilities, or who need to move frequently — have above-average rates of respiratory disease, chronic illness, and challenges with medication management. On the other hand, people with secure housing report fewer hospital visits and, when they go, shorter hospital stays, Swack said, citing UVM’s research.

One question on the minds of the UVM researchers, Swack said, was “’Who were the most expensive patients?’” 

“They found some of those patients included people experiencing housing insecurity or homelessness,” he said.

UVM Medical Center in Burlington launched several initiatives to address housing insecurity among patients. One was Bonvouloir House, a medical respite program run by the Community Health Centers and funded by UVM Medical Center. It offered a clean, safe environment for recovery from medical procedures or ailments for five years until it was abruptly shut down in 2023. 

Over its tenure, the program served more than 200 patients and saved the hospital system an estimated $9 million. However, in July, the program was abruptly shut down because of challenges in meeting the increasingly complex medical needs of its residents. 

Lessons learned

The New Hampshire effort has learned from this start and stop in Vermont. In contrast, Swack said, the Carsey School’s initiative is broader than one hospital and is rather a coalition of hospitals, community development organizations, health centers, government agencies and funders. The project is creating a fund that will be capitalized from multiple sources and fund multiple projects.  

“Projects affecting health outcomes can range from housing, decarbonization of buildings, including health centers and schools, to transportation, telemedicine, healthy food and more,” Swack said. “We hope to create a portfolio of investments across the state that contribute to positive health outcomes.”  

Going forward, the fund will be managed by the N.H. Community Loan Fund, a nonprofit community development financial institution that has successfully invested in communities across the state for over 40 years. Swack hopes that this fall, the fund will be open to investments, after which specific projects will be outlined. 

Another key player in the community loan fund’s development is the N.H. Hospital Association, whose involvement sprang from the work being done by Swack and others at the Carsey School.

“We were interested in creating a model for investing in social determinants of health, and what we’re doing with this fund is creating a model for investment that has never been done on a state level,” said Steve Ahnen, the hospital association’s president and CEO. 

Things that affect people’s health are often outside the hospital system, he said, such as a person’s culture, background, environment, housing, education, and other factors such as food insecurity.

 “As health care systems transition from a ‘sick-care’ system to one based on keeping people healthy — health promotion — we need to think more broadly than the four walls of a doctor’s office or clinic,” he said.

Driven by data

One way — but not the only way — that hospitals can address health promotion, Ahnen said, is to invest in housing. 

“I don’t think there’s a hospital in New Hampshire that isn’t looking at ways to deal with housing,” Ahnen said, referring to the need hospitals and communities in many parts of the state have for workforce housing and affordable housing.

“One thing we found was that a lot of hospitals have a lot of land,” Swack said, and land donations or long-term leases could help create affordable housing. “One of the biggest drivers of affordable housing costs is land, and using the N.H. Community Loan Fund means we don’t need to develop a whole new infrastructure for our fund.”

“The things that are driving health outcomes are things that we as a community need and are responsible for,” Ahnen says. “Hospitals do community needs assessments and work with community partners, but the reality is no one single entity can solve all problems on their own.”

Part of the hope for the loan fund, Ahnen says, is that it will bring stakeholders together outside of hospitals. 

“Insurers are a group we are very interested in talking with,” he says. “For them, a healthier population can mean more control in spending.”

While housing is a central issue for hospitals, Ahnen says transportation, child care and food insecurity also need to be addressed. “We’re looking at ways to partner together on major issues,” he says. “If we all work together, I’m optimistic we can have some impact.”

Ahnen says that, moving forward, the group wants to be driven by data to determine where the greatest challenges for health outcomes exist. 

“The good news is that we have a growing consensus around looking at these issues in a systemic and sustainable way,” he says. “There are great opportunities to partner with businesses and, if we can get multiple entities involved, we can have an even greater impact.”

Against the wind

Efforts to address New Hampshire’s affordable housing crisis, such as the Carsey School’s initiative, are facing some difficult headwinds.

In its annual report issued in June 2023, the National Low Income Housing Coalition ranked New Hampshire the 13th most expensive state for renters, with a $29.86 hourly wage needed to afford a two-bedroom apartment at the state’s average fair market rental rate of $1,553 a month. 

Of 153,349 renter households in New Hampshire, 36,782 fell below 30% of area median income and 68,108 households were below 50% of area median income. 

According to the N.H. Housing 2023 Residential Rental Cost Survey Report, the state’s rental vacancy rate of 0.8 percent for all rentals indicates an off-balance market for tenants and landlords. A vacancy rate of 5 percent is considered balanced, according to the report.

“45% of New Hampshire renter households are paying 30% or more of their household income on rent,” the report said. “Lower-income families are likely to be paying an even higher percentage of their household income towards rent.” 

And buying a home is a struggle for many, as well.

From 2000 to 2020, state median household incomes rose 73 percent while new home prices climbed 111 percent, according to a N.H. Association of Realtors report.

In August, the Realtors’ affordability index fell to 59, the lowest on record. That means the state's median household income is just 59 percent of what is necessary to qualify for a median-priced home under prevailing interest rates.

The median price for a New Hampshire single-family residential was $490,000 in August 2023, up 9 percent from August 2022, the highest ever for the month, and the second-highest of any month in state history.

“To make up for the current deficit of housing units and return the state to a healthy housing market, 88,400 new housing units will be needed by 2040,” the Realtors’ report says. “To maintain the state’s homeownership rate of 71%, 58,000 of these units should create homeownership opportunities and 30,000 should be rental units.

On the bright side, according to a July survey done by the Saint Anselm College Center for Ethics and Society, 78 percent of New Hampshire voters think their communities need more affordable housing to be built and 58 percent want more affordable homes in their own neighborhoods.

The percentage of people who think New Hampshire should change its planning and zoning laws to allow for more affordable housing has more than doubled since 2020, to 60 percent, according to the survey.

Max Latona, a philosophy professor who runs the Center for Ethics and Society at Saint Anselm, said the lack of affordable housing is holding people and communities back from achieving their potential, and building affordable housing is something communities ought to do. 

“This basic lack of housing is undermining our well-being at a community level and at a social level. We need more housing to help us flourish,” Latona said.

These articles are being shared by partners in The Granite State News Collaborative. For more information visit collaborativenh.org.