Ms. J., a 68-year-old retired health care worker, spent her career caring for other people. As she got older, however, Ms. J began to develop serious health issues of her own. Her chronic knee pain, for example, can make it difficult for her to enjoy her favorite activities, like browsing the food offerings at Reading Terminal Market.

Luckily for Ms. J., in February 2017, she was selected for a unit in The Apartments at Allegheny. The Apartments is an affordable housing building for seniors in north Philadelphia. The building was developed and is operated by NewCourtland Elder Services, a Germantown-based nonprofit that provides services, housing and skilled nursing care to Philadelphia seniors.

With The Apartments as her home, Ms. J. is able to live securely on her fixed income. In addition to the affordable rent, the building covers Ms. J.'s utility and laundry bills. Furthermore, Ms. J.'s health has benefited greatly from The Apartments' partnership with an on site “LIFE” program, which provides medical and supportive services to seniors. Through the LIFE program, Ms. J. gained access to specialists and care that helped her through major surgery and which continue to offer support for her health. For Ms. J., The Apartments' combination of affordability and supportive services have enabled her to age with security, health and vitality.

Regional Housing Legal Services (RHLS), a statewide nonprofit legal and advocacy organization, played an integral role in the development of The Apartments. RHLS provided vital legal representation to NewCourtland in structuring, financing and constructing the project. RHLS helped negotiate funding terms with investors and lenders, drafted and negotiated the construction and architect agreements and counseled NewCourtland on related corporate matters.

RHLS's representation of nonprofits in the development of affordable housing is core to its mission of combating housing injustice across the commonwealth. In its 45 years working in Pennsylvania, RHLS has assisted in the creation of over 10,000 units of housing across the state. That housing construction and preservation has injected over $1 billion into local economies. In addition to its development services work, RHLS also advocates for innovative policies at all levels of government that expand and preserve housing and economic opportunities for low income people and people of color.

Health and Housing

Supportive affordable housing like The Apartments exemplifies the close ties between health and housing. As a large body of research has demonstrated, this relationship is strong and multifaceted. Researchers have identified at least four pathways through which quality affordable housing can improve health outcomes: by preventing the physical and mental traumas people may experience when they are forced to live in shelters or other unsafe conditions; by allowing people to afford homes with healthy conditions (e.g., proper ventilation); by freeing up income that people can use to pay for healthy food and medical treatment; and by allowing people to live in safer neighborhoods that instill numerous health benefits, from offering safe areas for outdoor exercise to alleviating the stress that comes from living around frequent crime, see Lauren Taylor, “Housing and Health: An Overview of the Literature,” Health Affairs (June 2018). The integration of supportive services into housing—like at The Apartments—is a fifth pathway. When housing connects residents with health care providers, with transportation that allows them to remain active and with community activities and supports, it undoubtedly benefits those residents' physical and mental health.

To date, RHLS has worked on over three dozen supportive housing projects across the commonwealth. These projects serve a wide range of vulnerable populations—from seniors, to people with disabilities, to the formerly homeless. In providing legal counsel on these projects, RHLS has helped its nonprofit clients negotiate the myriad legal hurdles involved in complex affordable housing transactions—from piecing together financing from half a dozen funding sources, to solving issues that arise during design and construction, to navigating federal, state and local regulatory processes.

In addition to its work on supportive housing projects, RHLS has also participated in several other initiatives to increase the development of housing that aims to improve health outcomes. RHLS is currently part of an interdisciplinary team assisting families with developing independent living models for their family members with disabilities. Additionally, RHLS has served as legal counsel on a development that brought a medical clinic to a low-income neighborhood and has successfully advocated for state policy changes that increased support for affordable housing that includes supportive services.

RHLS, NewCourtland and other innovators in the commonwealth are not alone in pursuing projects at the intersection of housing and health. Across the country, the housing and health care sectors have increasingly begun to collaborate. They have worked together to remediate home conditions that trigger asthma, to integrate increased health care access into neighborhood revitalization efforts, and to offer health education classes in affordable housing developments, see Corianne Payton Scally, “Emerging Strategies for Integrating Health and Housing,” Urban Institute (July 2017).

Challenges to Systemwide Progress

Currently, the full promise of integrating housing and health is limited by the vast gulf between the health and housing sectors' respective regulatory regimes. Funding for affordable housing, for the most part, flows through the federal tax code (in the form of the low-income housing tax credit), through the federal department of Housing and Urban Development, and through state and local housing and economic development offices. In the portion of the health care sector that serves low-income people, on the other hand, federal and state Medicaid and Medicare offices control the fiscal flow. These regulatory bodies, and the laws that govern them, were not designed to work together—and they do not. Establishing systemwide collaborations, therefore, is often stymied by this incongruity.

One stark example of these difficulties is the difference in funding structures. Though some changes have been made recently, the health care system's predominant payment model is fee for service. Under this system, Medicare and Medicaid generally pay for services rather than outcomes. In some instances, these services can be housing related. Medicaid and Medicare will not, however, pay for housing development itself. Therefore, even though affordable housing has great health benefits to the populations Medicaid and Medicare serve, those programs' monies cannot be used for such development.

Innovative Projects and Policies

When it comes to knotty and important problems like these, RHLS is uniquely positioned to find solutions. RHLS attorneys have decades of experience closing sophisticated affordable housing transactions and with pushing the policy envelope in Philadelphia, Harrisburg and Washington. By combining these capabilities, RHLS has been able to help clients navigate current constraints in the health and housing spheres while, at the same time, advocating on a policy level to eliminate those obstacles in the future.

Currently, RHLS is working on several groundbreaking projects at the intersection of health and housing. In the field of supportive housing, RHLS continues to assist its clients with developing innovative housing models for underserved and vulnerable populations. One RHLS client, for example, recently opened a development for youth aging out of foster care. And another plans to develop housing for people returning to society from incarceration. On the funding side, RHLS and partners are exploring new sources of financing from the health sector that could be used to develop affordable housing. Finally, RHLS is also supporting efforts to conduct further research on the connection between health and housing in order to better understand the link between affordable housing programs and health outcomes.

Working on pioneering initiatives at the intersection of housing and health presents thorny and vitally important legal and policy issues. RHLS attorneys thrive on the intellectual challenges presented by such work. Ultimately, however, it is not the chance to set new legal precedents or develop new policy models that drives those as RHLS—it is the opportunity to improve the lives of people like Ms. J.

Joseph Jampel, of Regional Housing Legal Services, represents nonprofits that are developing and preserving affordable housing, with a focus on transactions involving new and underutilized funding sources.He is also involved in a variety of policy initiatives to increase affordable housing supply and equity. Contact him at [email protected].