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These are the Least Healthy Counties in Every State — And What to Do If You Practice in One

Want to know how the health of your county stacks up against those in the rest of your state?

Now you can, thanks to the 2019 County Health Rankings and Roadmaps, an annual analysis of the relationship between community environment and health outcomes. The report, conducted by the Robert Wood Johnson Foundation, uses a variety of state and national data to measure and rank the health of nearly every county in the country, with ranks No. 1 and No. 2 considered the healthiest. With the foundation’s interactive tool, you can check the ranking of your county.

Home is where your health is

This year, the report highlights an element that’s central to patient health: secure, affordable housing. As the report explains, “our homes, and those of our neighbors, play a critical role in shaping our health and the health of the whole community.”

Those who live near high-quality schools and jobs, for example, enjoy better access to good education and living wages. Similarly, eating healthier is far easier in neighborhoods with grocery stores that offer affordable, nutritious food.

On the other hand, poor housing location and conditions can have the opposite effect, and toxins like mold, lead, and smoke can cause residents to fall ill.

By the numbers

A key factor in the relationship between housing and health is affordability. When too much of a paycheck goes toward rent or mortgage payments, going to the doctor, paying utility bills, and getting to and from work become more difficult to afford.

For example:

  • Conventional financial wisdom holds that housing costs shouldn’t exceed 30 percent of monthly household income. People who spend more than 30 percent on their housing costs are considered housing-cost burdened.
  • Across the country, more than 1 in 10 households experience severe housing-cost burden, meaning they spend more than 50 percent of their monthly income on housing.
  • The problem is particularly acute for renters in large metro areas, 1 in 4 of whom spend more than half of their income on housing costs. While housing-cost burden has decreased over the past decade among homeowners, the load for renters hasn’t gotten any lighter.

Severe housing-cost burden is linked to more food insecurity, more child poverty, and more people in fair or poor health.

An unequal problem

Housing-related health challenges are not distributed equally across the country’s population. Both across and within counties, there are stark disparities in access to safe, affordable homes — especially for low-income people and people of color. 

Nearly 1 in 4 black households, for example, spend more than half their income on housing. And while owning a home can prove a crucial way to build wealth and family health, the country’s racial home-ownership gap has only widened in the past decade. The vast majority of households headed by whites are owners while more than half of households headed by blacks are renters. 

These disparities in cost burden and home ownership are largely the result of discriminatory practices put in place decades ago, such as redlining, restrictive zoning rules, and predatory lending. Those practices produce neighborhoods segregated by class and race, which decades of research show are a fundamental cause of health inequities.

As a result of all these factors, the report finds, “we consistently see worse health outcomes for people with low incomes and people of color.” Black residents have higher rates of child poverty, poorer birth outcomes, higher rates of premature death, and lower high-school graduation rates than whites. 

How HCPs can help

Housing-related health problems require broad, structural solutions. Fair housing laws and enforcement, for example, could increase access to living-wage jobs, high-quality health care, grocery stores, green spaces and parks, and public transportation systems. But according to Donald Schwarz, Senior Vice President of Programs at the Robert Wood Johnson Foundation, healthcare practitioners can help, too. 

“The first step is to understand that our health is about more than just healthcare,” he says. “Healthcare professionals generally know that, but they don’t always know how to act on that.”

Schwarz adds that it’s important for clinicians to understand their role within the larger context of a patient’s health environment and needs. “If we think of the healthcare sector as a place where people can be watchful and helpful around social issues and needs, then the healthcare sector’s role in larger questions about health becomes clearer,” he explains.

Attending to ambient stressors in a patient’s life, like financial hardship or access to nutritious food, for example, may prove more important to their long-term health than any given medical intervention. To that end, Schwarz says, HCPs can take advantage of the County Health Rankings Model. For any given health factor, HCPs can cross-check the Foundation’s linked database, called “What Works for Health,” to find actionable resources and policy solutions.

If your county has a high rate of sexually transmitted infections, for example, the foundation’s interactive tool will surface a clinical program for individual, group, and community-level interventions to prevent HIV and other STIs. And if a low-income patient is struggling with housing costs, the tool can provide them with information about how to receive the Earned Income Tax Credit.  

Schwarz also recommends that staff take advantage of organizations such as Health Leads, which links healthcare through online resources and directories to community social services. For example, if a patient is having trouble with a landlord, Health Leads may be able to provide legal assistance for eviction, services for finding a better apartment, or the public health department for lead and asthma inspections.

Fundamentally, though, Schwarz emphasizes that addressing health inequities will require collaboration with people outside the medical sector.

“Clinical care is one part of what affects health outcomes,” he says. “There are a bunch of other things, including behaviors, social and economic factors, and physical environment, and if you look at the breadth of those four categories, there are an awful lot of people, leaders, groups, and organizations whose work affects health. And they need to be connected to each other if ultimately we’re going to have healthy people.”

Our Homes Are Key To Our Health, Robert Wood Johnson Foundation.

Last updated on 10/8/19.

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