Dear Doctors Carson and Price,
Congratulations on being nominated to serve as Secretary for Housing and Urban Development and Secretary for Health and Human Services, respectively, in the new administration.
By now you have likely realized that if confirmed in the post, you will spend much of your time doing each other’s jobs. Our new report Health, housing and racial justice: An agenda for the Trump administration, shows how you can only improve health by improving housing, and vice versa. And by working together, you can do much to and narrow the race gaps that scar our society still.
Housing and health are deeply intertwined, as Dr. Carson noted in his testimony before the Committee on Banking, Housing, and Urban Affairs (kindly citing our earlier work). In particular, he correctly drew attention to the fact that “housing (and housing discrimination) is a ‘social determinant’ of health.” Substandard housing conditions, which disproportionately affect low-income and minority families, lead to health problems such as asthma, lead poisoning, heart disease, and neurological disorders.
Poor housing, then, can cause poor health. A good, safe home can often heal as effectively as a skilled surgeon’s hands. But there are broader connections between housing and urban policy and the health of our people, too. When poverty is concentrated, the health of the community is impacted negatively. When families with little money face steep rents, they have less to spend on healthy food. High-poverty neighborhoods are at risk of being trapped in a downward spiral, as poor health, limited employment opportunities, diminishing wealth, and limited access to quality transportation amplify the negative effects of each other.
Segregation is a social determinant of health. Here HUD has a vital role to play. Dr. Carson again sounded exactly the right note on this question in his written testimony, pointing out that complex zoning laws exacerbate the problem of racial segregation via “exclusionary zoning” ordinances that price some families out of certain neighborhoods.
We respectfully would urge you to see the push for fair housing not as “social engineering,” but actually as an attack on the social engineering of exclusionary zoning. Fair housing markets are freer markets. In our paper, we make a series of suggestions for opening up the American housing market to help lower-income families, including monitoring the flow of federal dollars to segregated cities; tuning housing vouchers more closely to local housing markets; and launching a “Let’s Live Together” campaign to take on the NIMBYism that hinders reform.
Dr. Price, at the top of your inbox you will no doubt have something called the Affordable Care Act. (On that front, we urge you to seek sensible, and crucially bipartisan reforms, for example to help child victims of the opioid crisis.) Right now, the way to organize, regulate, and fund health care dominates the news, for obvious political reasons. It will be important not to lose sight of the distinction between health and health care. Most of what we call “health care” is of course “sickness care.” This is important, and we all need it, but it is less important in terms of overall health and wellbeing than the “social determinants” mentioned by Dr. Carson. Compared to other nations, the U.S. is out of balance in terms of relative spending on social care versus health care and our lagging health outcomes are the result.
The intersection of neighborhoods, poverty, health and education is animating a stream of work at Brookings, led by our colleague Stuart Butler. As he puts it: “we should gradually be redirecting a lot of money from medical services to the so-called ‘upstream’ factors that are associated with health. Better to spend money on prevention, in other words, than on expensive medical repair shops after the damage has been done.”
In our new paper, which you can read in full here, we propose an action plan for closing the health gap, alongside the proposed reforms for housing. Specifically, you should recruit the president to the cause and urge him to issue a Health Equity Executive Order, which would stiffen existing efforts to reduce racial discrimination in health care delivery (including retaining and enforcing those sections of the ACA that target discrimination). There is also scope in both your departments to elevate and strengthen the work of the Offices of Civil Rights. You will chart new territory if those offices collaborate in order to prevent, rather than simply punish, discrimination.
It hardly needs saying that you face steep challenges in your new roles, and some very difficult and complex decisions. Plenty of honest arguments about policy lie ahead. But we hope that you will agree, first, that working together will make both of your jobs easier; second, that the challenges facing black Americans should be a high priority; and third, that using the power of federal government to promote equity is not only a legitimate responsibility, but a vital one.
Richard V. Reeves and Dayna Bowen Matthew, Brookings Institution