Housing insecurity can be defined as an individual’s or family’s limited or uncertain availability and access to stable, safe, and affordable housing. It is one of the most impactful unmet social needs in the United States (U.S.) with implications that affect people’s health and wellbeing. Although there is a general awareness among public health professionals and policy makers about housing insecurity, there are gaps in our knowledge of its different components as well as how its relationship to health outcomes may play a role in healthcare costs. According to a study published in American Health and Drug Benefits, almost 33% of visits to emergency rooms are made by the chronically homeless.

People experiencing homelessness have higher rates of chronic health problems such as high blood pressure, heart disease, diabetes, and asthma, leading to higher hospital admissions. The same study found that people experiencing homelessness visit the emergency rooms an average of 5 times annually, and the most frequent users visit them weekly. Each visit costs $3700, amounting to $18,500 spent annually for the average homeless individual and up to $44,400 for the most frequent. This only evaluates housing insecurity at its most severe. Research from The Journal of Internal Medicine found that 23.6% of 16,651 respondents reported having issues with housing stability and were experiencing treatable yet costly health issues.

People suffering from other forms such as poor housing quality have poor access to care and are more likely to utilize acute emergency services. Housing insecurity in relation to healthcare costs is a multifaceted issue that can perpetuate health disparities among vulnerable populations. There is a crucial need to explore the many dimensions of housing insecurity and the role it plays in our healthcare system.

Industry Efforts at Creating a Housing Insecurity Index

Efforts to tackle the complexity of housing insecurity have been attempted before. For example, the Washington Center of Equitable Growth developed a multidimensional housing scale including stability, housing affordability, housing quality, housing safety, neighborhood safety, neighborhood quality, and homelessness – with homelessness being the most severe form of housing insecurity, to understand the impact of housing insecurity on health outcomes. Similarly, the Urban Institute combines homelessness, housing cost burden, residential instability, evictions and other forced moves, living with family or friends to share housing costs (doubling- up), overcrowding, living in substandard, poor quality housing, or living in neighborhoods that are unsafe and lack access to transportation, jobs, quality schools, and other critical amenities. It is clear based on these two indices that assessing housing insecurity requires an elaborate approach, unfortunately not all dimensions can be so easily measured.

HSR.health is also undertaking an effort to define housing insecurity as we are attempting to understand the impact of social determinants on healthcare costs for defined populations, such as Medicare and Medicaid populations.

HSR.health Housing Insecurity Index

Each dimension of housing plays a part in the housing insecurity index. In our view, the following elements are critical to understanding housing insecurity include:

• Percent income going towards rent/mortgage – Healthy People 2020 considers housing to be a financial burden if more than 30% of household income goes towards rent or mortgage. Cost burdened households have little left each month to put towards other essentials such as food, clothing, utilities, and healthcare services, which can play a toll on their health.
• Unemployment claims – Any challenges to employment or the opportunity to earn income, may force individuals and family to rent in substandard housing that may expose them to health and safety risks such as mold, lead, and water leaks
• Housing density – Individuals may be forced to live with others resulting in a higher housing density and overcrowding. Overcrowding is defined as more than two people living in the same bedroom or multiple families living in residence designed for a single family. High density is often indicative of foreclosures and homelessness increasing the the risk of poor health outcomes.
• Foreclosures & housing starts – Foreclosures and housing starts go towards the potential availability of housing.
• Homelessness – The baseline demographic for housing insecurity.
• Housing quality – Even those secure in their home may suffer the consequences of housing insecurity if their home does not provide the essential feature of a healthy, stable, and safe environment with ready access to key resources.
• Median housing cost – Areas where housing prices are above the median value for the region may be placing pressure on housing affordability overall and therefore potentially increasing housing insecurity.

These elements, when considered together, result in the Housing Insecurity Index for Maryland at the ZIP Code level, as shown in Figure 1.

Figure 1: Housing Insecurity Index for Maryland by ZIP Code.

Use of a Housing Insecurity Index

In addition to being used to assess housing insecurity at multiple geographic levels, the Index can be used as a part of an analysis to identify a Risk Adjustment Factor for health systems based upon the prevalence and impact of all social determinants within the health system service delivery area.

For additional information, please contact HSR.health at (240)-731-0756.


1. Cox, R., Rodnyansky, S., Henwood, B., Wenzel, S. (2005). Measuring population estimates of housing insecurity in the United States: A comprehensive approach. Washington Center for Equitable Growth. Retrieved from https://equitablegrowth.org/wp-content/uploads/2017/12/12192017-WP-measuring-housing-insecurity.pdf
2. Garrett D. G. (2012). The business case for ending homelessness: having a home improves health, reduces healthcare utilization and costs. American health & drug benefits, 5(1), 17–19.
3. Kushel, M. B., Gupta, R., Gee, L., & Haas, J. S. (2006). Housing instability and food insecurity as barriers to health care among low-income Americans. Journal of general internal medicine, 21(1), 71–77. https://doi.org/10.1111/j.1525-1497.2005.00278.x
4. Leopold, J., Cunningham, M., Posey, L., Manuel, T. (2020). Improving Measures of Housing Insecurity: A Path Forward. Urban Institute. Retrieved from https://www.urban.org/research/publication/improving-measures-housing-insecurity-path-forward