More than 32% of households in the United States live in homes that are considered unaffordable,1 and the evidence linking unaffordable housing and worse health is growing. With efforts such as The Accountable Health Communities model from the Center for Medicare and Medicaid Innovation, insurers and health care institutions have increased screening for housing affordability as a social determinant of health. However, referral remains a key challenge, as the supply of affordable housing and federal assistance is limited. This past year, in an attempt to move upstream beyond screening and referral, 6 health care institutions, including Kaiser Permanente, Bon Secours Mercy Health System, and the University of Pittsburgh Medical Center, launched a collaboration to “deepen their investment in affordable housing, and advance policies and practices that foster equitable housing solutions.”2 Included in the collaboration’s framework of policies and practices is the potentially promising avenue of health care’s involvement in community land trusts (CLTs).
Developed in the United States during the Civil Rights era as a method to address housing disparities and land access for African Americans,3 CLTs promote a means to homeownership for individuals who would otherwise be unable to afford a home. The broader concept of shared equity housing refers to a variety of housing approaches that all have the key similarity of shared ownership between the individual who lives in the home and a group entity, often a nonprofit organization, that helps subsidize the purchase of the home for the co-owner.
The values of CLTs are encapsulated in the name. The CLT model emphasizes the role that the community can play in local decision-making by placing land that is in the community into the hands of community members.3 Furthermore, the approach aims to place these assets in trust for future generations. Rather than leaving them to individuals, including those who may be outside the community or with greater power or income, the model seeks to sustainably preserve the land, providing a mechanism to potentially mitigate the displacement associated with gentrification.
When a CLT first acquires a property, it turns it into a suitable home, often using either philanthropic or public funds. It then sells the property at below the market rate to an individual who makes less than the area median income. With the details defined by state law, the purchaser enters into an agreement with the seller (the CLT) to share ownership in the property. This agreement includes a formula that dictates the resale price of the home. Despite this, research shows that individuals, on average, have a reasonable return on their investment.4 The agreement regarding resale value is key to sustaining affordability, ensuring that the next purchaser, who also must meet income requirements, is able to afford the home without an undue housing cost burden.
As a form of shared equity housing, CLTs have been slowly growing in the United States. There were almost 190 CLTs in the United States by 2006, increasing to 230 by 2012.5-7 With a rough estimate of approximately 10 000 units in the United States, CLTs make up only approximately 0.1% of affordable housing.3
Two key features of CLTs hold promise for improving health. First, and unique among affordable housing programs, CLTs allow for wealth generation. Disparities in wealth by race/ethnicity are large, persistent, and linked with a range of health outcomes.7 With housing being the largest component of household wealth, this approach holds promise for overcoming intergenerational cycles of poverty.
Second, CLTs focus on giving community members greater influence in their neighborhoods. Although varying governance models exist, a CLT classically has a tripartite board composed of individuals who live in the properties, community members, and local stakeholder institutions. Working together, the board establishes bylaws, purchases land, approves the sale of land, and holds the CLT accountable. This coordination of social capital, financial capital, community leadership, and participatory governance holds promise for developing social cohesion and collective efficacy, both of which are known to confer public health benefits.
As stakeholders in their communities, hospitals and health care organizations are well suited to encourage CLT development as a means of addressing unaffordable housing as a root cause of health disparities. The role of health care organizations in CLTs can take on a variety of forms, including the provision of capital (in the form of land or financing) and the function of convener for spearheading development. Through partnerships with insurers, local governments, and local communities, health care organizations could also provide wraparound services to CLT members to address other health needs.
As with any effort to address affordable housing, CLTs have many barriers. The CLT model is not widely known; there is a need for on-the-ground expertise. Furthermore, CLTs may be challenging to implement owing to high upfront costs for land purchase and limited mortgage products from financial institutions.
Additionally, the model lacks rigorous evaluation of its health effects. A potential research agenda for CLTs would include assessing processes and outcomes for individuals, the broader community, and health care systems. Such studies might include investigating questions around who chooses and is selected to participate in CLTs, participant reflections on their experiences, short- and long-term health and financial benefits, and unintended consequences. For the community, researchers might address issues including capacity building, social capital, social cohesion, and gentrification. In addition, research for health systems should define best practices for investing and partnering with other stakeholders in CLTs to better understand the social return on investment.
CLTs are an underexplored solution for unaffordable housing that may provide unique public health benefits. As a model for affordable housing, CLTs provide an opportunity for health care entities to uniquely address the social determinants of health in their communities. Beyond merely emphasizing a structure to live in, the CLT seeks to provide a home by incorporating individuals into the life of the local community and empowering the local community to address the needs of its residents.
Corresponding author: Daniel J. Hindman, MD, MPH, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 2024 E Monument Street, Room 2-600, Baltimore, MD 21287 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Hindman’s fellowship in General Internal Medicine is funded by a T32 grant from the National Institutes of Health/National Heart, Lung, and Blood Institute (T32 HL007180-43). Dr Hindman also reports receiving funding from the Bloomberg American Health Initiative. He has no other disclosures to report. Neither the National Institutes of Health/National Heart, Lung, and Blood Institute nor the Bloomberg American Health Initiative had any role in the preparation, review, or approval of the manuscript and decision to submit the manuscript for publication. Dr Pollack reports stock ownership in Gilead Pharmaceuticals and being an unpaid member of the health advisory committee for the nonprofit organization Enterprise Community Partners and a paid consultant to the Open Communities Alliance. In September 2019, Dr Pollack entered into a contract with the United States Department of Housing and Urban Development to work part time on a temporary assignment assisting the agency on housing and health issues. He has no other disclosures to report. The findings and conclusions in this article are those of the authors and do not necessarily represent those of HUD or the other funders. None of the above funders had any role in the preparation, review, or approval of the manuscript and decision to submit the manuscript for publication.
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