Zeroing in on the Health of New Jersey’s Most Vulnerable Communities

What the Impact of Social Determinants of Health on Communities Tells Us About Necessary Investments

The New Jersey Hospital Association (NJHA)’s Center for Health Analytics, Research & Transformation (CHART) has a series of bulletins, white papers and studies on a variety of topics that received significant media attention.

A recent study, New Jersey’s Most Vulnerable Communities: A Zip Code Analysis of Social Gaps and Their Impact on Health, identified New Jersey’s most vulnerable communities from a health status perspective.

The study takes a deep dive into where and how health status and health vulnerability is poorest in New Jersey. The study looked at 12 health factors including but not limited to the presence of mental illness, the utilization of hospital emergency departments, supportive housing, unemployment and disability, while examining individual’s health status.

The 10 most vulnerable zip codes are located in Camden, Trenton, Newark, Paterson and Atlantic City.   When focusing on the communities with the lowest overall scores, just one of the common trends that emerged was that the median household income was less than $39,000. We can compare this CHART data with housing affordability data in New Jersey.

According to the National Low-Income Housing Coalition (NLIHC) Out of Reach 2019 report, across New Jersey, households would need an annual income of $60,030 to afford a two-bedroom apartment and not pay more than 30% of its household income on rent. And in Trenton as one example of a city with vulnerable zip codes, the annual income of $54,440 is needed to afford a two-bedroom apartment. Households with incomes less than the income needed to afford rent are vulnerable to eviction and homelessness which we know can impact their health.

In Mercer County, where Trenton is located, NJCounts 2019 found that on the night of January 22, 2019, 353 households, including 448 persons, experienced homelessness. NJCounts is the annual point-in-time count of the homeless. These 448 persons most likely have multiple social determinants of health that contribute to their homelessness. They may have disabilities and also frequently visit the emergency department. These households certainly have median incomes less than $39,000.

Recently, much has been written and reported about in both the healthcare and affordable housing and ending homelessness fields about the critical importance of social determinants of health (SDH.) Factors such as housing, food, education, employment, income, insurance coverage and access to needed services are the building blocks to improved health status. We now know that SDH’s have an impactful role in shaping individual’s and household’s health status.

Just one statistic around SDHs faced by a community, such as access to affordable housing, high unemployment or low high school graduation rate, can impact that community’s health status. In areas where several social determinants intersect, the effect on the health vulnerability of entire low-income communities can be lasting and profound.

According to Sean Hopkins, NJHA’s Senior Vice President of CHART, it is no surprise that New Jersey’s urban areas have residents with poor health status.

The dialogue around how to improve health status needs to be focused around investment.

A key message that comes out of this study, says Hopkins is that “A person’s zip code may be more important than their genetic code.”

If you are living in an urban area of New Jersey, or really an urban area anywhere in the country, it is hard to improve your health status without investments made and targeted in the neighborhoods most in need and at risk.

Sean Hopkins, NJHA’s Senior Vice President of CHART

This investment needs to be made among areas including affordable housing, education and workforce development. How do we help low-income individuals access jobs with employer-based health care giving them access to health insurance?

Some patients whose data was used for this study, visited hospital emergency departments for issues such as back pain simply because they do not have either their primary care doctor or health insurance to pay for a primary care doctor visit. But these patients could have been evaluated in a more appropriate setting.

Says Hopkins, “The study results speak to the vulnerability of the individuals living in the urban communities that were surveyed. They are not able to access our healthcare system in the most efficient manner possible.”

On a related note to the CHART study, homeless service providers know that if someone is paying for very expensive emergency department bills, this could put you at risk of not being able to afford rent and possibly eviction.


Hopkins says that we need to “Formulate building blocks that all improve health status across the state.”

These building blocks are the investments needed to positively impact the health of the most vulnerable zip codes.

The New Jersey Hospital Association (NJHA) works to improve the health of the people of New Jersey. In conducting the most recent study for this report, CHART evaluated 20 clinical and socioeconomic measures to score and rank the health status and vulnerability of 537 zip codes in the state.