Affordable Housing, Rental Assistance, and Population Health

The US is facing a growing and severe affordable housing crisis. Rents have outstripped wages, and in the vast majority of the country, full-time minimum wage work is insufficient to affordably rent a two-bedroom market-rate apartment. Today, half of low-income households spend more than 50% of their income on housing. This crisis  has contributed to poor housing conditions, housing instability, and eviction among low-income households. The shortage of affordable housing is not only a housing problem, it is also a population health problem, given the well-established relationship between housing conditions and health outcomes.

Federal rental assistance is one of the few sources of affordable housing for low-income renters. By setting a tenant’s rent at 30% of their income, these programs can improve housing affordability and stability, and may relieve economic stress and free up resources for other health  needs. The US Department of Housing and Urban Development (HUD) provides rent assistance to five million families in the form of housing vouchers, public housing, or multifamily affordable units. However, only one quarter of eligible households receive this rental assistance. Waiting lists average two years nationally and stretch to decades in some urban areas, and HUD cuts and new requirements have been recently proposed.

Rental assistance can improve mental health and health care access
Our recent research points to health and health care access benefits of rental assistance programs. For example, Fenelon and colleagues use a nationally representative data linkage and found that adults living in public housing report better self-rated health and less psychological distress than those who were also eligible but did not move into public housing for another two years, the average length of HUD waiting lists for housing assistance. A similar benefit was not found for housing choice voucher programs. Public housing may confer some network benefits and informal sources of support or information, which could improve mental health. In contrast, vouchers can reduce exposure to disadvantaged neighborhoods, which may produce benefits that take longer to emerge. In other work, Fenelon et al. find that adults currently receiving rental assistance are more likely to have health insurance and are less likely to report unmet needs for  health care due to cost than future recipients are. These effects were similar across all HUD housing programs.

Chronic disease management is easier in a home
Rental assistance may also help individuals manage chronic health conditions prevalent among low-income Americans who are also struggling with affordable housing challenges. Qualitative research by Keene and colleagues, conducted among low-income adults with type 2 diabetes, showed how rental assistance facilitated day-to-day diabetes management , allowing residents to prioritize their diabetes care, develop and maintain diabetes-related routines, and afford diabetes-related expenses.

One participant in this study, a 46 year-old African American woman named Regina (not her real name) described receiving her rent-assisted studio apartment, after years on the waiting list, as both a dream come true and also as a pronounced turning point for her diabetes. She explained in an interview, “Then I found housing. Everything, my numbers, as far as my health, got back on track. Since I’ve had housing, my diabetes changed. It went from up here to being down here in the right place.”  With her own apartment, Regina could prepare her own diabetes-friendly meals, store her medication on her bedside table, and sit in the same place when she took it each morning. Prior to moving into her apartment, she described her diabetes management as inconsistent. In her new apartment, she described taking medication as “like brushing my teeth.”

In contrast, a man named Justice, who was on the waiting list for rental assistance, described the challenges of establishing a routine and prioritizing his diabetes while living in homeless shelters and on his friend’s couch. For Justice, lack of stable housing was a consuming worry that was often more pressing than thinking about the long-term consequences of poor diabetes management. He explained, “When I was homeless, it was very hard to manage it because I would not pick up my prescription. It seemed like other things [came up that were] more important than that, so I just overlooked it.”

When the rent’s still too high, health suffers
Even for those with a stable place to live, unaffordable rents could interfere with diabetes management routines. Liane was also on the waiting list for rental assistance. Her rent consumed more than three quarters of her monthly income, and she narrowly avoided eviction by constantly juggling expenses. On this tight budget, seemingly small medication copays were significant. She explained, “That’s my extra gallon of milk or my extra loaf of bread. So do I get the food for the kid or do I get my medication so I can stay alive and take care of him? It’s a toss-up.”

Together, these individual’s stories and analyses of nationally representative data point to the health value of federal rental assistance programs, particularly for individuals who are living with chronic health conditions. Though more research is needed, these data suggest that an expansion of these programs to address the housing needs of all eligible households could improve population health, potentially reducing socioeconomic disparities in chronic disease outcomes, as well as health care costs associated with preventable complications.

About the authors

Danya Keene

Danya Keene’s mixed-methods research broadly explores how social policies contribute to health inequality, with a particular focus on issues related to housing, neighborhoods and place. For example, her work has examined how urban revitalization and public housing demolition may affect the health of low-income African American communities in Chicago, Atlanta and nationally. She is also conducting mixed methods research that explores linkages between home foreclosure and health. Dr. Keene is also interested in social stigma and its relationship to geographic and social inequality.

Andrew Fenelon

Andrew Fenelon is an Assistant Professor in the Department of Health Services Administration at the University of Maryland, College Park and a faculty associate at the Maryland Population Research Center. He is a sociologist and demographer and has studied racial/ethnic and socioeconomic differences in health in the United States, immigrant health and mortality, and cigarette smoking’s impact on US life expectancy. His current research addresses the effects of HUD housing assistance on health, health care access, and neighborhood attainment in the US using the recent linkage of HUD administrative records to the National Health Interview Survey and the National Health and Nutrition Examination Survey.