Policies for Healthy Housing

The relationship between housing and public health has been an area of interest for researchers, public officials, and policymakers since before the emergence of the nation’s modern housing market and system of housing finance.  

 

The growing body of evidence demonstrating linkages between the quality, location, and security of housing and individual, household, and public health outcomes underpins a renewed focus on the ways housing policy can improve health.

​

 Areas of Interest for Policy Makers 

​

There are three primary mechanisms through which housing impacts health:

 

• The internal characteristics of housing units, such as occupant density, safety features, and the general physical features of the residential dwelling, including air and water supply quality; 

• Housing security, broadly encompassing access to and stability of housing opportunity; and, 

• Proximity to external amenities and disamenities, such as public parks, the public transportation network, and source of pollution.

​

Housing Stability and Security

​

Health outcomes for the homeless offer a clear illustration of the importance of housing stability and security to health outcomes. While chronic homelessness as a public health challenge has unique causes and features that are outside the scope of this briefing , significant shocks to household income can threaten health and wellbeing even for households in relatively stable housing circumstances during periods of normalcy in the economy and labor market. Renters are a particularly vulnerable group  and the threat of eviction or loss of housing is associated with negative outcomes for mental health, physical health, and health-related behaviors. 

 

Recognizing the importance of secure housing as a public health intervention during the pandemic, the Centers for Disease Control and Prevention (CDC) issued an agency order in September 2020 barring most evictions, though it was later struck down by the courts:

​

In the context of a pandemic, eviction moratoria—like quarantine, isolation, and social distancing—can be an effective public health measure utilized to prevent the spread of communicable disease … Furthermore, housing stability helps protect public health because homelessness increases the likelihood of individuals moving into congregate settings 

 

Importantly, housing instability need not result in the extreme outcome of homelessness for the relationship to hold. Burgard et al. (2012) find that households that had moved for financial reasons were more likely to report anxiety and renters behind on payments were more likely to meet criteria for depression. 

​

Housing Affordability

​

Even when negative shocks to income do not threaten basic access to shelter, deterioration in housing affordability and increasing housing cost burdens require household budget allocations that reduce spending in other areas related directly and indirectly to health, including healthcare, food, clothing, and educational expenses.  Furthermore, income-constrained households in high-cost housing markets may locate in neighborhoods with relatively lower social capital, where the affordability profile is more favorable.

 

The link between affordability and health is particularly relevant in recent years, a period during which average rent growth has generally exceeded income gains and the supply of low-rent units has been declining. The most cost-burdened renters spend nearly 40 less on food and 70 percent less on healthcare than otherwise comparable households. 

 

Pollack et al. (2010) find an association between unaffordable housing commitments, which they define as more than 30 percent of income spent on housing costs, and a wide range of health measures, including self-reported health, hypertension, arthritis, and cost-related non-adherence with healthcare and prescriptions.  

​

Housing Quality

​

The relationship between the physical characteristics of housing units and health outcomes is well studied, particularly as relates to disamenities such as lead paint and water quality. The literature covers a wide range of environmental conditions that impact health, as well as the relationship between density and health, as in the long-established connection to communicable diseases. As described in Bashir (2002):

​

Significant research demonstrates the harmful association of asthma, neurological damage, malnutrition, stunted growth, accidents, and injury with house- hold triggers like poor insulation, combustion appliances, cock- roach and rodent infestation, dust mites, hyper- and hypothermia, unaffordable rent, and dangerous levels of lead in soil and household paint. 

 

An example of the interplay between housing, health, and financial capacity, the real or perceived role of density during the pandemic has fueled a shift in demand away from denser neighborhoods and, by extension, high within-unit density.  Households requiring access to public transportation, and those working in service occupations requiring physical co-location, are disadvantaged in this shift in favor of lower density, presumably healthier housing.

 

Neighborhood Characteristics

 

The characteristics of neighborhoods are increasingly understood as causally related to a range of outcomes, including social and economic mobility and health. In part, the relationship reflects features of the built environment that may directly impact health, such as air quality and access to public spaces. 

 

A more recent body of research explores how neighborhood characteristics influence health-related behaviors and provide access to amenities and disamenities that influence health outcomes. The role of transportation infrastructure in enhancing access to distant amenities and reducing social exclusion  is of particular relevance as the federal, state, and local governments develop frameworks for allocating a potentially historic increase in infrastructure spending.

 

In their study of nearly 80,000 Black and White individuals recruited between 2002 and 2009, Warren Andersen et al. (2017) find the most significantly socio-economically disadvantaged neighborhoods are associated with higher mortality across all causes for both men and women, with the strongest association for cardiovascular disease.   Larson et al. (2009) explore one mechanism in detail, finding a relationship between better access to grocery stores and weaker access to convenience stores to a lower prevalence of obesity.  

 

Cohen et al. (2007) describe how features of the neighborhood’s built environment influence energy expenditure.  As a public health intervention, neighborhood investments that increase energy expenditure may factor into strategies for addressing high-prevalence chronic conditions including cardio-vascular disease and diabetes mellitus. Focusing on public parks, they conclude they are important amenities in facilitating activity and that park utilization is related to proximity. 

 

While this suggests an investment in more public parks, we know from the economics literature and from real-world experience that the value of the desirable but costly amenity will be capitalized into prices. Where resources are available to support such investment, the challenge for policymakers at the local level is to discern how to make beneficial improvements without increasing the rent burden on income-constrained households or displacing them altogether through gentrification.

​