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Housing Is Health: A Renewed Call for Federal Housing Investments in Affordable Housing for Families With Children

      Decades of research demonstrate the importance of a safe, stable, affordable home as a foundation for health beginning in the prenatal period and extending over the life course.
      • Taylor L
      Housing and Health: An Overview of the Literature.
      Unfortunately, in the United States today, millions of children face housing circumstances that harm their health and, as a result, increase unnecessary health care utilization.
      • Poblacion A
      • Bovell-Ammon A
      • Sheward R
      • et al.
      Stable Homes Make Healthy Families.
      Families with extremely low incomes, particularly Black and Latinx families, are disproportionately impacted by adverse housing circumstances further exacerbating health disparities. These disparities are rooted in a long history of discriminatory policies and practices that shape the current housing landscape in the United States. In this commentary, we examine four domains of housing—quality, stability, affordability, and neighborhoods—critical for positive child health outcomes as well as policies and practices that should be employed to ensure all children live in homes that promote healthy growth and development.

      Four Domains of Housing for Optimal Child Health—Quality, Stability, Affordability, and Neighborhood

      Quality

      Living in a home with adequate heating and cooling
      • Cook JT
      • Frank DA
      • Casey PH
      • et al.
      A brief indicator of household energy security: associations with food security, child health, and child development in US infants and toddlers.
      that is free of pests, mold, lead, second-hand smoke and other known environmental hazards and meets the accessibility needs of children with special health care needs is critical for child health. Lead exposure—currently found in an estimated 24 million homes nationwide—during early childhood irreversibly damages a child's brain,
      • Etzel RA
      • Balk SJ
      • Bearer CF
      • et al.
      Screening for elevated blood lead levels. American Academy of Pediatrics Committee on environmental health.
      and mold, pests, and second-hand smoke have been shown to exacerbate asthma and other respiratory conditions.
      Institute of Medicine (US) Committee on the Assessment of Asthma and Indoor Air
      Clearing the Air: Asthma and Indoor Air Exposures.
      All of these exposures are more likely to be experienced by children of color, which in turn exacerbates racial health disparities.
      • Jacobs DE
      Environmental health disparities in housing.
      • Hughes HK
      • Matsui EC
      • Tschudy MM
      • et al.
      Pediatric asthma health disparities: race, hardship, housing, and asthma in a national survey.
      • White BM
      • Bonilha HS
      • Ellis C
      Racial/ethnic differences in childhood blood lead levels among children <72 months of age in the United States: a systematic review of the literature.
      The preponderance of literature linking these exposures to negative child health outcomes has led to the development of interventions, such as asthma home visiting programs, that reduce harmful indoor exposures through partnerships between housing advocacy groups, community-based providers and health care organizations.
      • Etzel RA
      • Balk SJ
      • Bearer CF
      • et al.
      Screening for elevated blood lead levels. American Academy of Pediatrics Committee on environmental health.
      ,
      • Krieger J
      • Jacobs DE
      • Ashley PJ
      • et al.
      Housing interventions and control of asthma-related indoor biologic agents: a review of the evidence.

      Stability

      Young children whose families move 2 or more times in a year are at risk of poor health and developmental outcomes and older children who experience residential mobility—defined variably in the literature, but often referring to frequent moves throughout childhood—are more likely to develop mental or behavioral health conditions compared to children in families who are stably housed.
      • Jellyman T
      • Spencer N.
      Residential mobility in childhood and health outcomes: a systematic review.
      ,
      • Sandel M
      • Sheward R
      • Ettinger de Cuba S
      • et al.
      Unstable housing and caregiver and child health in renter families.
      The impact of evictions, foreclosures, and forced displacement on child health has been increasing. Nearly 3 million families experience evictions annually in the United States and, as a result, research shows the health of children, the mental health of their mothers, and the economic stability of the family is adversely impacted.
      • Desmond M
      Poor Black Women Are Evicted at Alarming Rates, Setting off a Chain of Hardship.
      • Desmond M
      • Shollenberger T
      Forced displacement from rental housing: prevalence and neighborhood consequences.
      • Desmond M
      • Kimbro RT
      Eviction's fallout: housing, hardship, and health.
      • Desmond M
      Evicted: Poverty And Profit in the American City.
      • Desmond M
      • Gershenson C
      Who gets evicted? Assessing individual, neighborhood, and network factors.
      Inability to afford rent is overwhelmingly the main cause of eviction; often tenants owe landlords relatively small amounts in backed rent—in many cases, around 1 month of rent or less.
      • Badger E
      Many renters who face eviction owe less than $600: can Washington do something to help them? A growing number of politicians think so.
      Foreclosures are associated with increased health utilization, notably urgent health procedures for preventable conditions, among children and adults.
      • Currie J
      • Tekin E
      Is the Foreclosure Crisis Making Us Sick?.
      When families are forced to move, either due to eviction or foreclosure, they are often displaced to lower quality housing that may further exacerbate health complications.
      • Marcus J
      • Zuk M
      Displacement in San Mateo County, California: Consequences for Housing, Neighborhoods, Quality of Life, and Health.
      Homelessness—defined as living in a shelter, motel/hotel, or place not meant for human habitation—is one of the most extreme forms of instability for families and is prevalent in the United States with more 150,000 people families with children experiencing homelessness annually.

      National Alliance to End Homelessness. Children and families. Available at:https://endhomelessness.org/homelessness-in-america/who-experiences-homelessness/children-and-families. Accessed May 22, 2020.

      Beginning in the prenatal period and extending through childhood, any duration of homelessness is associated with adverse health, developmental, and educational outcomes.

      National Alliance to End Homelessness. Children and families. Available at:https://endhomelessness.org/homelessness-in-america/who-experiences-homelessness/children-and-families. Accessed May 22, 2020.

      • Buckner JC
      • Bassuk EL
      • Weinreb LF
      • et al.
      Homelessness and its relation to the mental health and behavior of low-income school-age children.
      • Cutts DB
      • Coleman S
      • Black MM
      • et al.
      Homelessness during pregnancy: a unique, time-dependent risk factor of birth outcomes.
      • Sandel M
      • Sheward R
      • Ettinger de Cuba S
      • et al.
      Timing and duration of pre- and postnatal homelessness and the health of young children.
      • Clark RE
      • Weinreb L
      • Flahive JM
      • et al.
      Health care utilization and expenditures of homeless family members before and after emergency housing.
      • Clark RE
      • Weinreb L
      • Flahive JM
      • et al.
      Infants exposed to homelessness: health, health care use, and health spending from birth to age six.
      Homelessness is an area where racial disparities are particularly pronounced. While Black households make up 13% of the overall population in the United States, they account for 40% of people experiencing homelessness and are 50% of families experiencing homelessness with children.

      National Alliance to End Homelessness. Children and families. Available at:https://endhomelessness.org/homelessness-in-america/who-experiences-homelessness/children-and-families. Accessed May 22, 2020.

      Further, as housing becomes more unaffordable and unavailable, homelessness increases. Research shows that in many areas of the country, even small rent increases can place thousands of people with very low incomes at heightened risks of homelessness.
      • Cutts DB
      • Bovell-Ammon A
      • Ettinger de Cuba S
      • et al.
      Homelessness during infancy: associations with infant and maternal health and hardship outcomes.

      Affordability

      According to research from the National Low Income Housing Coalition, there is a severe shortage of 7 million affordable and available homes for renters with the lowest incomes.
      • Glynn C
      • Casey A
      Homelessness Rises Faster Where Rent Exceeds a Third of Income.
      Steady increases in rent, stagnant increases in wages and chronic underfunding of federal programs to preserve and create affordable housing have contributed to this massive shortage. The number of households with very low incomes that either pay more than half their income for rent or live in severely substandard housing, and receive no housing assistance—has risen by 66% since 2001.
      • Aurand A
      • Emmanuel D
      • Errico E
      • et al.
      The Gap: A Shortage of Affordable Homes.
      Families who struggle to afford rent are at greater risk of other economic hardships including difficulty affording food, utilities, transportation, and medical care, and children and adults in these families are more likely to have worse health outcomes than those who can afford their rent.
      • Sandel M
      • Sheward R
      • Ettinger de Cuba S
      • et al.
      Unstable housing and caregiver and child health in renter families.

      Neighborhood

      Where a child lives, learns, and plays is important for healthy development. Intentional residential segregation, disinvestment in communities of color, exclusionary housing policies, and subprime lending practices throughout the United States have created and perpetuated health inequities across racial, ethnic, and socioeconomic lines.
      • Mazzara A
      Gap Between Federal Rental Assistance and Need Is Growing.
      ,
      • Rothstein R
      The Color of Law: A Forgotten History of How Our Government Segregated America.
      As a result of these intentional policies, today Black and Latinx families are significantly more likely to live in neighborhoods of concentrated poverty compared to white families, which hinders health, educational achievement, and upward income mobility.
      • Williams DR
      • Collins C
      Racial residential segregation: a fundamental cause of racial disparities in health.
      Studies show that when children live in stable, affordable homes located in neighborhoods with high-performing schools, safe outdoor spaces, and access to transportation and jobs, they are better able to thrive and become healthier adults.
      • Acevedo-Garcia D
      • Noelke C
      • McArdle N
      The geography of child opportunity: why neighborhoods matter for equity.
      Across the country, however, cities and towns have wide disparities between neighborhoods and the opportunities they provide.
      • Acevedo-Garcia D
      • Noelke C
      • McArdle N
      The geography of child opportunity: why neighborhoods matter for equity.

      Health Care and Clinical Transformation—What Pediatricians Can Do to Advance Housing and Health Equity

      Currently, health systems across the country are assessing health-related social needs, including housing, during clinic visits. Systematically screening families using tools such as the Housing Stability Vital Sign, Accountable Health Communities question on housing quality or others that assess multiple housing domains is critical for ensuring families living in housing situations that threaten health do not fall through the cracks.
      • Billioux A
      • Verlander K
      • Anthony S
      • et al.
      Standardized screening for health-related social needs in clinical settings: the accountable health communities screening tool.
      ,
      • Sheward R
      • Bovell-Ammon A
      • Ahmad N
      • et al.
      Promoting caregiver and child health through housing and stability screening in clinical settings.
      Further, health systems can use geocoded data to understand neighborhood level factors for clinical care.
      • Beck A
      • Sandel M
      • Ryan PH
      • et al.
      Mapping neighborhood health geomarkers to clinical care decisions to promote equity in child health.
      While screening for housing without an immediate solution may create concern among clinicians,
      • Garg A
      • Boynton-Jarrett R
      • Dworkin PH
      Avoiding the unintended consequences of screening for social determinants of health.
      systematically collecting information in clinics is important for understanding the scope of resource needs. Given the sensitivity of these issues, building rapport and setting reasonable expectations with families is necessary.
      Once housing instability, housing quality issues, or homelessness have been identified, health systems have opportunities to provide support to families in order to improve health. These solutions may include interventions delivered at different “dose” levels. For example, “low-dose” interventions may include the provision of resource guides
      • Garg A
      • Toy S
      • Tripodis Y
      • et al.
      Addressing social determinants of health at well child care visits: a cluster RCT.
      while “medium-dose” interventions may include co-locating or coordinating housing and social services in health care settings.
      • Sheward R
      • Bovell-Ammon A
      • Ahmad N
      • et al.
      Promoting caregiver and child health through housing and stability screening in clinical settings.
      For medically or socially complex families, “high-dose” interventions that integrate intensive housing case management and/or connection to high-quality, affordable housing options for patient families may be necessary.
      Regardless of the model, engaging in partnerships with local housing groups, community-based providers and social services providers is an effective solution for reducing barriers for families to access resources and increasing the capacity, knowledge, and communication between clinicians and social services and housing providers.
      • Sheward R
      • Bovell-Ammon A
      • Ahmad N
      • et al.
      Promoting caregiver and child health through housing and stability screening in clinical settings.
      Given the complexity of both housing issues that may arise from screening and solutions to respond to those needs, engaging in partnerships with external organizations while also building internal clinical capacity to address housing needs may be more effective for promoting housing stability than either strategy alone. For example, a recently published randomized control trial demonstrated significant improvements in child health and parental mental health in the first 6 months of a housing intervention for medically complex families that coordinated health, housing, legal, and financial services across health care and community-based organizations.
      • Bovell-Ammon A
      • Mansilla C
      • Poblacion A
      • et al.
      Housing intervention for medically complex families associated with improved family health: pilot randomized trial.
      Although health care institutions have begun implementing innovative interventions to address adverse housing conditions among patients, health care cannot solve this problem alone. In order to adequately meet the needs of patient families, people in the health care system must advocate to expand housing resources and to improve policies on the federal, state, and local levels. Because pediatricians see first-hand the connections between housing and health, they are uniquely positioned to advocate for better housing policy solutions through their professional associations including the American Academy of Pediatrics and with their individual institutions, if possible, to address upstream contributors to poor health and work across sectors to improve housing location, stability and affordability to promote health equity.
      • Sandel M
      • Faugno E
      • Mingo A
      • et al.
      Neighborhood-level interventions to improve childhood opportunity and lift children out of poverty.
      Pediatricians can engage in these efforts through cross-sector coalitions such as the Opportunity Starts at Home Campaign

      Opportunity starts at home. Available at: opportunityhome.org. Accessed May 22, 2020.

      and by directly contacting the elected officials who represent them to explain why stable, affordable housing is essential to child health and to urge stronger action on housing.

      Housing Policy—Engaging Policy Makers to Address a Root Cause of Health Disparities

      Without intervention from the government, housing developers and operators cannot build, operate, and maintain quality affordable homes for people with the lowest incomes. Government subsidies are necessary to fill the gap between what people with the lowest incomes can afford to pay in rent and the costs of developing and operating rental homes. Inaction on the housing crisis is expensive—Children's HealthWatch estimates that unstable housing among families with children will cost the US $111 billion in avoidable health and education expenditures over the next ten years.
      • Poblacion A
      • Bovell-Ammon A
      • Sheward R
      • et al.
      Stable Homes Make Healthy Families.
      Investing in affordable homes would generate multiplying returns, not only in the form of reduced healthcare costs, but also in new jobs, increased economic mobility, and higher educational attainment.
      • Cunningham M
      • MacDonald G
      Housing as a Platform for Improving Education Outcomes Among Low-Income Children.
      • Wardrip K
      • Williams L
      • Hague S
      The Role of Affordable Housing in Creating Jobs and Stimulating Local Economic Development: A Review of the Literature.
      • Chetty R
      • Hendren N
      • Katz L
      The Effects of Exposure to Better Neighborhoods on Children: New Evidence From the Moving to Opportunity Experiment.
      Achieving equity demands that we first focus finite resources on those most in need: people with extremely low incomes and other historically marginalized renters, who are, by far, more likely to struggle with the 4 domains of adverse housing that impact child health. Sixty-four percent of extremely low income households rely on the rental market for their housing and many face significant barriers in achieving or retaining homeownership.
      Addressing the deep structural inequities within the rental housing market demands a major, long-overdue federal response. States and localities have important roles to play, but they cannot fully solve this problem on their own. The following federal strategies are necessary to address the problem:
      • Bridge the gap between rent and income: Because rents are far outpacing wages, a substantial expansion of rental assistance is necessary to respond to the affordable housing crisis. The most well-known type of rental assistance is the Housing Choice Voucher program, which helps people with the lowest incomes afford housing in the private market by paying landlords the difference between what a household can afford to pay for rent and the rent itself, up to a reasonable amount. Vouchers are evidence-based solutions for ending homelessness and housing instability. A 2018 exploratory analysis from the National Low Income Housing Coalition estimates that an additional annual investment of $54.3 billion would be required to meet the needs of every eligible extremely low income renter household (in addition to the $20 billion already being spent on the program). Other promising policy innovations to bridge the gap between rent and income should be pursued, such as creating a new renter's tax credit for people with the lowest incomes.
      • Expand the affordable housing stock: Substantially larger investments in programs to produce and preserve homes for people with the lowest incomes are also essential. The national Housing Trust Fund, a dedicated funding stream that was created to efficiently build, rehabilitate, preserve, and operate rental housing specifically for people with extremely low incomes, should be significantly expanded. A 2018 exploratory analysis from the National Low Income Housing Coalition estimates that the Housing Trust Fund would need $29.9 billion per year over the next decade to fully meet the needs of extremely low income renters.
      • Stabilize households in crisis through emergency rental assistance: Most families in poverty spend at least half of their incomes on housing, leaving virtually no margin for an unexpected expense. By providing a relatively small amount of money and supportive services to families in crisis, emergency rental assistance programs can stabilize families before families are evicted, face foreclosure, or become homeless. In 2013, the Bipartisan Policy Center proposed a short-term emergency assistance program that would require $3 billion annually.
        Bipartisan Policy Center
        Housing America's Future: New Directions for National Policy.
      These strategies will help address all 4 domains of housing for optimal child health. For example, federal rental assistance requires minimum quality standards while also bridging the gap between rent and income for people with the lowest incomes to ensure affordability, which in turn promotes stability. There is also wide bipartisan support for a subset of vouchers—often called mobility vouchers—that provide families with low incomes the liberty to choose neighborhoods they have been historically priced out of, that receive greater funding and support contributing to higher performing schools, stronger job prospects, and other resources.
      Of course, policy action can and should be taken at all levels of government, not just in Washington DC. States and localities must also expand resources as well as implement more effective policies. These solutions include passing laws or regulations that eliminate source of income discrimination,

      Cunningham M, Galvez M, Aranda CL, et al. “A pilot study of landlord acceptance of housing choice vouchers.” Prepared for the US Department of Housing and Urban Development, Submitted by Urban Institute. 2018. Available at:https://www.huduser.gov/portal//portal/sites/default/files/pdf/ExecSumm-Landlord-Acceptance-of-Housing-Choice-Vouchers.pdf. Accessed June 15, 2020

      protect renters’ rights through policies including just-cause eviction and right to counsel laws, and reduce barriers to housing development that eliminate residential segregation.

      Conclusion

      A stable, affordable home in communities connected to opportunity is a prescription for good health. Unfortunately, this medication is not found on the shelves of pharmacies. This means pediatric providers and health care systems must work together across multisector partnerships and with policy makers to ensure all children live in homes that support healthy growth and development while also promoting health equity.

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        Housing and Health: An Overview of the Literature.
        2018 (Health Affairs Policy Brief)
        • Poblacion A
        • Bovell-Ammon A
        • Sheward R
        • et al.
        Stable Homes Make Healthy Families.
        2017
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        • Casey PH
        • et al.
        A brief indicator of household energy security: associations with food security, child health, and child development in US infants and toddlers.
        Pediatrics. 2008; 122: e867-e875
        • Etzel RA
        • Balk SJ
        • Bearer CF
        • et al.
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        • Institute of Medicine (US) Committee on the Assessment of Asthma and Indoor Air
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        National Academies Press, 2000
        • Jacobs DE
        Environmental health disparities in housing.
        Am J Public Health. 2011; 101: S115-S122
        • Hughes HK
        • Matsui EC
        • Tschudy MM
        • et al.
        Pediatric asthma health disparities: race, hardship, housing, and asthma in a national survey.
        Acad Pediatr. 2017; 17: 127-134
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        • Bonilha HS
        • Ellis C
        Racial/ethnic differences in childhood blood lead levels among children <72 months of age in the United States: a systematic review of the literature.
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        Unstable housing and caregiver and child health in renter families.
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        Is the Foreclosure Crisis Making Us Sick?.
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        Berkeley Institute of Governmental Studies, 2017
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        Infants exposed to homelessness: health, health care use, and health spending from birth to age six.
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        Center on Budget and Policy Priorities, Washington, DC2017
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        The geography of child opportunity: why neighborhoods matter for equity.
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        Standardized screening for health-related social needs in clinical settings: the accountable health communities screening tool.
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        Mapping neighborhood health geomarkers to clinical care decisions to promote equity in child health.
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        • Boynton-Jarrett R
        • Dworkin PH
        Avoiding the unintended consequences of screening for social determinants of health.
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        • Toy S
        • Tripodis Y
        • et al.
        Addressing social determinants of health at well child care visits: a cluster RCT.
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        Housing intervention for medically complex families associated with improved family health: pilot randomized trial.
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        Neighborhood-level interventions to improve childhood opportunity and lift children out of poverty.
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        Housing as a Platform for Improving Education Outcomes Among Low-Income Children.
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