Chart Book: Housing and Health Problems Are Intertwined. So Are Their Solutions.
Housing policy and health policy have historically been discrete. But there is growing recognition that health and well-being are significantly shaped by access to high-quality, affordable health care and housing. Deeper public investments in health care and housing, supported by cross-sector partnerships, are key to helping people with low incomes obtain and maintain housing that they can afford and that promotes their health and well-being.
Policy decisions like residential segregation and the failure of some states to expand Medicaid have created barriers to stable housing and access to health care, particularly for people of color and people with low incomes. This chart book describes the relationship between housing and health, then highlights cross-sector policy solutions that promote positive health outcomes, greater housing stability, and advancements in racial, health, and housing equity.
- How Housing and Health Are Intertwined
- Housing Costs Rising Faster Than Wages and Rental Assistance
- Housing Cost Burdens Especially Acute for Renters of Color, Those With Low Incomes
- People With Housing Difficulties Have Significant Health Needs but Often Forgo Care
- Housing Sector Solutions
- Health Sector Solutions
- It's Time for Stakeholders to Work in Tandem
Beyond health care, social, economic, and environmental conditions — often called social determinants or drivers of health — have a significant impact on physical and mental well-being. Housing is one crucial driver because where people live often predicts their access to quality health care, education, jobs, food, and other resources. Homes that are overcrowded, have pests, or are deteriorating pose a health and safety risk to the people who live there. Lack of affordable housing causes housing instability in the form of eviction, foreclosure, and homelessness, all of which can further strain health and mental well-being. Improving access to high-quality, affordable housing is associated with improvements in life expectancy and reductions in chronic disease and hospitalizations.
Discriminatory housing practices and the rising cost of housing often limit housing choices for people with low incomes. As a result, low-income people, disproportionately people of color, often live in communities facing systematic underinvestment where access to quality health care and services is limited. This lack of investment worsens health disparities for people with low incomes. For example, in Chicago, a city with significant racial and economic segregation, just 14 percent of households with housing vouchers — which help households with low incomes rent privately owned housing — live in low-poverty neighborhoods.
People with low incomes often cannot afford to choose where they live. Since 2001, median rental costs have risen at a faster rate than renters’ incomes. Many workers haven’t seen their wages grow in years, yet the cost of rental housing continues to rise, squeezing household budgets.
Before the COVID-19 pandemic hit, renters’ incomes had nearly returned to 2001 levels following the 2001 and 2007-2009 recessions. But rental costs continued to rise despite fluctuations in the economy. This gap forces many low-income households to struggle with homelessness, evictions, overcrowding, and unaffordable rents.
And while federal rental assistance programs help more than 5 million low-income households afford housing, another 15.8 million that qualify go unassisted due to funding limitations. In other words, the programs only serve about 1 in 4 qualifying families.
Families and Adults Without Children Have the Greatest Unmet Needs for Rental Assistance
Low-income households, assisted and unassisted, headed by someone who:
Note: Groups of household types are sized (on left) by number "needing assistance," which means they pay more than 30 percent of monthly income on housing and/or are living in overcrowded or substandard housing. "Low income" = 80 percent or less of median income. For more on how we count assisted renters, please see our federal rental assistance factsheets methodology.
Sources: Department of Housing and Urban Development (HUD) custom tabulations of the 2019 American Housing Survey and CBPP tabulations of 2018 HUD administrative data; 2020 McKinney-Vento Permanent Supportive Housing, Transitional Housing, Safe Havens, and Other Permanent Housing bed counts; 2019-2020 Housing Opportunities for Persons with AIDS grantee performance profiles; and the Department of Agriculture's FY2020 Multi-Family Fair Housing Occupancy Report.
Waiting lists for rental assistance can be years long in communities around the country. More than 700,000 households are on waiting lists, but some housing authorities have closed their waiting list to new applicants; far more households experiencing housing instability and homelessness need assistance but can’t get it due to federal funding limitations.
A major reason for these funding limitations is that Housing Choice Vouchers, one of the main federal housing assistance programs, are funded through the annual federal appropriations process — not as an entitlement program, like Medicaid or Medicare, available to anyone who meets the eligibility criteria. Over the last decade, funding available for rental assistance has not kept pace with the number of families struggling to afford rental costs.
In 2019, 20.7 million U.S. renter households (about 46.3 million people) paid more than 30 percent of their income for rent, a common benchmark for what’s considered affordable. Of these, 11 million households (23.6 million people) were “severely cost burdened,” meaning they spent more than half of their income on rent, leaving little to cover other necessities. Extremely low-income renters — people living below the poverty line or earning less than 30 percent of the local median income — make up the great majority of severely cost-burdened renters.
Housing affordability in the United States varies significantly by race. Black and Latino renters are the most likely to be housing cost burdened, while white renters are the least likely.
High housing costs can force people with low incomes to choose between paying rent and getting needed medical care. People who are worried about paying their rent or mortgage are more likely to postpone getting care due to cost, to not have a usual source of care, and to skip an annual check-up. This lack of routine health care is especially problematic because people worried about paying their rent are also more likely to have multiple chronic conditions, such as hypertension, heart disease, and diabetes. These conditions can be difficult to manage without reliable access to health care and stable housing.
The lack of affordable housing in the U.S. leaves many low-income renters and homeowners at risk of foreclosure, eviction, and homelessness. Living in crowded shelters, on the street, or in overcrowded homes can take a toll on health and mental well-being. People experiencing homelessness are at greater risk of exposure to violence, extreme weather, poor sanitation, and infection and severe illness from communicable diseases such as COVID-19. People experiencing unsheltered homelessness often have the most health care needs, with half reporting a combination of physical, mental, and substance use conditions that can make it even harder to get and maintain housing.
Just as housing and health problems are intertwined, so are their solutions. We group the steps stakeholders should take by sector (for example housing vouchers are a housing sector solution; expanding Medicaid coverage of tenancy support services is a health sector solution), but effectively implementing these solutions requires cross-sector collaboration.
Housing Choice Vouchers are a vital intervention to address overcrowding, homelessness, and housing instability. Expanding the program to give vouchers to all who need them would do more than any available option to reduce these problems, which are associated with negative effects on health and well-being. Vouchers subsidize the cost of housing and let participants use their assistance to rent modest housing listed on the private market. This program has given low-income families more choice in where they live.
Vouchers are also key to addressing the health and housing needs of people experiencing homelessness. Families experiencing homelessness who receive vouchers are less likely to experience food insecurity, drug use, alcohol dependence, and psychological distress.
Voucher expansion would be one effective strategy to reduce poverty and racial disparities. If Housing Choice Vouchers reached all eligible households, they would lift 9.3 million people out of poverty, reducing child poverty by a third, reducing poverty among people with disabilities by a quarter, and narrowing the gaps in poverty across racial demographics.
In addition to rental assistance, renters with complex health needs may need supportive services to maintain their health, housing, and independence. Permanent supportive housing can help address long-term homelessness in tandem by providing affordable housing and voluntary supportive services, such as help remembering to take medications and scheduling medical appointments, help understanding a lease agreement, and making connections to other health and social services in the community. This coordination of services is critical to addressing housing and health care access barriers that people with disabilities and other complex health needs often experience.
A large body of research has shown the far-reaching health benefits of supportive housing. States can leverage Medicaid funding to provide supportive housing, as we describe below.
Supportive housing can increase opportunities to receive health care in outpatient settings and reduce the need for high-cost health care like emergency room visits and hospitalizations for people experiencing homelessness. People with chronic health conditions experiencing homelessness who received supportive housing spent fewer days in hospitals and nursing homes and had fewer emergency room visits per year, one study found. These reductions in health care utilization resulted in over $6,000 in annual savings per person.
Medicaid is the main source of health coverage for people with some of the greatest barriers to stable housing, including people experiencing or at risk of homelessness, especially in states that have expanded Medicaid to cover adults with income under 138 percent of the federal poverty level. Medicaid is also a critical source of health coverage for people with mental health conditions or substance use disorders, people with a history of involvement with the criminal legal system, and people with disabilities who need services to live successfully in the community.
Medicaid expansion under the Affordable Care Act (ACA) has increased health insurance coverage rates among people with low incomes. States that expanded have seen widespread improvements in enrollee health and financial outcomes and fewer evictions of low-income renters. But 12 states have not expanded Medicaid, leaving more than 2 million people in those states without a pathway to affordable coverage. Medicaid is at the heart of collaboration between the health and housing sectors; ensuring it is equally available to low-income adults regardless of what state they live in is critical to maximizing Medicaid’s role in ensuring stable housing.
Medicaid expansion is a key strategy for addressing housing instability for people with low incomes; by providing enrollees with financial protection from high medical bills, Medicaid can free up income that enrollees can use to pay rent or to avoid eviction by paying back rent and halting eviction proceedings. Evictions fell by about 20 percent in expansion compared to non-expansion states. The 12 states that have not yet expanded Medicaid should do so, and in the meantime Congress should close the coverage gap and ensure all low-income people have an affordable coverage option. This would improve access to health care and reduce housing insecurity.
For people experiencing homelessness, access to health insurance increases access to primary care, mental health services, substance use treatment, supported employment, and transportation to medical appointments. After Medicaid expansion, Health Care for the Homeless clinics in expansion states saw a large increase in insurance coverage among clients experiencing homelessness and housing insecurity. People experiencing homelessness in non-expansion states are three times more likely to be uninsured than those living in expansion states.
In Medicaid, states are obligated to cover long-term care only in institutional settings; home- and community-based services (HCBS) are optional. Many states have addressed this “institutional bias” by implementing HCBS waivers and state plan options to provide services in the community to targeted populations. Since 2013, more than half of Medicaid long-term services and supports (LTSS) have been delivered in community-based settings, although the proportion varies widely by state.
Medicaid is the major source of funding for HCBS, but states can limit how many people they serve through their HCBS waivers, which means thousands of people go without the care they need to live in the community. In addition, the lack of affordable, accessible housing makes it difficult for many people to transition out of institutional settings and into their own homes. People with disabilities, mental illness, and substance use disorders face some of the greatest barriers to securing and maintaining housing.
The American Rescue Plan Act temporarily increased federal matching funds for Medicaid HCBS. States must spend the increased funding on activities to enhance, expand, or strengthen HCBS. Twenty-one states plan to use a portion of their funds for housing-related investments, an indication of need in this area as well as an opportunity for stronger cross-sector collaboration.
States can use Medicaid HCBS waivers and state plan options to help people find and retain affordable housing (known as pre-tenancy and tenancy supports). States can also cover other services that can help people get and maintain stable housing, such as peer supports, supported employment, and case management.
Housing-related services and supports are particularly valuable for Medicaid enrollees affected by homelessness, housing instability, mental illness, or substance use, or who are reentering the community from jail or prison.
Not all states cover tenancy supports in their Medicaid programs, and eligibility and scope of services vary significantly in those that do. Six states provide tenancy supports through a section 1915(i) state plan amendment (SPA). Unlike HCBS waivers, expanding services through a SPA lets states offer services to people who do not require an institutional level of care, including people with mental illness who often don’t qualify for HCBS waiver services. The 1915(i) option allows states to target benefits based on functional and need-based criteria on the premise that providing the benefit(s) may improve health and prevent the need for future institutionalization for these people. For example, some states use 1915(i) to make tenancy supports available to people with a mental health or substance use disorder who are experiencing or at risk of experiencing homelessness. When a state adopts a 1915(i) SPA, it must provide services to everyone who meets the eligibility criteria; states may not set enrollment caps or use waiting lists.
Partnerships between the health and housing sectors are key to helping people with low incomes obtain and maintain housing that they can afford. Neither sector has the funding, infrastructure, or expertise to deliver housing and services singlehandedly. One way the housing and health sectors can maximize their resources and expertise is to advance unified policy goals including increased federal funding for affordable housing (especially vouchers targeted for people with the lowest incomes) and increased Medicaid coverage (adopting the ACA’s Medicaid expansion and expanding optional coverage of housing-related services). Funding is also needed to support effective coordination of Medicaid and other federal health funding (such as grants for behavioral health services, community health centers, and public health) with housing resources to comprehensively meet people’s physical, behavioral, and social support needs.