Associations Between Federal Rental Housing Assistance and Childhood Asthma—A Renewed Call for Investing in Housing for Health

In this issue of JAMA Pediatrics, the findings of Boudreaux et al1 suggest that federal rental assistance for families with low incomes may be important for reducing emergency department visits for asthma. This study adds to the increasing body of research on the ways in which housing assistance is associated with health and has implications for housing and health care policies, especially given the emergence of value-based care and housing and health partnerships.

Previous research2 on housing and health outcomes, particularly in association with asthma, has predominately focused on housing quality. The evidence base on the associations between poor housing quality, including mold, pests, and secondhand smoke, and adverse outcomes associated with asthma has led to the development of interventions that seek to improve the quality of housing specifically for families with children diagnosed with asthma.

This new study highlights an additional potential dimension of housing that affects children, especially those with special health care needs such as asthma: housing affordability. Previous research3 at Children’s HealthWatch has shown how 3 forms of housing instability and unaffordability are significantly associated with child and parent health outcomes as well as economic hardships. Families with young children who have fallen behind on rent in the previous year, moved 2 or more times in a year, and/or experienced homelessness in the lifetime of the young child experienced higher rates of child hospitalizations, developmental delays, and maternal depression compared with stably housed families. Furthermore, previous research4 has found that families of children with special health care needs, most of whom had an asthma diagnosis, are at greater risk of housing instability compared with families with low incomes whose children do not have special health care needs. Before enrolling in a rental assistance program, the families in the wait-list group in the study by Boudreaux et al1 were likely to be housing unstable and facing similar adverse health challenges.

Federal rental assistance administered through the US Department of Housing and Urban Development (HUD) is designed to promote housing stability but may also have the added benefit of being associated with improved health. As the authors note, the high prevalence of children with asthma in this study compared with rates of asthma in the general population suggest that families who apply for assistance are particularly disadvantaged and therefore at high risk for adverse health. However, not all federal rental assistance is similarly administered, and the findings of Boudreaux et al1 of differences between place-based rental assistance in multifamily or public housing vs mobile vouchers used in the private rental market are notable for public policy discussions in the future.

The reduction in emergency department visits for asthma exacerbations among children in multifamily or public housing may be associated with 2 positive benefits of these place-based programs. First, public housing often receives annual, mandated housing inspections using state-based housing codes, which can be stringent in making any pest infestations and long-term dampness a violation in need of repair. In contrast, inspection standards can be different for mobile vouchers, sometimes using a more lenient housing quality standard that allows for pest infestations as long as they are not severe. In addition, some tenants may be reluctant to report housing code violations for fear that a landlord will retaliate and refuse to take their voucher in the future. Second, public housing places a limit of 30% on how much a family is required to spend of their household income on housing-related costs and includes utility costs in monthly rent. In contrast, mobile voucher rental caps can vary by up to 40% or more of household income and often do not include utility costs. Of note, energy-insecure families with young children may have adverse health outcomes, including higher rates of hospitalizations.5

Therefore, place-based assistance may be associated with reduced emergency department use for asthma attacks through both better housing quality enforcement when violations exist and more-extensive affordability protections. Previous research6 has found that poor housing quality only partially explains asthma disparities and that other material hardships may also be contributing factors. Although future research is necessary to elucidate the differences between place-based housing assistance and mobile housing vouchers, this study potentially demonstrates the ways in which children with medical complexity may disproportionately benefit from specific housing assistance given their potential housing instability and the associated health outcomes.

In addition to quality, affordability, and stability, a fourth dimension of housing has also been correlated with health outcomes in children: neighborhood. Research indicates that neighborhood-level factors are associated with health disparities in asthma among children,7 and understanding the association of neighborhood with child health is necessary to inform policies that promote health equity.8 A recent study9 found significant reductions in hospitalizations and inpatient costs among children whose families received mobile housing vouchers designed to support families’ movement into neighborhoods with greater access to opportunity. Even though mobile vouchers may in theory provide opportunities for families to move to higher-opportunity neighborhoods that promote health, housing discrimination against voucher holders prevents many families from residing in certain neighborhoods.10 The federal Fair Housing Act of 1968 made it illegal to discriminate against people in housing based on their race, religion, national origin, and, since 1974, sex but does not include rental income source. The act also included a mandate to affirmatively further the purposes of the act by eliminating residential segregation. The data for this study preceded both the Obama administration’s attempt to set regulations that enforce this section of the law and the subsequent efforts by the Trump administration to weaken those provisions, but this study placed within the context of fair housing, especially given disproportionally high rates of asthma among nonwhite children, may provide additional insight into the differential findings across groups.

Examining the multidimensional nature of how housing is associated with health may provide better insights into the complex factors associated with child health disparities. Solutions that respond to families’ need to afford rent and utilities without sacrificing other basic needs and to live in high-quality housing in neighborhoods that are connected to opportunities without fear of discrimination may be associated with further health benefits that promote equity.

The findings of Boudreaux et al1 may also have implications for health care delivery transformation. Although health care cost discussions have predominately focused on adult health care use, reframing cost savings for pediatric care as well as potential savings in other sectors, including education and child welfare, associated with improving child health is necessary.11,12 Given the long-term and cross-sector benefits associated with better child health, particularly for prominent and costly conditions, such as asthma, exploring opportunities to increase resources and support for health-promoting programs, including rental assistance and investing in affordable housing development, may yield benefits for multiple children and their parents across sectors. Although health care systems considering health and housing partnerships may be reticent to directly fund rental subsidies without specific targeting given limited, short-term cost-savings models of accountable care organizations,13 emerging opportunities to engage in partnerships to create more affordable housing, spur community development, and advocate for local, state, and federal investments will be needed to advance health equity through housing across the life span.14

The research of Boudreaux et al1 provides an important basis for a new call to invest in affordable housing by the federal government as a mechanism for improving child health and potentially reduce increasing health care costs. Even though investments in HUD rental assistance have federal budgetary implications, it is important to consider the potential avoidable health costs associated with housing instability. Our colleagues have previously estimated that the avoidable health-related costs associated with housing instability among families with children in the United States are conservatively $111 billion for the next 10 years.15 As such, a national debate during this year’s election cycle on the importance of new federal investment in rental assistance should consider how this investment may be associated with improved child health, reduced health care use, and promotion of equity across the life span.