Without Affordable, Accessible, and Adequate Housing, Health Has No Foundation

Abstract

Policy Points.

• Today's housing disparities are rooted in the increasing commodification of housing that has taken precedence over the need for shelter, a basic human right.

• With rising housing costs across the country, more residents are finding their monthly income going to rent, mortgage payments, property taxes, and utilities, leaving little for food and medication.

• Housing is a determinant of health, and with increasing housing disparities, action must be taken to ensure no individual is displaced, communities remain intact, and cities continue to thrive.

Disparities in access to safe, adequate, and affordable housing contribute to health inequities worldwide. Today's housing disparities are rooted in the increasing commodification of housing that has taken precedence over the need for shelter, a basic human right. In the United States, historical and contemporary policies have created and maintained racial, ethnic, gender, and other systemic disparities in opportunities to access economic resources and quality housing. A 2022 report by the National Association of Realtors showed that although homeownership rates in the United States increased by 1.3% in 2020, the highest annual rise recorded, homeownership rates for Black Americans (43.4%) remained lower than White Americans (72.1%). ¹

Such housing disparities can impact both the physical and mental well‐being of populations. For example, mortgage foreclosures have been associated with worse mental health and physical symptoms like trouble sleeping, chest pain, and stomach cramps. ² Furthermore, the impacts of foreclosure go beyond individuals directly affected. Existing research demonstrates that those who resided in neighborhoods that experienced high foreclosure rates were more likely to seek treatment in hospitals and emergency rooms for various conditions including mental health, stroke, and heart attacks. ³

The neighborhood environment beyond housing also impacts health. Public health research has provided strong evidence on the connection between a neighborhood's social, economic, and physical environmental factors such as poverty, access to healthy food, and levels of crime to various mental and physical health outcomes, including anxiety, depression, heart disease, and stroke. ⁴ , ⁵ , ⁶ , ⁷ However, much of this research has overlooked the potential role of housing in moderating the effect of neighborhood conditions on health. For example, retrofitting older houses in neighborhoods with greater exposure to air pollution could provide a level of protection against toxins through better air filtration systems. ⁸ Also, the stress of being at risk for eviction may offset the health benefits of neighborhood amenities.

This Perspective demonstrates that housing insecurity—which encompasses the dimensions of housing unaffordability, inaccessibility, and inadequacy—is a major public health issue with strong ramifications affecting households, neighborhoods, and cities. ⁹ Here, I examine each of these dimensions in relation to health and health inequities and discuss policies that have contributed to each dimension, and, in the face of glaring housing disparities in the United States and their effect on health inequities, I propose the important role of public health research to provide additional evidence to inform and advance policies designed to mitigate negative neighborhood impacts, housing disparities, and health inequities.

Affordable Housing

Housing is unaffordable for many Americans. Nearly one‐third of Americans spend 30% or more of their household incomes on housing costs, including rent or mortgage payments, property taxes, and utilities. ¹⁰ Among all renters, half spend more than 30% of their income on housing costs, and a quarter spend 50% or more. ¹¹ Table 1 shows how unaffordability disproportionately impacts lower‐income households, with 83.4% of renter and owner‐occupied households that make less than $20,000 a year paying more than 30% of their income toward housing costs in the past 12 months. ¹⁰ That is approximately 11.5 times more than households earning $75,000 or more a year. Housing affordability can influence access to other goods, including food and medical care, that are critical for maintaining health. ¹² Research has also connected housing insecurity, which results from being cost‐burdened, to poorer self‐reported health, delayed doctor visits, and higher distress. ¹³ , ¹⁴

Table 1.

Proportion of Housing Cost Burden and Household Income of Renters and Owners in the United States ^a

Household Income	Percentage of Renter and Owner‐Occupied Households Paying >30% of Income Toward Housing Costs in the Past 12 Months b	Proportion of Households by Household Income Among Renters and Owners c
Less than $20,000	83.4%	12.6%
$20,000 to $34,999	63.0%	13.0%
$35,000 to $49,999	41.9%	12.1%
$50,000 to $74,999	24.4%	17.5%
$75,000 or more	7.2%	44.8%

Data from the American Community Survey 2016–2020 five‐year estimates.

^a Total number of renters and owner‐occupied households excludes households with zero or negative income and those with no cash rent, making up less than 2% of the population.

^b Denominator is all renter and owner‐occupied households within that income bracket.

^c Denominator is all renter and owner‐occupied households.

With housing prices steadily rising since the mortgage foreclosure crisis in the late 2000s, wages remaining relatively unchanged, overall living costs increasing due to inflation, and a housing supply that has not met the demand, the number of Americans considered to be cost‐burdened is projected to increase. ¹⁵ As homeownership has become less attainable for first‐time buyers, rental prices have also increased across the country, with some major cities experiencing average rent increases of up to 40%. ¹⁶ In 2021, the hourly wage necessary to afford a two‐bedroom apartment at fair‐market rent in the United States was $24.90, well above the current federal minimum wage of $7.25 per hour. ¹⁷ , ¹⁸ In some states like California, the hourly wage needed was $39.03. ¹⁷ In that same year in California, the median hourly wage of firefighters was $37.77, $29.17 for bus drivers, and $14.73 for a retail salesperson, all important positions for cities to function. ¹⁹

The COVID‐19 pandemic has exacerbated housing disparities. From 2020 to 2022, there was a 20% rise in housing prices compared to the overall inflation rate. ²⁰ With more than 40 million jobs lost early in the pandemic and financial uncertainty, housing unaffordability placed a great burden on millions of Americans across the country. ²¹ According to the US Census Bureau's Household Pulse Survey data collected between April and July 2020, homeowners with mortgage debt and renters experienced greater mental distress and poorer self‐rated health, compared to owners with no mortgage debt. ²² Renters were also more likely to experience job loss, food insecurity, and the inability to pay housing‐related costs during this period compared to homeowners. ²²

On September 4, 2020, the Centers for Disease Control and Prevention (CDC) imposed a nationwide temporary federal moratorium on residential evictions, taking effect less than two weeks after the expiration of a different set of eviction protections established by the Coronavirus Aid, Relief, and Economic Security (CARES) Act earlier in the year. ²³ Using evidence from public health research on the consequences of eviction for COVID‐19 transmission, the CDC took unprecedented actions to mitigate many evictions and provide additional time for individuals to access emergency rental assistance. ²⁴ Although this helped in reducing overall evictions, in the three months following the end of the moratorium in August 2021, in some cities like Las Vegas and Houston, eviction filings were restored to historic numbers. ²⁵ Approximately half of the $46 billion allocated by Congress for emergency rental assistance had been used by the time the program ended in the summer of 2022, resulting in some extensions. ²⁶ Nonetheless, the CDC's implementation of an eviction moratorium is an example of the role public health agencies can have on preventing housing instability, particularly in emergency situations. Eviction and health are intricately linked; several studies have documented the negative impacts of evictions on depression, stress, and hospital readmissions. ²⁷ , ²⁸ , ²⁹ , ³⁰ Also, the stigma associated with evictions, including referral checks, makes it more difficult for individuals to find housing posteviction, further contributing to negative health and health inequities.

Increasing rents, inflation, and climbing eviction rates have together contributed to higher rates of homelessness across the country, with shelters and encampments in US cities seeing a surge of people. ³¹ The public health literature shows individuals experiencing homelessness are at greater risk of exposures to crime, violence, and extreme weather, all contributing to poorer physical and mental well‐being. ³² , ³³ , ³⁴ Homelessness is not a new problem, dating back to decades of policies restricting the supply of housing. For example, single‐family zoning has limited housing development to single‐family homes rather than multifamily apartment buildings or duplexes, resulting in limited supply and increased housing costs. ³⁵ , ³⁶ The need for more long‐term solutions is critical to prevent housing loss, a growing public health concern.

Access to Housing

In the United States, beyond the financial barriers of obtaining and maintaining a home, historical and contemporary housing policies have disproportionately benefited non‐Hispanic Whites by providing them more opportunities to become homeowners and build their wealth. ³⁷ Such policies have restricted housing choices for Hispanics and non‐Hispanic Blacks to neighborhoods that are often economically underserved and overexposed to environmental toxins. ³⁸ , ³⁹

One example of a policy restricting housing access by race is the action taken by the Home Owner's Loan Corporation (HOLC), one of the many agencies designed by the Roosevelt administration as part of the New Deal. ⁴⁰ In the early 1930s, to stabilize the nation's mortgage‐lending system and help middle‐income Americans purchase new homes by providing long‐term and low‐interest mortgages, the HOLC was formed. ⁴¹ The agency created maps to grade neighborhoods based on their level of risk: A (green) for “best”; B (blue) for “still desirable”; C (yellow) for “definitely declining”; and D (red) for “hazardous.” ⁴⁰ , ⁴¹ Neighborhoods that had a larger proportion of non‐White racialized groups, mainly non‐Hispanic Blacks, were classified as “hazardous” or “too risky” for investment. This restricted homeownership opportunities in these areas and led to a heavy reliance on land contracts in which the buyer would pay the owner directly. Without the safety net offered through mortgages, if a buyer was unable to make a payment on time, they could be evicted and lose any equity they had built in their home. ⁴² Land contracts were also more expensive. A 2019 study of the Chicago area during the time redlining maps were widely used showed that on average, Black Americans were paying $587 more per month (in 2019 dollars) for their home compared to those who had conventional mortgages. From 1940 to 1960, instead of Black residents building equity in their homes, approximately $4 billion was taken from Black households attempting to become homeowners in this area. ^{43 p19}

While residential segregation, an outcome of such policies, has been studied in relation to health and neighborhood conditions cross‐sectionally, ⁴⁴ , ⁴⁵ the role of the housing system in shaping these neighborhoods has been examined less over time. Researchers like Nancy Krieger have led some of the work examining historical redlining practices with present‐day health outcomes, including preterm birth and cancer. ⁴⁶ , ⁴⁷ Other researchers have connected redlining practices to other health and health‐related outcomes, including asthma‐related emergency department visits, lack of food retailers, and increased urban heat island effects. ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ Evidence from these studies and others is crucial for discussions around reparations for Black Americans and the development of policies addressing the racial wealth gap through housing opportunities.

Another example of a policy that contributed to the racial wealth gap in the United States is the GI Bill, or the Servicemen's Readjustment Act of 1944. ⁵² The bill aimed to provide education, employment, medical, and housing opportunities to more than 8 million World War II veterans, but in practice the program restricted eligibility to certain discharge statuses not often given to Black veterans. ⁵³ This limited many Black veterans from accessing public assistance for housing purchase, restricting homeownership opportunities once again. However, the health impacts of these actions have rarely been discussed or studied in public health. Existing studies on the impacts of the GI Bill on health are limited to education benefits overall ⁵⁴ and by race. ⁵⁵

For those who have succeeded in becoming homeowners, studies have reported better health outcomes compared to renters, largely attributed to the stability and wealth accumulation homeownership can provide. ⁵⁶ , ⁵⁷ For example, among children, homeownership and the residential stability it provides has been linked to greater educational attainment and stronger vocabulary skills and contributing to positive childhood development. ⁵⁸ However, whether homeownership is always good for one's health has been questioned in recent years, particularly after the 2008 mortgage foreclosure crisis in which predatory lending targeted low‐income communities largely of color and led to disproportionate rates of default and dispossession. ³⁷ During the foreclosure crisis, Black and Hispanic families’ wealth fell by 47.6% and 44.3%, respectively, while White families lost 26.2% of their wealth. ⁵⁹ Even some who did not lose their property, especially those in neighborhoods with higher rates of foreclosures and vacancy, saw their home values never recover and were unable to move to a new house. ⁶⁰ , ⁶¹ Combined with the evidence linking historical policies such as redlining, these events question whether homeownership always provides health benefits. ⁶² , ⁶³

One of the most important pieces of legislation to promote equal opportunities in housing is the Fair Housing Act (FHA) of 1968. The FHA, as amended, prohibits discrimination based on race, color, sex, religion, disability, national origin, and familial status at the time of purchase, rent, lease, sale, or finance of a home. ⁶⁴ The FHA protects individuals and communities from discrimination and provides opportunities for good‐quality schools, as well as access to healthy foods and other resources that promote good health. ⁶² , ⁶⁵ Although enforcement of the FHA across the country has reduced more overt types of discrimination, subtle incidents continue to exist and impact housing choice. ⁶⁶

Housing discrimination is linked to poor health outcomes. Research has connected racial discrimination in mortgage‐lending practices to poor health, including poorer self‐rated health, reduced colorectal cancer survival rates, and greater Black‐White disparities in cancer generally. ⁶⁷ , ⁶⁸ , ⁶⁹ Additional studies have linked housing discrimination to higher stress levels ⁷⁰ and potentially greater exposure to environmental toxins. ⁷¹ Research shows that experiencing housing discrimination could even outweigh the potential mental health benefits of moving into a lower‐poverty neighborhood. ⁷²

This growing literature on housing discrimination has disproportionately examined race and lacks studies on disability, which continues to account for the greatest number of complaints (54.6%) in the United States. ⁶³ This population is especially important to study because the average national rent for a studio/efficiency unit in 2016 was nearly equal to the monthly Supplemental Security Income payment that is usually the only source of income for non‐elderly adults with disabilities. ^{73 p56} Furthermore, while we are learning more about the relationship between housing discrimination and health, few studies have focused on the role of neighborhood characteristics in predicting housing discrimination. ⁷⁴ , ⁷⁵ , ⁷⁶

More research is needed to understand neighborhood dynamics, including how housing discrimination patterns correspond with changes in racial and economic patterns such as housing value shifts, financial investments, and local business closures. This evidence would allow policies to monitor neighborhoods for housing discrimination risk and engage neighborhoods with highest risk of housing discrimination.

Adequate Housing

The global use of stay‐at‐home orders as a method to prevent COVID‐19 transmission highlights the importance of housing conditions. Staying at home limits the risks of acquiring and transmitting COVID‐19. However, for some, staying at home posed other threats to their health and well‐being, including infestations, mold, and structural housing problems. ⁷⁷ In 2019, the American Housing Survey, a joint initiative between the US Department of Housing and Urban Development and the US Census Bureau, published findings from 124.1 million occupied housing units. ⁷⁸ According to their findings, nearly 14 million households (11.3%) reported seeing signs of cockroaches in the past year, with more renters (15.9%) than owners (8.7%) reporting sightings. ⁷⁹ Furthermore, 3.6 million households (3.0%) reported signs of mold in their homes in the past year, with again more renters (4.4%) than owners (2.1%) reporting mold. ⁷⁸ A 2016 report showed that 30 million homes in the United States had some form of serious health and safety hazard, including damaged plumbing, gas leaks, and structural problems. ^{80 p24}

Historically, the public health and housing literature has well established the connection between physical conditions of a house—such as inadequate ventilation, lack of protection from extreme temperatures, pest infestation, exposure to toxins, and poor infrastructure—and health outcomes. ⁸¹ , ⁸² , ⁸³ For example, poor air ventilation can be linked to mold buildup, which is strongly associated with respiratory diseases like asthma and allergies. ⁸⁴ , ⁸⁵ Overcrowding in the home has also been linked to increased exposures to various communicable diseases, including tuberculosis and more recently COVID‐19, ⁸⁶ , ⁸⁷ while rat and other pest infestations have been associated with numerous diseases and disorders, including allergies. ⁸³ Finally, poor infrastructure from lack of maintenance has posed hazardous threats such as flooding and roof caving, resulting in an increased risk for home‐based injuries. ⁸⁸

By identifying the risks of housing conditions on health, public health research has played a vital role in changing industry practices. For example, studies examining the dangers of lead‐based paint and lead poisoning ⁸⁹ , ⁹⁰ led to the federal government banning consumer uses of lead‐based paints. ⁹¹ However, decades after the law was implemented, studies continue to show child lead poisoning across the country. ⁹² , ⁹³ One recent study showed that lead‐poisoning cases in Detroit, Michigan, were higher among children under the age of six living in rental properties owned by investors who purchased the properties in bulk out of foreclosure sales. ⁹⁴ Other studies have shown the connection between investor‐owned rentals and the deterioration of housing conditions. ⁹⁵ , ⁹⁶ With a chronic shortage of affordable housing across the country, the high demand for housing allows landlords to increase rent while failing to improve the conditions of their properties. This is of particular concern in cities like Detroit, where large proportions of tax‐foreclosed homes were sold to investors and speculators through tax auctions and 90% of eviction cases filed during the pandemic came from landlords whose property lacked a certificate of compliance, a quality assurance document certifying that the house is safe for occupancy. ⁹⁷ , ^{98 p21} Therefore, better understanding of landlord practices and business models as they relate to housing conditions and health outcomes is needed to develop policies that protect renters’ health.

In attempts to improve housing conditions, state and local governments enact housing and building codes aimed at ensuring residential properties meet the minimum safety and health standards. However, code enforcement strategies differ across cities because resource constraints and priorities vary across local governments. ⁹⁹ , ^{100 p92} Enforcement of housing codes should be combined with financial resources to support repairs for renters and low‐income homeowners who may be especially impacted by punitive enforcement. ⁹⁹ Cities have implemented cost‐sharing programs to finance capital projects and property tax incentives, but these programs tend to be limited and benefit more resourced landlords, leaving nonprofit and small programs to address low‐income landlords and renters. ¹⁰¹ The programs that exist to help low‐income owners with repairs only benefit owner‐occupied households. The Department of Agriculture's Section 504 Home Repair program assists low‐income rural homeowners, ¹⁰² and the Department of Energy's Weatherization Assistance Program helps low‐income homeowners make weather resistance modifications. ¹⁰³ As the housing stock continues to age, more government investment is needed to meet the growing demand. Federal programs should prioritize home repair investments, while state and local governments should provide home repair loans with 0% interest and no credit score requirement. ¹⁰⁴

Another pressing area needing more attention is the impact of climate change, notably rising temperatures and increasing natural disasters, on housing conditions. As cities continue to sprawl and temperatures rise, more urban areas are experiencing the urban heat island effect, where temperatures are higher in cities than surrounding suburban areas. ¹⁰⁵ The urban heat island effect has been associated with increased risk of hospitalization, respiratory illness, and death. ¹⁰⁶ , ¹⁰⁷ Homes that are energy efficient and equipped with cooling options provide a level of protection again rising heat levels, while those that do not have these features could increase the adverse risk effects of tenants. ¹⁰⁸ , ¹⁰⁹

Although rising temperatures affect health inside the home, natural disasters—which are becoming more common with climate change—can result in severe housing loss and displacement. In 2005, Hurricane Katrina ravaged New Orleans, leaving homes uninhabitable and disproportionately displacing thousands of Black residents. ¹¹⁰ The Lower Ninth Ward, one of the hardest‐hit neighborhoods, had some of the highest rates of Black homeownership in the city. ¹¹¹ Additionally, due to the mismanagement of funding and slow regeneration, more than two‐thirds of New Orleans's Black residents moved to other cities without ever regaining their losses. ¹¹² , ¹¹³ With climate change posing significant threats for housing in 21^st‐century cities, more research is needed to identify health outcomes related to housing in a climate‐adverse environment and develop strategies to help urban populations stay safely housed.

Reducing Health Inequities Related to Housing Disparities

Housing is the foundation for a healthy life, but addressing housing disparities is becoming more challenging with a housing market that continues to ignore housing as a basic human right. The public health research makes the case for more affordable, accessible, and adequate housing to promote better physical and mental health. ¹¹⁴ , ¹¹⁵ Immediate action is needed to address and prevent the growing health equity gaps associated with housing. Public health can do more to protect certain populations, such as seniors, children, women, people of color, those with low income, and those with disabilities, from experiencing housing instability and displacement. Such populations are at risk because they are considered place‐bound, meaning they tend to have greater interaction and time spent within their homes and neighborhoods. ¹¹⁶ Research has highlighted significant health impacts of housing in the elderly population. A 2010 study by James and Sweany showed that cognitive decline in seniors could be slowed by improving the small percentage of housing in the worst physical conditions. ¹¹⁷ As a result, the difference in cognitive decline associated with living in housing conditions considered “poor” compared to those rated “good” was nearly equivalent to aging six more years. ¹¹⁷

The negative health impacts of dispossession and displacement are also important themes to address. Displacement can result in the loss of social networks, lack of access to health care, and difficulties in adhering to medical treatment. ¹¹⁸ , ¹¹⁹ , ¹²⁰ In cities with greater shortages of affordable housing, gentrification is displacing Black and brown Americans and immigrants. ¹²¹ , ¹²² In cities like Miami, where the effects of climate change are most prominent, investors and developers have dispossessed populations to build “safe zones,” or areas considered to be less affected by climate change. ¹²³ One of these neighborhoods is Little Haiti, where in the past decade, developers have purchased considerable land in the area for high‐rise condos and upscale businesses, with little consideration for a community of Haitians that has been established there for 50 years. ¹²⁴

To address these issues and others, a strong understanding of housing as a public health issue must be included across disciplines and incorporated into public and private decision making. Moreover, an understanding of health equity in housing is necessary to ensure that all individuals, regardless of their race, ethnicity, gender, socioeconomic position, and disability status, can access affordable and adequate housing. Therefore, strategies to retain affordable housing stock for low‐ and middle‐income households must be prioritized.

Numerous strategies exist that can together improve affordability, accessibility, and adequacy in the housing market. To retain and increase affordable housing options, the National Housing Trust Fund can be used to build, rehabilitate, and preserve affordable housing for people with low income, while elimination of restrictive zoning policies would allow for the development of affordable units, and explanation of public housing can increase the affordable housing stock. ¹²⁵ , ¹²⁶ To keep rents affordable, the Housing Choice Voucher and the Low Income Housing Tax Credit programs can be used to subsidize rents, rent stabilization can be used to protect the affordable housing stock, and an extension of emergency rental assistance programs can provide temporary financial assistance to renters during unexpected financial hardships. To improve homeownership access, shared‐equity homeownership models like community land trusts can provide homeownership opportunities for low‐ and middle‐income residents while stabilizing property values and preserving affordability over the long term. To prevent housing discrimination and promote housing accessibility for marginalized populations, more education and resources are needed to enforce the Fair Housing Act of 1968. Finally, to ensure that all tenants live in safe and secure housing, housing and building code enforcement is needed alongside sufficient financial support.

Public health can inform these policy changes by continuing to provide the evidence on the impacts of policies and the health effects of housing insecurity and displacement. Public health departments, particularly at the local level, can also partner with city neighborhood and housing departments to use community health assessments and identify major housing needs of residents with the goal of addressing those needs. ¹²⁷ With a growing renter population, more affordable housing is needed, including the expansion of public housing in cities. In addition, greater protection of existing housing that is affordable is needed through mechanisms like rent stabilization.

Conclusion

Housing as a commodity has presented a fundamental threat to health and health equity by making housing less affordable, accessible, and adequate. Throughout this paper I have explored emerging issues as cities continue to become more economically exclusive by pricing out low‐ and middle‐income residents. Public health must prioritize and address housing disparities in our society to reduce displacement and promote healthier and more vibrant cities. Housing is a determinant of health, and with increasing housing disparities, action must be taken to ensure no individual is displaced, communities remain whole, and cities continue to thrive.

Acknowledgments: I would like to thank Alexa Eisenberg, Jamison Koeman, and Natasha Pilkauskas for their feedback throughout this process.