Affordable Housing: A Key Lever to Community Health for Older Americans

America is aging. By 2050, the number of adults aged 65 years and older will nearly double; the number of elders of color will more than triple.¹ The notion of advancing public health for older Americans may seem contradictory in our youth-oriented culture, yet people aged 65 years have an average of almost 20 years or more remaining in their lives, an increase of more than 50% during the past century. Lower income adults become economically insecure older adults who do not have the resources to pay for a decent quality of life in those remaining years. A key lever to promote healthy aging in communities is affordable housing, especially for older adults who have limited incomes. As housing supply and quality decrease for low-income older adults, rising housing costs correspondingly impinge on family support, including availability of food, transportation, in-home assistance, and medical care. The problem is not new, but a rapid transition to an older society, with marginal assets in disadvantaged communities, highlights a problem requiring comprehensive public policy response.

Older Americans’ health is shaped by their life course. Early and long-term exposure to detrimental environments and lifestyles results in a higher risk of health problems and disability at earlier ages. Recent economic trends have dramatized these patterns, with a report from the National Academies of Sciences showing a growing gap in US life expectancy between the lowest and highest quintiles of income, increasing from a five-year gap in 1980 to nearly 12 years in 2010.² Women in the lowest income segments experienced decline in life expectancy and the poorest men experienced no increase in life expectancy, but wealthier groups had significant increases. This profile is consistent with abundant evidence of adverse health consequences of living in America in underresourced communities, especially for disadvantaged older Americans.³

The goal of public health is to optimize the health of all people, yet new knowledge and behavioral interventions are easiest to adopt by the affluent, who are also the most likely to benefit from these strategies. This is reflected in the health determinants model used in the County Health Rankings in 2014, which identified four specific domains and their estimated relative contribution to heath: social and economic factors (40%), health behaviors (30%), clinical care (20%), and physical environment (10%).⁴ This picture presents a troubling paradox. While we may be committed as public health professionals to improving all four domains, the least accessible domain, social and economic factors, are the major determinants of community health, and are undermining progress in the other three domains. This presents a liability to community revitalization and engenders political consequences of lower social power to create change.

A recent report found that almost half of older Californians who live alone struggle to make ends meet economically.⁵ Using a measure of income security called the Elder Economic Security Standard Index (Elder Index), the analysis found that the cost of housing was a major contributor to the economic struggles of most low-income older adults in the state while health care costs were the highest risk for others. Table 1 shows that nearly half of African American and Latino seniors have low incomes (< 200% of the US Census federal poverty level) and are disproportionately renters. While more economically secure older adults (incomes at ≥ 300% of the federal poverty level) are less likely to rent across all races/ethnicities, elders of color have higher rates of living in a home where they are still paying off a mortgage.

TABLE 1—

Percentages of Renter/Owner Status by Income Below the Federal Poverty Level (FPL) and Race/Ethnicity Among Noninstitutionalized Adults Aged ≥ 65 Years: United States, 2013

	Non-Latino White, %	Non-Latino Black, %	Non-Latino Asian, %	Latino, %	American Indian,a %
Income level
< 200% FPL	27.2	45.5	31.3	48.8	42.8
200–299% FPL	19.3	17.3	14.9	18.9	17.8
≥ 300% FPL	53.5	37.2	53.8	32.3	39.4
Renter/owner status for those with incomes < 200% FPL
Owner, mortgage paid off	52.3	30.7	25.3	31.6	48.2
Owner, paying mortgage	19.1	22.4	21.6	23.3	18.3
Renter	25.1	43.6	48.7	42.3	29.7
Renter/owner status for those with incomes ≥ 300% FPL
Owner, mortgage paid off	52.6	30.8	35.8	32.9	44.8
Owner, paying mortgage	38.7	51.6	51.9	50.9	41.9
Renter	7.8	16.4	11.2	14.8	11.8

Note. Totals do not equal 100 because table does not include those without cash rent.

Source. US Census Bureau. American Community Survey 2013. Integrated Public Use Microdata Series: Versionx 6.0 [Machine-readable database]. Minneapolis, MN: University of Minnesota, 2015.

^aAmerican Indian can be of any race/ethnicity.

A national study found that California had the highest rate of cost-burdened households headed among adults (aged ≥ 50 years) who rented—almost three fifths (57.9%) spent more than 30% of their incomes on rent. Nationally, 19 states had a majority of renters aged 50 years and older paying more than the standard of 30% on housing.⁶ Housing costs are affected by community planning and other political dynamics, and low-cost housing is often concentrated in areas of concentrated poverty, which reinforces barriers to social benefits and health promoting conditions. Among Americans with incomes below the federal poverty level, 67% of African Americans, 39% of Latinos, and 27% of White non-Latinos were residing in high poverty counties where at 20% or more residents live in poverty.⁷ And it is important to note that by the age of 65 years, the common routes out of poverty—jobs and marriage—are largely closed.

The most “upstream” approach to improving health equity among older adults is improving the economic status of all low-income American families because that would assist both current and future generations of older adults. The cost components of the Elder Index also point to place-based strategies that would benefit current older adults. Since housing is the largest financial burden for older adults, increasing the amount and dispersion of affordable housing for older adults would have the greatest impact on the economic security of low-income older adults. This can occur through supply-side efforts (e.g., promoting construction of affordable units through financing and zoning) as well as demand-side policies (e.g., Section 8 rental subsidies), or increasing social security payments for recipients in poverty to increase their housing options.

The advantage of interventions and policies that impact the entire community is that they change the conditions under which people can be healthy (the definition of public health) and garner wider public support than narrowly designed benefits. Increasing affordable housing follows a “health in all policies” approach that is consistent with the community health indicators findings; targeting older adults is often easier to accomplish politically and financially. Older adults are a growing component of the population that is experiencing health inequities and would experience significant health improvements from increased access to affordable, quality housing that is accessible to the services they need and the family and friends they depend upon.