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

Roshanak Mehdipanah

To celebrate its 100th year, The Milbank Quarterly has published a centennial anniversary issue with 36 articles that consider the future of population health. In this Q&A, Roshanak Mehdipanah, PhD, MS, of the University of Michigan School of Public Health discusses her contribution to the issue, “Without Affordable, Accessible, and Adequate Housing, Health Has No Foundation.” She describes housing through the lenses of affordability, access, and adequacy, and argues that housing is a human right and determinant of health.

Can you describe the dimensions of housing and security that you discussed in your article.

There’s no longer a place in the United States where folks can live on a minimum wage income and afford a two-bedroom apartment. Low-income households face the greatest burden related to housing costs. Affordable housing is lacking. After the Great Recession of the late 2000s, there was a large wave of mortgage foreclosures. And in cities like Detroit, this wave was followed by a large wave of tax foreclosures related to unpaid property taxes.

Access beyond the ability to pay is about discrimination in housing access, whether it is at the point of trying to attain a home or maintaining the home. The 1968 Fair Housing Law made it illegal to discriminate on various factors like race, gender, and age, and, although overt discrimination practices have decreased, more subtle types of discrimination have continued to persist. There are cases across the US where a Black household is being appraised at a lower rate compared to a White household. This plays a role in access to housing, but also access to wealth generation through equity.

Historically, dimensions of unaffordability and inadequacy of housing have been studied separately. There needs to be greater focus on the joint effects because when we talk about housing conditions, we have to talk about affordability. You can’t expect folks to get a new roof or do lead remediation without financial support. Poor housing conditions tend to impact lower income households. There have to be programs in place to support these folks.

How does housing unaffordability, inaccessibility, and inadequacy contribute to health and health inequities?

Studies show that households that are insecure, paying more than 30% of household income toward housing costs, are also more likely to be food insecure and less likely to seek or adhere to medical treatment. During the pandemic, there was an increase in housing insecurity associated with poor mental health and poor self-rated health. There are also stressors associated with the risk of potentially losing a home, whether through eviction or foreclosure. Living in a home where the roof is leaking on a daily basis can have huge implications for your mental wellbeing and stress too.

Redlining practices have led to contemporary poor health outcomes and are connected to worse social determinants of health outcomes. Studies also show that folks who experience discrimination are more likely to have worse mental health. Discriminatory mortgage access is associated with worse physical health.

Housing conditions are the area in which public health has done the most research. Lead is associated with poor health in children developmentally, mold is associated with asthma, and allergens and pests are associated with poor health outcomes. We have to start accounting for not just physical accessibility, but also cognitive accessibility. How do you make their homes safer?

How did the COVID-19 pandemic affect housing disparities?

The COVID-19 pandemic showed how prevalent housing insecurity is placing households at higher risk for eviction. COVID-19 really exacerbated the issues. Across renters and homeowners, self-rated health decreased, and mental distress increased. But hardships compounded differences in health status; renters fared worse than homeowners. There was also a difference between homeowners who had a mortgage versus homeowners who didn’t have a mortgage, with the latter group faring better.

During the pandemic, there were programs and policies put in place like the eviction moratorium and the COVID Emergency Rental Assistance, but the rollout and uptake was very slow, leading to an increase in pandemic-related evictions. On the other hand, homeowners experienced a foreclosure moratorium, and were also given opportunities not to pay their mortgages for a year if they had traditional mortgages. They were given financial safety nets that came with home ownership. This contributed to disparities in renters versus homeowners.

COVID-19 forced people to stay home, and in some cases that meant overcrowded conditions in homes. Children needed space to do their education, parents needed space to do their work, so overcrowding was a huge hardship for folks who didn’t have spaces and opportunities. Some studies even connected overcrowding to the increased risk of COVID-19 exposure. Utility shutoffs during this period — although there were some moratoria — took away the first line of defense: washing your hands. Meanwhile homeowners and renters with higher incomes moved to areas that had beaches and cities that offered recreational pursuits, inadvertently driving up the prices of homes in those areas. During the pandemic, we saw one of the steepest increases in housing prices, at one point a 20% increase in [the price of] homes in some places, which further impacted the housing affordability crisis.

How will climate change affect housing and housing disparities?

Approximately 52% of occupied homes across the United States were built prior to the 1980s, and only 21% of homes were built since 2000. It is an old housing stock that hasn’t necessarily been retrofitted or updated, particularly in areas with lower resources. Flooding and other situations have caused an uptick in poor housing conditions. Addressing those conditions is very hard because many homes don’t have home insurance or access to funding for repairs. It starts this process of housing instability for a mostly low-income population.

During Hurricane Katrina, and other recent natural disasters, homes were destroyed beyond repair in neighborhoods that were primarily low income or primarily populated by people of color. There are promises to rebuild and regenerate, but the number of homes that are created often do not replace the number of homes lost. We also see the process of gentrification occurring in these areas, making it very difficult for people to move back to their old neighborhoods. A lot of climate change displacement is occurring. In cities like Miami where there are threats of rising ocean levels, folks want to resettle to areas that have higher altitudes. Traditionally those higher altitude places are where people, mostly migrants, have been forced out. For example, Little Haiti in Miami is being targeted by developers that want to build homes for their rich clientele. Neighborhoods are being impacted by climate gentrification.

What are some strategies to retain and increase affordable housing options?

When we started valuing housing and using it as a commodity, we started losing sight of housing as a basic human right. Communities need to be involved in the planning, implementation, and evaluation of programs. There needs to be greater protection of existing residents in neighborhoods that are being targeted for gentrification, whether it’s policies and programs that control how much rent can be increased, solutions and policies like community land trusts, which give properties to folks to invest in, or models of home ownership with communities in mind.

We need to have more protection for renters. Code enforcement is a really big area of work. Cities don’t have the resources to do code enforcement, so folks are living in horrific places, but they have no power over their landlords or opportunities to address these issues.

We need to increase understanding of the Fair Housing Act laws and housing discrimination. Not enough people know whether they are being targeted for one of their characteristics or demographics, such as gender, disability status, or race/ethnicity and national origin.

Cities need to have conversations about affordability. Essential workers who were praised during COVID-19 are being priced out of cities. There are cities where teachers can’t afford to live, impacting public school systems. Housing is really at the center. All of these determinants of health need to be brought in when discussing affordability, quality, conditions, and everything else that comes with a neighborhood: transportation, sidewalks, access to parks, access to food sources, policing.

Housing needs to be centered as a critical determinant of health. By addressing factors, not just at the extreme levels of homelessness, but talking about prevention and improvements can have a lot of impact.

What is the role of public health and health care in improving housing?

Public health has a critical role. Some of the best examples of housing policies have been lead remediation programs that were public health driven. Public health has done a lot of work linking blight, houses that are abandoned or vacant land, to negative health outcomes.

More health care systems are getting involved in addressing housing. Social screening programs now include housing. Doctors are able to write prescriptions for rent and for utilities, and hospital systems are building affordable housing and investing in the neighborhoods.

Are there local, state, and federal solutions?

The eviction fund was a federally implemented program, but when it trickled down to the local level there weren’t enough resources to run the programs. A lot of the money wasn’t used at the time that it was supposed to be used, and folks lost their homes. There is definitely room for more cross-government interactions with housing programs.

READ THE CENTENNIAL ISSUE ARTICLE