The Benefits of Rental Assistance for Children's Health and School Attendance in the United States

Federal Housing Assistance and Blood Lead Levels in a Nationally Representative US Sample Age 6 and Older: NHANES, 1999-2018

BACKGROUND

Federal housing assistance is an important policy tool to ensure housing security for low-income households. Less is known about its impact on residential environmental exposures, particularly lead.

OBJECTIVES

We conducted a quasi-experimental study to investigate the association between federal housing assistance and blood lead levels (BLLs) in a nationally representative US sample age 6 y and older eligible for housing assistance.

METHODS

We used the 1999-2018 National Health and Nutrition Examination Survey (NHANES) linked with US Department of Housing and Urban Development (HUD) administrative records to assess BLLs of NHANES participants with concurrent HUD housing assistance (i.e., current recipients, n = 3 , 0 71 ) and those receiving assistance within 2 y after the survey (i.e., pseudo-waitlist recipients, n = 1,235 ). We estimated BLL least squares geometric means (LSGMs), odds ratio (OR) for BLL ≥ 3.5 μ g / dL , and percent differences in LSGMs by HUD housing assistance status adjusting for age, sex, family income-to-poverty ratio, education, country of birth, race/ethnicity, region, and survey year. We also examined effect modification using interaction terms and stratified analyses by program type [i.e., public housing, multifamily, housing choice vouchers (HCV)], and race/ethnicity.

RESULTS

Current HUD recipients had a significantly lower LSGM [1.07 μ g / dL ; 95% confidence interval (CI): 1.02, 1.12] than pseudo-waitlist recipients (1.21   μ g / dL ; 95% CI: 1.14, 1.28), with an adjusted OR of 0.60 (95% CI: 0.42, 0.87) for BLL ≥ 3.5 μ g / dL . Some effect modification were observed: The protective association of HUD assistance on BLL was strongest among public housing (- 19.5 % LSGM; 95% CI: - 27.5 % , - 1 0 . 7 % ), multifamily (- 12.5 % LSGM; 95% CI: - 2 0 . 7 % , - 3.5 % ), and non-Hispanic White (- 2 0 . 6 % LSGM; 95% CI: - 29.8 % , - 1 0 . 3 % ) recipients. It was weaker to null among HCV (- 5.7 % LSGM; 95% CI: - 12.7 , 1.7%), non-Hispanic Black (- 1.6 % LSGM; 95% CI: - 8.1 % , 5.4%), and Mexican American (-12.5% LSGM; 95% CI: - 31.9 % , 12.5 % ) recipients.

DISCUSSION

Our research underscores the importance of social-structural determinants like federal housing assistance in providing affordable, stable, and healthy housing to very low-income households. More attention is needed to ensure housing quality and racial equity across HUD's three major housing assistance programs. https://doi.org/10.1289/EHP12645.

Cumulative housing cost burden exposures and disadvantages to children's well-being and health

Housing affordability is a growing challenge for households in the United States and other developed countries. Prolonged exposure to housing cost burden can have damaging effects on households, and, in particular, children. These burdens can exacerbate parental stress, reduce investments in children and expose households to greater neighborhood disadvantage. In this study, we use national survey data to assess whether cumulative housing cost burden exposure is associated with disadvantages to children's well-being and health. We observe that long-term exposures are linked to lower achievement in math and reading standardized test scores, as well as higher levels of behavior problems. Moreover, we identify that three mechanisms--caregiver distress, economic strain, and neighborhood disadvantage--operate as mediating pathways for these disadvantages to different degrees between these three outcomes. Overall, our study highlights how the dimension of time is increasingly important to our understanding of the challenges that families face related to housing affordability.

Policy solutions to eliminate racial and ethnic child health disparities in the USA

Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors-including housing, employment, health insurance, immigration, and criminal legal-have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality-thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children.

Integration and coordination across public benefit programs: Insights from state and local government leaders in the United States

•Integration across public benefit programs could streamline access to services.•Modernized technology and shared missions among agencies promote integration.•Limited financial resources and insufficient guidance hinder integration.•State agencies view integration as a way to create human-centered experiences.•Additional resources from federal agencies could help establish greater integration.

Race, housing policy, and the demographic and spatial structure of modern housing programs: Who receives rental assistance and where do they live?

Housing policy in the United States has long been characterized by unequal investment in homeownership and low-income rental assistance, with implications for racial (and ethnic) inequality in access to stable housing. In this study, I examine socioeconomic status and neighborhood characteristics of non-Hispanic White and non-Hispanic Black adults with children receiving HUD rental assistance using a nationally representative linked survey-administrative dataset. Results show that Black and White adults who receive rental assistance tend to have similar (low) incomes, yet Black adults experience significantly higher levels of neighborhood disadvantage than White adults. Furthermore, living in poverty is a substantially stronger predictor of receiving HUD rental assistance for White than Black adults. The results support the notion that rental assistance programs are a last resort for White households, many of whom may benefit from historical federal government support for homeownership. Rental assistance serves as an important safety net for Black families but fails to provide significant improvement in the neighborhood environment. The results contribute to a comprehensive understanding of racial inequality in the impacts of U.S. rental housing policy and the historical legacy of racial exclusion in U.S. homeownership programs.

Social Spending and Educational Gaps in Infant Health in the United States, 1998-2017

Recent expansions of child tax, food assistance, and health insurance programs have made American families' need for a robust social safety net highly evident, while researchers and policymakers continue to debate the best way to support families via the welfare state. How much do children-and which children-benefit from social spending? Using the State-by-State Spending on Kids Dataset, linked to National Vital Statistics System birth data from 1998 to 2017, we examine how state-level child spending affects infant health across maternal education groups. We find that social spending has benefits for both low birth weight and preterm birth rates, especially among babies born to mothers with less than a high school education. The stronger benefits of social spending among lower educated families lead to meaningful declines in educational gaps in infant health as social spending increases. Our findings are consistent with the idea that a strong local welfare state benefits infant health and increases equality of opportunity, and that spending on nonhealth programs is equally beneficial for infant health as investments in health programs.

Association Between Rental Assistance Programs and Hemoglobin A1c Levels Among US Adults

Importance

Programs that provide affordable and stable housing, such as federal rental assistance, may be associated with improved mean blood glucose levels and related diabetes outcomes.

Objective

To assess whether 2 different types of federal rental assistance programs are associated with glycated hemoglobin A1c (HbA1c) levels among middle-aged and older US adults.

Design, Setting, and Participants

This cohort study used data from the National Health and Nutrition Examination Survey (NHANES) linked with US Department of Housing and Urban Development records of rental assistance participation. Adults aged 45 years or older who were receiving 2 types of rental assistance (project-based housing or housing vouchers) at the time of the NHANES interview and those who would receive rental assistance within the subsequent 2 years (waitlist group) were included. Data were collected from January 1999 to December 2016 and analyzed in October 2021.

Exposures

Rental assistance participation, including project-based housing (subsidized housing developments including public housing) and housing vouchers (tenant-based subsidies for private market housing).

Main Outcomes and Measures

The primary outcome was continuous HbA1c level, a common measure of blood glucose reflecting diabetes control. Linear regression was used to estimate the association between the 2 rental assistance programs and HbA1c level. Logistic regression was used to assess the association between rental assistance programs and HbA1c cut points (prediabetes: 5.7% to ≤6.5%; diabetes: >6.5%; uncontrolled diabetes: ≥9% [to convert to proportion of total Hb, multiply by 0.01]). Analyses used weights created by the National Center for Health Statistics that adjust for linkage eligibility.

Results

Among 1050 adults in the study (41.6% aged ≥65 years; 70.1% female), 795 were receiving rental assistance at time of the NHANES interview (450 lived in project-based housing, and 345 had housing vouchers), and 255 received rental assistance within 2 years after the interview. Participants in project-based housing had lower HbA1c levels compared with individuals in the waitlist group (β, -0.290; 95% CI, -0.599 to 0.020), but the difference was not significant. No significant differences in HbA1c levels were found between those receiving housing vouchers and those in the waitlist group (β, 0.051; 95% CI, -0.182 to 0.284). Receiving project-based housing was associated with a reduced likelihood of uncontrolled diabetes (-3.7 percentage points; 95% CI, -7.0 to -0.0 percentage points) compared with being in the waitlist group.

Conclusions and Relevance

In this cohort study of a nationally representative sample of US adults, living in project-based, federally subsidized housing was associated with a reduced likelihood of uncontrolled diabetes. The findings suggest that affordable housing programs may be associated with improved diabetes outcomes.

Does rental assistance improve mental health? Insights from a longitudinal cohort study

Almost half of renters in the United States are rent-burdened, meaning that they pay more than 30% of their income toward housing costs. Rental assistance through programs administered by the U.S. Department of Housing and Urban Development, alleviates these financial strains for around 5 million households. However, due to budgetary constraints, fewer than one in four eligible households actually receive this assistance and waitlists average two years nationally. Using longitudinal data from a cohort of 400 low-income adults living in New Haven, CT, this paper investigates how access to rental assistance affects mental health through two analytical methods that address selection into rental assistance. First, we performed a cross-sectional analysis to identify how psychological distress differs among those receiving and those on a waitlist for rental assistance. Second, we used a within-person fixed-effects analysis to compare changes in individuals following entry into rental assistance. We find that those receiving rental assistance report significantly less psychological distress than those on waiting lists and that transitions into rental assistance are associated with statistically non-significant decreases in psychological distress. Our findings suggest that expanding rental assistance may be one potential step toward improving the mental health of low-income individuals in the United States.

Does Public Housing Increase the Risk of Child Health Problems? Evidence from Linked Survey-Administrative Data

Research on the effects of major federal housing assistance programs on children's outcomes has produced mixed results. Although housing assistance programs provide one of the few sources of affordable and stable housing for low-income families, there remains concern that living in public housing developments increases the risk of poor health for children. This paper uses a unique survey-administrative linked dataset to examine the effect of living in public housing on children's risk of health problems, including frequent diarrhea, frequent headaches, skin allergies, asthma, and fair/poor health status. Children living in public housing have substantially more health problems than children who do not live in public housing. However, the analysis develops several additional comparison groups to demonstrate that the excess health problems reflect unobserved selection into public housing. The main selection adjustment compares children living in public housing to children who enter public housing in the near future. Results indicate that public housing does not increase the risk of child health problems, and it is important to consider the substantial selection into public housing on factors that are likely to be correlated with children's outcomes. The broad effects of public housing may be mixed, but policymakers should not confuse the economic and health challenges of public housing residents for the effects of the program itself.