Housing is a key social determinant of health, and the array of U.S. Department of Housing and Urban Development (HUD) low-income housing assistance programs represent a potentially powerful policy lever to promote population health and reduce health disparities. Because HUD-assisted households typically pay 30% of their income towards rent, the monetary value of housing assistance varies across households as a function of household income, the prevailing market rents that HUD-assisted households would otherwise have to pay, and the rents of units in which assisted household reside. Variation in the value of housing assistance is likely to translate into meaningful differences in health outcomes. Our study addresses the following questions: 1) Does the monetary value of housing assistance impact health outcomes? and 2) Does this impact vary across federal housing assistance programs?
We capitalize on a newly available dataset that links responses from the nationally-representative National Health Interview Survey (NHIS) for the period from 1999 to 2012 with HUD administrative records from 1999 to 2013. Our sample is comprised of 58,398 adult NHIS respondents, of whom 8,240 were currently in HUD housing and 50,158 who were income-eligible non-recipients. We create novel measures of both the “explicit” and “implicit” value of HUD housing assistance by combining information from the HUD records on tenant income, tenant and HUD rent payments and data on prevailing fair market rents. We assess the impact of the value of housing assistance on measures of overall health and mental health, chronic health conditions, acute health conditions, and access to health care using three different approaches: 1) comparing current HUD housing recipients with income-eligible, non-recipients; 2) comparing current and future HUD housing recipients; and 3) using an instrumental variables approach in which we use the local supply of HUD-assisted housing as an instrument for the value of housing assistance.
We find no evidence that the value of housing assistance has a positive impact on overall health, chronic health conditions or acute health conditions. However, we find that the value of housing assistance is associated with improved access to healthcare, with our analysis identifying consistent negative relationships between the value of housing assistance and the odds of delaying seeking medical care due to cost and not being able to afford medical care. We also find that receipt of higher amounts of HUD assistance is associated with reduced odds of experiencing very low food security.
Conclusions and Implications
The relationship between the value of housing assistance and health is likely to operate via an income effect, wherein receipt of a relatively more valuable benefit is likely to free up resources to spend on needed medical care, or other things necessary for the health promotion, like food. Our findings suggest that recent policy proposals that would require HUD-assisted households to contribute more of their income towards rent—a de facto cut in the value of HUD assistance—would have negative health-related impacts.