A Health Picture of HUD-Assisted Children
Policymakers and public health professionals increasingly recognize the need to better understand how neighborhood and housing affordability, quality, and stability affect people’s health and well-being.
An interagency effort from the U.S. Department of Housing and Urban Development (HUD) and the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) advances this understanding through new research on the health of children living in HUD-assisted housing. The publication provides the first reliable estimate at the national level of the prevalence of health conditions and healthcare utilization among children living in assisted housing. Although the differences were not tested for statistical significance, the research shows distinct differences in the health of children living in HUD-assisted housing compared with low-income children not residing in assisted housing and children in the general population.
Data and Methods
HUD and NCHS linked longitudinal HUD administrative data with two cross-sectional health surveys across a 14-year period (1999 to 2012): the National Health Interview Survey (NHIS) and the National Health and Nutrition Examination Survey. The surveys include basic demographic information, household information, and data on health topics such as health status, health injuries, healthcare access, healthcare utilization, and health insurance. The analysis examined sociodemographic characteristics and health outcomes among three groups of children aged 17 years and younger:
- HUD-assisted children — children living in public housing or HUD-assisted multifamily housing as well as households using housing choice vouchers.
- Unassisted low-income renters — children living in housing that was not HUD assisted and whose household income fell below the federal poverty level.
- General child population — includes all children from the health surveys regardless of income, housing tenure, or housing assistance status.
Although multiple data sources were linked by HUD and NCHS, this study only utilized 2006-2012 data from the National Health Interview Survey.
General Health Status Among Children Aged 0 to 17
The study analyzed individual health characteristics among the three aforementioned child population groups. The NHIS asks a knowledgeable adult to rate the health of each child on a 5-point scale: excellent, very good, good, fair, or poor. The distribution of health status varied across the three groups. Among the general population, 2.4 percent of respondents ranked the health of their children as fair or poor compared with 5.2 percent of children in HUD-assisted housing and 6.1 percent of unassisted low-income children.
The NHIS also includes information about emergency room (ER) visits, which can indicate chronic health emergencies as well as a lack of access to primary care physicians and other forms of preventative care. Among HUD-assisted households, 14.2 percent of children had two or more ER visits in the past 12 months; among unassisted low-income renters, 15.7 percent had been to the ER twice or more in the past 12 months. Children in the general population had fewer ER visits, with only 8.5 percent of these children visiting the ER at least twice in the previous 12 months.
The prevalence of asthma in children can reflect poor housing quality. The potentially fatal inflammatory disease can be triggered by mold, cockroach infestations, and indoor allergens. The prevalence of asthma was highest among HUD-assisted children (21.2%) and slightly less among low-income children living in unassisted housing (17.7%). Among the general population, 11.3 percent of children had asthma. The high prevalence of asthma among HUD-assisted renters could contribute to the higher rate of ER visits.
Learning-Related Health Status Among School-Aged Children
The NHIS collects indicators relevant to understanding school performance among children aged 6 to 17. HUD-assisted children reported missing more school days due to injury or illness than children in the general population. Among HUD-assisted children, 16.2 percent missed between 6 and 10 days of school, with an additional 8.5 percent missing 11 or more days. Among the general population, 12.2 percent of children missed between 6 and 10 days, and an additional 6.3 percent missed 11 days or more.
The prevalence of learning disabilities among HUD-assisted children was high, with 26.5 percent of parents indicating that a representative from a school reported that their child has a learning disability. Among the general population, 20 percent of parents reported that their child had been identified as having a learning disability. HUD-assisted children also had a high prevalence of attention deficit hyperactivity disorder (ADHD) or attention deficit disorder (ADD), with approximately 16.1 percent of HUD-assisted children having ADHD/ADD compared with 12.7 percent of children in the general population.
Access to Health Care Among Children Aged 0 to 17
NHIS includes information about access to health care and health insurance coverage. Most HUD-assisted children and low-income children in unassisted rental housing are covered under public health insurance programs (e.g., Medicare, Medicaid, or the Children’s Health Insurance Program), with 86.8 percent of HUD-assisted children and 90.3 percent of low-income children in unassisted rental housing being covered by a public plan; 41.9 percent of children in the general population are covered by public insurance and 49.8 percent are covered under a private plan. The prevalence of uninsured children is highest among the general population, with 8.2 percent of these children not covered by insurance compared with 5.6 percent of low-income children in unassisted rental housing and 4.1 percent of HUD-assisted children.
Healthcare costs can limit access to treatment. The NHIS indicates that among HUD-assisted children, 10.9 percent have unmet healthcare needs because of their cost compared with 12.1 percent of children in unassisted low-income renter households and 10.5 percent of the general child population.
HUD-assisted children are more likely to have annual physicals and well-child visits; they are high utilizers of the healthcare system. Among HUD-assisted children, 84.4 percent had a checkup in the past year compared with 80.2 percent of low-income children in unassisted rental housing and 76.8 percent of children in the general population. Among HUD-assisted children, 14.4 percent visited a medical specialist in the previous year compared with 12.6 percent of low-income children in unassisted rental housing. The prevalence of visits to specialists was highest among children in the general population, at 16.1 percent. Only 1.6 percent of HUD-assisted children had no usual care compared with 2.7 percent among the general population; at 3.3 percent, low-income children in unassisted rental housing had the highest prevalence of receiving no usual care. A household is considered to have no usual care if the adult respondent did not specify that the child has a healthcare provider that they consistently visit for care.
Access to Health Care Among School-Aged Children Aged 6 to 17
The NHIS also captures information about dental care, mental health care, and eyeglass affordability among children aged 6 to 17 years old. Among HUD-assisted children, 81.1 percent had visited a dentist in the previous year compared with 79.8 percent of low-income children in unassisted rental housing and 84.5 percent of children in the general population. Among HUD-assisted children, 16.1 percent visited a mental health counselor in the previous year, exceeding the 12.7 percent of low-income children living in unassisted rental housing and 11.2 percent of children in the general population who received mental health services. The percentage of children with unmet eyeglass needs was similar among HUD-assisted and unassisted low-income renters at 5.6 percent and 5.3 percent, respectively; these rates were higher than that of children in the general population (3.2%).
The research represents the first nationally representative estimates regarding health outcomes and access to health care among HUD-assisted children. Overall, the research suggests that the health status of children of HUD-assisted and low-income renters is worse than that of children in the general population even though these groups have greater access to health care as evidenced by public health insurance coverage and healthcare utilization.
Compared with children in the general population, HUD-assisted children had a high likelihood of being in fair or poor health, a high utilization of ER services, and a high prevalence of unmet medical care needs. HUD-assisted children also had a high prevalence of health problems, including higher rates of missed school days, a higher prevalence of asthma, and a greater likelihood of having a learning disability than did low-income children in unassisted rental housing or children in the general population.
Moving forward, the potential linkage of health and housing policy could improve cost effectiveness and outcomes for program participants — particularly among children, for whom better coordination of healthcare services at a young age could bring substantial benefits to individual, community, and population health.