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COVID-19 Risk Factors Among HUD-Assisted Renters

Two women wearing surgical masks sit facing each other on a couch.Roughly one-third of HUD-assisted households are headed by an individual aged 65 or older, an age group at higher risk of hospitalization and mortality than younger individuals. Credit: FatCamera/istockphoto.com

In this column, Janet Li discusses COVID-19 risk factors among HUD-Assisted renters.

The COVID-19 pandemic continues to have far-reaching effects on societal health and well-being. Certain groups are more at risk than others for becoming infected with COVID-19 or for experiencing more severe health outcomes if they do get infected. How are these at-risk populations represented among tenants of HUD-assisted housing? This article considers some of the health risk factors of COVID-19 that the Centers for Disease Control and Prevention (CDC) has identified and examines data from HUD’s Picture of Subsidized Households (PSH) and the American Housing Survey (AHS) to show that HUD-assisted tenants are particularly vulnerable to these risks.

Known individual health risk factors for COVID-19 include age and certain preexisting medical conditions and disabilities. Socioeconomic risk factors include race as well as factors associated with income and employment. Other public health factors include congregate settings and household crowding. Examining each of these variables in turn suggests a need for policies that protect the health of HUD-assisted renters, including in the rollout of COVID-19 vaccines.

Risk Factor: Age

Because older adults who contract COVID-19 have a higher risk of hospitalization and mortality (exhibit 1), states have largely prioritized vaccinating elderly individuals over other members of the public.

Exhibit 1. Age increases risk for hospitalization and death from COVID-19

Age group

Hospitalization

Death

18 to 29 years

Comparison group

Comparison group

30 to 39 years

2x higher

4x higher

40 to 49 years

3x higher

10x higher

50 to 64 years

4x higher

30x higher

65 to 74 years

5x higher

90x higher

75 to 84 years

8x higher

220x higher

85+ years

13x higher

630x higher

Source: Centers for Disease Control and Prevention. 2020. “Older adults at greater risk of requiring hospitalization or dying if diagnosed with COVID-19,” 13 December. Accessed 4 February 2021.


Roughly one-third of HUD-assisted households are headed by an individual aged 65 or older. According to the PSH, 38 percent of HUD-assisted households are headed by someone aged 62 years or older, and 4 percent are headed by someone aged 85 years or older. AHS estimates are similar; among household heads, 31 percent of renters receiving HUD assistance are aged 65 years or older compared with 19 percent of renters who are eligible but not assisted, 8 percent of ineligible renters, and 16 percent of owners (exhibit 2).

Exhibit 2. Age distribution of HUD-assisted household heads compared with other groups

A table showing age distribution of HUD-assisted household heads compared with other groups.

Risk Factor: Disability

According to the CDC, adults with disabilities are three times more likely than adults without disabilities to experience heart disease, stroke, diabetes, or cancer. Other risk factors affecting people with disabilities may arise from those with limited mobility who rely on physical contact for day-to-day support, those who may have trouble understanding how to take preventive measures, and those who may have trouble communicating symptoms of illness.

The PSH estimates that 23 percent of all HUD-assisted households include a person with a disability. Among heads or coheads of HUD-assisted households, 35 percent of those aged 61 or younger have a disability, whereas 46 percent of those aged 62 or older have a disability. AHS estimates are higher: 41 percent of HUD-assisted households include a person with a disability compared with 24 percent of eligible unassisted renter households, 11 percent of renter households ineligible for assistance, and 21 percent of owner households.

According to the AHS, 25 percent of HUD-assisted household heads use a mobility device such as a wheelchair, motorized cart or scooter, crutches, cane, or walker, compared with 15 percent of eligible unassisted renter households, 7 percent of renter households ineligible for HUD assistance, and 13 percent of owner households.

The prevalence of mobility disabilities and other types of disabilities among HUD-assisted households, along with their higher average age, increases their risk for severe illness caused by COVID-19.

Risk Factor: Race

Race can pose risks for COVID-19 infection and negative outcomes due to the effects of social determinants of health such as discrimination and racism, which create chronic stress and cause disparities in access to health care, housing, education, and jobs, among other needs.

According to the PSH, 66 percent of HUD-assisted household heads belong to a racial or ethnic minority. Specifically, 43 percent of HUD-assisted household heads are non-Hispanic black, 19 percent are Hispanic, 4 percent are non-Hispanic Asian or Pacific Islander, 1 percent are non-Hispanic Native American, and 1 percent identify as multiracial. On average, HUD-assisted units are in census tracts where 55 percent of the population is nonwhite and 25 percent of the population have incomes below the federal poverty level. These findings indicate risk at the neighborhood level that extends beyond household-level risks.

The AHS shows that the number of black households is disproportionately higher among HUD-assisted renters than among owners, renters ineligible for HUD assistance, or renters eligible for HUD assistance but not assisted. There are more Hispanic households among eligible unassisted renters than among renters receiving HUD assistance. Asian households are concentrated among renters not eligible for HUD assistance, and white households are concentrated among homeowners.

Supporting HUD-assisted households with COVID-19 preparedness and mitigation strategies would also support some of the populations disproportionately affected by COVID-19.

Risk Factor: Income and Employment

Income and employment affect households through their financial capacity to meet their needs and through the potential exposure to infection associated with certain types of jobs. In particular, essential workers — those who work in the healthcare, transportation, retail, agriculture, and manufacturing sectors — face higher risks of COVID-19 exposure because their jobs do not allow them to work remotely.

According to the PSH, 22 percent of HUD-assisted households report that wages are a major source of income, a drop from the steady 26 percent of HUD-assisted households in previous years. The AHS also reports that a minority of HUD-assisted households earn wages or salaries. Compared with eligible unassisted renters, ineligible renters, and homeowners, a much higher percentage of HUD-assisted households receive Supplemental Security Income, public assistance or welfare, or Social Security or Railroad Retirement, although homeowners and HUD-assisted renters have comparable takeup rates for Social Security/Railroad Retirement.

On the one hand, HUD-assisted households may be better protected from occupational COVID-19 hazards because fewer of them are working; on the other hand, those who are working are more likely to be classified as essential workers with higher risk of exposure and more limited job flexibility.

A larger percentage of HUD-assisted households (51%) receive Supplemental Nutrition Assistance Program benefits than do eligible unassisted renter households (18%), ineligible renter households (3%), and owner households (4%). Financial insecurity and food insecurity both have detrimental effects on physical and mental health outcomes. Increasing costs stemming from preparedness measures, medical expenses from contracting COVID-19, or the concurrent exacerbation of other medical conditions can in turn affect financial security, further deteriorating health. Supporting HUD-assisted households would protect essential workers and some of those whose basic needs are at risk during an economic crisis.

Risk Factor: Crowding

Although many media sources at the start of the pandemic tended to focus on population density as a factor for the spread of COVID-19, more nuanced research by the World Bank and others has determined that the density of people within a household, rather than the density of people within a local area, is of greater concern.

Because the CDC recommends 6 feet of social distancing, 113 square feet represents the area of a circle formed by a person at the center with 6 feet of clearance all around. This 113-square-foot threshold has been suggested by the U.S. Fire Administration as the minimum “occupant load factor” of a building during the COVID-19 pandemic. However, states such as Colorado have suggested raising the space requirement to 226 square feet per person to allow additional space for movement.

Examining the number of square feet per person shows that HUD-assisted renters have the least space in their units, followed by eligible but unassisted renter households; among these households, 21 percent and 17 percent, respectively, report having less than 300 square feet per person (exhibit 3). HUD-assisted renters are less crowded than unassisted renters when looking at the number of persons per bedroom; 32 percent of eligible but unassisted renter households and 31 percent of ineligible renter households house more than 1 person per bedroom, compared with 25 percent of HUD-assisted renters (exhibit 4). In general, overcrowding is much more common among renters than owners.

Exhibit 3. Square feet per person, HUD-assisted households compared with other groups

A graph showing square feet per person of units for HUD-assisted housing, compared with other groups.

Note: The category of 1,500 square feet or more per person is not included because there was not sufficient reporting for it among HUD-assisted households.

Exhibit 4. People per bedroom, HUD-assisted households compared with other groups

A graph showing people per bedroom for HUD-assisted households compared with other groups.

HUD-assisted renters report the highest number of one-person households (exhibit 5), which, although beneficial because it limits exposure from other household members, may also negatively affect social-emotional health and other types of support needed during the societal disruptions caused by the pandemic. So, whereas overcrowding is a more significant problem among unassisted renters, isolation and loneliness pose greater challenges among HUD-assisted households.

Exhibit 5. People per household, HUD-assisted households compared with other groups

A graph showing people per household for HUD-assisted households compared with other groups.

Summary of Risk Factors

Exhibit 6 summarizes the risk factors discussed in this article: age; disability; race; sources of income; and measures of household crowding, including the number of square feet per person, the number of persons per bedroom, and the number of people per household. HUD-assisted households are more vulnerable than other groups because of the prevalence of elderly residents, residents with disabilities, and black residents. For many residents, the overlapping nature of these vulnerabilities can compound their COVID-19 risk. Interpreting the risk factors of HUD-assisted households regarding sources of income and household crowding is more challenging. Although a smaller percentage of HUD-assisted households are working, these workers are more likely to be employed in essential jobs with increased risk of COVID-19 exposure. In addition, the square footage per person in HUD-assisted households is smaller than that of homeowners and renters ineligible for HUD assistance. However, eligible renters who do not receive HUD assistance live in more crowded settings than those receiving housing assistance, in terms of the number of persons per bedroom. Finally, most (54 percent) HUD-assisted households are single-person households, which limits COVID-19 exposure but increases the risks of loneliness and isolation.

Exhibit 6. Prevalence of risk factors among HUD-assisted renters, compared with other groups

Risk factor

HUD-assisted renters

Renters eligible for HUD assistance but not assisted

Renters not eligible for HUD assistance

Owners

Age (head of household)

75 years and older

13.7 %

9.4 %

3.0 %

7.4 %

65 to 74 years old

16.6 %

10.5 %

4.5 %

8.8 %

55 to 64 years old

22.2 %

14.9 %

12.6 %

14.7 %

Disability

Households with a person with a
disability

40.6 %

24.4 %

11.2 %

20.9 %

Heads of households using a
mobility device

25.0 %

15.4 %

7.2 %

13.2 %

Race* (head of household)

Black

45.8 %

21.1 %

16.4 %

9.3 %

Hispanic

19.1 %

23.7 %

15.3 %

10.5 %

Asian

2.7 %

4.9 %

7.8 %

4.8 %

Income sources** (head of household)

Wages or salary

39.7 %

66.0 %

89.9 %

71.0 %

Social Security or Railroad
Retirement

32.9 %

22.7 %

9.2 %

34.5 %

Retirement or survivor pension

4.9 %

7.4 %

6.4 %

21.0 %

Supplemental Security Income
(SSI)

23.4 %

7.1 %

1.3 %

3.2 %

Public assistance or public
welfare

15.2 %

5.0 %

0.7 %

1.2 %

Receiving food stamps

51.4 %

18.0 %

2.7 %

4.0 %

Crowding (household)

Square feet per person

Less than 200 square feet per
person

8.2 %

6.7 %

3.2 %

1.3 %

200 to 299 square feet per
person

12.7 %

11.0 %

9.2 %

4.0 %

Persons per bedroom

1.51 or more persons per
bedroom

12.2 %

19.7 %

17.2 %

6.2 %

1.01 to 1.50 persons per
bedroom

12.3 %

12.4 %

13.9 %

12.1 %

People per household

1 person

53.7 %

42.5 %

28.2 %

22.6 %

2 persons

18.7 %

23.6 %

36.1 %

37.8 %

3 persons

13.0 %

13.7 %

17.2 %

15.5 %

4 persons

8.6 %

10.5 %

11.4 %

14.2 %

5 or more persons

6.1 %

9.7 %

7.1 %

9.9 %


Note: Percentages represent the percent of households or heads of households reporting the characteristic for each group.
*Only minority racial and ethnic groups with sufficient reporting for all groups are included.
**Only income sources with sufficient reporting for all groups are included. Totals do not add up to 100 percent because each household can have multiple income sources.
Source: 2019 American Housing Survey Table Creator.


Conclusion

The investigation of risk factors affecting HUD-assisted households, including age, disability, race, income, and isolation, indicates that a COVID-19 response that supports these groups, including vaccine distribution, is critically important. HUD-assisted households are especially vulnerable to COVID-19 risks because of their intersectionality and compounding of multiple reported risk factors. States can target HUD-assisted households for vaccinations and testing through existing outreach mechanisms employed by the public housing agencies that serve them.

Households eligible for HUD assistance who do not receive any are also vulnerable. Several studies have found that HUD housing assistance is associated with improved healthcare access and health outcomes. Identifying and targeting households that are eligible for HUD assistance but do not receive it may be challenging for state and local policymakers, but from a public health perspective, the effort would be worthwhile.

Some states and localities are working with public housing agencies to vaccinate their residents and provide other support. In Rhode Island, residents under the Central Falls Housing Authority had previously endured the largest COVID-19 outbreak in the state, with a 28 percent positivity rate among those tested. Many of these residents are essential workers working in local meatpacking plants and factories. The Central Falls Housing Authority was the first organization to administer the vaccine in the state; however, vaccination takeup rates were lower among younger residents and residents with disabilities, as well as among voucher holders not directly renting property owned or managed by the housing agency.

Source:

Data for this analysis come from the PSH and the AHS. The most recent PSH data, published on HUD USER, are from 2020 and include reporting from 9.34 million people in 4.60 million occupied units out of 5.08 million total subsidized units. The PSH includes information on the following HUD programs: public housing, housing choice vouchers, moderate rehabilitation, project-based Section 8, Rent Supplement/Rental Assistance Payment, Section 236 Preservation Program/Below Market Interest Rate, Section 202 Supportive Housing for the Elderly/Project Rental Assistance Contracts (PRAC), and Section 811 Supportive Housing for Persons with Disabilities/PRAC.

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Source:

Data from the AHS comes from tabulations from the American Housing Survey Table Creator, which reflect a national longitudinal sample of 86,151 housing units, including an oversample of 5,185 units of HUD-assisted renters. Based on this sample, the AHS estimates a total of 4.50 million HUD-assisted units, 17.2 million renter households not eligible for HUD assistance, and 22.9 million renter households eligible for HUD assistance who are not assisted as well as 79.5 million owner households. HUD-assisted programs are divided into public housing, housing choice vouchers, and privately owned multifamily (which includes the Rent Supplement, Section 221(d)(3) Below Market Interest Rate, Section 236, Section 202 Supportive Housing for the Elderly, Project-Based Section 8, and Moderate Rehabilitation programs as well as other smaller programs). This article does not include information for other types of households funded by HUD programs or of interest to HUD, including mortgages insured by the Federal Housing Administration, the Housing Trust Fund, the HOME Investment Partnerships Program, community development block grants, and low-income housing tax credits, among others. This article focuses on renters rather than on vulnerable HUD-assisted homeowners, who likely also face higher risks related to COVID-19. ×

 
 
Published Date: 8 February 2021