# Housing quality and health outcomes in the United States

Housing quality and health outcomes in the United States are inextricably linked. Substandard housing conditions, such as poor ventilation, lead exposure, overcrowding, and structural hazards, have been linked to respiratory illness, injuries, mental health disorders, and chronic diseases.
Housing is recognized as a key social determinant of health by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). The COVID-19 pandemic further exposed housing-related health disparities. Overcrowded conditions contributed to higher infection rates and worsened housing instability.Climate change is also increasing housing-related health risks. Rising temperatures and poor insulation contribute to heat-related illnesses, while extreme weather events such as flooding exacerbate mold-related respiratory conditions. Low-income communities are particularly vulnerable due to limited access to climate-resilient housing and infrastructure.
To address these challenges, federal and state programs such as the Housing Choice Voucher Program (Section 8) and Low-Income Home Energy Assistance Program (LIHEAP) aim to improve housing conditions. Despite these efforts, disparities in housing quality persist, highlighting the argument for continued policy enforcement and investment in sustainable housing solutions.

## Background

According to the World Health Organization, housing should provide:
* protection against communicable diseases
* protection against injury, poisoning, and chronic diseases
* and reduce psychological and social stresses to a minimum
The United States Department of Housing and Urban Development (HUD) 2007 American Housing Survey determined that 6 million households live with moderate or severe physical housing problems. Homes that are lacking toilets, have faulty or unreliable heating systems, or have exposed electrical wiring do not protect inhabitants from disease and injury and can cause serious psychological stress are categorized as being "severe" housing problems. "Moderate" housing problems are things such as having unvented gas, oil, or kerosene as the primary heating source, or lacking a kitchen sink. Again, the lack of commonplace appliances like a furnace or sink can expose inhabitants to diseases and injury.
The U.S. Census Bureau gathers data on several factors related to the housing: plumbing, heating, hallways, upkeep, electric service and kitchen equipment. As many as 24 million households have lead-based paint hazards. Maintenance and upkeep of public and low-income housing remains a major issue, leading to chronic problems of water infiltration, pest infestation and unsafe physical conditions. The disproportionate burden of these problems falls to children, the elderly and those with chronic illnesses, and minorities.

## Neighborhoods

Housing quality is also an indicator of neighborhood conditions. Neighborhoods that are seen as bad or deteriorating are often characterized by the conditions of the housing in that neighborhood. Poor neighborhood conditions can be defined as having abandoned buildings, vacant lots, no access to quality schools, and high levels of poverty. These neighborhood dynamics can contribute to a person's psychological and social stress. For example, individuals residing in neighborhoods with poor conditions face an increased risk of adverse mental health outcomes, including psychological distress, anxiety, depression, substance use, and suicide.
In low-income neighborhoods crime and noxious noise and odors can force individuals to isolate in substandard homes, which often characterize low-income neighborhoods. The combination of avoiding outside activity and isolating in dangerous living spaces leads to negative health outcomes such as obesity, lead poisoning, and asthma.

## History

Housing quality has greatly improved since the beginning of the 20th century. However, today close to 6 million American live in severe or moderate housing conditions. The majority of those living in these extreme housing conditions are minorities and renters. Historic patterns of disinvestment and housing policy decisions have contributed to disparities in housing quality across U.S. neighborhoods. Research indicates that the federal housing policies have historically favored suburban development, while inner city areas, particularly those with predominantly minority populations, faced reduced investment and greater housing insecurity.
After World War II, the Federal Housing Administration (FHA) played a major part in influencing those with the means to leave the inner city for the suburbs. According to Schwartz, the FHA gave preferential treatment to insuring mortgages in the suburbs rather than the inner city. Inner-city neighborhoods, particularly those with predominantly Black populations, faced disinvestment and reduced mortgage access. These patterns contributed to housing insecurity and neighborhood decline in many urban areas.
The COVID-19 pandemic significantly affected housing stability and public health in the United States. During the early stages of the pandemic, federal and state-level eviction moratoriums temporarily reduced housing displacement. However, once these protections expired, eviction rates surged past pre-pandemic levels in many cities. Housing conditions also influenced the spread and severity of COVID-19. Research has shown that overcrowded living spaces and inadequate ventilation increased transmission risks. Households experiencing housing instability were also more likely to face challenges in accessing healthcare, social distancing, and maintaining mental well-being during lockdowns. In response, government programs such as the Emergency Rental Assistance (ERA) program were introduced to provide temporary financial relief to tenants. However, the long-term impact of the pandemic on housing security remains a concern, particularly for low-income and minority communities disproportionately affected by housing instability.

## Statistics

Poor housing conditions are often influenced by race and geography. Marginalized groups such as Black and Hispanic individuals are more likely to experience substandard housing compared to their White counterparts. Additionally, poor housing conditions are disproportionately prevalent in inner cities and rural areas, rather than in suburban regions. Inner-city minorities tend to have poorer health outcomes compared to suburban Whites. Black homeowners are more likely than Hispanic and white homeowners to experience severe and moderate housing problems; 2.1% of all homeowners have moderate housing quality problems; 5.9% of Black homeowners and 3.8% of Hispanic homeowners experience moderate housing quality problems.
Black renters are more likely than Hispanics and whites to experience severe and moderate housing conditions. 6.9% of all renters have moderate housing quality problems; 7.9% of Black renters and 7.1% of Hispanic renters. 3.1% of all renters have severe housing problems; 4.2% of Black renters and 3.4% of Hispanic renters.
Homeowners and renters in central cities and rural areas are more likely than homeowners and renters in the suburbs to experience severe or moderate housing problems. Of those with severe housing problems, 20% more were in central cities and 10% more were located in rural areas than in suburban areas. Of those with severe housing problems, nearly 20% more were located in central cities.

## Specific health outcomes

Substandard housing quality can have detrimental impacts on the physical and mental health of residents. In the United States, high-quality housing has become difficult to afford and access. Because of the inaccessibility, many individuals and families settle to build homes in spaces with poor living conditions. As of 2017, 8.3 million homes were considered homes with “worst case needs.” This number is describing the amount of rental households which are occupied by individuals with extremely low incomes, and living in severely inadequate conditions. Characteristics of inadequate housing include spaces with poor ventilation or leaks, peeling paint or cracked walls and ceilings, faulty smoke alarms, as well as having deficiencies in heating, electricity and plumbing.
Individuals and families living in spaces that exhibit these characteristics face a heightened risk of experiencing poor health. Residing in poorly ventilated homes can increase risks of respiratory illnesses. Additionally, poor ventilation can increase the likelihood residents will be exposed to mold, and other allergens, of which can have significant health impacts, increasing the risk of experiencing negative health effects. In addition to the physical health impacts experienced by residents in poorly maintained spaces, these individuals and families also suffer from stress and anxiety caused by their living conditions.
Evaluating the quality of housing, as well as recognizing its inadequacies, is an essential aspect of ensuring the health and safety of people within their homes. Additionally, recognizing the correlation between poor housing quality and poor health helps to determine the location of investment initiatives by providing information on where funds are most needed.

### Climate change and housing

Climate change has emerged as a significant factor influencing housing quality and public health. Research indicates that rising global temperatures, increased, flooding, and worsening air quality have disproportionately affected low-income housing communities.

#### Extreme heat and energy inefficiency

Poorly insulated housing contributes to heat stress, especially in urban areas where the urban heat island effect amplifies temperature extremes. A lack of air conditioning or proper ventilation has been linked to increased hospitalizations for heat-related illness.Programs aimed at retrofitting homes with insulation and energy-efficient cooling systems have shown positive health outcomes.

#### Flooding and mold growth

More frequent and severe storms have led to increased flooding, particularly in coastal and low-income neighborhoods. Flooded homes are prone to mold and damp conditions, which exacerbate respiratory diseases such as asthma.

#### Air pollution and respiratory disease

Climate change has also worsened air pollution, contributing to increased rates of asthma and other respiratory conditions. Low-income housing is often situated near industrial areas, exposing residents to elevated levels of pollutants such as particulate matter (PM2.5).

### Asthma and respiratory illnesses

Asthma is a major reason for childhood hospitalizations as well as absenteeism from schools. Asthmatic children living in homes with cockroaches, mice and mold may be especially prone to episodes requiring medical care. Direct health care costs of asthma totaled more than $14.7 billion in 2008. $5 billion annually in indirect costs, primarily from lost productivity, can be added to the total. According to the Centers for Disease Control and Prevention, almost 13 million lost school days, 4 million asthma attacks and nearly 4,000 deaths yearly are associated with asthma. Water infiltration and poor ventilation increases the likelihood that moisture will be an issue in a home, which can lead to infestation of pests and to mold growth, known triggers of allergies and asthma.

### Lead

High lead levels (blood levels ≥10 micrograms per deciliter) are associated with a number of poor health outcomes, including: learning disabilities, behavioral and neurological problems, and, in severe cases, death. Even relatively low blood lead levels can have negative health impacts. The impact on the individual and on society in terms of lost potential can be dramatic. Those living in older, poorly maintained housing are at the greatest risk, and many of these housing units are home to low-income families Even though blood levels are dropping in much of the population in the United States, the poorest children remain at the greatest risk because they are most likely to live in older, poorly maintained housing.

### Unintentional injuries

Unintentional injury is the leading cause of death among children under the age of 15. Deaths from residential injuries accounted for an average of 2,822 deaths annually from 1985 to 1997. The rates of death associated with residential injury are equally significant amongst those aged 65 and older. Poorly maintained stairs, sidewalks, bad lighting, and inadequate facilities for people with limited mobility or sensory impairments are all implicated in injury rates.

### Chronic illness

Even after accounting for other potential contributors like income, smoking or employment status, poor housing conditions are associated with an increased risk of chronic respiratory infection. Unsanitary conditions made more severe by aging and poorly constructed structures, exacerbate the problem. Poor heating and cooling lead to an increased risk of temperature related illnesses. Heat stroke and exhaustion are a major cause of mortality and morbidity, especially for the elderly. Conversely, exposure to cold temperatures can contribute to an increased use of health services.

### Nutrition and obesity

“Food deserts”, areas that lack grocery stores or markets that contain healthful foods like fruits and vegetables, are primarily found in high poverty, inner-city areas where residents lack the resources to travel. Rates of obesity and the related illnesses are much higher in these areas than in higher income communities with easy access to fresh foods. A correlation has been determined for a connection between food insecurity associated with housing cost burdens and under-nutrition. A lack of adequate play areas for children, poor lighting or sidewalk condition can also lead to a lack of physical activity which is associated with increased obesity and associated morbidities, such as type II diabetes, cancer and cardiovascular disease.

## Housing hazards

Most significant aspects of poor housing are linked to various adverse health effects ranked by highest number of people affected. These housing hazards are linked to many health effects like respiratory symptoms, asthma, lung cancer, depression, injury, hypothermia and death.
* Air quality
* Hygrothermal conditions (warmth and humidity)
* Radon
* Noise
* House dust mites
* Environmental tobacco smoke
* Fires

## Policy responses and interventions

Government and community-driven policies aim to mitigate housing-related health risks by addressing affordability, safety, and environmental sustainability. Effective interventions focus on housing assistance programs, regulatory protections, and climate-resilient initiatives.

### Affordable housing programs and financial assistance

Economic barriers remain a major driver of poor housing quality. Several federal and state-level initiatives provide financial support to low-income households:
* Housing Choice Voucher Program (Section 8) - Administered by the U.S. Department of Housing and Urban Development (HUD), this program helps low-income families afford private rental housing.
* Low-Income Home Energy Assistance Program (LIHEAP) - Provides financial aid for heating and cooling expenses, reducing exposure to extreme temperatures.
* National Housing Trust Fund (HTF) - Supports the construction and preservation of affordable housing, particularly for very low-income households.

### Housing quality regulations and tenant protections

Federal and state policies set minimum standards for housing safety and habitability:
* Fair Housing Act (1968) - Prohibits discrimination in housing based on race, disability, and family status, ensuring equitable access to safe housing.
* Healthy Homes Initiative (HUD) - Targets lead poisoning, mold remediation, and pest management to improve indoor air quality.
* Eviction Prevention Programs - During COVID-19, eviction moratoriums temporarily reduced housing instability; however, post-pandemic eviction rates remain high.

### Climate-resilient housing policies

As climate change exacerbates housing-related health risks, policies have emerged to address energy efficiency, disaster resilience, and environmental justice:
* Weatherization Assistance Program (WAP) - Funds energy-efficient home upgrades to lower heating and cooling costs.
* Green Building Standards (LEED Certification) - Encourages sustainable construction practices to reduce indoor pollution and improve air quality.

### Community-led housing initiatives

Local programs and nonprofit organizations play a critical role in housing advocacy and tenant protections:
* Community Land Trusts (CLTs) - Allow low-income residents to collectively own land and maintain affordable housing.
* Right to Counsel Laws - Cities like New York and San Francisco have implemented legal aid programs for tenants facing eviction. Recent annual reports indicate that these programs enabled 84% of participating tenants in New York to remain in their homes, while 92% of assisted tenants in San Francisco successfully avoided homelessness.

### Conclusion

Policies aimed at improving housing quality must address affordability, safety, environmental sustainability, and tenant protections. While federal programs provide crucial funding and legal protections, state and local policies often determine the effectiveness of interventions in reducing housing-related health disparities.