By: Christopher Clark
Housing policy has a profound impact on public health in Los Angeles. Housing unaffordability, residential instability, and poor living conditions have all been linked to serious mental and physical health problems among adult residents, as well as developmental problems in children. These three areas of housing policy (affordability, stability, and quality) are interrelated: when housing becomes less affordable, residents are more likely to lack a consistent place to sleep^[1] and more likely to live in unsafe and unclean units.^[2] Understanding the health impacts of these three elements of housing policy is vital for promoting public health and alleviating health disparities.
 
Housing Unaffordability
Over half of all households in Los Angeles County are cost burdened, meaning they spend 30% or more of their monthly income on rent or mortgage payments.^[3] As housing prices in Los Angeles increase, families have less and less money to spend on other necessities, such as food and medical care.^[4]

• Cost burdened families have to choose between seeing a doctor and paying the rent. As a result, families living in unaffordable housing are three times more likely than other families to avoid seeing a doctor about a health problem, forgo purchasing prescription medicine, or leave mental health problems untreated.^[5] People who spend over half of their monthly income on housing have it even worse, spending an average of 74% less on healthcare than people who live in affordable housing and have similar incomes.^[6]
• With so much of their income going towards housing, families are struggling to put food on the table. Los Angeles County residents who had trouble paying their rent or mortgage were twice as likely to experience “low food insecurity” (decreased quality and variety of diet) and four times as likely to have “high food insecurity” (disrupted eating habits and reduced food intake), compared to otherwise

 
similar residents in affordable housing.^[7] Renters are particularly at risk—a nationwide study found that a $500 increase in yearly rental costs on average leads to a 3% spike in food insecurity rates.^[8]

• Cutting corners like this takes a serious toll on the health of residents. Compared to people who can afford their housing, cost burdened residents have significantly worse self-reported physical health,^[9] unhealthier diets,^[10] and twice the risk of clinical depression.^[11] If a family becomes food insecure, more than just nutrition suffers. Food insecurity hinders brain and cognitive development for very young children,^[12] makes adolescents more likely to develop depressive disorder and suicidal symptoms,^[13] and leads to poorer overall health for elderly residents.^[14]

 
Housing Instability
Though housing instability is most often associated with homelessness, less visible forms of instability, like switching residences multiple times per year or having to stay with friends or family, also carry serious health consequences.

• Without a stable place to call home, residents can’t get consistent and adequate medical care. A study of low-income Americans found that people who had to move in with family or friends were less likely than those with residential stability to have a consistent source of medical care, see a doctor when they need to, or purchase prescription drugs.^[15]
• An unstable housing situation damages mental health. Adults with housing instability in Los Angeles County were found to have triple the risk of major depression as residents with stable housing.^[16] Mothers who had to move twice in two years were at higher odds of generalized anxiety disorder and depression, independent of their socioeconomic status.^[17] Children who grew up with high rates of residential change exhibited more behavioral problems during childhood and more risk-taking behaviors during adolescence than children living in stable housing.^[18]

 
Poor Living Conditions
When the housing market is unaffordable or unstable, families are forced to settle for dangerous living arrangements and unsafe units. Housing instability^[19] and high cost burdens^[20] have both been linked with increased rates of overcrowding and problems with pests or mold.

• Living in overcrowded conditions weakens physical and mental health. Household overcrowding allows dangerous diseases, such as hepatitis A, pneumonia, meningococcal disease, and tuberculosis, to infect higher rates of people.^[21] It also strains important social support systems, leading to higher rates of psychological distress among overcrowded adults.^[22] Children are affected too—important developmental measures, such as elementary school reading test scores and early IQ scores, are significantly lower for children living in overcrowded conditions than for other socioeconomically similar children.^[23]
• In low-quality housing, residents are exposed to dangerous substances that jeopardize their health. Low-income families are more likely to live alongside pests^[24] and mold,^[25] both of which have been shown to aggravate asthma and other chronic respiratory conditions.^[26] Having pests, like mice and cockroaches, often drives families to use dangerous pesticides, increasing their risk of acute poisonings and developing cancer.^[27]

 
 
Suggested Policy Approaches
Promote affordability: Regulate demolitions and condominium conversions, encourage the production of new affordable housing, and mitigate the rising costs that often result from development projects and transit expansion.
Ensure stability: Guarantee a “right of return” for low-income tenants whose units have been demolished, proactively address loopholes in the Ellis Act to prevent illegal evictions, and strengthen the enforcement of the Rent Stabilization Ordinance.
Address poor living conditions: Bolster the enforcement of code violations, monitor and combat landlord absenteeism, and strengthen the Rent Escrow Account Program.
^[1] Yelowitz, Aaron. Local housing costs and basic household needs. 2016.
^[2] Joint Center for Housing Studies of Harvard University, State of the nation’s housing 2012. 2012: Cambridge, MA.
^[3] Los Angeles County Department of Public Health, Office of Planning, Evaluation, and Development. Community Health Assessment 2015; March 2015.
^[4] Hickey, Robert, Jeffrey Lubell, Peter Haas, and Stephanie Morse. Losing Ground: The Struggle of Moderate-Income Households to Afford the Rising Costs of Housing and Transportation. 2012. Center for Housing Policy and Center for Neighborhood Technology.
^[5] Ibid.
^[6] Joint Center for Housing Studies of Harvard University. 2012. State of the nation’s housing 2012. Cambridge, MA. Ch.6, p.32.
^[7] Housing and Health in Los Angeles County. Social Determinants of Health, Issue no.2. Los Angeles: Los Angeles County Department of Public Health; February 2015
^[8] Fletcher, Jason M., Tatiana Andreyeva, and Susan H. Busch. “Assessing the effect of changes in housing costs on food insecurity.” Journal of Children and Poverty 15.2. 2009: 79-93.
^[9] Pollack, Craig Evan, Beth Ann Griffin, and Julia Lynch. 2010. “Housing Affordability and Health Among Homeowners and Renters.” American Journal of Preventative Medicine 39 (6): 515–521.
^[10] Dixon, L. B., Winkleby, M. A. & Radimer, K. L. Dietary intakes and serum nutrients differ between adults from food-insufficient and food-sufficient families: Third National Health and Nutrition Examination Survey, 1988–1994. J. Nutr. 2001; 131:1232-1246.
^[11] Housing and Health in Los Angeles County. Social Determinants of Health, Issue no.2. Los Angeles: Los Angeles County Department of Public Health; February 2015
^[12] Cook, John T., and Deborah A. Frank. “Food Security, Poverty, and Human Development in the United States.”
^[13] Alaimo, K., Olson, C. M., & Frongillo, E. A. Family food insufficiency, but not low family income, is positively associated with dysthymia and suicide symptoms in adolescents. The Journal of nutrition. 2002; 132(4), 719-725.
^[14] Lee, J.S., and Frongillo, EA. Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. Journal of Nutrition. 2001; 131, 1503–1509.
^[15] Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med 2006; 21(1):71–7.
^[16] Housing and Health in Los Angeles County. Social Determinants of Health, Issue no.2. Los Angeles: Los Angeles County Department of Public Health; February 2015
^[17] Suglia, Shakira Franco, Cristiane S. Duarte, and Megan T. Sandel. “Housing quality, housing instability, and maternal mental health.” Journal of Urban Health 88.6. 2011; 1105-1116.
^[18] Jelleyman, T., and N. Spencer. “Residential Mobility in Childhood and Health Outcomes: A Systematic Review,” Journal of Epidemiology and Community Health. 2008; 62: 584–592.
^[19] Browning, Christopher R. and Kathleen A. Cagney. Moving Beyond Poverty: Neighborhood Structure, Social Processes, and Health. Journal of Health and Social Behavior. 2003; 44(4): 552-571.
^[20] Joint Center for Housing Studies of Harvard University, State of the nation’s housing 2012. 2012: Cambridge, MA.
^[21] Baker, M. G., McDonald, A., Zhang, J., & Howden-Chapman, P. Infectious diseases attributable to household crowding in New Zealand: A systematic review and burden of disease estimate. 2013; Vol. 1, No. 1.26, p. 33. Wellington: He Kainga Oranga/Housing and Health Research.
^[22] Lepore S, Evans GW, Schneider M. The dynamic role of social support in the link between chronic stress and psychological distress. J. Personal. Soc. Psychol. 1991; 61:899–909
^[23] Evans GW. “Child Development and the Physical Environment.” Annu Rev Psychol. 2006; 57: 423-51.
^[24] U.S. Centers for Disease Control and Prevention, National Center for Environmental Health. A Healthy Home for Everyone: The Guide for Families and Individuals, Available from https://www.cdc.gov/nceh/lead/publications/final_companion_piece.pdf
^[25] Reponen, Tiina, et al. “Family and home characteristics correlate with mold in homes.” Environmental research 124. 2013; 67-70.
^[26] U.S. Centers for Disease Control and Prevention, National Center for Environmental Health. A Healthy Home for Everyone: The Guide for Families and Individuals, Available from https://www.cdc.gov/nceh/lead/publications/final_companion_piece.pdf
^[27] Ibid.