Without Affordable, Accessible, and Adequate Housing, Health Has No Foundation

This Perspective argues that housing insecurity—encompassing unaffordability, inaccessibility, and inadequacy—is a major public health issue affecting households, neighborhoods, and cities. It outlines how each dimension contributes to health and health inequities, reviews policies that have shaped these disparities (historical and contemporary), and proposes roles for public health research to generate evidence that informs and advances policies to mitigate negative neighborhood impacts, housing disparities, and health inequities.

The paper synthesizes extensive evidence linking housing to health across three dimensions. Affordability: Nearly one-third of Americans spend 30% or more of income on housing; among renters, half spend over 30% and a quarter spend 50% or more. Cost burden is highest among very low-income households (e.g., 83.4% of renter and owner households earning under $20,000 pay over 30% of income to housing). Rising prices since the late-2000s foreclosure crisis, stagnant wages, inflation, and supply constraints have increased cost burdens. During COVID-19, housing prices rose about 20% (2020–2022); renters and mortgaged owners experienced greater mental distress and poorer self-rated health than owners without mortgage debt. The 2020–2021 CDC eviction moratorium, informed by public health evidence, temporarily reduced evictions, but filings rebounded in some cities after its expiration. Homelessness has risen in the context of rent increases and inflation; zoning practices (e.g., single-family zoning) have historically constrained supply and affordability. Access: Historical and ongoing policies have advantaged non-Hispanic White households and restricted opportunities for Black and Hispanic households, shaping residential segregation and environmental exposure. HOLC redlining maps deemed neighborhoods with higher shares of Black residents as "hazardous," restricting mortgage access and forcing reliance on costly land contracts; in mid-century Chicago, Black buyers paid on average hundreds more per month and lost billions in equity. The GI Bill’s implementation limited many Black veterans’ access to housing benefits. Research links historical redlining to present-day adverse health outcomes (e.g., preterm birth, cancer, asthma ED visits) and environmental risks (e.g., urban heat). While homeownership is associated with stability and some health benefits, the 2008 foreclosure crisis and predatory lending disproportionately harmed Black and Hispanic households, undermining wealth and neighborhood conditions, raising questions about uniform health benefits of ownership. The Fair Housing Act (1968) prohibits housing discrimination, yet subtle discrimination persists and is associated with poor health, elevated stress, and potential toxin exposure; disability-related complaints constitute the majority of recent fair housing complaints, highlighting gaps in research and enforcement. Adequacy: Substandard housing conditions are common and unequally distributed. In 2019, 11.3% of households reported cockroach sightings, 3.0% reported mold, and an estimated 30 million homes had serious health and safety hazards (e.g., gas leaks, structural problems). Poor ventilation and dampness contribute to asthma and allergies; overcrowding increases risks for communicable diseases (e.g., TB, COVID-19); pest infestations relate to allergies; poor maintenance increases injury risks. Historic lead paint hazards persist despite regulatory bans, with investor-owned rental properties linked to ongoing lead exposure risks. Code enforcement exists but can be punitive without paired financial support; existing repair programs often favor owners over renters and are insufficient against aging stock. Climate change exacerbates housing risks via urban heat islands (linked to hospitalizations and mortality) and more frequent disasters, with disproportionate displacement of Black communities (e.g., post-Katrina New Orleans) and climate-driven gentrification pressures (e.g., Miami’s Little Haiti). The literature underscores compounded risks for place-bound populations (seniors, children, low-income households, people with disabilities, and communities of color) and calls for cross-sector strategies to protect health through housing policy.

• Housing unaffordability is widespread and worsening: nearly one-third of Americans are cost-burdened (≥30% of income to housing); about 50% of renters spend >30%, and 25% spend ≥50% of income on housing.
• Cost burden is highly inequitable: approximately 83.4% of households earning < $20,000 spend >30% on housing, far exceeding higher-income households.
• Affordability gaps outpace wages: in 2021, the hourly wage needed to afford a 2-bedroom at fair-market rent was $24.90 nationally (vs. $7.25 federal minimum), and $39.03 in California, exceeding wages for many essential workers.
• COVID-19 intensified disparities: housing prices rose ~20% (2020–2022); renters and mortgaged owners reported greater mental distress and poorer self-rated health than owners without mortgages; eviction moratoria reduced evictions temporarily but filings rebounded post-expiration in some cities.
• Eviction and homelessness harm health: eviction correlates with increased health care utilization (e.g., hospital readmissions, ER visits), psychological distress, and instability; homelessness is associated with adverse mental and physical health outcomes.
• Access inequities stem from systemic policy: HOLC redlining and GI Bill implementation restricted Black homeownership, contributing to the racial wealth gap; Black homeownership (43.4%) lags far behind White (72.1%). Historical redlining is linked to present-day adverse health outcomes and environmental burdens (e.g., asthma ED visits, urban heat exposure).
• The foreclosure crisis disproportionately harmed Black and Hispanic families’ wealth (losses of 47.6% and 44.3% vs. 26.2% for Whites), undermining stability and potential health benefits of homeownership.
• Housing discrimination persists despite the Fair Housing Act, with measurable negative health effects (e.g., higher stress, potential toxin exposure) and large unmet needs in disability-related access and affordability.
• Substandard conditions are prevalent: about 14 million households reported cockroaches (11.3%); 3.6 million reported mold (3.0%); roughly 30 million homes have serious hazards. Poor conditions contribute to respiratory illness, communicable disease transmission, allergies, injuries, and lead exposure.
• Investor ownership and weak maintenance contribute to deteriorating conditions and ongoing hazards; code enforcement without financial support can penalize low-income tenants and small landlords.
• Climate change magnifies risks: urban heat islands increase hospitalization and mortality; disasters (e.g., Katrina) drive displacement and long-term loss, with climate gentrification threatening established communities.
• Policy pathways exist: expanding affordable supply (National Housing Trust Fund, public housing, zoning reform), rent supports (vouchers, LIHTC, rent stabilization, emergency rental assistance), equitable ownership (shared-equity, community land trusts), stronger FHA enforcement and anti-discrimination efforts, and housing/ building code enforcement paired with robust repair financing.

The synthesis demonstrates that the three intertwined facets of housing insecurity—affordability, access, and adequacy—jointly shape health outcomes and inequities. Cost burdens reduce resources for health-sustaining needs (food, medication); discriminatory access and historical disinvestment concentrate marginalized groups in under-resourced, environmentally burdened neighborhoods; inadequate conditions directly cause illness, injury, and toxic exposures. These mechanisms explain observed disparities in mental and physical health, health care utilization, and community stability. The findings highlight the necessity of integrating public health evidence into housing policy: emergency measures (e.g., eviction moratoria) can mitigate acute harms; long-term structural reforms (supply expansion, fair access, condition improvements, and climate resilience) are essential to protect health and reduce inequities. Public health agencies can partner with housing and planning departments to identify needs, monitor risks (including discrimination), evaluate policies, and prioritize protections for place-bound and vulnerable populations.

Housing’s treatment as a commodity undermines health and health equity by making it less affordable, accessible, and adequate. As cities become more economically exclusive, public health must prioritize housing disparities to prevent displacement and promote healthier, more vibrant, and equitable communities. Action is required to ensure no individual is displaced, communities remain whole, and cities thrive, through coordinated policies that expand and preserve affordable housing, enforce fair access, and ensure safe, climate-resilient homes.

This is a perspective and narrative synthesis without primary empirical methods, limiting causal inference. Some quantitative figures are drawn from secondary sources and may vary by locality and time. Important research gaps remain, including limited studies on housing discrimination against people with disabilities, longitudinal assessments of how housing moderates neighborhood effects on health, and comprehensive evaluations of enforcement mechanisms and landlord practices. Generalizability of cited studies may be constrained by geographic and temporal contexts.