More and more families across Massachusetts and the nation are struggling to keep a roof over their heads. Many pay more than half their income in rent, crowd into apartments that are too small, double up with other families, or forego health care and other basic needs in order to pay the rent. For some, the struggle is too great and they fall behind, suffering what we now understand are serious consequences to their health. New research by Children’s HealthWatch shows that being behind on rent or mortgage correlates strongly with negative health outcomes for mothers and children. Children in families that have been behind on rent within the last year are more likely to be in poor health and have an increased risk of developmental delays than children whose families are stably housed. The mothers in these families also have a much higher likelihood of experiencing symptoms of depression and being in poor health than mothers living in stable housing. The high levels of depressive symptoms and poor health experienced by these women approach those of mothers living in homeless shelters.

The data are clear. Being behind on rent or mortgage is not only a risk factor for homelessness but a risk factor for seriously compromised maternal and child health. Short- and long-term interventions that help stabilize families in housing they can afford will reduce the numbers of families in homeless shelters and improve the health of mothers and very young children.

Key Terms and Definitions

• Household Food Insecurity is limited or uncertain access to enough nutritious food for all household members to lead an active and healthy life due to economic constraints. Food insecurity increases the likelihood that children will be hospitalized, have developmental delays, iron-deficiency anemia and/or fair or poor health.
• Energy Insecurity occurs when there is limited or uncertain access to home heating or electricity. Energy insecure families have heated with a cooking stove (a known risk for fires), gone without heat within the last year, been served a utility shut-off notice, or had their utility services terminated within the last year.
• Child Food Insecurity occurs when children experience reductions in quality and/or quantity of meals because their caregivers can no longer buffer them from the household’s inadequate food resources. 

Background

Millions of Americans are working hard to pay rents that present a crushing burden to their budgets. Over 5.6 million of the nation’s lowest-income households are paying more than 50 percent of their income for rent, a staggering 45 percent increase since 2003, when just under four million families faced rent burdens this high. With one of the nation’s most expensive housing markets, Massachusetts faces a particular challenge. The Special Commission to End Family Homelessness in the Commonwealth noted in 2007 that 30,000 Massachusetts families were at risk of becoming homeless and as many as 650,000 were “shelter poor” meaning their incomes could not adequately cover housing costs and other basic household expenses. Nationally, the problems of an already inadequate supply of affordable housing have been exacerbated by a decline in the number of households receiving federal rent assistance, an increase in rents as a result of the foreclosure crisis, and an economy that has left a record number of people out of work or with significantly reduced work hours.

There is extensive clinical research on the negative effects of homelessness on the health of parents and children. Homeless children are less likely to have been immunized and more likely to be in poor health and at risk of developmental delays, while school age children who are homeless are more likely to have behavioral and academic problems as well as higher rates of asthma and infectious disease. There has been little research, however, on the health impacts for children and adults of living in families that are behind on rent. The struggles these families face are rarely known outside of the family until it becomes an issue of eviction. 

Research Results

To understand how the health of children and mothers is affected by a family’s struggle to consistently pay the rent, we compared the health status of families in stable housing with those that were either behind on rent sometime in the past twelve months or currently living in a homeless shelter.

We looked at two questions:

1. How are the health and well-being of young children and mothers in families that are behind on rent different from those living in stable housing?
2. How are they different from those living in homeless shelters?

How are the health and well-being of young children and mothers in families that are behind on rent different from those living in stable housing?

We found that households that are behind on rent more frequently:

• Experience food and/or energy insecurity
• Receive assistance through the Supplemental Nutrition Assistance Program (SNAP — formerly food stamps) and the Low Income Home Energy Assistance Program (LIHEAP)
• Make trade-offs among household expenses, such as rent and utilities, in order to pay medical bills
• Include parents who have foregone health care for themselves or another family member in order to pay basic household expenses
• Include a mother who has symptoms of depression

We also found that children in these families are more likely:

• To be in fair or poor health
• To be child food insecure
• To be at risk of delays in their social, emotional, motor or cognitive development
• To be significantly below average in length or height (an indication of under-nutrition)

In short, the data tell a story of families that are struggling not only to pay the rent but to pay for food, utilities and medical bills. While they are more likely to receive assistance through SNAP and LIHEAP, neither of these sources of support has been sufficient to keep them stably housed or food and energy secure. Mothers in these families are also more likely to experience depression and poor health, both of which are significant risk factors for poor child health and development.

How are the health and well-being of young children and mothers in families that are behind on rent different from families living in a homeless shelter?

When we compare mothers in families that are behind on rent with mothers in shelter, we see that they:

• More frequently report having made trade-offs among household expenses in order to pay medical bills
• More frequently report having foregone health care for themselves or another family member in order to pay basic household expenses
• Are almost equally likely to be in poor health
• Are only slightly less likely to experience symptoms of depression

We also know from the data that households that were behind on rent had an average of 1.2 adults in the household who were employed, and that 34 percent included a mother or other primary caregiver who had lost her job or had her work hours reduced in the last year. Together, these data paint a picture of working families making trade-offs in order to stay housed that are compromising the health of both the adults and children in the household.

Policy Implications

Until recently, Massachusetts has focused on meeting the needs of homeless families by funding the shelter system rather than expanding prevention and early intervention systems. The state allocated $114 million in FY’09, $152 million in FY’10 and $135 million in FY’11 for emergency assistance (i.e. the family shelter system). At the same time, funding for the Commonwealth’s program to prevent homelessness (Residential Assistance for Families in Transition or RAFT) declined from $5.5 million at the start of FY’09 to $260,000 in FY’11. Housing available to extremely low income families and individuals funded through the Massachusetts Rental Voucher Program (MRVP) also declined over the same time period.

For many families, especially those living in areas with high fair market rents, long-term subsidized housing is the only solution to intolerably high rent burdens. Meeting the housing needs of all the Commonwealth’s families, including those currently in shelter, will require an increase in Section 8 and MRVPs, as well as construction of units specifically designed to meet long-term needs of extremely low-income families. An increase in Section 8 vouchers would allow redirecting of state emergency assistance funds to support expansion of housing assistance programs. For families that can be stabilized with short-term, relatively low-cost assistance to regain stability, there need to be programs that can provide: up to 36 months rental assistance, including security deposits and other upfront costs; assistance with utility bills; landlord/tenant mediation services; and financial counseling.

Consistent with the recommendations of the Special Commission to End Family Homelessness in the Commonwealth, Massachusetts has begun to take steps toward a system for vulnerable families that emphasizes prevention, access to permanent housing and development of affordable housing. This shift in focus has been reinforced with resources through the federal government’s Homelessness Prevention and Rapid Re-Housing Program that has brought $44 million into the state for prevention and stabilization programs. In addition, some funding dedicated to Emergency Assistance has been redirected to provide housing support for families that would otherwise enter the shelter system.

These state and federal programs are well aligned to address the fact that being behind on rent is not only a risk factor for homelessness but a risk factor for poor health and well-being. Unfortunately, federal funding made available through the Homeless Prevention and Rapid Re-Housing Program is nearly exhausted, leaving some families again in precarious housing situations, and neither the state nor the federal government has indicated plans to fill this shortfall in homelessness prevention assistance.

Recommendations

As physicians and public health researchers we see the toll that struggling to pay rent takes on the health of families. We see the damaging impact that trade-offs around paying for basic household expenses have on the healthy growth and development of very young children. These data clearly show that families are struggling behind closed doors, forced to make trade-offs that are harmful to their health and costly to the Commonwealth. As a Commonwealth, it is incumbent upon us not only to keep families out of shelters whenever possible, but to take whatever steps we can to help families remain stably housed. To address the serious impacts on maternal and child health of being behind on rent, we must:

• Increase the supply of affordable housing, especially housing that is affordable to extremely low-income families (those below 30 percent of area median income)
• Replace funding provided through the Federal Homelessness Prevention and Rapid Re-Housing Program with increased funding for the State’s Residential Assistance for Families in Transition program
• Increase the number of available state and federal rental vouchers
• Increase funding for LIHEAP
• Implement effective programs that provide an array of services and support to families when they are struggling to pay the rent

We recognize that none of these solutions is without significant costs. However, the cost to our nation and the Commonwealth of children whose health and development are compromised must be part of the calculation. Being behind on rent is not simply an issue of economics. It is a condition that affects whether parents can provide the nurturing, food and health care they and their children need, and whether our youngest children are healthy and arrive at school ready to learn. We need to bring this problem out from behind closed doors and craft solutions that invest in the healthy development of our youngest citizens.