COVID-19 Risk Factors Among HUD-Assisted Renters

COVID-19 Risk Factors Among HUD-Assisted Renters

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

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

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

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

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

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.

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.