Federal rental assistance yields improvements in asthma-related ED visits

Children with asthma can find improvement outside the hospital walls, according to a new report, which associates fewer emergency department (ED) visits for children with asthma who are in federal housing assistance programs.

The report, published in JAMA Pediatrics, revealed that federal rental assistance programs may be linked to fewer ED visits for asthma attacks or diagnosis in children.¹

“Housing programs help children,” says Michel Boudreaux, PHD, assistant professor of Health Policy and Management at the University of Maryland School of Public Health in College Park and lead author the study. “Our study suggests that when children obtain rental assistance, they are less likely to turn to the ED to treat conditions that usually can be cared for in other settings.”

The study used data from the National Health Interview Survey, examining records from the US Department of Housing and Urban Development’s (HUD)rental assistance programs from 1999 to 2014. The records applied to nearly 3000 children aged to 17 years who had or would have received rental assistance within 2 years of the survey. The survey considered previous asthma diagnoses, as well as 12-month histories of asthma attacks or other asthma-related ED visits within that time frame.

The research team concluded that children who had been a part of a rental assistance program in the prior year had asthma-related ED use decrease by roughly 18 percentage points. These improvements occurred only after a rental assistance program was entered. Similar results were found in children whose families participated in public or multifamily housing programs, but not in housing choice voucher programs. Additionally, benefits only applied to asthma-related ED use, and not to the number of asthma attacks or diagnoses. The change in the number of asthma attacks was not statistically significant and the decrease in asthma diagnoses was minimal.

Although benefits to children with asthma applied only to ED usage rather than to their overall health condition, the report suggests that these observations could still have major implications when it comes to the well-being of low-income families and overall health care costs.

The study did not examine why there were differences in ED use in children with asthma based on their housing status, only that there were differences.

“Our study did not examine why housing assistance might affect asthma outcomes, it just examined if it did,” Boudreaux says. “However, we did try to rule some things out. For example, it does not appear that they work by improving access to primary care. However, more work needs to be done to understand the underlying mechanisms.”

As far as how the children in this study fared against the general public or children in different socioeconomic groups in terms of ED use, Boudreaux says they were only slightly more likely than low-income children in private homes to make asthma-related ED visits.

“For example, among children participating in a HUD program, 19.8% with an asthma diagnosis visited the ED in the previous 12 months to obtain treatment for asthma,” he says. “Comparatively, 17.2% of low-income children that never had contact with a HUD program visited the ED. However, among children that are waiting to enter HUD, the rate is 27.7%. That high rate underscores that families that come into HUD generally are facing a number of challenges, more than would be expected from their income alone.”

Why more research like this is needed

In an editorial, also published in JAMA Pediatrics, that accompanied the study, experts say this newest research adds to a growing body of evidence that supports the positive effect of housing assistance on the health and welfare of participants.² Poor housing quality has long been associated with asthma prevalence, according to the editorial, and this newest research highlights how housing instability can contribute to asthma-related outcomes as well. More research is needed to identify exactly how housing assistance could best be used to help medically complex children in low-income families.

Boudreaux says the health system needs to continually be assessing the impact that social issues have on care, and this study highlights that more than ever.

“I hope health care practitioners and families continue to think about the large array of social determinants that affect the well-being of children and keep coming up with creative solutions for helping children thrive,” Boudreaux says. “Our study speaks to a broader and more systemic problem. Housing policy in the United States is failing our children and our study illuminates one of the many consequences of that failure-when children are in an unstable and unaffordable housing environment they frequently need to use the ED for things that could be managed in the community.”

These HUD programs help to mitigate those problems, he adds, but there are still 2 housing policy problems that remain to be addressed.

 “We need to build more housing. That will make housing more affordable for everyone. Second, we need to spend more money on helping low-income families find high-quality, affordable housing that meets their needs,” he says. “All we need to do is spend more money on the programs we currently have and that would make a world of difference.”

Unlike Medicaid programs, HUD programs are not an entitlement, he adds.

“There are many families that are income eligible but unable to obtain support. We turn them away because we don't properly fund the programs we have,” he says. “Our study, and others like ours, demonstrate that this policy choice has consequences.”

References:

1. Boudreaux M, Fenelon A, Slopen N, Newman SJ. Association of childhood asthma with federal rental assistance. JAMA Pediatr. March 9, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2019.6242

2. Sandel MT, Bovell-Ammon A. Associations between federal rental housing assistance and childhood asthma-a renewed call for investing in housing for health. JAMA Pediatr. March 9, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2019.6272