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Two Simple Changes to Improve Health Outcomes In the Section 8 Voucher Program (April 2011)

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1Patterns of government-supported racial and economic segregation are a key cause of minority health disparities. Leading public health scholars recognize that neighborhoods play a crucial role in determining health outcomes:

The rapidly growing evidence on neighborhood effects finds that after taking into account individual-level factors, disadvantaged neighborhood environments (for example, poverty concentration) are associated with detrimental health outcomes, negative health behavior, developmental delays, teen parenthood, and academic failure. And although neighborhood conditions may influence health outcomes in all age groups, exposure to neighborhood disadvantage during childhood may be particularly harmful, as the effects of this exposure may continue into adolescence and adulthood.2

Given the mounting evidence on the impact of neighborhoods on health, it is unfortunate that HUD regulations do not do more to address the health of residents. This omission is particularly surprising in the Section 8 Housing Choice Voucher Program since a broad concern about public health and the health of low-income families was an impetus and justification by Congress for its original support of the program. In the Housing and Community Development Act of 1974, which authorized the Section 8 program, Congress declared one of the objectives of the bill to be “the elimination of conditions which are detrimental to health, safety, and public welfare.”3 Congress further clarified that it considered more than the unit to be significant in these efforts, declaring an intent to help provide “a decent home and a suitable living environment for all persons.”4

Two key ways that HUD could strengthen its commitment to healthy housing are through its Section 8 Management Assessment Program (SEMAP) and its Housing Quality Standards (HQS).

SECTION 8 MANAGEMENT ASSESSMENT PROGRAM

The Section 8 Housing Choice Voucher Program is the nation’s largest federal housing program. According to HUD, “The goal of the housing choice voucher program is to provide affordable ‘decent, safe and sanitary’ housing to low-income families.”5 SEMAP is a system by which HUD measures Public Housing Agency (PHA) performance in certain identified Section 8 program areas and assigns performance ratings.6 PHAs also can use the SEMAP performance analysis to assess and improve their own program operations.7 SEMAP provides 14 indicators that are designed to assess whether PHAs are assisting “eligible families to afford decent, safe, and sanitary housing at the correct subsidy cost.”8 None of these SEMAP performance indicators directly relate to health:

SEMAP INDICATORS9

  1. Proper selection of applicants from the housing choice voucher waiting list
  2. Sound determination of reasonable rent for each unit leased
  3. Establishment of payment standards within the required range of the HUD fairmarket rent
  4. Accurate verification of family income
  5. Timely annual reexaminations of family income
  6. Correct calculation of the tenant share of the rent and the housing assistancepayment
  7. Maintenance of a current schedule of allowances for tenant utility costs
  8. Ensure units comply with the housing quality standards before families enter intoleases and PHAs enter into housing assistance contracts
  9. Timely annual housing quality inspections
  10. Performing of quality control inspections to ensure housing quality
  11. Ensure that landlords and tenants promptly correct housing quality deficiencies
  12. Ensure that all available housing choice vouchers are used
  13. Expand housing choice outside areas of poverty or minority concentration
  14. Enroll families in the family self-sufficiency (FSS) program as required and helpFSS families achieve increases in employment income.

To the extent that Housing Quality Standards (discussed below) protect the health of residents, SEMAP helps protect the health of residents through SEMAP’s indicators requiring HQS inspections. However, adding additional health-related SEMAP factors would be an important step towards achieving HUD’s mandate to ensure healthy housing for its residents.

SEMAP could incentivize healthy housing by revising the criteria for the deconcentration bonus. Currently, SEMAP’s “deconcentration bonus,” 24 CFR § 985.3(h), is determined by neighborhood poverty rate, which does not necessarily provide the best indicator of the healthiness of the neighborhood. One possible way to address this issue would be to use a broader list of factors related to neighborhood health, such as the opportunity measures delineated by the Kirwan Institute: the availability of sustainable employment, high performing schools, a safe environment, access to high quality health care, adequate transportation, quality child care, safe neighborhoods, and institutions that facilitate civic and political engagement.10 Like the current deconcentration bonus, additional points would be given to PHAs that place families in healthy neighborhoods. A more direct approach would be a separate neighborhood indicator highlighting childhood health outcomes, wherein PHAs need to demonstrate health-promoting efforts. Professor Dolores Acevedo-Garcia of Northeastern University unveiled a prototype of such an index at an October 2010 White House Conference on rental housing.

HOUSING QUALITY STANDARDS

HQS, found at 24 CFR 982.401, are the program regulations that HUD has created in order to define both “standard housing” and the criteria “necessary for the health and safety of program participants.”5 HUD requires that units funded through Section 8 meet these standards in order for participating tenants to reside within them. Local public housing agencies conduct initial and annual inspections to ensure compliance with all of the HQS. These local authorities can supplement HUD’s guidelines with more stringent regulations; however, HUD discourages PHAs from being too forceful in the application of higher standards, even when local laws or codes include higher requirements. HUD’s concern is that higher HQS standards could make voucher-assisted units face a higher standard than those in the unassisted market, resulting in restricted housing choice for voucher holders.11 While it is important that voucher holders have sufficient housing options, housing that detrimentally affects residents’ health is in no one’s best interest.

HQS inspections include a number of categories, most of which relate to the physical unit itself. One other category relates to the safety of the building site and the surrounding neighborhood. The HQS standards address health in several ways:

Housing Quality in the Unit

HQS offer the only requisite health checks before a unit is deemed acceptable for voucher holders to rent, however, they are minimal compared to many other healthy housing guidelines available. The requirements, while protecting residents’ health in the sense that they ensure a “decent” unit, deal only with the most rudimentary aspects of housing unit healthfulness. For example, HQS provide guidelines requiring the existence of operative sanitary facilities, available hot and cold water, functional and intact windows, available electrical outlets, and locks on exterior doors. A sample HQS checklist is provided as Appendix A.

By comparison, there are a multitude of housing guidelines that far surpass HQS in terms of health analysis, and which by now are widely accepted by environmental health professionals. HQS could benefit from the inclusion of many of these criteria.

> For example, HUD and Centers for Disease Control and Prevention (CDC) have developed a “Healthy Housing Reference Manual” that seeks to address HUD’s health mandate but does not yet apply to HQS:

The principal function of a house is to provide protection from the elements. Our present society, however, requires that a home provide not only shelter, but also privacy, safety, and reasonable protection of our physical and mental health. A living facility that fails to offer these essentials through adequately designed and properly maintained interiors and exteriors cannot be termed “healthful housing.12

The Manual delves into a large number of specific health threats and solutions, such as alternatives to chemical control measures for dealing with pests; remediation of radon, asbestos and arsenic; and addressing indoor air quality through remediation of allergens, mold, and volatile organic compounds from paints and varnishes. This could be an excellent source of materials to apply to the HQS.

> Another valuable resource, the Asthma Regional Council of New England, offers well- respected advice for creating asthma-free homes, including guidance on avoiding toxic products, mold reduction, and other household issues with the goal of keeping the unit dry and clean, well ventilated, and pest free. Examples include preventing negative air flow that can draw contaminants like radon into homes, by sealing forced air ductwork on the return side; and safe pest-reduction suggestions like sealing utility openings with non- corrosive materials.14 The NCHH criteria strive to make certain that the unit is dry, safe, contaminant-free, pest-free, and maintained. The NCHH’s guidelines include specifications for health such as, ventilating all the unit’s living spaces by providing 15 cubic feet per minute of fresh air, per occupant, either via the HVAC system or through natural ventilation; ensuring safe water temperatures of no more than 120 degrees Fahrenheit; and installing carbon monoxide detectors in units with combustion appliances or attached garages, and accessible housing for seniors and people with mobility impairments.15

> EPA’s new “lead safe work practices” rule (effective April 2010) requires nearly all landlords to use lead safe work practices if conducting any activity that will disturb lead paint.16 Unfortunately, HUD’s Housing Choice Voucher regulations do not yet reference the EPA rule.17 Given that vouchers are often used in older housing at the highest risk of containing lead-based paint hazards, it is incumbent upon HUD to assure that PHAs take steps to make sure that landlords are aware of, and will comply with, the EPA requirements. Special initiatives should be adopted for units that are known to be located in areas of high risk as determined by local health or code enforcement officials.18

Site and Neighborhood Quality

HQS requires that “the site and neighborhood must be reasonably free from disturbing noises and reverberations or other dangers to the health, safety, and general welfare of the occupants.”19 In its guidebook, HUD clarifies that this means that “the site and neighborhood may not be subject to serious adverse natural or manmade environmental conditions, such as dangerous walks or steps, instability, flooding, poor drainage, septic tank back-ups or sewer hazards, mudslides, abnormal air pollution, smoke or dust, excessive noise, vibration, or vehicular traffic, excessive accumulations of trash, vermin, or rodent infestation, or fire hazards.”20

 

However, HUD stresses in its guidebook that “PHAs should be careful not to restrict housing choice in deciding acceptability. Failing a unit because the neighborhood is considered “bad” is not appropriate. Take into account whether private unassisted residents are living in the same neighborhood.”21

HUD’s guidance ignores much of the recent evidence on neighborhood health effects and leaves out several important factors likely to deeply impact the health and safety of residents, such as violence rates in the area, availability of parks, grocery stores, and safe pedestrian routes.

The Kirwan Institute’s opportunity model, discussed above, and Professor Acevedo- Garcia’s neighborhood health index both provide useful directions for further elaboration of neighborhood health standards under SEMAP. The Urban Institute’s National Neighborhood Indicators Partnership offers another potential model for considering the healthfulness of neighborhoods. A 2003 Partnership study measured the strength of relationships between various indicators of the quality of a neighborhood and health outcomes, which provides compelling information about how to achieve the greatest health benefits through neighborhood choice. In particular, the study found associations between neighborhood health outcomes and the age of housing, crime rate, number of people per unit, home value, vacancy rate, and mobility rate.22 Each of these indicators is readily available for use through U.S. Census data.23

Both in the assessment of the individual housing unit and in the analysis of neighborhood health factors, HQS could be a far more dynamic tool to ensure that residents’ health is not negatively impacted by where they live. HUD should consider revising its regulations and handbook to encourage a more expansive use of HQS to protect residents’ health. In the meantime, administrators of PHA voucher programs should pay closer attention to the health impacts of their HQS approvals, and not reflexively approve unit and neighborhood placements for families (especially families with children) that will foreseeably put them in harm’s way.

Balancing unit and neighborhood health factors

HUD should encourage a commonsense application of HQS standards to promote overall family health. Too-stringent application of unit-based standards to deny a family a chance to live in a healthier community or allow a child to attend a higher performing school do not further the goals of the HQS system. Likewise, the overall lack of accessible units for low-income persons with mobility impairments24 suggests that PHAs should show some discretion, as a “reasonable accommodation” in their application of the HQS, rather than deny a family accessible housing.

CONCLUSION

Through SEMAP and HQS, HUD provides valuable standards for PHA performance, but both of these regulatory structures are missing key opportunities to achieve the goals of Section 8 authorizing legislation to provide “decent, safe, and sanitary” housing for residents. HUD’s new Health Council has as its mission to bring health into the foreground of discussions about housing at HUD, and updating HUD voucher regulations to promote healthier outcomes would be a valuable extension of the council’s work. In addition, HUD is one of 17 agencies actively participating in the National Prevention, Health Promotion, and Public Health Council, which is an interagency effort led by the Surgeon General.25By expanding its collaboration with other agencies (particularly the EPA and HHS), and exploring new models for improving the health of homes and neighborhoods, HUD can live up to its mandate for health.

  1. Policy Associate, PRRAC. We are grateful for the comments of Michael Hanley, Empire Justice Center, on an earlier draft of this paper.
  2. Dolores Acevedo-Garcia, Theresa L. Osypuk, Nancy McArdle & David R. Williams, Toward A Policy-Relevant Analysis Of Geographic And Racial/Ethnic Disparities In Child Health, 27 HEALTH AFFAIRS 321, 323 (2008).
  3. 42 U.S.C. § 5301(b) (2).
  4. Id. at (b) (3).
  5. U.S. Dep’t of Hous. & Urban Dev., Housing Choice Voucher Guidebook, 10.1 (April 2001).
  6. U.S. Dep’t of Hous. & Urban Dev., SEMAP Fact Sheet, (April 25, 2002), available at http://www.hud.gov/offices/pih/programs/hcv/semap/semap.cfm.
  7. Id.
  8. U.S. Dep’t of Hous. & Urban Dev., Housing Choice Voucher Guidebook, 1.10 (April 2001).
  9. U.S. Dep’t of Hous. & Urban Dev., SEMAP Fact Sheet, (April 25, 2002), available at http://www.hud.gov/offices/pih/programs/hcv/semap/semap.cfm. Figure 1 from the Fact Sheet is reproduced here.
  10. Kirwan Institute, “Opportunity Mapping Methodology,” http://kirwaninstitute.org/research/gismapping/opportunity-mapping/methodology.php.
  11. Id. at 10.2.
  12. Ctrs. for Disease Control & Prev. and U.S. Dep’t of Hous. & Urban Dev., Healthy Housing Reference Manual, 6-1 (2006), available at http://www.cdc.gov/nceh/publications/books/housing/housing.htm.
  14. Asthma Regional Council of New England, Guidance for Healthy Homes, (2006).

    > The National Center for Healthy Housing (NCHH) also provides healthy housing guidelines, developed by a group of national experts under a cooperative agreement from the CDC for use in a nationwide training and education program.13National Center for Healthy Housing, Comparing Green Building Guidelines and Healthy Homes Principles: A Preliminary Investigation (April 2006), http://www.nchh.org/Portals/0/Contents/Green_Analysis.pdf.

  15. National Center for Healthy Housing, How Healthy Are National Green Building Programs? (September 2008), http://www.nchh.org/LinkClick.aspx?fileticket=zgK1gmAXbeg%3d&tabid=244.
  16. 73 Fed. Reg. 21692 (April 22, 2008). Information regarding the EPA the “Renovation, Repair and Painting” (RRP) rule is set out at http://www.epa.gov/lead/pubs/renovation.htm.
  17. Lead poisoning prevention rules for HUD’s “Tenant-Based Rental Assistance” programs are set out at 24 CFR Subpart M and apply to the Section 8 voucher program, the HOME program, the Shelter Plus Care program, the Housing Opportunities for Persons With AIDS (HOPWA) program, and the Indian Housing Block Grant program. The question of whether to regulations implementing the federal Residential Lead-Based Paint Hazard Reduction Act of 1992 should be extended to include these programs was controversial and is discussed at 64 FR 50216 (Sept. 15, 1999) at 50146, and 50176-77. (http://www.gpo.gov/fdsys/pkg/FR-1999-09-15/pdf/99-23016.pdf)
  18. The recent increase in numbers of foreclosures has also created a significant gap in the effectiveness of the lead-paint hazard disclosure requirements which were included in Section 1018 of the federal Residential Lead-Based Paint Hazard Reduction Act of 1992. Title X of the HCDA of 1992, Sections 1012- 13, 42 USC §4822 (specific requirements applicable to HUD programs). The regulations promulgated under section 1018 exempts properties in which title was obtained through foreclosure from its requirement that known lead-paint hazards be disclosed to renters or purchasers. Given the disproportionate (and increasing) number of foreclosed properties in neighborhoods with high concentrations of Section 8 vouchers, this exemption now threatens the effectiveness of the disclosure rule. With respect to voucher units, HUD can address this issue by using its existing HQS authority to require participating landlords to determine whether properties they have acquired through foreclosure have a history of recorded lead hazards and if so, to require owners to assure that the property is currently lead-safe. HUD should also consider reevaluating whether exempting foreclosures from the disclosure rule makes sense.
  19. 24 CFR 982.401(l)(1).
  20. 24 CFR 982.401(l)(2).
  21. U.S. Dep’t of Hous. & Urban Dev., Housing Choice Voucher Guidebook, 10.13 (April 2001).
  22. Kathryn Pettit et al., Neighborhoods and Health: Building Evidence for Local Policy, (U.S. Department of Health and Human Services, 2003), available at http://aspe.hhs.gov/hsp/neighborhoods-health03.
  23. All of these indicators, with the exception of crime rates, are available as part of the U.S. Census Bureau’s American Community Survey (ACS), providing yearly data on American demographics. Crime data is available as part of the National Crime Victimization Survey, conducted twice yearly by the U.S. Census Bureau on behalf of the Bureau of Justice Statistics. See Census Bur., Comparing 2009 American Community Survey Data,  National Archive of Criminal Justice Data, National Crime Victimization Survey Resource Guide, http://www.icpsr.umich.edu/icpsrweb/NACJD/NCVS/.
  24. See U.S. Dep’t of Hous. & Urban Dev., Worst Case Housing Needs 2009: Report to Congress (February 2011), http://www.huduser.org/Publications/pdf/worstcase_HsgNeeds09.pdf.
  25. See Healthcare.gov, National Prevention, Health Promotion and Public Health Council (National Prevention Council), www.healthcare.gov/center/councils/nphpphc/index.html.