Designing LIHTC Developments to Improve Health Outcomes

This post is the second in a series aimed at highlighting the benefits and unrealized potential of using the Low Income Housing Tax Credit program to boost economic opportunity and improve health outcomes for low-income Americans.

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Since its inception, the Low Income Housing Tax Credit (LIHTC) program has supported the development or preservation of 3 million affordable rental homes, the creation of 3.4 million jobs, and an estimated $323 billion of local income. Judging by the numbers, LIHTC has been a critical provider of affordable housing in a nation that faces serious shortages of affordable housing. However, LIHTC has also inhibited or simply failed to incentivize innovative design strategies that improve the long-term health outcomes of low-income residents and their communities.

A more health-centered design process in LIHTC developments could:

• Produce healthy homes that improve residents’ long-term health outcomes; and
• Support healthy aging, allowing low-income older adults to age safely in their homes and communities.

As we review below, qualified allocation plans or QAPs are a critically important tool in addressing both aims.

Healthy Homes

Research over the past decade has shown that there is a direct connection between the design of the built environment and a host of specific life and health outcomes. Because people typically spend much of their time at home, they are particularly vulnerable to hazards within and around them. For example, structural deficiencies, environmental hazards, pests, and unsafe designs can contribute to health problems such as infectious and chronic diseases, injuries, and poor childhood development.

In recent years, there has been an increased focus on designing, testing, and evaluating interventions to ensure that affordable homes are both safe and healthy. In fact, building on this wealth of new evidence, BPC recommended in HUD-HHS Partnerships: A Prescription for Better Health that HUD and HHS work together to tackle two specific home hazards?lead exposure and asthma triggers. Reducing these hazards requires the wide-spread dissemination of tested interventions and home design features into affordable housing units.

Addressing asthma triggers is a perfect example of the potential upside of healthier homes. Six million children, or 8.4 percent of kids in the United States, live with asthma, making it one of the most common chronic childhood diseases and a leading cause of school absenteeism. Environmental triggers for asthma flares include allergens such as dust mites, mold, and cleaning chemicals. Each year over 11.5 million Americans suffer an asthma exacerbation, 1.6 million visit the emergency department, and 439,000 are hospitalized. As such, the United States is estimated to collectively spend upwards of $63 billion per year on asthma.

Home-based asthma interventions are cost-effective, yielding significant returns for every dollar invested. Potential interventions and design specifications can be as simple as using hard surface flooring, such as linoleum for kitchens and cork flooring for bedrooms; and preventing the use of foam plastic insulation.

As another example, an “active design” approach that incorporates the health and well-being of residents into the design of affordable homes has demonstrated that health problems such as obesity can be addressed through innovative home design. Prospect Plaza in Brooklyn, New York, is one such example, a development that includes:

• On-site and easily accessible outdoor exercise areas and recreation courtyards that encourage physical activity among residents;
• Inviting stairs for daily physical activity that can improve cardiovascular health; and
• Bike parking facilities that encourage residents to use bicycles for travel and leisure.

Building affordable homes that support the health of residents can alleviate inequities in health across different segments of the population and generate healthcare cost savings. As the largest federal program to finance and preserve affordable rental homes, LIHTC is an important point of departure to supporting healthy homes. Moreover, more than 40 percent of the occupants of LIHTC units earn 30 percent or less of area median income, a threshold referred to as “extremely low-income households.” These families have few financial resources, are disproportionately at risk of environmentally triggered illnesses, and also typically least able to remedy health issues that result from unhealthy and unsafe housing conditions.

Healthy Aging

With American’s aging population, there is a distinct need to incorporate the needs of older Americans in the designs of affordable housing, a topic highlighted extensively in BPC’s Healthy Aging Begins at Home and HUD-HHS Partnerships: A Prescription for Better Health. HUD estimates that 25 percent of LIHTC properties house at least one older adult resident, a number projected to increase. Older renters, especially low-income renters, often have physical disabilities or otherwise struggle with common activities of daily living (ADLs) such as bathing, dressing, and grooming.

Accessible housing becomes increasingly important for older adults as their functional limitations increase. However, one study found that the United States has an insufficient number of the accessible units that are needed to serve the growing number of those with physical challenges. In 2016, 17 percent of households age 50 and over included someone who had difficulty climbing stairs or walking. However, only 3.5 percent of homes had the three key features for those with mobility challenges: single-floor living, no-step entries, and extra-wide halls and doors. Moreover, by 2030, the number of renter households headed by someone age 65 or older is slated to increase by 6 million, further exacerbating this problem.

Modifying homes to help prevent older adult falls is perhaps the most obvious and pressing need when it comes to supporting healthy aging. One in four older adults falls every year. Falls are both common and costly, resulting in annual medical costs of $50 billion. The good news is that falls are often preventable with certain key home modifications, often called universal design features, such as:

• No-step entries;
• Single floor living;
• Switches and outlets accessible at any height;
• Extra-wide hallways; and
• Doors to accommodate walkers and wheelchairs.

There is a clear economic case to make that directing additional resources toward home assessments, modifications, and repairs for older adults would improve health outcomes while also reducing health care costs.

Using Qualified Allocation Plans (QAPs)

There is clear and growing need to embed health considerations in the regulatory framework governing affordable housing. LIHTC presents such an opportunity through its QAP process, as states can determine the specific selection criteria on which affordable housing proposals are evaluated. QAP criteria can incorporate elements that promote healthy living, such as active design and universal design features. As competition for tax credits is often tight, developers would be incentivized to propose housing that promotes health at all ages.

QAPs can also be used to impose certain requirements. For example, deteriorating paint in older homes is the primary source of lead exposure for children. Lead poisoning irreversibly affects brain and nervous system development, resulting in lower intelligence and reading disabilities. In 2016, HUD identified 57,000 federally assisted housing units with lead hazards. The risk of lead poisoning falls disproportionately on minority children, with black children being three times more likely than white children to have elevated blood-lead levels. A study of 52 states found that only 4 states’ QAPs explicitly require lead-based paint hazards to be eliminated or controlled in housing units being rehabilitated under LIHTC. An expansion of this requirement across more states’ QAPs could help to eliminate lead-based exposure in more affordable housing units.

Conclusion

Taking a health-centered approach to the design of affordable housing units presents immense potential benefits of improving the health of our communities. LIHTC, the nation’s largest affordable housing provider, therefore offers an opportunity to retool the investment decision framework to work for long-term societal health benefits.