Affordability of Housing That Supports Health and Independence for Vulnerable Older Adults and Individuals with Disabilities
The workshop’s first panel featured two presentations addressing the affordability of housing. Purvi Sevak, a senior researcher at Mathematica Policy Research and a professor of economics at Hunter College of the City University of New York, spoke about the ties between financial security and housing and the importance of infusing disability awareness into all housing policy discussions. Jen Molinsky, a senior research associate at the Joint Center for Housing Studies of Harvard University, then discussed the results of a new report from the Joint Center on the implications for housing based on the growing population of older adults. A discussion with the workshop audience followed the two presentations.
Senior Researcher, Mathematica Policy Research
Professor of Economics,
Hunter College of the City University of New York
Disability, said Purvi Sevak of Mathematica Policy Research and Hunter College of the City University of New York, is a function of both health and the environment. Disability is not a yes-or-no concept in that environmental factors, including housing, can affect functioning and thus
turn a health problem into a disability. Therefore, she said, it is important to keep disability in mind when making housing policy.
Some 10.5 percent of all adults ages 18 to 64—20 million nonelderly individuals in the United States—have disabilities, with the prevalence of disability higher among vulnerable populations. For example, Sevak said, 20 percent of individuals living in poverty have a disability, as do 27 percent of individuals living in public housing, 34 percent of individuals with subsidized rent, and 40 percent of homeless individuals (Hoffman and Livermore, 2012; Houtenville et al., 2015). Because disability is so prevalent in vulnerable populations, she said, any discussion about housing policies for these populations is not complete without a discussion of disability. Sevak also noted that in the context of the need for accessible housing, it is irrelevant whether disability leads to financial insecurity or whether financial insecurity increases the likelihood of developing health impairments that lead to disability. In either case, accessible housing is the focus, although the direction of the cause-and-effect relationship may be important to discussions about reducing the rates of disability and improving economic well-being.
There are many different types of disability, Sevak noted, so individuals with disabilities may have very different housing needs. Federal surveys, such as the American Community Survey,1 classify disability into six categories: hearing, vision, cognition, ambulation, self-care, and independent living (see Figure 3-1). Sevak said that in discussions about housing, the emphasis is usually on individuals who have an ambulatory disability, which is present in slightly more than 5 percent of the adult population ages 18 to 64 years. Concern is likely to focus on the ramps and bathrooms fixtures needed to make federal housing accessible for an individual with an ambulatory disability, but other types of disabilities require other types of accommodations. Making housing accessible to an individual with a cognitive disability, for instance, should begin with concern about the complexity of the application forms, Sevak said
Having a disability is associated with greater financial vulnerability, Sevak said. In 2015 the employment rate among individuals without disabilities was 75.4 percent versus 34.4 percent for those with a disability, even though the majority of individuals with disabilities report in surveys that they would like to work. Median earnings among individuals with disabilities who were working was $21,232 versus $31,324 for individuals who were working but did not have a disability. Median family income was $36,800 for the household of an adult with a disability versus $66,000 for households where the adults did not have a disability. The poverty
rate among those with disabilities was nearly double that of those without disabilities in 2015, and only 54.5 percent of those with disabilities lived in an owned home, compared with 61.7 percent of individuals without disabilities. Sevak noted that many individuals with disabilities collect benefits through either the Social Security Disability Insurance program or the Supplemental Security Income program. Once individuals with disabilities reach age 65, their income is less than one-third of the income of their peers who do not have a disability ($24,900 versus $75,900), which puts the financial security of those with disabilities at greater risk than that of their peers as they enter retirement. Furthermore, among adults ages 18 to 64 years who have incomes below the poverty level, those who have a disability are more likely to have material hardship (She and Livermore, 2007) (see Figure 3-2). These disparities persist in households with income above the poverty level as well, Sevak said.
Given these data, Sevak said, it should not be a surprise that disability
is also associated with disparities in housing. Data from the American Housing Survey have shown that 48 percent of people with disabilities, compared with 38 percent of those without disabilities, report housing deficiencies which include holes in the floor, rodents, leaks, toilet breakdowns, unsafe drinking water, cracks in the home’s foundation, and missing electrical outlets (Hoffman and Livermore, 2012). Similarly, she said, 76 percent of individuals with disabilities, compared with 66 percent of those without disabilities, report neighborhood problems such as crime, odors, noise, vandalism, and poor condition of neighborhood streets. These disparities persist, she added, even after controlling for demographics, income, region, and household size.
In concluding her presentation, Sevak offered two takeaway messages. The first was the importance of disability awareness in policy and practice, especially when one is focusing on vulnerable populations. Considering the needs of individuals with disabilities is paramount when making housing-related policies, she said. The second takeaway was that
individuals with disabilities are a heterogeneous group and thus have varied needs with respect to housing.
Senior Research Associate
Joint Center for Housing Studies of Harvard University
The U.S. population is aging rapidly, said Jen Molinsky of the Joint Center for Housing Studies of Harvard University, and by 2035 there will be 79 million people ages 65 and older, compared with 48 million in 2016. This demographic shift led her and her colleagues to conduct a study to understand how the soaring population of older adults will affect the nation’s housing needs over the next 20 years (Joint Center for Housing Studies, 2016). This study focused on three dimensions of housing that Molinsky said are critical for helping people remain independent and secure in their homes: accessibility, the home as a locus for long-term care, and affordability.
Projections of the Older Population and Households
Households headed by individuals age 65 and older are projected to grow from 30 million in 2016 to 41 million in 2025 and to nearly 50 million by 2035, at which point they will account for one-third of households in the United States. Households headed by someone of age 80 and older will double from 8 million in 2016 to 16 million in 2035, with much of the growth occurring between 2025 and 2035 when the leading edge of the baby boomers is in their 80s. The oldest households, Molinsky said, will drive growth in the number of single-person households over the next two decades.
Most households headed by an older adult own their homes, with more than 80 percent of Americans age 65 and older owning their home, compared with 64 percent for all U.S. households. The level of home ownership declines slightly as people enter their late 70s and early 80s and become renters, often in order to live in a home with lower maintenance demands and greater accessibility. “But looking ahead,” Molinsky said, “we generally expect a high continued rate of ownership for this group.” However, these projections are clouded somewhat by the uncertain long-term effects of the Great Recession, which saw individuals in their pre-retirement years experiencing a 5 percent decline in homeownership and a greater loss of wealth than adults who were age 65 and older. Among
the latter, home ownership fell by only 1 percent during the Great Recession. As a result, Molinsky said, in 20 years ownership could be lower than she and her colleagues have projected.
Some older adults neither own their home nor rent, but rather live with relatives or in group quarters such as a nursing home, Molinsky said. Approximately 11 percent of adults ages 65 to 79 live in these types of arrangements, with more than half living with family, typically their children. For those 80 and older, 23 percent live in these arrangements, with nearly 12 percent living with family. In the future, the number of older adults living with family members could rise, given that living with family is more common among Hispanic and Asian households, which are demographic groups that are increasing as a percentage of the U.S. population. Currently, some 8 percent of the U.S. population ages 65 and older is Hispanic, and that is projected to rise to 13 percent by 2035, Molinsky said, while the population of older Asian adults is estimated to grow from 5 percent to 7 percent. The possibility of there being more multigenerational families in the future has some implications for such housing features as size, flexibility, and layout.
The demand for group quarters is hard to predict given that the trend over the past 20 years has shown a distinct move away from living in nursing homes even as the population over age 50 has increased, Molinsky said. The increasing availability of home-based, long-term care might continue to drive down nursing home use. However, because the population of older Americans continues to grow, the number of people living in nursing homes may still grow even if that number decreases as a percentage of the older adult population.
Estimations of Housing Accessibility
To understand how the predicted increasing prevalence of disability in the population will affect housing specifically, Molinsky and her colleagues divided disability into three categories: mobility disability; disability that affects self-care, which includes activities of daily living such as eating, bathing, dressing, and toileting; and disability that affects household activities, which includes instrumental activities of daily living such as meal preparation, food shopping, using the telephone, taking medication, driving, managing money, and housework. Their analysis found that the number of people in these three categories rises distinctly when people reach their late seventies, and that this rise occurs regardless of race, ethnicity, housing tenure, or income. “No one is immune,” Molinsky said. One finding of note, she added, was that the difference in disability rates by tenure and income converge with age, while disparities by race persist (see Figure 3-3).
Projecting disabilities was challenging, Molinsky said, because of the heterogeneity in disabilities. She and her colleagues examined the literature on obesity, diabetes, arthritis, dementia, and overall trends in morbidity and longevity to get a sense of whether older adults in the future will be more or less likely to have disabilities. “In the end,” she said, “we found that despite some recent gains in disability-free years, the trends in obesity and diabetes convinced us that there really was not much reason to decrease that rate so we held it constant for each age, race, and household type.” The results of this analysis predict that by 2035 there will be 31 million households that are headed by someone age 65 or older and that have at least one individual with a disability. Broken down by disability, there will be 17 million households with a mobility disability, 12 million households with a disability that limits self-care, and 27 million households with a disability related to household activity (see Figure 3-4).
Despite the growing demand for accessible housing, the nation’s stock of accessible housing is small, Molinsky said. She and her colleagues evaluated whether different classes of housing—single-family detached, single-family attached, small multifamily with fewer than five units, midsize multifamily with 5 to 49 units, large multifamily with 50 or more units, and mobile homes—had the accessibility features of single-floor living, no-step entrances, and extra wide hallways and doors. They found
that only 4 percent of the nation’s housing—public and private, although not including group quarters such as nursing homes and dormitories—has all three of these features (see Figure 3-5). Units in large multifamily buildings are most likely to have accessible features—in large part, she said, because they tend to be newer construction.
Projections on Housing Affordability
Median income falls with increasing age for every demographic group after the mid 50s, which helps to explain why households headed by older adults are more likely to experience challenges with housing affordability, Molinsky said. People are said to experience a housing cost burden when they pay 30 percent or more of their gross household income on housing costs, including utilities, and a severe housing cost burden when housing costs, including utilities, account for more than half of the gross household income. For adults ages 65 and older, affordability depends strongly on tenure. For example, housing costs are burdensome for 17 percent of older adults who have paid off their mortgage, compared with 45 percent of owners who still have a mortgage when they retire and 55 percent of renters.
One repercussion of having unaffordable housing is that individuals will spend less on other necessities, Molinsky said. For example, lower-income older adults who are burdened by housing costs spend 67 percent less on transportation, 51 percent less on health care, and 37 percent less on food than lower-income adults who have affordable housing. In the future, she added, the number of individuals who face housing cost burdens will increase simply because of the expansion of the older population. “By 2035, we expect that nearly 11 million homeowners will face housing cost burdens, as will over 6 million renters,” she said. “The number of the severely burdened is particularly alarming, projected to reach nearly 9 million among both of those groups by 2035.” These projections, she explained, assume that today’s income distributions will hold constant, but there are factors that could change those distributions, including trends in mortgage debt, income, and assets. One concerning trend, Molinsky said, is the rising share of older adults who enter retirement with mortgage debt, a rate that has been rising for the past 20 years. The median amount of mortgage debt at retirement has also been rising.
Household Income, Wealth, and Long-Term Care
Molinsky cited both hopeful and worrisome trends in household incomes for older adults. She said that more women are earning their own Social Security benefits and that both men and women are working beyond age 65. A caveat to this latter point, however, is that those who are working past age 65 tend to have higher incomes and less physically demanding jobs; low-income individuals are not necessarily working longer. One worrisome trend is that fewer people have traditional pension plans now than in the past, and the future of Social Security benefits is not certain. The Social Security Administration projects that there will be
a decrease in the percentage of older adults who will be able to maintain their pre-retirement lifestyle into retirement, from 43 percent of older adults today down to 39 percent in the future.
Accumulated wealth can compensate for falling incomes, but wealth is not distributed equally across the population, Molinsky noted. For example, the median level of wealth among homeowners (when wealth includes the value of the home) is 42 times greater than the median level of wealth among renters. Even if home equity is excluded, the median home owner still has more than $100,000 in accumulated wealth, compared with $6,000 of accumulated wealth for the median renter. One result of this distribution of wealth, Molinsky said, is that while many older homeowners can afford long-term care for at least some period of time, most renters cannot (see Table 3-1). One study estimated that 69 percent of those who reach age 65 will need an average of 3 years of some type of long-term care at some point in their lives (Kemper et al., 2005). However, the average renter can only afford to pay for 2 months of long-term care. Of additional concern, Molinsky said, is that the ratio of family caregivers to older adults has been declining—family caregivers today supply the majority of care for older adults.
Molinsky also noted that while 15 million adults today earn less than 80 percent of their area’s median income, which puts them in the low-income category, that number is projected to rise to 27 million by 2035. The number of older adults who earn less than half of their area’s median income, which would make them eligible for federal rental subsidies, will grow from 4 million in 2016 to 7.6 million in 2035. “This is significant,”
TABLE 3-1 Most Older Owners Can Afford Long-Term Care While Most Older Renters Cannot
|Number of Months Before Median 65 and Over Household Spends Down Wealth|
|Care Category||Median Monthly Cost (Dollars)||Renters||Owners, Including Home Equity||Owners, Excluding Home Equity|
|Home Health Aide||3,813||2||68||27|
|Adult Day Health Care||1,408||4||184||73|
|Assisted Living Facility||3,500||2||74||29|
|Nursing Home Care||6,448||1||40||16|
SOURCES: Molinsky presentation, December 12, 2016. Adapted from Joint Center for Housing Studies, 2016.
Molinsky said, “because out of the current 4 million, we only serve a third of the eligible senior population.” While this is slightly higher than the overall average of serving only one quarter of those in need, it still leaves a large number of older eligible adults without subsidies. “Even if we somehow figured out how to keep supporting one-third,” she said, “we are still going to have 5 million older adults who are eligible for subsidies but who will not receive them and will have to find affordable housing in the private market.”
Geographic Location of Housing
Based on data from the U.S. Census Bureau’s American Community Survey and from the U.S. Department of Agriculture, Molinsky said that she and her colleagues have estimated that approximately three-quarters of older adults live outside of cities and that nearly half are aging in low-density locations—i.e., areas with less than one housing unit per acre. While urban living does not guarantee people will have access to services or that they will remain engaged in their communities, Molinsky said that people living in low-density areas generally face more challenges to accessing services and remaining engaged in the community. Most people want to remain in their homes for as long as possible, and if they do move, they usually do not move very far from home, Molinsky said. Aging in place can work, but not if individuals are isolated in their homes, she said.
When taken together, Molinsky said, all of the statistics she presented demonstrate that the nation must increase its supply of accessible housing. One possible policy solution, she said, would be to provide assistance to owners and landlords to pay for modifications that meet accessibility standards. Another policy solution would be to create incentives and regulations to ensure that new housing constructed in the future is built in compliance with standards for accessibility. Assistance for meeting accessibility standards could be in the form of grants, tax credits, or policies that would help owners safely tap into their home equity. While some of these options already exist, there is a need to scale them up to reach more older adults in more places across the United States, Molinsky said. There is also a need to increase housing options in the communities where people live. “So if half of the people are aging in these low-density suburbs and rural areas and they say they want to stay in those communities but their house may not be appropriate,” Molinsky asked, “how about options for people to live in town centers, such as multifamily options or accessible dwelling units?” She said that she thinks there are many possibilities for creating more accessible housing, more affordable housing, and housing that older adults can more easily manage.
Molinsky also suggested that the nation build on promising pilot pro-
grams that support older adults with disabilities and health challenges in the home, including the 12 million people who have self-care disabilities. Molinsky’s final recommendation was to consider how to support the 7.6 million low-income adults in their search for affordable housing so that they do not need to cut back on food, care, and support. “The sheer growth of the older population means there is much work to be done,” she said.
Dara Baldwin of the National Disability Rights Network remarked that the discussions that she often hears portray disability and aging as something wrong or bad. She reminded the workshop participants that because of the Americans with Disabilities Act, individuals with disabilities have a civil right to live in the community. Sevak agreed, adding that researchers and policy makers have the obligation to develop policies that respect those civil rights. Molinsky added that the solutions that work for older adults should work for everyone, which is the principle behind universal design.
Phyllis Meadows from The Kresge Foundation asked the panelists if they had any insights into whether building development across the nation is displacing aging and vulnerable populations. Molinsky replied that the Joint Center for Housing Studies is evaluating how pressure from neighborhood changes affects vulnerable people. Sevak said that in many cities, developers are constructing accessible multiunit structures, but many of them are luxury units and therefore are not affordable for middle-income and low-income individuals. She said that it is important that the national conversation around housing include discussion of housing that is both affordable and accessible.
Daniela Koci of Loveland Center, Inc., asked if the panelists knew how to identify the best financing approaches to help support the housing needs of those who are living with disabilities or aging into disabilities. “To progress, we may need to go the extra step of asking the questions of would it be helpful to have certain types of tax credits, tax policies, or other types of approaches,” she said. Molinsky replied that there are many piloted models available, including various kinds of loan and grant programs, but it can be challenging to bring these ideas to scale. She noted that Congress is currently considering a tax credit to help older adults and those with disabilities modify their homes. Another challenge is to identify the kinds of incentives that can be offered to landlords who own multifamily housing to convince them to improve accessibility by making modifications. Similarly, she said, there need to be policies in place to help homeowners safely use the equity in their homes—beyond offering
reverse mortgages and home equity loans. Nonetheless, she said, there is no one-size-fits-all approach, and solutions will need to be tailored to individuals.
Koci also asked if there are any national efforts to provide better data regarding the income and needs of specific subpopulations of individuals with disabilities. For example, Koci said, someone with a developmental or intellectual disability would have different housing support needs than someone with diabetes. Sevak replied that some of the data in her presentation came from the Annual Disabilities Statistics Compendium,2 which the University of New Hampshire releases each year. Those data break down disability into subgroups, but they do not include individuals with intellectual or development disabilities as a subgroup. The Social Security Administration does provide data with fine levels of detail, but those data are limited to individuals who receive federal benefits. Sevak also noted that whether a health condition becomes disabling can be a function of environmental factors. While nobody would question whether an individual born with Down syndrome has a disability, she said, someone with poorly managed type 2 diabetes is likely to suffer kidney disease, amputation, blindness, or one of many other disabling outcomes. “I think it is important, if we want to reduce rates of disability and increase rates of functioning, whether it is employment or other kinds of functioning, to think about health conditions that can lead to disability and intervene,” Sevak said.
Margaret Campbell of Campbell & Associates noted that the surveys that are used to identify and characterize disabilities in the general population do not use the same categories as those that look at disability among older adults. The result, she said, are two different and inconsistent frameworks that need to be harmonized. In the same way, most surveys do not account for the fact that an individual can have multiple disabilities. “Just because a person has intellectual and developmental disabilities does not mean they do not have a hearing impairment or a vision impairment and vice versa,” she said, adding that she thinks data exist that may be able to put various conditions together to look at different levels of need. The U.S. Department of Health and Human Services’ Multiple Chronic Conditions Initiative3 may be able to provide such data, she said, while also noting that identifying and specifying target populations in a sensitive and more accurate manner is important in terms of bridging the aging and disability fields and to forming partnerships.
3 For more information, see https://www.hhs.gov/ash/about-ash/multiple-chronic-conditions/index.html (accessed February 21, 2017).
Craig Ravesloot from the Research and Training Center on Disability in Rural Communities at the University of Montana asked about the availability and quality of data for assessing the needs for housing in rural America. Sevak said that basic data on the adequacy of the rural housing stock do exist, but more data are needed to understand how transportation serves that housing, how people in rural areas access the services they need, and how they engage with their communities. A great deal of attention is given to age-friendly communities in large metropolitan areas, such as New York City or Atlanta, she said, but one project that she will be working on will look at the frail elderly in rural areas who may not be able to get out into the community.
Robyn Stone of LeadingAge commented that the nation has paid very little attention to the demand for community housing options over the near term. “There is very little research on options in the community beyond some multifamily housing, a little bit of work on mobile home parks, a little bit on co-housing, but there is almost nothing in the literature around the future,” said Stone, who called this a public health issue. Perhaps thinking of housing as a social determinant of health and a public health issue could lead to some different types of investments in housing for low-income older adults and individuals with disabilities, she suggested, adding that the data presented by Sevak and Molinsky demonstrate that there are going to be more lower-income older adults in the future who may not be able to remain in their homes. The homeless elderly population is the fastest growing segment of the homeless population in the United States, she said. Molinsky noted that in her hometown, housing for older adults is running into the same “not in my backyard” issues that create obstacles for affordable housing, so thinking about these types of housing as a means of addressing a public health issue might address the barrier of public acceptance.