The Looming COVID-19 Housing and Health Crisis in the US: Results from a National and Four-City Survey

: Affordable housing is a key determinant of health, and it has become a major issue for millions of vulnerable households during the COVID-19 pandemic. Little is known about Americans’ financial burdens in paying for housing costs during the COVID-19 pandemic, particularly after federal aid was initially distributed. In a randomized, representative survey of households nationally and in the four largest U.S. cities during the COVID-19 pandemic (n=3,454), we found widespread, serious burdens reported with paying for housing costs (including rent, mortgage, and utilities). Nationally, forty percent of households with employment disruptions (40%) reported serious financial problems paying their housing costs, including half or more in New York (50%), Los Angeles (50%), and Houston (60%). More than one-third of renters nationally (38%) and in the four largest U.S. cities (Houston – 59%, Los Angeles – 50%, New York City – 38%, Chicago – 37%) reported serious problems paying housing costs during this time. Serious cost burdens were concentrated among renters, Black and Hispanic households, and households with recent job or wage losses. The federal government earmarked limited funding specifically toward improving housing stability in December 2020, but it was a fraction of what is believed necessary to provide stability to the housing market for vulnerable groups. A patchwork of housing and financial protection programs are set to expire in 2021 with limited ongoing mechanisms to cover back rent or utility payments, widely placing vulnerable households at risk for health and economic problems unless further policy action is taken.


Introduction
The COVID-19 pandemic has caused major upheavals to the U.S. economy, leaving millions of households vulnerable for poverty, eviction, housing displacement, and homelessness [1][2][3][4][5]. This situation has been worsened by a lack of sustained federal policy protection for many households. In March 2020, the federal government offered an economic relief package with a one-time stimulus payment and expanded unemployment insurance benefits, which largely expired in July 2020. After a five-month gap, in December 2020 the federal government offered a more limited economic relief package [6]. It includes scaled back unemployment insurance benefits set to expire in March 2021; and limited rental and utilities assistance, with no requirements for utility companies to forego shut-offs. While the Biden administration extended the federal eviction moratorium until March 31, 2021 and proposed a $1.9 trillion "American Rescue Plan," these measures are only a fraction of what is believed necessary to provide stability to the housing market for vulnerable groups over the next decade.
Meanwhile, the U.S. continues experiencing high numbers of COVID-19 cases with limited economic recovery, setting the stage for a housing crisis among vulnerable groups in 2021. Because little is known about households' experiences with financial strain related to housing, we conducted a survey of households nationally and in the four largest U.S. cities prior to the expiration of the first round of federal coronavirus aid programs. This sample was chosen to examine the unique circumstances of major cities apart from national during the COVID-19 pandemic.

Study Data and Methods
This study is an in-depth secondary analysis of a multi-part national survey conducted in 2020. Data for this study were obtained from an original survey designed by the Harvard TH Chan School of Public Health, Robert Wood Johnson Foundation, and National Public Radio. We used a randomized, address-based sample of adults aged ≥18 years designed to be generalizable to the nation and the four largest U.S. cities, gathered from the U.S. Postal Service Computerized Delivery Sequence file. Participants were allowed to complete surveys via cellphone, landline telephone, or online. Interviews were conducted in English and Spanish between July 1 and August 3, 2020. The study was determined exempt by the Harvard Chan School of Public Health Office of Human Research Administration.
The survey instrument gathered demographic characteristics of respondents and asked adults about their household-level experiences with serious financial problems. The primary outcome of this study is serious problems reported paying for housing costs during the COVID-19 pandemic, created by combining "yes" responses to two questions: serious problems paying rent/mortgage and serious problems paying utilities. Additional details on the survey methodology and question wording are available in the Appendix.
The final sample included 3,454 households nationally, with oversamples from New York City (n=512), Los Angeles (n=507), Chicago (n=529), and Houston (n=447). Data for each subsample were weighted in multiple stages to account for oversampling, nonresponse, and demographic factors to reflect the appropriate populations, benchmarked to the Census Bureau's 2018 American Community Survey. We compared differences in outcomes by self-reported racial/ethnic identity (non-Hispanic Blacks and Hispanics/ Latinos vs. non-Hispanic whites), homeownership (rented vs. owned), and employment disruption among adult household members during the COVID-19 pandemic (yes/no), using twotailed t-tests in STATA v. 15.0, with statistical significance determined at p<0.05. For all analyses, we separately analyzed data from the nation and each city, using survey weights to approximate the target population in each sample.

Study Results
Selected demographic characteristics of survey respondents are displayed in Table 1. Notably, half or more adults in the four largest U.S. cities reported their household experienced job or wage losses during the Covid-19 pandemic (New York City -50%, Los Angeles -61%, Chicago -51%, Houston -57%). While 36% of adults nationally reported living in rented homes, a majority of adults in cities reported renting (New York City -67%, Los Angeles -65%, Chicago -52%, Houston -56%).  All estimates self-reported by adults reporting on behalf of their households, estimated with survey weights to adjust for unequal probability of sampling. Responses may not add to 100% due to rounding. Don't know/refused responses included in the total but not reported b Self-reported race/ethnicity of respondent. Racial/ethnic identity of other household members unknown. c Adults reporting no adults in the household were working before the Covid-19 outbreak included in the total but not reported in Table 1.
Among households with employment disruptions during the COVID-19 pandemic, 40% nationally reported serious problems paying for housing costs (see Figure 1). This includes widespread issues reported among households with employment loss in the four largest U.S. cities -60% of households in Houston, 50% of New York City households, 50% of Los Angeles households, and 44% of households in Chicago. By comparison, only 9% of households without employment loss nationally reported serious problems paying for housing costs, as did fewer than one in five of these households in the four largest U.S. cities (Houston -18%, Los Angeles -15%, New York City -13%, Chicago -11%).
We examined serious problems paying for housing costs by homeownership and found serious financial burdens concentrated among renters, as shown in Figure 2. Renters were significantly more likely to report serious problems than homeowners across cities and nationally (all p-values <0.05). More than one-third of renters nationally (38%) and in the four largest U.S. cities (Houston -59%, Los Angeles -50%, New York City -38%, Chicago -37%) reported serious problems paying housing costs during the COVID-19 pandemic. Comparatively, less than onequarter of homeowners reported serious problems paying housing costs during this time (nationally -16%, Houston -24%, Chicago -21%, New York City -21%, Los Angeles -12%).

Figure 1. Serious Problems Paying for Housing Costs Reported During the COVID-19 Pandemic by Employment/Wage Losses (Yes/No), a Nationally and in the Four Largest U.S. Cities.
Notes: Authors' analysis of a US national and four-city survey, conducted July 1 -August 3, 2020. a Statistically significant difference between households with job/wage losses and households without any job or wage losses at p<0.05 (measured by t-tests). Weighted percentages displayed. Unweighted sample sizes: National n=1,570 households with job/wage loss and 1,417 households with no job/wage loss. New York City n=243 households with job/wage loss and 199 households with no job/wage loss. Los Angeles n=270 households with job/wage loss and 192 households with no job/wage loss. Chicago n=248 households with job/wage loss and 232 households with no job/wage loss. Houston n=203 households with job/wage loss and 182 households with no job/wage loss. Notes: Authors' analysis of a US national and four-city survey, conducted July 1 -August 3, 2020. a Statistically significant difference between households who rent vs. own homes at p<0.05 (measured by t-tests). Weighted percentages displayed. Unweighted sample sizes: National n=1,508 renters and 1,940 owners. New York City n=336 renters and 174 owners. Los Angeles n=264 renters and 242 owners. Chicago n=263 renters and 266 owners. Houston n=210 renters and 237 owners.
When examining serious problems paying for housing costs by race and ethnicity, we found widespread reported problems among non-Hispanic Black and Hispanic households, as shown in Figure 3. More than one-third of Hispanic households nationally and in the four largest U.S. cities (national -41%, Los Angeles -57%, Houston -55%, New York City -46%, and Chicago -38%) reported serious problems paying housing costs during the COVID-19 pandemic. Similarly, more than three in ten Black households nationally and in the four cities reported serious problems paying housing costs during this time (national -38%, Houston -67%, Chicago -42%, Los Angeles -38%, New York City -31%). Comparatively, fewer white households nationally (18%) and in the four cities (New York City -26%, Chicago -16%, Los Angeles -15%, and Houston -15%) reported these problems. Hispanic and Black households were significantly more likely to report serious problems paying housing costs during the COVID-19 pandemic than non-Hispanic whites across cities and nationally (all p-values <0.05), with the exception of a non-significant difference between Black and whites households in New York City (p=0.463). Notes: Authors' analysis of a US national and four-city survey, conducted July 1 -August 3, 2020. a Statistically significant difference between Latino vs. white or Black vs. white households at p<0.05 (measured by t-tests

Discussion
Affordable housing is a key determinant of health, and housing policies have been important drivers of the COVID-19 pandemic's spread and mitigation [1][2][3][4][5]7]. Over a year into the COVID-19 pandemic, an alarming share of Americans are confronting major threats of housing instability, alongside joblessness, poverty, eviction, and housing insecurity. Our findings show widespread cost burdens reported by renters, Blacks, Hispanics, and households with employment disruptions in major U.S. cities and nationally; results which are supported by Census Bureau estimates showing 19 million Americans are behind on rent and mortgage payments [4,8].
Importantly, we fielded this survey in the summer of 2020, prior to the expiration of the first round of federal protection programs under the CARES Act. Despite the federal policies in place and more than $2 trillion in federal aid, our findings show a substantial share of households in America were financially burdened and reported serious problems paying for rent and utilities by August. These results are supported by other research showing federal policies have done little to put a financial cushion under large shares of eligible households during the COVID-19 pandemic, signaling economic relief has not reached its purported targets [9,10].
While the federal government earmarked limited funding specifically toward improving housing stability in December 2020, it was a fraction of what is believed necessary to provide stability to the housing market for vulnerable groups. It is not clear whether less generous, delayed federal aid will be adequate to sustain the financial situations of vulnerable households in 2021. If households are not significantly better off in 2021 than they reported being in our survey in July 2020, the next year will see high rates of both COVID-19 infections and housing instability concentrated among lowerincome and racial/ethnic minority households. This poses major health and financial risks for affected families, as the financial, health and housing consequences of eviction are pervasive and severe [1,11]. As a patchwork of limited recent federal protections are set to expire, additional policies are needed to help vulnerable populations, particularly in major cities.
From a health equity perspective, these results are especially concerning given the lack of federal action to protect against worsening economic and racial divides in America during the COVID-19 pandemic. Housing aid in federal policies has been stronger for homeowners than renters, despite the more vulnerable pre-pandemic financial position of renters, who are disproportionately Black, Hispanic, and lower-income [1,4]. Though eviction moratoria are important to control COVID-19 transmission [1,7], they are not automatic, they do not cover everyone, and they delay evictions without preventing them. Federal policies have been limited in providing direct financial relief for renters, landlords, and utility companies during the pandemic.
We expect these results to be a lower-bound estimate of financial housing strain, as we separately examined experiences of racial/ethnic minorities, renters, and households with employment disruption-groups that substantially overlap. Racial and ethnic disparities are particularly concerning, given the importance of health equity in light of historical housing discrimination and structural racism [12]. Blacks and Hispanics are more likely than their white counterparts to rent, live in cities, pay higher housing prices, face evictions, work in jobs affected by the COVID-19 pandemic, and contract and die from COVID-19 [1,4,[11][12][13][14][15]. These factors all compound historical disadvantages, placing them at extremely high risk for contracting COVID-19 as unpaid rent, utilities, and other debt mount, while simultaneously facing eviction, housing instability, joblessness, and long-term poverty.

Limitations
This study is subject to important limitations, including common limitations in survey research such as self-reporting, recall bias, selection bias, and nonresponse bias. Another notable limitation of this study is its sample size, which did not allow us to explore burdens across respondents' intersectional identities. However, this study was strengthened by its unique sample of households in the largest US cities, and by using a probability-based, addressbased sample with multi-staged weighting techniques (see the Appendix), which adhere to best practices set by the American Association for Public Opinion Research. In addition, the survey went through extensive pretesting and external expert review for bias, balance, and respondent comprehension. Encouragingly, the results we observed are consistent with outcomes observed in the Census Bureau's Household Pulse Survey, suggesting selection bias did not drive our results [13].

Conclusion
Over a year into the COVID-19 pandemic, an alarming share of Americans are facing a housing affordability crisis. Serious cost burdens were widely reported by renters, Black and Hispanic households, and households with employment disruptions in major U.S. cities and nationally. A patchwork of housing and financial protection programs are set to expire in 2021 with limited ongoing mechanisms to cover back rent or utility payments, widely placing vulnerable households at risk unless further policy action is taken.

Appendix 1. Survey Methods
This survey was designed by researchers at the Harvard T. H. Chan School of Public Health, Robert Wood Johnson Foundation, and National Public Radio. The survey was conducted July 1 st -August 3 rd , 2020, among a representative random sample of 3,454 U.S. adults, focusing on the four largest cities in the U.S., the remaining urban, suburban, and rural areas, and by race groups within these areas and in total. The core of the sample was address-based, with respondents sampled from the United States Postal Service's Computerized Delivery Sequence (CDS) file.
Sampled households were sent an invitation letter including a link to complete the survey online, and a toll-free number that respondents could call to complete the survey with a telephone interviewer. All respondents were sent a reminder postcard, which also included a QR code they could scan to be linked to the survey via a smart device. Households who were flagged in the sample file as either living in cities or in high-Hispanic areas, received bilingual mailings, including text in both English and Spanish. The letters requested, for each household, that the person living at the address who had the most recent birthday complete the survey. Households that could be matched to telephone numbers and that had not yet completed the survey online or by inbound computer-assisted telephone interview (CATI) were called by CATI interviewers to attempt to complete an interview.
The sample was stratified by geographic area and population density of various racial or ethnic groups. The seven geographic areas consisted of the city limits for the U.S. cities with the largest populations: New York, Los Angeles, Chicago and Houston; and three other areas: Urban, defined as all census blocks inside the principal city/cities of a Metropolitan Statistical Area (MSA) with a population of 50,000+, excluding the four largest cities (but including other urban census blocks in their metropolitan area); Rural, defined as central city of an MSA with a population under 50,000, and counties that are not part of an MSA; and Suburbs, all other areas. Within each of these geographic areas, Census block-groups with relatively higher density of Hispanic, Black, Asian American, and American Indian/Alaska Native (AI/AN) were oversampled in order to reach minimum thresholds of these populations within-region, and overall.
In order to represent the hardest-to-reach populations, the address-based sample (ABS) was supplemented with 156 telephone with respondents who had previously completed interviews on the weekly random-digit dialing (RDD) SSRS Omnibus poll and identified as being from one of the target ethnic/racial groups and regions. An additional 29 respondents were reached through the SSRS Opinion Panel, an online probability-based panel that recruits respondents through ABS and RDD.
A total of 2,992 respondents completed the questionnaire online, 127 by calling in to complete, and 335 were completed as outbound CATI interviews. Data collection was conducted in English (n=3,071) and Spanish (n=383) by SSRS of Glen Mills, PA.
The final sample included 3,454 households nationally, with oversamples from New York City (n=512), Los Angeles (n=507), Chicago (n=529), and Houston (n=447). Data for each subsample were weighted to reflect the appropriate population, benchmarked to U.S. Census Bureau data. Weighting adjusts for the fact that not all survey respondents were selected with the same probabilities, it accounts for the sample design strategies, and it accounts for systematic nonresponse along known population parameters.
Data weighting involved multiple stages: First, within each geography, the sample was weighted to account for oversampling of the high-density ethnic/racial-group areas. The callback and panel samples were also weighted to adjust for propensity of responding to the invitation to participate based on known demographic factors. Each area's sample was then weighted to match the distribution of the population based on data from the U.S. Census Bureau's 2018 American Community Survey (ACS). Weighting parameters included: gender, age, race/ethnicity, education level, national region, and party identification. The final weight combined each of the seven regions' weight and balanced the combined total sample to match each region's proportion to the U.S. adult population. The weighting also ensured that the demographics of each race-group nationally matched its demographic makeup by age, gender, and educational attainment. All statistical tests of significance account for the effect of weighting. The margin of sampling error including the design effect for the full sample is plus or minus 3.3 percentage points nationally, 5.4 percentage points for New York City, 7.1 percentage points for Los Angeles, 5.4 percentage points for Chicago, and 6.3 percentage points for Houston.
This survey adheres to best practices set by the American Association for Public Opinion Research (AAPOR), and prior to fielding, it went through extensive pretesting and external expert review for bias, balance, and respondent comprehension.
The survey instrument gathered demographic characteristics and included questions about household experiences with serious financial problems not typically covered in federal surveys. Adults were asked to report on serious problems facing both themselves and others living in their households. As a result, for all questions asked about the household, measures are reported as a percentage of households. On racial/ethnic identity, respondents selfreported their own race/ethnicity, and the racial/ethnic identity of others living in respondents' households was not asked. As a result, measures are reported as a percentage of households according to the respondent's own race/ethnicity (e.g., Black households, Hispanic households). Race/ethnicity are categorized as non-Hispanic white, non-Hispanic Black, or Hispanic. Income categories (reported 2019 household income) are set at <$30,000, $30,000 -<$100,000, and $100,000+. Notably, this survey only covered the non-institutionalized U.S. population, excluding those living in nursing homes, prisons, and hospitals, who have been disproportionately impacted by the coronavirus outbreak.

Appendix 2. Question Wording
The primary outcome is a summary measure of reported serious problems paying for housing costs during the COVID-19 pandemic by combining "yes" responses to two questions: Q4a. At any point since the start of the coronavirus outbreak, has anyone living in your household had serious problems paying their rent or mortgage, or not?
Q4b. At any point since the start of the coronavirus outbreak, has anyone living in your household had serious problems paying for utilities, like gas or electricity, or not?