In this study, we assessed the prevalence of housing and food insecurity in adults with common chronic diseases. In states that administered the optional social context module of the BRFSS in 2015, we found a high prevalence of housing and food insecurity among individuals with common chronic conditions. Cardiovascular disease and chronic lung disease significantly increased the risk of housing and food insecurity, after controlling for relevant confounders such as socioeconomic and health insurance status, with cancer increasing risk of food insecurity alone. In turn, we showed that housing and food insecurity independently increased the likelihood of health care access hardship and poorer health status, although we did not detect an interaction between the two independent variables. All chronic illnesses except stroke increased the risk of health care access hardship. All chronic illnesses without exception increased the risk of poorer health.
Our results are in line with previous studies showing that housing and food insecurity can worsen health status and reduce access to health care.9 Pobutsky et al., correlating data from the 2012 BRFSS with the Hawaii Health Survey, demonstrated increased mental stress with perceived food and housing insecurity among Hawaiians.4 Using the 2009 BRFSS, Pan et al. described obesity in the food-insecure, and revealed that one in three food-insecure adults suffered from obesity.5 Among Washington state residents, the housing-insecure were twice as likely to report poorer health and delayed doctor visits.8 Others have demonstrated that disabled adults are more likely to report housing and food insecurity, regardless of employment status.13
The mechanisms by which different chronic illnesses influence housing and food insecurity were varied. Notably, stroke correlated with neither housing nor food insecurity. Stroke is the leading cause of long-term disability in the United States.14 Studies have found that about 65% of patients cannot use the affected hand for their usual activities 6 month after stroke,15 and only 25% of patients were found to return to the level of everyday physical functioning in matched controls who had not had a stroke.16 Stroke survivors are more likely to move in with family (or into nursing facilities), which we hypothesize explains, at least in part, the lack of housing and food insecurity compared to other chronic illnesses. Choi and colleagues found that among cardiovascular events (stroke, myocardial infarction, and chronic heart failure), stroke was the most significant predictor of disability and of family moving geographically closer.17 Individuals experiencing a first stroke were almost twice as likely either to move in with or move closer to their children,17 increasing the availability of support systems and potentially alleviating housing and food anxiety. We posit that the same family circumstances also mitigate the development of care access hardship. However, as with other chronic illnesses, the disease condition itself significantly affects health status.
Cardiovascular and chronic lung disease significantly increased the likelihood of housing and food insecurity. The total annual cost of cardiovascular disease in the United States in 2012–2013 averaged $316.1 billion,18 surpassing the costs of other chronic conditions. Pharmaceutical costs contribute to the expense of chronic heart and lung disease treatment. Medicare Part B generally does not cover most prescription drugs used at home,19 creating a financial burden for patients with these chronic conditions. Researchers found that patients with chronic ischemic heart disease were reimbursed for approximately 64% of the total medication expense; average out-of-pocket costs approached $80 per month.20 Inhaled medications are critical for relief of symptoms in patients with chronic obstructive pulmonary disease (COPD). However, up to 31% of Medicare beneficiaries using COPD inhalers have reported nonadherence due to cost.21 Tseng and colleagues demonstrated projected annual out-of-pocket costs of at least $900 under a standard 2015 Medicare Part D plan for patients using a single inhaler each month, even without other medications.22 A study including 60 patients with COPD showed that about 60% of patients experienced two or three exacerbations per year, which resulted in almost a doubling of treatment costs.23 Unlike those with stroke, patients with chronic heart and lung disease are less likely to relocate closer to their children,17 reducing the probability of additional family support that could alleviate housing and food insecurity.
Cancer increased the likelihood of food but not housing insecurity. The expense and out-of-pocket costs for cancer treatment depend on a variety of factors, including cancer type and stage, insurance status and type, service location, and treatment.24 The stage of the disease impacts the quality of life for cancer patients, as many with stage I or II cancers can work and live independently, minimizing the effect on their pre- versus post-diagnosis income.25 Further, the effect of treatment costs on housing and food security status may be blunted by insurance coverage of outpatient chemotherapy and radiotherapy. Insurance may also cover prescription drugs such as oral medication and anti-nausea medication, thereby reducing the burden of treatment cost to cancer patients19 compared to those with cardiovascular or chronic lung disease, lowering the risk of housing insecurity. We cannot deny that the cost of cancer care induces distress,26 but the extent, and impact on housing and food security, depends on a variety of clinical factors, analyses of which are beyond the scope of our review.
Comparing across chronic illnesses, we speculate that as costs of care increase, there is a corresponding development of food and then housing insecurity, until individuals are sufficiently disabled as to require family support and non-independent housing, thereby reducing food and housing anxiety. As expected, however, all chronic illnesses reduced health status independent of housing and food insecurity, due to decrements in physical and mental health. Insurance status and gender independently influenced health care access after controlling for chronic illness. However, the effects of these sociodemographic variables on health status dissipated after adjusting for health care access hardship, which we hypothesized would mediate the effect of insurance status and gender. Similarly, the effects of education and employment on health care access hardship were likely mediated by insurance status; however, persistent independent effects—particularly of employment—on health status may be due to psychological effects such as social connection and meaningful activity,27 self-identity,28 or mental health,29 the measurement of which was beyond the scope of our study. These effects may be accentuated if individuals lose employment due to chronic illness before they are prepared to leave work formally.
Previous studies have focused on adult general populations.9 Our study highlights the association of housing and food insecurity with health status and care access among the chronically ill adult population. As chronic illness may affect half of the US population by 2025,30 factors associated with managing chronic conditions require special attention, particularly as housing and food insecurity can result from chronic illness and, in turn, can exacerbate it.31
Social factors can have a significant impact on health outcomes. A meta-analysis of 47 studies found that lower level of education, racial discrimination, lack of social support, and poverty were factors in over one third of all deaths in the United States in 2000.32 Food insecurity increases the likelihood of cost-related medication underuse,33 which can lead to poorer health status. Poverty can also negatively impact patient health care utilization, as those who struggle financially may prioritize meeting their basic needs over seeking health care. In 2015, 12.7% of American households were affected by food insecurity, meaning they did not have access to adequate food for an active, healthy life for all household members.34 Estimates show that about 6.4 million low-income renters and 11 million homeowners will be spending more than 30% of their income on housing by 2035.35 With the cost of care rising, patients with chronic illness are at particular risk of financial hardship, including housing and food insecurity. Those who cannot afford basic necessities such as housing and food tend to perceive appropriate health care as a lower priority.36
Several limitations in this study are worth noting. First, BRFSS relies on self-reported information, which may under/overestimate the frequency of our main variables. In addition, the study’s cross-sectional design limits our ability to provide information on causal effects of housing and food insecurity with regard to health care access and health status. Finally, as information on housing and food insecurity is available only for 12 states and jurisdictions, the findings may not be generalizable to all US adults.