In this issue of Pediatrics, Leifheit et al1 present timely findings on the consequences of cost-driven residential moves on social safety net disruption among families with children <48 months of age. The authors of this study demonstrate how disruption in 1 facet of family life can have a marked impact on multiple programs affecting family budget and wellness. Cost burden is when households spend >30% of their income on rent and utilities; if they spend >50%, households are classified as severely cost-burdened. Cost-burdened households have fewer resources for other critical needs, such as food, transportation, and childcare.2 According to the US Census Bureau, the number of renter-occupied households considered cost-burdened increased from 46.3% in 2019 to 49.0% in 2021.3 That means that just under one-half of all renter-occupied units in the United States were cost-burdened in 2021.
In this study, Leifheit et al specifically examine moves precipitated by families reporting difficulty paying rent or a mortgage, eviction, foreclosure, becoming homeless, or lack of housing subsidy. Housing instability is a broader construct that can encompass circumstances that may precede or include a cost-related move, such as having trouble paying rent, overcrowding, multiple moves, or cost burden, and is a known risk to maternal and child health.4,5 Additionally, being housing unstable may make it harder to access health care.
Leifheit et al found that young children and their families who experienced cost-driven moves were significantly more likely to have disrupted participation in the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and Medicaid.1 Novel in Leifheit et al’s findings are both the careful comparison of those with cost-related moves not only to those who did not move at all but also to those who moved for more positive reasons like searching for a bigger home or a better neighborhood.
The unsettling nature of a cost-driven move for families with young children could be especially stressful. Young children need both constant supervision and structured schedules to develop optimally.6 The authors chose covariates that they theorized could be related to caregivers’ capacity for managing stress.7 This point is important because in addition to the sheer logistics of moving, such as mail not being forwarded to a new address, families in this sample were likely faced with a fraught move precipitated by inadequate family income. The mental labor of tracking details of appointments, paperwork, and recertifications to stay connected to SNAP, WIC, and Medicaid while caring for young children could become formidable.
The authors also rightly point out that the relationship could work in the reverse: loss of benefits leading to housing destabilization. Adjunctive eligibility, the vitally important policy ensuring children who have Medicaid or participate in SNAP are automatically eligible for WIC, also has the potential to lead to adverse consequences, in which the loss of one benefit could require requalifying for another.8 In the context of the coronavirus disease 2019 public health emergency ending with staggering numbers of children being disenrolled from Medicaid,9 this study’s analysis highlights that pediatric providers must also be aware of additional ripple effects that such loss of health insurance could trigger.
Beyond clinical implications, there are major policy implications. First and foremost, this study’s findings underscore the essential need for active analysis and planning in policymaking for cross-sector impacts, as well as streamlining access to public programs.10 Pediatric providers may influence policy on adjacent areas (eg, housing assistance policy relationships with childcare access, cash transfers, or food assistance). Pediatric providers are important advocates for reducing administrative burdens and creating common applications and processes for public benefits. Providers see the downstream health impacts of confusing and burdensome policies and, thus, are important and credible voices in these spaces. Creative thinking on information that can be shared across public agencies without requiring families to submit the same paperwork repeatedly is urgently needed and is also a key Biden Administration strategy addressing social determinants of health.11 Common applications for multiple programs are in use in several states. Short of a common application, requiring states to securely share enrollment and other data across programs, such as SNAP, WIC, Medicaid, and potentially, housing assistance, to address participation gaps would help ensure that families participating in 1 program are also participating in others.
Housing-specific policy investments are also vital. These include expanding rental assistance to include all income-eligible households, increasing the inventory of housing affordable to the lowest-income families, and providing emergency assistance to keep people in their homes.
Innovation in public policy that keeps families at the center by streamlining access to public benefits and supporting families in achieving economic stability is essential for supporting children’s health.12 Pediatric providers have an important role to play in both keeping families connected to support and advocating for nuanced, cross-sector policies that help families stabilize, in turn freeing bandwidth for basic needs, as well as planning for a brighter future.
Dr Ettinger de Cuba drafted the initial manuscript; Ms Coleman cowrote the manuscript; and both authors critically reviewed and revised the manuscript, approved the final manuscript as submitted, and agreed to be accountable for all aspects of the work.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2023-061934.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: Dr Ettinger de Cuba offered feedback on the study for which the commentary is written and was acknowledged in the article. Ms Coleman has indicated she has no potential conflicts of interest relevant to this article to disclose.
Comments