Federal Housing Assistance and Stage at Cancer Diagnosis Among Older Adults in the US

85 Background: Despite growing awareness that stable and affordable housing is a key social determinant of health, little research has examined the role of federal housing assistance in cancer outcomes. This study uses a novel data linkage to examine the association of federal housing assistance (i.e. various rent subsidy programs) on stage at diagnosis for the 4 most common cancers in the US. Methods: Individuals aged 66-95 years newly diagnosed with breast, colorectal, non-small cell lung (NSCLC) or prostate cancer in 2006-2019 with fee-for-service coverage were selected from SEER-Medicare Housing and Urban Development (HUD) administrative data. After identifying individuals with housing assistance at diagnosis, controls without housing assistance at diagnosis were propensity score matched in a 3:1 ratio by cancer site, age, sex, race/ethnicity, marital status, registry, year of diagnosis, area-level Yost socioeconomic status index, dual Medicaid eligibility, rural/urban residence, reason for Medicare entitlement, and pre-diagnosis comorbidity. Associations of housing assistance and diagnosis stage (SEER summary stage: localized vs. regional/distant) were examined with separate logistic regression models by cancer type. Results: A total of 7335 individuals with breast, 5660 with colorectal, 7399 with NSCL and 4309 with prostate cancer received housing assistance at diagnosis (Table). Compared to matched controls, a smaller percentage of individuals with housing assistance were diagnosed with regional/distant breast (36% vs. 33%), colorectal (59% vs. 57%), and NSCL (71% vs. 69%) cancers. Individuals receiving housing assistance were less likely to be diagnosed with later-stage breast (OR: 0.87; 95% CI: 0.83, 0.92) and NSCL (OR: 0.93; 95% CI: 0.88, 0.99) cancers. Housing assistance was not significantly associated with stage for individuals with colorectal or prostate cancers. Conclusions: Federal housing assistance is associated with earlier-stage breast and NSCL cancer diagnosis, highlighting its potential role in mitigating the adverse effects of housing insecurity on cancer outcomes. Housing assistance and cancer diagnosis stage. No Housing Assistance at Dx,N (%) Housing Assistance at Dx,N (%) OR [95% CI], P Breast Localized 14291 (64) 4890 (67) 1.0 (ref) Regional/Distant 8179 (36) 2445 (33) 0.87 [0.83, 0.92] P<0.001 Colorectal Localized 7046 (42) 2422 (43) 1.0 (ref) Regional/Distant 9934 (59) 3238 (57) 0.95 [0.89, 1.01] P=0.09 NSCLC Localized 6572 (30) 2298 (31) 1.0 (ref) Regional/Distant 15625 (71) 5101 (69) 0.93 [0.88, 0.99] P=0.02 Prostate Localized 10293 (80) 3401 (79) 1.0 (ref) Regional/Distant 2634 (20) 908 (21) 1.04 [0.96, 1.14] P=0.33 Dx=Diagnosis; OR=Odds Ratio; CI=Confidence Interval.

Federal housing assistance is an important policy tool to ensure housing security for low-income households. Less is known about its impact on residential environmental exposures, particularly lead. We conducted a quasi-experimental study to investigate the association between federal housing assistance and blood lead levels (BLLs) in a nationally representative US sample age 6 y and older eligible for housing assistance. We used the 1999-2018 National Health and Nutrition Examination Survey (NHANES) linked with US Department of Housing and Urban Development (HUD) administrative records to assess BLLs of NHANES participants with concurrent HUD housing assistance (i.e., current recipients, ) and those receiving assistance within 2 y after the survey (i.e., pseudo-waitlist recipients, ). We estimated BLL least squares geometric means (LSGMs), odds ratio (OR) for BLL , and percent differences in LSGMs by HUD housing assistance status adjusting for age, sex, family income-to-poverty ratio, education, country of birth, race/ethnicity, region, and survey year. We also examined effect modification using interaction terms and stratified analyses by program type [i.e., public housing, multifamily, housing choice vouchers (HCV)], and race/ethnicity. Current HUD recipients had a significantly lower LSGM [; 95% confidence interval (CI): 1.02, 1.12] than pseudo-waitlist recipients (; 95% CI: 1.14, 1.28), with an adjusted OR of 0.60 (95% CI: 0.42, 0.87) for BLL . Some effect modification were observed: The protective association of HUD assistance on BLL was strongest among public housing ( LSGM; 95% CI: , ), multifamily ( LSGM; 95% CI: , ), and non-Hispanic White ( LSGM; 95% CI: , ) recipients. It was weaker to null among HCV ( LSGM; 95% CI: , 1.7%), non-Hispanic Black ( LSGM; 95% CI: , 5.4%), and Mexican American (-12.5% LSGM; 95% CI: , ) recipients. Our research underscores the importance of social-structural determinants like federal housing assistance in providing affordable, stable, and healthy housing to very low-income households. More attention is needed to ensure housing quality and racial equity across HUD's three major housing assistance programs. https://doi.org/10.1289/EHP12645.

240 Background: Housing insecurity is a growing problem in the US and is linked with worse cancer outcomes and increased mortality compared to individuals with secure housing. The availability of federal housing assistance to mitigate housing insecurity—through housing vouchers, public housing, and related programs—may support better cancer care and outcomes. Households receiving housing assistance must complete a recertification process roughly every 1 to 3 years to maintain this support. For individuals with cancer and their household caregivers, the physical and mental demands of cancer and its treatment may make it especially difficult to manage the administrative burden of recertification, increasing their risk of losing housing assistance. This study examined whether a cancer diagnosis is associated with a loss of federal housing assistance. Methods: Using the Surveillance, Epidemiology, and End Results (SEER) Cancer Registry-Medicare data linked with administrative records from the US Department of Housing and Urban Development (HUD), we identified individuals aged 66-95 years who were newly diagnosed with female breast, colorectal, non-small cell lung (NSCL), or prostate cancer between 2007 and 2019 with at least one episode of housing assistance between 2006 and 2020. Using a modified case-crossover design, which leverages cancer patients as their own controls, we modeled the time from first housing episode to loss of housing assistance (event) or death/study end (censor) with cancer diagnosis as a time-dependent exposure. The risk of losing housing assistance in the time after a diagnosis relative to before was estimated with a Cox proportional hazards model. Results: The study included 81,677 individuals (24,946 breast, 16,532 colorectal, 25,164 NCSL, and 14,635 prostate cancer). At diagnosis, 53,327 (66%) were receiving housing assistance, 16,979 (21%) lost their housing assistance before diagnosis, and 10,971 (13%) obtained housing assistance after diagnosis. The median time from initiating housing assistance to loss of housing assistance was 11.6 years. The rates of loss of housing assistance in the periods before and after cancer diagnosis were 5.2 and 6.9 per 100 person-years, respectively. Cancer diagnosis was associated with a significantly increased risk of housing assistance loss (Hazard Ratio (HR) 1.32; 95% CI [1.28–1.36]; p < 0.001). Conclusions: A cancer diagnosis is associated with increased risk of loss of housing assistance in older adults. Policies that streamline housing recertification or provide temporary protection post-diagnosis may be considered to support continued housing stability during a vulnerable period.

Lack of stable, affordable housing is an important social determinant of health. Federal housing assistance may buffer against housing vulnerabilities among low-income households, but research examining the association of housing assistance and cancer care has been limited. We introduce a new linkage of Surveillance, Epidemiology, and End Results (SEER) program-Medicare and US Department of Housing and Urban Development (HUD) administrative data. Individuals enrolled in HUD public and assisted housing programs between 2006 and 2021 were linked with cancer diagnoses between 2006 and 2019 identified in the SEER-Medicare data from 16 states using Match*Pro (National Institutes of Health, Bethesda, MD) probabilistic linkage software. HUD administrative data include timing and type of housing assistance as well as verified household income. Medicare administrative data are available through 2020. A total of 335 490 unique individuals who received housing assistance at any time point, including 156 794 who received housing assistance around the time of their diagnosis (at least 6 months before diagnosis until 6 months after diagnosis or death), were matched to SEER-Medicare data. A total of 63 251 individuals receiving housing assistance at the time of their diagnosis were aged 66 years and older and continuously enrolled in Medicare parts A and B fee for service; 12 035 had a diagnosis of lung cancer, 8866 of breast cancer, 7261 of colorectal cancer, and 4703 of prostate cancer. This novel data linkage will be available through the National Cancer Institute and can be used to explore the ways in which housing assistance is associated with cancer diagnosis, care, and outcomes, including the role of housing assistance status in potentially reducing or contributing to inequities across racialized and ethnic groups.

201 Background: Federal housing assistance (HA)—which limits household spending on rent and utilities—has been linked with earlier stage non-small cell lung cancer (NSCLC) diagnosis. However, prior research has not examined association of HA with the receipt of cancer treatment. Methods: Patients aged 66-95 years who were newly diagnosed with NSCLC between 2007 and 2019 and survived at least 3 months after diagnosis were selected from the linked SEER-Medicare Housing and Urban Development data. HA was defined as continuous enrollment in any housing program from 6 months before, to 3 months after diagnosis. Patients with NSCLC without HA were identified as controls using 3:1 propensity score matching on demographic and clinical characteristics. Medicare claims data were used to identify receipt of surgery, radiation, and chemotherapy within 3 months of diagnosis. Predicted probabilities of treatment receipt were estimated using multivariable logistic regression models, stratified by stage and adjusted for all matching variables. Median time to first treatment initiation (TTI) was also estimated by stage. Results: The sample included 3,836 patients with HA at diagnosis and 11,508 matched controls. Small variations in treatment patterns between patients with and without HA were observed across treatment types and stage, although differences were not statistically significant (Table). Among patients with stage I disease, approximately one-third received surgery (39.1% with HA vs. 34.8% without), and about 10% received chemotherapy (10.1% vs. 8.9%) within 3 months of diagnosis. For those with stage III/IV, < 10% underwent surgery, about 3%-14% received immunotherapy, while approximately 40% received chemotherapy. Radiation use ranged from approximately 25% in stage I to > 40% in Stage III, with minimal differences by HA status. Median TTI ranged from approximately 48 days for patients with Stage II to 44 days for patients with Stage IV and were similar by HA status. Conclusions: Supporting housing affordability through federal housing assistance may, in itself, not be sufficient to increase rates of NSCLC treatment. Future studies are warranted to examine associations of housing assistance with care coordination and receipt of timely guideline-concordant care. Predicted probabilities of treatment receipt among patients with NSCLC, with vs. without HA. Surgery Radiation Chemotherapy Immunotherapy HA No HA HA No HA HA No HA HA No HA Stage I 39.1 34.8 25.1 27.5 10.1 8.9 1.0 0.0 II 29.7 25.9 31.9 33.0 24.4 24.3 0.7 0.9 III 9.4 9.6 41.8 41.1 40.1 39.7 5.9 3.2 IV 4.4 4.2 34.2 34.5 43.8 43.8 13.8 12.7 Note: The analysis of immunotherapy includes data from 2015 to 2019. Models adjusted for age, sex, race and ethnicity, marital status, SEER registry, year of diagnosis, Yost index, dual Medicaid enrollment, rural/urban residence, Medicare entitlement reason, and Charlson comorbidity index.

200 Background: Lack of stable and affordable housing is an important social determinant of health. Federal housing assistance—through housing choice vouchers, public housing, and other programs—may buffer against housing vulnerabilities among low-income households, but research examining the association of housing assistance and cancer care has been limited. We introduce a new linkage of SEER-Medicare and Housing and Urban Development (HUD) administrative data that can be used to examine housing assistance and cancer care and patient outcomes to inform efforts to reduce inequities. Methods: Individuals enrolled in HUD programs 2006-2021 were linked with cancer diagnoses 2006-2019 identified in the SEER-Medicare data from 16 states using Match*Pro probabilistic linkage software. HUD administrative data include timing and type of housing assistance and verified household income. Medicare administrative data are available through 2020. We describe the cohort aged ≥66 years with continuous Medicare fee-for-service Parts A/B coverage surrounding diagnosis who had episodes of housing assistance: 1) at diagnosis or 2) starting within 3 years after diagnosis. Because supply of housing assistance is limited, eligible, low-income families are frequently wait-listed; individuals who receive housing assistance after diagnosis can serve as controls for individuals with housing assistance at diagnosis. Results: Among 42,197 individuals aged ≥66 years diagnosed with cancer and with housing assistance, the most common diagnoses were female breast (n=8,108), lung (n=5,400), colorectal (n=5,197), and prostate (4,548) cancers. Sociodemographic characteristics were similar among the 35,873 individuals with HUD assistance at diagnosis and 6,334 who received it later (Table). Both groups were majority female and non-Hispanic white and with median household income <$14,000. Private multifamily housing programs were the most common form of assistance, followed by housing choice vouchers, and public housing. Conclusions: This novel data linkage will be available through the National Cancer Institute and can be used to explore the ways in which housing assistance is associated with cancer diagnosis and outcomes, including the role of housing assistance in potentially reducing or contributing to inequities across racialized and ethnic groups.[Table: see text]

To assess the impact of the dollar value of federal low-income housing assistance on adult health outcomes and whether this impact varies across housing assistance programs. We use the National Health Interview Survey (NHIS) from 1999 to 2016 linked with administrative records from the Department of Housing and Urban Development (HUD) tracking receipt of low-income housing assistance from 1999 to 2017. We use two approaches to assess the impact of the value of housing assistance among HUD housing assistance recipients on outcomes capturing overall health and mental health, chronic and acute health conditions, health care hardship, and food insecurity. First, we use multivariable regression models that adjust for a wide array of possible confounders. Second, we use an instrumental variable approach in which the county-level supply of HUD housing serves as an instrument for the value of housing assistance. Our sample includes all 12,031 adult HUD linkage-eligible NHIS respondents who were currently in HUD housing at the time of their NHIS interview. We find the most consistent associations between the value of housing assistance and measures of health care hardship, a relationship that is most robust for Housing Choice Voucher recipients, where we find a $100 increase in the value of housing assistance is associated with a 6.2 percentage point decrease in probability of needing but not being able to afford medical care. We find little evidence that the value of housing assistance impacts overall health or chronic health outcomes. The relationship between the value of housing assistance and health likely operates via an income effect, wherein receipt of a more valuable benefit frees up resources to spend on needed care. Policy changes to increase the value of housing assistance may have tangible health benefits for tenants receiving housing assistance.

Although screenings for breast and colorectal cancer are widely recommended, patient screening rates vary greatly and remain below public health targets, and primary care physicians' (PCPs') counseling and referrals play critical roles in patients' use of cancer screenings. Recent adverse events may influence PCPs' decision-making, but it remains unknown whether cancer screening rates of PCPs' patients change after PCPs are exposed to new cancer diagnoses. To investigate whether PCPs' exposures to patients with new diagnoses of breast or colorectal cancer were associated with changes in screening rates for other patients subsequently visiting the affected PCPs. This cohort study used stacked difference-in-differences analyses of all-payer claims data for New Hampshire and Maine in 2009 to 2015. Participants were PCPs caring for patients. Data analysis was performed from June 2020 to May 2022. New diagnosis of a PCP's patient with breast cancer or colorectal cancer. Patients' breast and colorectal cancer screening rates within 1 year of a PCP visit. The sample included 3158 PCPs (1819 male PCPs [57.6%]) caring for 1 920 189 patients (1 073 408 female patients [55.9%]; mean [SD] age, 41.0 [21.9] years) aged 18 to 64 years. During the study period, 898 PCPs had a patient with a new diagnosis of breast cancer and 370 PCPs had a patient with a new diagnosis of colorectal cancer. In the preexposure period, 68 837 female patients (37.3% of those visiting a PCP) underwent breast cancer screening within 1 year of the visit, and 13 137 patients (10.1% of those visiting a PCP) underwent colorectal cancer screening within 1 year of the visit. For both cancer types, after exposure to a new cancer diagnosis, PCPs' cancer screening rates displayed a rapid, sustained increase. Breast cancer screening rates increased by 4.5 percentage points (95% CI, 3.0-6.1 percentage points; P < .001). Colorectal cancer screening rates increased by 1.3 percentage points (95% CI, 0.3-2.2 percentage points; P = .01). Observed breast cancer screening increases were higher for male PCPs than for female PCPs (3.1 percentage points; 95% CI, 0.4-5.8 percentage points; P = .03). This study found significant, sustained increases in cancer screening rates for patients visiting PCPs recently exposed to new breast and colorectal cancer diagnoses. These findings suggest that PCPs may update practice patterns on the basis of recent patient diagnoses. Future work should assess whether salient cues to PCPs about patient diagnoses when clinically appropriate can improve screening practices.

Cancer is the second leading cause of death in the USA, and cardiovascular disease is the second leading cause of morbidity and mortality among cancer survivors. Cancer survivors share common risk factors for cardiovascular disease with non-cancer patients. With improved survival, cancer patients become susceptible to treatment-related toxicity often involving the heart. The impact of concurrent malignancy on outcomes particularly among heart failure patients is an area of active research. We studied the trends in the prevalence of a concurrent diagnosis of breast, prostate, colorectal, and lung cancer among admissions for acute heart failure and the associated trends for in-hospital mortality. Patients aged ≥ 18years who were admitted with a primary diagnosis of "congestive heart failure" (CCS codes 99 and 108) from years 2003 to 2014 were included. We analyzed the rate of admission and in-hospital mortality among patients who had a concurrent diagnosis for either lung cancer, colorectal cancer, breast cancer (among females), or prostate cancer (among males). We performed a multivariate analysis to assess the role of a concurrent diagnosis of any cancer in predicting in-hospital mortality among HF admissions. From 2003 to 2014 across over 12 million HF admissions, ≈ 7% had a concurrent diagnosis of either lung, breast, colorectal, or prostate cancer. The prevalence was highest for breast cancer (2.3%) followed by prostate cancer (2.1%) and colorectal cancer (1.5%) and lowest with lung cancer (1.1%). The prevalence of cancer increased over the duration of study among all four cancer types with the largest increase in prevalence of breast cancer. Baseline comorbidities including hypertension, diabetes, smoking, chronic kidney disease, and coronary artery disease increased over time among patients with and without cancer. In-hospital mortality was higher among those with a diagnosis of lung cancer (5.9%) followed by colorectal cancer (4.0%), prostate cancer (3.5%), no diagnosis of cancer (3.3%), and breast cancer (3.2%). In-hospital mortality declined across HF admissions with and without a cancer diagnosis from 2003 to 2014. Decline in such mortality among heart failure was highest for patients with lung cancer (8.1 to 4.6% from 2003 to 2014; p < 0.001). Multivariate analysis showed that a concurrent diagnosis of cancer was associated with a marginally lower hospital mortality compared with controls (adjusted odds ratio 0.95, 95% confidence interval 0.94-0.96; p < 0.001). Among HF admissions, the prevalence of a concurrent cancer diagnosis increased over time for breast, lung, colorectal, and prostate cancer. Baseline in-hospital mortality was higher among HF admissions with either lung cancer, colorectal cancer, or prostate cancer and lower with breast cancer compared with controls without a cancer diagnosis. Adjusted analysis revealed no evidence for higher hospitalmortality among HF admissions with any accompanying cancer diagnosis.

IntroductionThe linkage of survey data with administrative data enhances the scientific value and analytic potential of both sources of information. Combining multiple data sources facilitates richer analyses and allows data users to answer research questions that cannot be addressed easily using a single data source.&#x0D; Objectives and ApproachRecently, the United States National Center for Health Statistics (NCHS) and Department of Housing and Urban Development (HUD) collaborated to link two population health surveys conducted by NCHS with housing assistance program data maintained by HUD. The resulting linked data files enable researchers to examine relationships between the receipt of federal housing assistance and health. In this talk, we will describe some of the challenges faced when initiating a data sharing agreement between two federal agencies governed by distinct legislative authorities, particularly issues related to legal requirements and data access.&#x0D; ResultsWe will describe each of the data sources used in the linkage as well as the methodology used to combine the data. Lastly, the discussion will focus on the inter-agency collaboration that led to the production of the supporting technical documentation developed to assist researchers using the linked data files. The linkage of NCHS survey data and HUD administrative data serves as an example of how two agencies were able to overcome challenges to successfully form a data sharing partnership as a cost-effective means to develop a robust data source that benefits the collaborating agencies as well as policy makers and outside researchers.&#x0D; Conclusion/ImplicationsBoth agencies anticipate that this partnership will continue as additional survey and administrative data are collected.

Housing insecurity is associated with poor health outcomes. Characterization of chronic disease outcomes among adults with and without housing assistance would enable housing programs to better understand their population's health care needs. We used National Health and Nutrition Examination Survey (NHANES) data from 2005 through 2018 linked to US Department of Housing and Urban Development (HUD) administrative records to estimate the prevalence of obesity, diabetes, and hypertension and to assess the independent associations between housing assistance and chronic conditions among adults receiving HUD assistance and HUD-assistance-eligible adults not receiving HUD assistance at the time of their NHANES examination. We estimated propensity scores to adjust for potential confounders among linkage-eligible adults who had an income-to-poverty ratio less than 2 and were not receiving HUD assistance. Sensitivity analysis used 2013-2018 NHANES cycles to account for disability status. Adults not receiving HUD assistance had a significantly lower adjusted prevalence of obesity (42.1%; 95% CI, 40.4%-43.8%) compared with adults receiving HUD assistance (47.5%; 95% CI, 44.8%-50.3%), but we found no differences for diabetes and hypertension. We found significant associations between housing assistance and obesity (adjusted odds ratio = 1.29; 95% CI, 1.12-1.47), but these were not significant in the sensitivity analysis with and without controlling for disability status. We found no significant associations between housing assistance and diabetes or hypertension. Based on data from a cross-sectional survey, we observed a higher prevalence of obesity among adults with HUD assistance compared with HUD-assistance-eligible adults without HUD assistance. Results from this study can help inform research on understanding the prevalence of chronic disease among adults with HUD assistance.

1628P Impact of COVID-19 pandemia on the diagnosis of breast cancer in one region of north of Portugal: One year experience

rightly point out that currently approved biomarkers have focused on the assessment of single proteins, even though no single biomarker has demonstrated sufficient sensitivity and reproducibility for clinical use in the diagnosis of breast cancer among individuals presumed to be healthy and disease free. Approved biomarkers for the diagnosis of recurrent breast cancer perform rather poorly and are not in routine use in most large centers. The authors cite investigations with autoantibodies and DNA methylation as holding particular promise in biomarker development for the diagnosis of new and recurrent breast cancer. For many years, prostate-specific antigen (PSA) was considered one of the best diagnostic cancer markers, and was part of clinical practice. However, the lack of specificity of PSA as a marker for prostate cancer, combined with the relatively benign nature of prostate cancer progression in many men who develop the disease has led clinicians to question its continued use. Because national bodies such as the US Preventive Services Task Force now recommend against PSA screening for prostate cancer, the research community has searched for other noninvasive markers such as proteins, circulating tumor cells and nucleic acids in the blood or urine of patients with prostate cancer. As Sardana and Diamandis point out, these markers, in combination with PSA, are being evaluated to develop a multiple-biomarker approach to the diagnosis of new and recurrent prostate cancer [2]. Adenocarcinoma of the pancreas (pancreatic cancer) is generally lethal. The reasons for this are many, but certainly one of the most important is late diagnosis. Survival is rare in the absence of early diagnosis, yet >50% of individuals with very small lesions confined to the pancreas are alive 5 years after diagnosis. Indeed, as Batra et al. point out, pancreatic cancers on average have a relatively long time There has been measurable progress in personalizing the treatment of adult malignancies. Once the diagnosis of cancer is made and the tumor is available, it can be genotyped and phenotyped to optimize the intervention that will be administered. Moreover, large-scale assessment of tumors has allowed the development of targeted therapies based on the mutations that drive tumor progression. Far less progress has been made in the development of biomarkers for the diagnosis of new or recurrent cancer. Perhaps this is not surprising, given the multitude of mutational and epigenetic events that can occur during cancer development and progression. In this issue of Biomarkers in Medicine, we review the state of the science in biomarker development for breast, ovarian, prostate and pancreatic cancer. Tang and Gui review the current state of breast cancer biomarker research, and future directions [1]. They present four principal areas of promise from biomarker development� combining new with established markers to optimize cancer diagnosis; using biomarkers for the early determination of treatment response and disease recurrence/survival; guiding therapy; and facilitating the identification of the most promising drug candidates for therapeutics worthy of further development. The articles in this themed issue focus on the first and second areas� the diagnosis of new and recurrent cancer. The authors review several serum and tissue markers that have been identified as clinically useful in the management of patients with breast cancer. One major advantage of biomarker research for individuals with cancer is the presence of tumor tissue for analysis, which is not present in individuals without such a diagnosis. Tissue sampling in the absence of a suspicion of cancer is difficult to justify. For this reason, body fluid analysis holds greater promise in biomarker development for individuals without the presence of a lesion that requires biopsy. The authors Foreword

To compare blood lead levels (BLLs) among US children aged 1 to 5 years according to receipt of federal housing assistance. In our analyses, we used 2005 to 2012 data for National Health and Nutrition Examination Survey (NHANES) respondents that were linked to 1999 to 2014 administrative records from the US Department of Housing and Urban Development (HUD). After we restricted the analysis to children with family income-to-poverty ratios below 200%, we compared geometric mean BLLs and the prevalence of BLLs of 3 micrograms per deciliter or higher among children who were living in assisted housing at the time of their NHANES blood draw (n = 151) with data for children who did not receive housing assistance (n = 1099). After adjustment, children living in assisted housing had a significantly lower geometric mean BLL (1.44 µg/dL; 95% confidence interval [CI] = 1.31, 1.57) than comparable children who did not receive housing assistance (1.79 µg/dL; 95% CI = 1.59, 2.01; P < .01). The prevalence ratio for BLLs of 3 micrograms per deciliter or higher was 0.51 (95% CI = 0.33, 0.81; P < .01). Children aged 1 to 5 years during 2005 to 2012 who were living in HUD-assisted housing had lower BLLs than expected given their demographic, socioeconomic, and family characteristics.

To investigate whether receiving US Department of Housing and Urban Development (HUD) housing assistance is associated with improved access to health care, we analyzed data on nondisabled adults ages18-64 who responded to the 2004-12 National Health Interview Survey that were linked with administrative data from HUD for the period 2002-14. To account for potential selection bias, we compared access to care between respondents who were receiving HUD housing assistance at the time of the survey interview (current recipients) and those who received HUD assistance within twenty-four months of completing the survey interview (future recipients). Receiving assistance was associated with lower uninsurance rates: 31.8percent of current recipients were uninsured, compared to 37.2percent of future recipients. Rates of unmet need for health care due to cost were similarly lower for current recipients than for future recipients. No effect of receiving assistance was observed on having a usual source of care. These findings provide evidence that supports the effectiveness of housing assistance in improving health care access.