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We’re talking about housing for four weeks, thanks to the support of the RWJF! The Low Income Housing Tax Credit (last week’s episode topic) stimulates production in order to increase the supply of affordable housing available to poorer people in the United States. But there’s another way to tackle our housing problem, and that’s by targeting /demand/ by giving people vouchers to help them pay for housing and assisting them to move to higher opportunity neighborhoods. While helping people with their rent can be helpful, the real benefits start to accrue when people move to neighborhoods with more opportunity. Vouchers alone don't insure that outcome.

Rebecca Gale wrote about this in a recent Health Affairs Policy Brief. It’s also the topic of this week’s HCT.

Resources used in the making of this episode:
-Housing Mobility Programs And Health Outcomes: https://tinyurl.com/y79c3aox
-HOUSING CHOICE VOUCHERS FACT SHEET: https://tinyurl.com/y92l4ts6
-One in four: America’s housing assistance lottery: https://tinyurl.com/yxobb4j4
-ICP’s Apartment Survey Results: https://tinyurl.com/y6qn9hxo
-A Guide to Small Area Fair Market Rents (SAFMRs): https://tinyurl.com/y4v5a8b4
-Realizing the Housing Voucher Program’s Potential to Enable Families to Move to Better Neighborhoods: https://tinyurl.com/y5qns63e
-Housing mobility – coming to a PHA near you?: https://tinyurl.com/y3aapx9g

Related HCT episodes:
https://www.youtube.com/watch?v=zNzFnHL-8Zk&list=PLkfBg8ML-gIn1gcQ1IczJ-DjWYA4hSLHN&index=2&t=0s

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Credits:
John Green -- Executive Producer
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Today, we're continuing our series on affordable housing, and we're picking up where we left off last week. The Low Income Housing Tax Credits stimulate production in order to increase the supply of affordable housing available to poorer people in the United States. But, there's another way to tackle our housing problem, and that's by targeting demand by giving people vouchers to help them pay for housing and assisting them to move to higher opportunity neighborhoods. Rebecca Gale wrote about this in a recent Health Affairs policy brief. It's also the topic of this week's Healthcare Triage.

[Intro]

As we'd discussed in our first episode a couple of weeks ago, people who live in areas where there's a high concentration of poverty have an increased risk of premature mortality, heart disease, obesity, serious mental illness, suicide, unemployment, dropping out of school, and poor overall health in general.

In 1974, the federal Housing Choice Voucher program was begun. It was originally known as "Section 8," and that's how some still refer to it. The program provides vouchers to beneficiaries and covers enough so that most need to pay only 30% of their income on housing. This is not an entitlement program. Not everyone who qualifies for the program gets it. There are limited vouchers, and that means that only a small percentage, likely less than a quarter, of those who could use assistance get it.

The biggest problem historically is that while getting a voucher is great, most people could only use them to stay in the same neighborhoods they were already in. Research shows that having housing is necessary but not sufficient. Community matters, too.

Enter the Moving to Opportunity for Fair Housing (or MTO) demonstration and study. From 1994 to 1998, more than 4,600 families entered the program, which was based in LA, Chicago, Baltimore, New York City, and Boston. Those families had to have at least one child and live in a high-poverty area in public housing. 

Those families were randomized to one of three groups. The first received a voucher that could only be used to subsidize their rent in low-poverty areas, plus counseling and support in getting housing. The second received a voucher that could be used anywhere, but no counseling or support. The third got no vouchers and no certificate, but they were still eligible for whatever program, services, and project based assistance for which they qualify.

Most of the household consisted of people of minority race or ethnicity. Most were headed by women. Most had 2 or 3 children, and most of the households had no members who had graduated from high school.

Let's pause and acknowledge how hard it is to do these kinds of studies. They are super difficult. They are very expensive and real follow-up of real outcomes takes an impossibly long time. But, these researchers did it in a randomized controlled trial! And, now we've got results!

Some top line outcomes. At the end of the program, fewer than half of those in group one (who could only use their vouchers in low-poverty areas) had actually moved. This speaks to the difficulty of finding housing in low-poverty areas. But still, 47% of households moved to better areas.  In group two (who could use their voucher anywhere), 62% of people moved, likely because it was easier to find available housing in poorer places. And more people moved in either of these groups than in the third group, which received no support.

No matter what type of vouchers they were given, people who were given support to move wound up in neighborhoods that had lower poverty rates. In the year after the intervention, they were in tracts where the poverty rate was 11 to 13 percent lower. Even many years later, they were still in areas with rates 7 to 9 percent lower.

But, it's in health outcomes that the moves to better neighborhoods really shine. More than a decade after the study began, adults who were in group one saw the prevalence of diabetes drop 5.2%, severe obesity drop 3.4%, and physical limitations drop 4.8%. Those in group two also some benefits in obesity prevalence, but not in diabetes. 

We wish there were more data, but, unfortunately, this wasn't set up as a health study. We only have self-report stuff. So, for harder data, we have to look at education and financial results, and they exist. The kids who were in group one households, who moved at a young age, were 32% more likely to go to college. They had 31% higher average earnings each year. They were less likely to be single parents. And, all of these things were good.

This was a randomized controlled trial. Moving to a better neighborhood made a huge difference in these kids' lives. Arguably, more than almost any other intervention I can think of.

There's some issues with the federal programs. Vouchers only allow you 2 to 4 months to find housing. If you don't find it, you can lose them. Second, a lot of states don't prohibit landlords from preferentially choosing from renters who don't have vouchers. Third, voucher values are typically based on average rent in a city, so they don't always cover rental costs in better neighborhoods. Fourth, voucher program rules can also put geographic limitations on where people can move, and that can cause problems, too. 

Sometimes, better neighborhoods have less public transportation. They may have more social restrictions, and they may be farther from jobs. They may also be unwelcoming to new neighbors from different life circumstances or who are of a different race. Families using vouchers may have a hard time feeling accepted, which was born out in some of the MTO findings focusing on adolescents. Those downsides can outweigh families' desires for better schools.

There are things we could do to make this work better. Fixes could include:
  • Antidiscrimination laws
  • Small area fair market rent rules (which would allow vouchers to cover rents in high-opportunity areas more effectively)
  • Better incentives for housing agencies to achieve better location outcomes
  • Support for renters and landlords in mobility programs to increase their chances of success.

There are also some local programs in the United States that have been successful. The Inclusive Communities Project in Dallas, funded through a huge settlement from a housing segregation lawsuit, provides vouchers. The Mobility Works Consortium, which includes groups and agencies in Baltimore, Chicago, Dallas, St. Louis, Milwalkee, Richmond, Charlotte, and more, works to get mobility programs going in metropolitan areas. Such efforts are usually funded by private foundations.

There's also reason for optimism. Congress recently approved a 28 million dollar housing mobility competitive grants program as part of the bipartisan 2019 HUD budget. This could fund more than a dozen housing mobility programs, additional Housing Choice Vouchers, and research, so that we can learn more about how this all works in the real world. 

No one disputes that vouchers work. They're necessary, but not sufficient, though. Supply matters, too. More on that next week.

[Outro]

Did you like this episode? You should watch the whole series. So, click this link to see the whole playlist for everything.

While we've got you, go to Patreon.com/HealthcareTriage to support the show. We'd especially like to thank our research associate, Joe Sevits, and our surgeon admiral, Sam.