Paper of the Year 2024: Investigating the Long-Term Health Impacts of the Moving to Opportunity Study
Aug 16, 2024
Article: “Using the Moving to Opportunity Experiment to Investigate the Long-Term Impact of
Neighborhoods on Healthcare Use by Specific Clinical Conditions and Type of Service”
Published Online: 10 Sept 2021
Authors: Craig Evan Pollack, Debra G. Bozzi, Amanda L. Blackford, Stefanie DeLuca, Rachel L. J. Thornton & Bradley Herring
DOI: https://doi.org/10.1080/10511482.2021.1951804
Researchers have long been interested in the links between housing and neighborhoods and life outcomes, including health (Schwartz, 2021; Bergman et al., 2020; Weismann, Rolfe, Kye, & Knudsen, 2020). One experiment in particular has been groundbreaking in enabling researchers to tease out the benefits of living in low-poverty neighborhoods. The Moving to Opportunity (MTO) study, conducted in the 1990s, has long been recognized for its rigorous experimental design (Sanbonmatsu, Ludwig, & Katz, 2011). Starting in 1994, the U.S. Department of Housing and Urban Development (HUD) randomly assigned 4,600 low-income families living in public housing in Baltimore, Boston, Chicago, New York, and Los Angeles to one of three groups: one group receiving a section 8 voucher for housing that could only be used in a low-poverty neighborhood, one group receiving a section 8 voucher for housing without restrictions on neighborhood destination, and a control group.
The results of the experiment were complex. With respect to health, follow-up surveys with MTO participants suggested that vouchers were associated with positive health outcomes through reductions in obesity and diabetes and improvements in mental health (though these varied by gender). However, health outcomes that are self-reported via surveys may be subject to inaccuracy or bias. The surveys also captured mainly short-term health impacts rather than long-term ones. Craig Evan Pollack, Debra G. Bozzi, Amanda L Blackford, Stefanie DeLuca, Rachel J. Thornton and Bradley Herring’s “Using the Moving to Opportunity Experiment to Investigate the Long-Term Impact of Neighborhoods on Healthcare Use by Specific Clinical Conditions and Type of Service” study helps to fill these research gaps. Their study, which won Housing Policy Debate’s Paper of the Year Award for the 2023 volume, uses 21 years’ worth of hospital discharge and Medicaid data to analyze the relationship between moves to lower-poverty neighborhoods and long-term health outcomes.
Methods
Researchers used participants’ Social Security numbers to link their MTO data to state all-payer hospitals and emergency department data, and Medicaid data for inpatient, emergency department, and outpatient services, as well as program enrollment. They used binomial regression models to investigate not just the link between receiving a voucher and overall hospitalizations and services, but also the relationship with the specific conditions being treated, in order to understand the effect of neighborhood moves on health outcomes that may plausibly be linked to housing (such as asthma, injury, mental health, diabetes, obesity, and hypertension). Further, they broke the MTO sample into adults, older children, and younger children at the time of randomization in order to understand whether the treatment affected different age groups differently. Finally, the authors performed additional analyses to understand the magnitude of their findings, that is, how much a 10-percentage-point decrease in neighborhood poverty levels would be predicted to affect healthcare use outcomes.
Findings
The research team found no significant difference amongst adults in the voucher group compared to the control group for hospital and emergency department visits when housing-sensitive conditions were the primary diagnosis. However, they did find a decrease in hospital and emergency room visits for children from the voucher group compared to the control group for asthma and for mental health. Regarding Medicaid service use, the researchers again found no significant difference among adults who did and did not receive a voucher but detected a significant difference among children with respect to psychiatric services, outpatient hospital services, clinic services, and durable medical equipment.
A ten-point reduction in neighborhood poverty level was associated with 25% lower rates of mental health related hospitalizations for children. Adults who moved to less poor neighborhoods were less reliant on transportation services, and children were less reliant on clinic services and durable medical equipment.
Conclusion
These findings, the researchers write, are crucial for understanding the health benefits for children whose families are able to move to higher income neighborhoods, and shed light on the importance of early childhood interventions for asthma and mental health on an environmental and neighborhood level. The findings also support the idea that initiatives promoting family mobility can slightly lessen strain upon tax-payer funded healthcare programs. The researchers advise that as Medicaid programs increasingly expand coverage to housing-related services, they should also consider the potential health benefits of mobility counseling and related programs.
Citations:
Bergman, P., Chetty, R., DeLuca, S., Hendren, N., Katz, L., & Palmer, C. (2019). Creating moves to opportunity: Experimental evidence on barriers to neighborhood choice. Cambridge, MA: National Bureau of Economic Research. Retrieved from https://www.nber.org/papers/w26164
Google Scholar
Ludwig, J., Duncan, G. J., Gennetian, L. A., Katz, L. F., Kessler, R. C., Kling, J. R., & Sanbonmatsu, L. (2012). Neighborhood effects on the long-term well-being of low-income adults. Science, 337(6101), 1505–1510.
Sanbonmatsu, L., Ludwig, J., Katz, L. F., Gennetian, L. A., Duncan, G. J., Kessler, R. C., Adam, E., McDade, T. W., & Lindau, S. T. (2011). Moving to Opportunity for fair housing demonstration program—final impacts evaluation. Washington, DC: U.S. Department of Housing and Urban Development. Retrieved from https://www.huduser.gov/publications/pdf/MTOFHD_fullreport_v2.pdf.Published
Google Scholar
Schwartz, A. F. (2021). Housing policy in the United States. New York: Routledge.
Weismann, G., Rolfe, N., Kye, P., & Knudsen, B.; Housing Mobility Programs in the U.S. (2020). PRRAC. Retrieved from https://prrac.org/pdf/housing-mobility-programs-in-the-us-2020.pdf
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Google Scholar
Aug 16, 2024
Article: “Using the Moving to Opportunity Experiment to Investigate the Long-Term Impact of
Neighborhoods on Healthcare Use by Specific Clinical Conditions and Type of Service”
Published Online: 10 Sept 2021
Authors: Craig Evan Pollack, Debra G. Bozzi, Amanda L. Blackford, Stefanie DeLuca, Rachel L. J. Thornton & Bradley Herring
DOI: https://doi.org/10.1080/10511482.2021.1951804
Researchers have long been interested in the links between housing and neighborhoods and life outcomes, including health (Schwartz, 2021; Bergman et al., 2020; Weismann, Rolfe, Kye, & Knudsen, 2020). One experiment in particular has been groundbreaking in enabling researchers to tease out the benefits of living in low-poverty neighborhoods. The Moving to Opportunity (MTO) study, conducted in the 1990s, has long been recognized for its rigorous experimental design (Sanbonmatsu, Ludwig, & Katz, 2011). Starting in 1994, the U.S. Department of Housing and Urban Development (HUD) randomly assigned 4,600 low-income families living in public housing in Baltimore, Boston, Chicago, New York, and Los Angeles to one of three groups: one group receiving a section 8 voucher for housing that could only be used in a low-poverty neighborhood, one group receiving a section 8 voucher for housing without restrictions on neighborhood destination, and a control group.
The results of the experiment were complex. With respect to health, follow-up surveys with MTO participants suggested that vouchers were associated with positive health outcomes through reductions in obesity and diabetes and improvements in mental health (though these varied by gender). However, health outcomes that are self-reported via surveys may be subject to inaccuracy or bias. The surveys also captured mainly short-term health impacts rather than long-term ones. Craig Evan Pollack, Debra G. Bozzi, Amanda L Blackford, Stefanie DeLuca, Rachel J. Thornton and Bradley Herring’s “Using the Moving to Opportunity Experiment to Investigate the Long-Term Impact of Neighborhoods on Healthcare Use by Specific Clinical Conditions and Type of Service” study helps to fill these research gaps. Their study, which won Housing Policy Debate’s Paper of the Year Award for the 2023 volume, uses 21 years’ worth of hospital discharge and Medicaid data to analyze the relationship between moves to lower-poverty neighborhoods and long-term health outcomes.
Methods
Researchers used participants’ Social Security numbers to link their MTO data to state all-payer hospitals and emergency department data, and Medicaid data for inpatient, emergency department, and outpatient services, as well as program enrollment. They used binomial regression models to investigate not just the link between receiving a voucher and overall hospitalizations and services, but also the relationship with the specific conditions being treated, in order to understand the effect of neighborhood moves on health outcomes that may plausibly be linked to housing (such as asthma, injury, mental health, diabetes, obesity, and hypertension). Further, they broke the MTO sample into adults, older children, and younger children at the time of randomization in order to understand whether the treatment affected different age groups differently. Finally, the authors performed additional analyses to understand the magnitude of their findings, that is, how much a 10-percentage-point decrease in neighborhood poverty levels would be predicted to affect healthcare use outcomes.
Findings
The research team found no significant difference amongst adults in the voucher group compared to the control group for hospital and emergency department visits when housing-sensitive conditions were the primary diagnosis. However, they did find a decrease in hospital and emergency room visits for children from the voucher group compared to the control group for asthma and for mental health. Regarding Medicaid service use, the researchers again found no significant difference among adults who did and did not receive a voucher but detected a significant difference among children with respect to psychiatric services, outpatient hospital services, clinic services, and durable medical equipment.
A ten-point reduction in neighborhood poverty level was associated with 25% lower rates of mental health related hospitalizations for children. Adults who moved to less poor neighborhoods were less reliant on transportation services, and children were less reliant on clinic services and durable medical equipment.
Conclusion
These findings, the researchers write, are crucial for understanding the health benefits for children whose families are able to move to higher income neighborhoods, and shed light on the importance of early childhood interventions for asthma and mental health on an environmental and neighborhood level. The findings also support the idea that initiatives promoting family mobility can slightly lessen strain upon tax-payer funded healthcare programs. The researchers advise that as Medicaid programs increasingly expand coverage to housing-related services, they should also consider the potential health benefits of mobility counseling and related programs.
Citations:
Bergman, P., Chetty, R., DeLuca, S., Hendren, N., Katz, L., & Palmer, C. (2019). Creating moves to opportunity: Experimental evidence on barriers to neighborhood choice. Cambridge, MA: National Bureau of Economic Research. Retrieved from https://www.nber.org/papers/w26164
Google Scholar
Ludwig, J., Duncan, G. J., Gennetian, L. A., Katz, L. F., Kessler, R. C., Kling, J. R., & Sanbonmatsu, L. (2012). Neighborhood effects on the long-term well-being of low-income adults. Science, 337(6101), 1505–1510.
Sanbonmatsu, L., Ludwig, J., Katz, L. F., Gennetian, L. A., Duncan, G. J., Kessler, R. C., Adam, E., McDade, T. W., & Lindau, S. T. (2011). Moving to Opportunity for fair housing demonstration program—final impacts evaluation. Washington, DC: U.S. Department of Housing and Urban Development. Retrieved from https://www.huduser.gov/publications/pdf/MTOFHD_fullreport_v2.pdf.Published
Google Scholar
Schwartz, A. F. (2021). Housing policy in the United States. New York: Routledge.
Weismann, G., Rolfe, N., Kye, P., & Knudsen, B.; Housing Mobility Programs in the U.S. (2020). PRRAC. Retrieved from https://prrac.org/pdf/housing-mobility-programs-in-the-us-2020.pdf
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