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Health Equity: Tenant-Based Housing Voucher Programs

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 7 studies in 20 publications (search period January 1999 to July 2019).

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to health equity and housing. This finding updates and replaces the 2001 CPSTF recommendation for Tenant-Based Rental Assistance Programs pdf icon [PDF - 664 KB].

Context

Housing is an established social determinant of health (Fullilove 2010, Healthy People 2030). In the United States, housing quality, housing security, and neighborhood characteristics have been associated with health and health-related outcomes (Alley et al. 2009; Cutts et al. 2011; Chetty 2016).

The U.S. Department of Housing and Urban Development (HUD) administers the Housing Choice Voucher External Web Site Icon program—a tenant-based voucher program designed to assist households with very low incomes. HUD conducted a ten-year randomized study—the Moving to Opportunity experiment—to assess the effectiveness of tenant-based voucher programs for households living with at least one child under the age of 18. The experiment provided pre-move counseling and required households to move to low poverty neighborhoods. Both the Housing Choice Voucher program and the Moving to Opportunity experiment are included in this review.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 7 studies.

Households who used vouchers experienced the following outcomes when compared with households who were eligible, but not offered, assistance from voucher programs.

Housing quality:

  • 7.9 percentage point increase in the proportion of adults who rated housing conditions as excellent or good (2 studies, 3 study arms)
  • 35.5 percentage point decrease in housing insecurity (1 study)

Income:

  • 6.7 percentage points decrease in the proportion of households living at or below the poverty line (2 studies, 3 study arms)
  • 7.2 percentage point decrease in the proportion of households who had difficulties securing enough food (2 studies, 3 study arms)

Health:

  • 4.0 percentage point decrease in the proportion of adults who reported one of five conditions (asthma, obesity, diabetes, high blood pressure, mobility limitation; 1 study, 2 study arms)
  • 3.4 percentage point decrease in the proportion of adults with a mental health condition (1 study, 2 study arms)
  • 1.6 percentage point decrease in youth asthma-related emergency department use (1 study)
  • 4.1 percentage point decrease in the proportion of adults with unmet medical needs (3 studies, 4 study arms)

Children who were aged 12 years or younger when their families joined the voucher program experienced the following outcomes during adulthood when compared to their counterparts who did not enter the program.

  • 3.4 percentage point increase in the proportion attending college (1 study)
  • 3.0 percentage point increase in the proportion employed (1 study)
  • 20.6% increase in income (1 study)

Children aged 13-18 years when their families joined the voucher program experienced the following outcomes during adulthood when compared to their counterparts who did not enter the program.

  • 7.9 percentage point decrease in the proportion attending college (1 study)
  • 4.0 percentage point decrease in the proportion employed (1 study)
  • 1% increase in income (1 study)

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

A systematic review of economic evidence shows the societal benefits of Moving to Opportunity (MTO)-type housing voucher programs exceed the societal cost. MTO-type programs provide vouchers and counseling to households with young children living in public housing and move them to neighborhoods with greater opportunities. The cost-benefit evidence was mixed for housing voucher programs alone.

The economic review included 27 studies from the United States (search period 1980 to November 7, 2020). Studies evaluated housing voucher programs used alone (21 studies), MTO-type programs (12 studies), or both (6 studies).

Intervention cost

MTO-type programs (compared with public housing)

  • Taxpayer cost reduced by $8 to $52 for every $100 of program spending per year by offering vouchers for rental units in the private market instead of offering rental units in public housing (6 studies)

Housing voucher program used alone (compared with no housing assistance)

  • Taxpayer cost per household per year increased: $3,145; $7,697; $14,927 (3 studies)

Intervention benefits

MTO-type programs (compared with public housing)

On balance, total economic benefits for MTO-type housing voucher programs increased from employment income, consumption of housing, and reduced use of other assistance programs.

Housing voucher programs used alone (compared with public housing, no housing assistance, or no comparison group)

It was unclear whether there was an increase or decrease for the sum of economic benefits for the housing voucher programs used alone because the direction of change is mixed for employment, use of other assistance programs, and neighborhood property values.

Cost-effectiveness

MTO-type programs (compared with public housing)

  • The lifetime net cost was a reduction of $7,448 per person and quality adjusted life year gained was 0.23 per person due to averted obesity and diabetes, indicating cost-savings with positive health benefit (1 study)

Housing voucher programs used alone

  • None of the included studies reported this information.

Cost-benefit

MTO-type programs (compared with public housing)

  • Cost savings for taxpayers was $9,215 per household and the societal economic benefit was $69,601 per household over the lifetime, indicating societal cost-savings (1 study)

Housing voucher programs used alone had mixed results (compared with no housing assistance)

  • The societal cost was $9,012 per household and societal benefit was $10,882 per household over a period of 1 year, indicating benefit exceeded cost (1 study)
  • Cost to taxpayer per household and societal benefits per household: $27,376 in cost and $24,912 in benefit over 8 years; $10,660 in cost and $6,958 in benefit over 1 year, indicating cost exceeded benefit (2 studies)

Applicability

Based on results for interventions in different settings and populations, the finding should be applicable to families with low incomes who are living in urban areas.

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

  • How would the following policies influence the effectiveness of tenant-based housing voucher programs?
    • Source of income laws
    • Small Area Fair Market Rent laws
    • Inclusive zoning policies
  • How would the following program factors influence the effectiveness of tenant-based housing voucher programs?
    • Allowing more time for a housing search
    • Recruitment and education of landlords to the voucher programs
    • Assistance for voucher users to move to high-opportunity areas (e.g. pre-move counseling)
    • Short-term payments to cover initial move expenses
  • Young males whose families used vouchers reported worse physical and mental health outcomes than did their counterparts in comparison groups. What is needed to better address the underlying causes of these outcomes? What additional services might be offered to support young men in housing voucher programs?
  • What is the program cost for public housing?
  • What is the program cost for tenant-based housing voucher programs?
  • What is the cost-effectiveness of these programs based on improvements in mental health and wellbeing?
  • How do programs affect the economic condition of neighborhoods participants move out of?

Study Characteristics

  • Studies were conducted in urban communities across the United States.
  • All studies examined the HUD Housing Choice Voucher program. One study also examined the Moving to Opportunity experiment.
  • Most households were headed by females (92%, 5 studies). Among studies that reported race or ethnicity, a median of 44% of participants were Black or African American (4 studies), and a median of 23% were Hispanic or Latino (5 studies).
  • Study designs included individual randomized control trials (3 studies), prospective cohorts using data from databases (3 studies), and a cross-sectional comparison of Housing Choice Voucher program users to other renters with low incomes (1 study).