Social Determinants of Health: Tenant-Based Housing Voucher Programs
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends tenant-based housing voucher programs to improve health and health-related outcomes for adults based on sufficient evidence of effectiveness. Health-related outcomes include housing quality and security, healthcare use, and neighborhood opportunities (e.g., lower poverty level, better schools).
Children ages 12 years and younger whose households use vouchers show improvements in education, employment, and income later in life. Outcomes for adolescents vary by sex. Females 10-20 years of age whose families use tenant-based vouchers to live in lower poverty neighborhoods experience better health outcomes while males of the same age experience worse physical and mental health outcomes. Additional research is needed to better understand and address challenges faced by adolescent males.
CPSTF finds societal benefits exceed the cost of tenant-based housing voucher programs that serve families with young children who are living in public housing, provide pre-move counseling, and move families to neighborhoods with greater opportunities.
Tenant-based housing voucher programs give many people access to better housing and neighborhood opportunities, both of which are considered social determinants of health. Because these programs are designed for households with low incomes, they are expected to advance health equity.
The full CPSTF Finding and Rationale Statement and supporting documents for Social Determinants of Health: Tenant-Based Housing Voucher Programs are available in The Community Guide Collection on CDC Stacks.
Intervention
Tenant-based housing voucher programs help households with very low incomes afford safe and sanitary housing in the private market. Vouchers are tied to households rather than specific housing units, so that households can use vouchers to move to neighborhoods with greater opportunities. Tenant-based housing voucher programs pay a substantial portion of the rent, which leaves households with money to cover other needs.
Tenant-based housing voucher programs may vary in the following ways:
- Eligibility criteria (e.g., family income level)
- Rental process (e.g., time allowed to find and rent a property)
- Assistance (e.g., counseling in finding rentals)
- Relocation requirements (e.g., housing in low-poverty neighborhoods)
- Availability of short-term payments for initial expenses (e.g., rental deposits)
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.
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).
Summary of Results
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
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).
Intervention cost: MTO-type programs (compared with public housing): Taxpayer cost reduced by $8 to $52 for every $100 of program spending per year (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).
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).
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.
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
- 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?
Implementation Considerations and Resources
- Voucher programs could reduce barriers to participation for eligible households by giving them more time to search for and arrange housing (i.e., more than 60 days), offering intensive pre-move counseling, providing short-term financial assistance to cover initial moving expenses, or recruiting landlords to participate in the program (Bergman et al. 2020)
- State and local source of income laws or ordinances could be enacted to address market constraints by prohibiting discrimination against renters based on the source of their income
- Establishing voucher amounts at the neighborhood level rather than metropolitan rental level would allow vouchers to pay more in high-rent neighborhoods. This policy, known as Small Area Fair Market Rents, can increase the number of available rental units in high-opportunity neighborhoods (Dastrup et al. 2018)
- The CPSTF suggests research is needed to identify effective individual, community, and societal-level interventions to support male youth in new environments
Crosswalks
Healthy People 2030 includes the following objective related to this CPSTF recommendation.