Spotlight Exclusives

The Missing Pieces: Housing, Health, and the Moving to Opportunity Experiment

Thomas D. Cook, Northwestern University Thomas D. Cook, Northwestern University, posted on

As chronic health worsens nationally, the role housing plays in health is more important than ever. The good news is that a recent study published in The New England Journal of Medicine has shown that housing can make a real difference in health.

Unfortunately, the study’s results alone are inadequate to guide policy. We must also develop a future research agenda that takes into account other important realities facing low-income families who receive housing vouchers.

The recently published Moving to Opportunity (MTO) experiment was designed to compare life in public housing where about half of the households were poor to life in neighborhoods where at most ten percent were poor. Public housing families were offered a housing voucher on the condition they moved to a radically more affluent neighborhood for at least one year. About half of the randomly assigned MTO families moved into better physical units in neighborhoods with fewer poor families, less crime, and less fear of crime.

The results are heartening for families offered the chance to move. Extreme obesity and diabetes decreased in adults and anxiety and depression decreased among youths. When the analysis was limited to those who actually moved, the diabetes and extreme obesity effects roughly doubled in size.

Yet the study failed to uncover effects on any of the outcomes considered highest priority at the study outset—labor force participation, welfare use, and educational performance.

Crime results were also unclear. After moving, MTO adults were victimized less, but adult youths committed more crimes.

Despite these uncertainties, the MTO health results provide a welcome relief and suggest that voucher-based housing mobility programs may have their biggest impact in promoting better health.

Yet several factors limit the relevance of MTO to the most central aspects of current policy about housing mobility.

First, the study targeted public housing residents, a small fraction of all voucher eligible families.

Second, restricting mobility to very affluent neighborhoods is limiting because affordable rental housing is scarce in such communities. The number of poor families wanting to move to them is probably also limited. About half of the MTO voucher families ultimately did not move though offered the chance to do so. Of those that did move, most wound up in settings similar those in which control group without vouchers settled.

Third, MTO did not take into account some critical income effects. Only families in the private market are able to use their voucher to offset their current out-of-pocket rental expenses, thus increasing their disposable income. For public housing residents, they must consume the voucher for rent in the private sector.

By limiting itself to public housing residents, MTO ruled out disposable income as a causal mechanism affecting health and focused instead on neighborhood affluence. Yet most voucher holders are in the private housing market when they get a voucher, and evidence suggests they use most of it to augment their income rather than to upgrade their homes or neighborhoods.

Fourth, although MTO demonstrated a real impact of housing on health, the health-related elements of the research design seem incomplete. They failed to report all of the biomarker data collected from saliva and dried blood, collected only at the study’s end when health issues had finally emerged as central in MTO.

Fifth, MTO did not report health results for children despite the fact that past, non-experimental work has led to claims about lead paint, dust, and mites causing child respiratory problems. Additionally, other studies have shown that biomarkers can change in children as young as two in response to family stressors linked to the location of housing and household income.

Researchers would do well to ask themselves how much health is affected, both by the real but limited neighborhood moves and unit upgrades that most voucher holders already in the private housing market make, and by the sometimes large income supplements these families also experience thanks to a voucher.

Existing research can provide some clues here, but little more. Since most families convert most of their voucher’s value into disposable income, vouchers will likely affect health in the same way that sudden income shocks promote health. Studies have shown that income shocks equivalent to the monetary value of a voucher can improve some indicators of mental health and body mass. Income changes can also influence biological processes, specifically those linked to blood pressure, cardiovascular disease, obesity, and diabetes.

The MTO experiment has begun to seed a health-based rationale for housing mobility programs—a good thing for the field. Yet such a case would be even more compelling if the next generation of research could go beyond MTO.

MTO achieved what it set out to do for public housing residents.  Now is the time to learn how vouchers affect health in adults and children in the majority of voucher-holding families—those already in private housing when they get a voucher.

Tom Cook is the Joan and Sarepta Harrison Chair in Ethics and Justice, a professor of sociology, psychology, education, and social policy at Northwestern University, and a faculty fellow at the Institute for Policy Research.

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