Exclusive Commentary

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

Thomas D. Cook, Northwestern University - Posted December 5, 2011


In collaboration with the John D. and Catherine T. MacArthur Foundation’s How Housing Matters Initiative, Spotlight on Poverty and Opportunity will be running a series of commentaries for the next two months exploring the relationship between housing and three topics: health, economic opportunity, and education. Please be sure to read Michael Stegman’s “An Introductory Note to learn more.

This commentary is the fourth installment in the series, which is entitled “How Housing Matters to Families and Communities.”

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.

Although the study represents a big step forward, a more expansive research agenda could achieve even more.

The recently published Moving to Opportunity (MTO) experiment was designed to compare living in neighborhoods where about half of the households are poor to those where at most ten percent are poor. To do this, public housing families were offered a housing voucher on the condition they moved to a radically more affluent neighborhood for 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 study’s health results are heartening. For families offered the chance to move, extreme obesity and diabetes decreased in adults over a 10-year period. In analysis limited to those who actually moved, these two effects roughly doubled in size and decreases were observed in anxiety and depression among youths.

However, the study failed to uncover positive effects on labor force participation, welfare use, and educational performance and the crime results were unclear. After moving, MTO adults were victimized less, but adult youths committed more crimes.

The positive health results provide a welcome relief and suggest that voucher-based housing mobility programs may have their biggest impact, and best justification, in promoting health.

Yet several factors limit the relevance of MTO for justifying a health rationale for housing voucher policy.

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

Second, scaling-up the results could be difficult because affordable rental housing is scarce in very affluent neighborhoods and few poor families seem to want to make such radical moves. About half of the MTO voucher families ultimately did not move though offered the chance to do so. Of those that did move, within a decade most had relocated to settings similar to those in which control group families without vouchers finished up.

Third, MTO did not take into account some critical income effects. 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. But public housing residents have to use their entire voucher for rent in the private sector.

In limiting itself to public housing residents, MTO ruled out disposable income as a mechanism for improving health and instead emphasized neighborhood poverty. Yet most families getting a voucher are already in the private housing market, and evidence suggests that they use most of their voucher’s value to augment income rather than upgrade dwellings or neighborhoods.  

Fourth, while the medical research and policy communities appreciate biological measures, these were only collected once in MTO. One biomarker related to obesity and diabetes showed positive results, but the study fails to report others although information was collected on a number of other biomarkers associated with cardiovascular problems, including diabetes.

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 because of family stressors linked to household income and the location of housing.

Researchers need to learn how much child and adult health are affected, both by the real but limited neighborhood moves and unit upgrades that most voucher winners from the private housing market make, and also by the sometimes large income supplements a voucher allows.

Existing research provides some promising clues. MTO shows neighborhood effects on health, albeit with neighborhood moves more dramatic than ordinarily take place. Since most families convert much of their voucher’s value into disposable income, vouchers should also affect health as sudden income shocks do. Studies have shown that income shocks roughly equivalent to the monetary value of a voucher have improved some indicators of mental health and body mass and have also influenced biological processes linked to blood pressure, cardiovascular disease, obesity, and diabetes.

MTO achieved what it set out to do for public housing residents and has begun to seed a health-based rationale for housing mobility programs—a good thing for the field. Yet this rationale would be still more compelling if we knew how vouchers affected biology and health in families receiving a voucher while living in private housing, as well as whether vouchers impact health through changes they cause in disposable income, housing quality, or neighborhood quality.

MTO is a great start. Now is the time to enrich our understanding of the link between housing and health further.


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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.