Failing the Least Advantaged: An Unintended Consequence of Local Implementation of the Housing Choice Voucher Program.
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ABSTRACT:
SUBMITTER: Kim H
PROVIDER: S-EPMC8993032 | biostudies-literature | 2022
REPOSITORIES: biostudies-literature
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Failing the Least Advantaged: An Unintended Consequence of Local Implementation of the Housing Choice Voucher Program.
Housing policy debate 20201125 2
While scholars have acknowledged that shrinking federal resources for low-income housing programs increase economic inequality across U.S. society as a whole, the question of how the allocation of these resources affects inequality among the poor has received little attention. Using a mixed methods approach, this study examines local administrative practices of distributing scare housing resources and the potential redistributive effects of those choices. Analyses of administrative and qualitati ...[more]
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Project description:Literature on neighborhood effects on health largely employs non-experimental study designs and does not typically test specific neighborhood mediators that influence health. We address these gaps using the Moving to Opportunity (MTO) housing voucher experiment. Research has documented both beneficial and adverse effects on health in MTO, but mediating mechanisms have not been tested explicitly. We tested mediation of MTO effects on youth asthma (n = 2829). MTO randomized families living in public housing to an experimental group receiving a voucher to subsidize rental housing, or a control group receiving no voucher, and measured outcomes 4-7 years following randomization. MTO had a harmful main effect vs. controls for self-reported asthma diagnosis (b = 0.24, p = 0.06), past-year asthma attack (b = 0.44, p = 0.02), and past-year wheezing (b = 0.17, p = 0.17). Using Inverse Odds Weighting mediation we tested mental health, smoking, and four housing dimensions as potential mediators of the MTO-asthma relationship. We found no significant mediation overall, but mediation may be gender-specific. Gender-stratified models displayed countervailing mediation effects among girls for asthma diagnosis by smoking (p = 0.05) and adult-reported housing quality (p = 0.06), which reduced total effects by 35% and 42% respectively. MTO treatment worsened boys' mental health and mental health reduced treatment effects on asthma diagnosis by 27%. Future research should explore other potential mediators and gender-specific mediators of MTO effects on asthma. Improving measurement of housing conditions and other potential mediators may help elucidate the "black box" of neighborhood effects.
| S-EPMC4070421 | biostudies-literature
Project description:ImportanceAlthough neighborhoods are thought to be an important health determinant, evidence for the relationship between neighborhood poverty and health care use is limited, as prior studies have largely used observational data without an experimental design.ObjectiveTo examine whether housing policies that reduce exposure to high-poverty neighborhoods were associated with differences in long-term hospital use among adults and children.Design, setting, and participantsExploratory analysis of the Moving to Opportunity for Fair Housing Demonstration Program, a randomized social experiment conducted in 5 US cities. From 1994 to 1998, 4604 families in public housing were randomized to 1 of 3 groups: a control condition, a traditional Section 8 voucher toward rental costs in the private market, or a voucher that could only be used in low-poverty neighborhoods. Participants were linked to all-payer hospital discharge data (1995 through 2014 or 2015) and Medicaid data (1999 through 2009). The final follow-up date ranged from 11 to 21 years after randomization.ExposuresReceipt of a traditional or low-poverty voucher vs control group.Main outcomes and measuresRates of hospitalizations and hospital days, and hospital spending.ResultsAmong 4602 eligible individuals randomized as adults, 4072 (88.5%) were linked to health data (mean age, 33 years [SD, 9.0 years]; 98% female; median follow-up, 11 years). There were no significant differences in primary outcomes among adults randomized to receive a voucher compared with the control group (unadjusted hospitalization rate, 14.0 vs 14.7 per 100 person-years, adjusted incidence rate ratio [IRR], 0.95 [95% CI, 0.84-1.08; P = .45]; hospital days, 62.8 vs 67.0 per 100 person-years; IRR, 0.93 [95% CI, 0.77-1.13; P = .46]; yearly spending, $2075 vs $1977; adjusted difference, -$129 [95% CI, -$497 to $239; P = .49]). Among 11 290 eligible individuals randomized as children, 9118 (80.8%) were linked to health data (mean age, 8 years [SD, 4.6 years]; 49% female; median follow-up, 11 years). Receipt of a housing voucher during childhood was significantly associated with lower hospitalization rates (6.3 vs 7.3 per 100 person-years; IRR, 0.85 [95% CI, 0.73-0.99; P = .03]) and yearly inpatient spending ($633 vs $785; adjusted difference, -$143 [95% CI, -$256 to -$31; P = .01]) and no significant difference in hospital days (25.7 vs 28.8 per 100 person-years; IRR, 0.92 [95% CI, 0.77-1.11; P = .41]).Conclusions and relevanceIn this exploratory analysis of a randomized housing voucher intervention, adults who received a housing voucher did not experience significant differences in hospital use or spending. Receipt of a voucher during childhood was significantly associated with lower rates of hospitalization and less inpatient spending during long-term follow-up.
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Project description:BackgroundCoronavirus disease 2019 (COVID-19) is likely to exacerbate the symptoms of poor mental health in family caregivers.AimsTo investigate whether rates of depressive symptomatology increased in caregivers during COVID-19 and whether the unintended consequences of health protective measures, i.e., social isolation, exacerbated this risk. Another aim was to see if caregivers accessed any online/phone psychological support during COVID.MethodData (1349 caregivers; 6178 non-caregivers) was extracted from Understanding Society, a UK population-level data-set. The General Health Questionnaire cut-off scores identified those who are likely to have depression.ResultsAfter adjustment for confounding caregivers had a higher risk of having depressive symptoms compared with non-caregivers, odds ratio (OR) = 1.22 (95% CI 1.05-1.40, P = 0.008) evidenced by higher levels of depression pre-COVID-19 (16.7% caregivers v. 12.1% non-caregivers) and during the COVID-19 pandemic (21.6% caregivers v. 17.9% non-caregivers), respectively. Further, higher levels of loneliness increased the risk of depression symptoms almost four-fold in caregivers, OR = 3.85 (95% 95% CI 3.08-4.85, P < 0.001), whereas accessing therapy attenuated the risk of depression (43%). A total of 60% of caregivers with depression symptoms reported not accessing any therapeutic support (for example online or face to face) during the COVID-19 pandemic.ConclusionsCOVID-19 has had a negative impact on family caregivers' mental health with loneliness a significant contributor to depressive symptomatology. However, despite these detriments in mental health, the majority of caregivers do not access any online or phone psychiatric support. Finally, psychiatric services and healthcare professionals should aim to focus on reducing feelings of loneliness to support at-risk caregivers.
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Project description:Online platforms have become an integral component of the housing search process in the United States and other developed contexts, but recent studies have demonstrated that these platforms offer uneven representation of different neighborhoods. In this study, we use listings covering the largest 50 U.S. metropolitan areas to assess how GoSection8, a platform uniquely focused on affordable housing and voucher-assisted households, compares with "mainstream" alternatives of Craigslist, Apartments.com and Zillow. Through descriptive and regression analyses of the housing and neighborhoods represented on these websites and a new way of measuring the distribution of rental housing opportunities, we advance a multisource perspective on the role of online information exchanges in housing search processes. Specifically, we find that GoSection8 and mainstream alternatives capture spatially-segmented information about housing markets, with GoSection8 ads representing units that are more affordable but also more constrained to higher-poverty neighborhoods where assisted households are already concentrated. The findings suggest that disadvantaged households are potentially funneled toward high-poverty, isolated neighborhoods by the operation of stratified information systems available for online housing searches.
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Project description:BackgroundPublic health resources are limited and best used for effective programs. This study explores associations of mis-implementation in public health (ending effective programs or continuing ineffective programs) with organizational supports for evidence-based decision making among U.S. local health departments.MethodsThe national U.S. sample for this cross-sectional study was stratified by local health department jurisdiction population size. One person was invited from each randomly selected local health department: the leader in chronic disease, or the director. Of 600 selected, 579 had valid email addresses; 376 completed the survey (64.9% response). Survey items assessed frequency of and reasons for mis-implementation. Participants indicated agreement with statements on organizational supports for evidence-based decision making (7-point Likert).ResultsThirty percent (30.0%) reported programs often or always ended that should have continued (inappropriate termination); organizational supports for evidence-based decision making were not associated with the frequency of programs ending. The main reason given for inappropriate termination was grant funding ended (86.0%). Fewer (16.4%) reported programs often or always continued that should have ended (inappropriate continuation). Higher perceived organizational supports for evidence-based decision making were associated with less frequent inappropriate continuation (odds ratio = 0.86, 95% confidence interval 0.79, 0.94). All organizational support factors were negatively associated with inappropriate continuation. Top reasons were sustained funding (55.6%) and support from policymakers (34.0%).ConclusionsOrganizational supports for evidence-based decision making may help local health departments avoid continuing programs that should end. Creative mechanisms of support are needed to avoid inappropriate termination. Understanding what influences mis-implementation can help identify supports for de-implementation of ineffective programs so resources can go towards evidence-based programs.
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Project description:ObjectiveTaiwan has instituted a pay-for-performance (P4P) program for diabetes mellitus (DM) patients that rewards doctors based in part on outcomes for their DM patients. Doctors are permitted to choose which of their DM patients are included in the P4P program. We test whether seriously ill DM patients are disproportionately excluded from the P4P program.Data source/study settingThis study utilizes data from the National Health Insurance (NHI) database in Taiwan for the period of January 2007 to December 2007. Our sample includes 146,481 DM-P4P patients (16.56 percent of the total) and 737,971 non-DM-P4P patients.Data collection/extraction methodsWe use logistic and multilevel models to estimate the effects of patient and hospital characteristics on P4P selection.Principal findingsThe results show that older patients and patients with more comorbidities or more severe conditions are prone to be excluded from P4P programs.ConclusionsWe found that DM patients are disproportionately excluded from P4P programs. Our results point to the importance of mandated participation and risk adjustment measures in P4P programs.
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Project description:ImportanceThe Veterans Choice Program (VCP) was implemented in 2014 to help veterans gain broader access to specialized care outside of the Veterans Health Administration (VHA) facilities by providing them with purchased community care (CC).ObjectiveTo describe the prevalence and patterns in VCP-funded purchased CC after the implementation of the VCP among veterans with prostate cancer.Design, setting, and participantsThis cohort study used VHA administrative data on veterans with prostate cancer diagnosed between January 1, 2015, and December 31, 2018. These veterans were regular VHA primary care users. Analyses were performed from March to July 2023.ExposuresDriving distance (in miles) from residence to nearest VHA tertiary care facility. The location (VHA or purchased CC) in which treatment decisions were made was ascertained by considering 3 factors: (1) location of the diagnostic biopsy, (2) location of most of the postdiagnostic prostate-specific antigen laboratory testing, and (3) location of most of the postdiagnostic urological care encounters.Main outcomes and measuresThe main outcome was receipt of definitive treatment and proportion of purchased CC by treatment type (radical prostatectomy [RP], radiotherapy [RT], or active surveillance) and by distance to nearest VHA tertiary care facility. Quality was evaluated based on receipt of definitive treatment for Gleason grade group 1 prostate cancer (low risk/limited treatment benefit by guidelines).ResultsThe cohort included 45 029 veterans (mean [SD] age, 67.1 [6.9] years) with newly diagnosed prostate cancer; of these patients, 28 866 (64.1%) underwent definitive treatment. Overall, 56.8% of patients received definitive treatment from the purchased CC setting, representing 37.5% of all RP care and 66.7% of all RT care received during the study period. Most patients who received active surveillance management (92.5%) remained within the VHA. Receipt of definitive treatment increased over the study period (from 5830 patients in 2015 to 9304 in 2018), with increased purchased CC for patients living farthest from VHA tertiary care facilities. The likelihood of receiving definitive treatment of Gleason grade group 1 prostate cancer was higher in the purchased CC setting (adjusted relative risk ratio, 1.79; 95% CI, 1.65-1.93).Conclusions and relevanceThis cohort study found that the percentage of veterans receiving definitive treatment in VCP-funded purchased CC settings increased significantly over the study period. Increased access, however, may come at the cost of low care quality (overtreatment) for low-risk prostate cancer.
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Project description:BackgroundRandomized trials may have different effects in different settings. Moving to Opportunity (MTO), a housing experiment, is one such example. Previously, we examined the extent to which MTO's overall effects on adolescent substance use and mental health outcomes were transportable across the sites to disentangle the contributions of differences in population composition versus differences in contextual factors to site differences. However, to further understand reasons for different site effects, it may be beneficial to examine mediation mechanisms and the degree to which they too are transportable across sites.MethodsWe used longitudinal data from MTO youth. We examined mediators summarizing aspects of the school environment over the 10-15 year follow-up. Outcomes of past-year substance use, mental health, and risk behavior were assessed at the final timepoint when participants were 10-20 years old. We used doubly robust and efficient substitution estimators to estimate (1) indirect effects by MTO site and (2) transported indirect effects from one site to another.ResultsDifferences in indirect effect estimates were most pronounced between Chicago and Los Angeles. Using transport estimators to account for differences in baseline covariates, likelihood of using the voucher to move, and mediator distributions partially to fully accounted for site differences in indirect effect estimates in 10 of the 12 pathways examined.ConclusionsUsing transport estimators can provide an evidence-based approach for understanding the extent to which differences in compositional factors contribute to differences in indirect effect estimates across sites, and ultimately, to understanding why interventions may have different effects when applied to new populations.
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Project description:In 2005, the United Network for Organ Sharing (UNOS) adopted the Share 15 policy to improve organ allocation by facilitating transplantation for local and regional patients with Model for End-Stage Liver Disease (MELD) scores of 15 or higher. There has been concern that the lack of standardization in the use of exception points is potentially diminishing the benefits of this policy. We reviewed all applications for 15 exception points submitted through UNOS from January 1, 2005 through March 14, 2011 (notably, there were only 5 applications for 15 MELD exception points submitted before the initiation of the Share 15 policy). Four hundred fifty-two applications were submitted for 301 patients. There was significant regional variability, with regions 3 and 10 submitting 72.1% of all applications. More than one-quarter of the applications (32.7%) specifically requested exception points to make a patient eligible for a local, regional, or higher risk organ. All applications were accepted for 74.1% of the patients, and 72.2% of these patients ultimately underwent transplantation; however, when all applications were denied, only 54.0% underwent transplantation (P = 0.006). Overall, 197 applicants (65.4%) underwent transplantation with a deceased donor organ, and 80.2% of these patients had a native MELD score at transplantation less than 15. In conclusion, these analyses demonstrate several important changes in practice that have occurred as a result of the implementation of the Share 15 policy. Since 2005, there has been a marked increase in the number of applications for 15 exception points, with significant regional variability in their use and a lack of standardization in their approval.
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