Background: The U.S. Department of Housing and Urban Development (HUD), in collaboration with the Centers for Medicare and Medicaid Services, allocated Housing Choice Vouchers to 28 public housing authorities (PHAs) in January 2011. PHAs were required to partner with the state Money Follows the Person program, or the relevant health and human services (HHS) agency, to help voucher recipients access the community-based services and supports necessary for independent living. The vouchers, known as non-elderly disabled Category 2 (NED2) housing choice vouchers, were exclusively available for non-elderly disabled people who lived in an institution.
Objectives: (1) To identify effective implementation methods by assessing patterns between voucher distribution rates and approaches to program operations; and (2) to estimate the impact of the availability of NED2 vouchers on the rate of transition from institutions to the community.
Data Sources: Phone discussions with PHA and health agency staff (process study); HUD administrative data, the Minimum Data Set, and the National Provider Identifier Registry (impact analysis).
Study Design: Via semi-structured interviews with staff at PHAs and health agency partners in the 13 sites that received at least 35 vouchers, we examined the processes used to implement the major program components. We also assessed the vouchers' impact on transitions from nursing facilities (nearly all voucher users initially resided in such settings and data were unavailable for those in other institutions) to the community in the five treatment PHAs that issued and leased the most vouchers in 2011. To do this, we used a difference-in-differences method to estimate how likely nursing home residents eligible for NED2 vouchers were to move to the community before and during the period of voucher availability, compared with similar people who did not have access to vouchers.
Principal Findings: Several implementation procedures were associated with a quicker distribution of vouchers, including strong communication between PHA and health staff, the involvement of a housing specialist, and relaxed portability rules for vouchers. Results from the quantitative analysis indicate that voucher use was most common among people who were male, unmarried, had relatively few functional limitations, and lived in an institution for more than one year. Further, in a pooled sample of three of the five sites, NED2 vouchers were found to increase community transition rates by 8.7 percentage points, an impact that was not significantly different from the maximum potential impact of 10.6 percentage points. The estimated impact is large relative to the 19.0 percent transition rate among a similar group of people in the treatment areas during the period before vouchers were made available.
Conclusions: The success of NED2 vouchers hinges on how well they are targeted. Vouchers are more quickly distributed when allocated to PHAs with well-established relationships with their HHS partners. Further, targeting vouchers to communities with low transition rates has the potential for larger impacts on the number of transitions, compared with communities with higher transition rates at baseline. However, even among PHAs and partners with a demonstrated capacity to support an efficient NED2 voucher program, barriers to finding affordable and accessible housing persist. Additional efforts to overcome these barriers may be worth the investment if the total costs to Medicaid, Medicare, and HUD are less than the cost of paying for longer stays in an institution.