Non-Elderly Disabled Category 2 Housing Choice Voucher Program: An Implementation and Impact Analysis. B. Impact Analysis: Conclusions and Ideas for Future Research

01/01/2014

We found several notable differences between NED2 voucher users and people under age 62 who did not use NED2 vouchers in the five sites with the highest number of voucher users:

  • Voucher users were significantly less likely to be married (9 percent) than people who made transitions to the community without vouchers (25 percent). This finding suggests NED2 vouchers have helped people who do not have access to community supports that are associated with marriage: a home to which they might return and the personal and financial support of a spouse.

  • NED2 voucher users had fewer functional limitations than non-users (both those who transitioned to the community without a voucher, and those who remained in nursing facilities over the observation period). While the reasons for this are unclear, it may be easier to find housing and set up community care plans for people with less need for assistance with activities of daily living. It also suggests that vouchers are most useful to people facing barriers to independent living beyond the services needed to address their functional limitations.

  • The average length of stay in a nursing facility among NED2 voucher users (379 days) was significantly longer than for those who made transitions without vouchers (53 days). This suggests vouchers were used by people who had been unable to make transitions without them, perhaps for a considerable length of time, and were at risk of remaining in institutions for an extended period, perhaps for the rest of their lives.

  • The majority of NED2 voucher users were male (62 percent) compared with just under half of non-users who made transitions without vouchers (47 percent). The gender gap was reflected in all three states, but was particularly pronounced in the Cincinnati site. We are not aware of an obvious explanation for the relatively high rate of voucher use by males.

The availability of NED2 vouchers in Baltimore and Cincinnati was found to have had a substantial, positive impact on community transitions. Estimated impacts in Cincinnati (12.6 percentage points) and the pooled sample of Baltimore and Cincinnati (8.7 percentage points) were statistically different from zero and large relative to the treatment area pre-intervention period transition rates (22 percent and 19 percent, respectively). Perhaps more important, the estimated impacts were not statistically significantly different from the maximum potential impacts (12.7 percent and 10.6 percentage points, respectively). The estimated impact for Baltimore alone was not statistically different from zero but, like the Cincinnati estimate, was nearly as large as the maximum potential impact (9.1 percentage point estimated impact compared to a 9.7 percentage point maximum potential impact) and large relative to the pre-intervention period transition rate (17.7 percent). Hence, it appears likely that the statistical insignificance for the Baltimore estimate reflects insufficient statistical power rather than lack of an impact. In contrast, we found a very small and statistically insignificant effect in Washington.

The fact that the Baltimore and Cincinnati estimates were only slightly lower than the corresponding maximum potential impacts results, separately and pooled, is consistent with the hypothesis that every voucher in those sites was used by an individual who would not have made a transition to the community without it. That does not appear to be the case for Washington, where the estimated impact was just a small fraction of the maximum potential impact, and the hypothesis that the two are equal is on the margin of being rejected.

Limitations. Both our descriptive findings and impact results should be interpreted with caution. Our results are based on just over 100 voucher users in five of the 28 total PHAs. The PHA areas analyzed and the voucher users in the selected PHAs in 2011 may not be representative of all PHAs or all voucher users. Comparisons of NED2 voucher users not included in our analysis and non-users may generate different results. Furthermore, the effects of the NED2 program on the rate of transition from institutions to the community may not be representative of all PHAs. Over the time frame considered, however, we expect the largest estimates in this report might serve as an upper bound for other sites, which leased fewer vouchers.

Future Research. Several avenues of future research have the potential to strengthen and extend our current analysis. Additional or more recent data would make it possible to address unanswered questions regarding the effect of NED2 vouchers on community living outcomes, and strengthen our analyses in other ways:

  • Effects of NED2 vouchers on other outcomes. We were unable to analyze the extent to which vouchers affected other important outcomes, such as rates of reinstitutionalization and post-transition health events, because 2012 MDS and 2012 MSIS data were not yet available. Once these data can be obtained, they can be used to assess whether NED2 voucher use is associated with lower rates of reinstitutionalization or lower rates of hospitalization.

  • An analysis of 2012 voucher users. Once MDS data covering calendar year 2012 become available, the sample for estimating the impact of the vouchers on community transitions can be increased by including 2012 NED2 voucher users. Based on the HUD administrative data through December 2012, the number of voucher users in the analysis would increase by at least 62 percent, potentially improving the reliability of the estimates.39

  • Differences in impact among sites. An additional year of MDS data might allow for the inclusion of other sites in the analysis. With the passage of time, the number of vouchers used in other sites also might be large enough to meet the minimum threshold needed to include them in the analysis.40 This would permit additional checks on the robustness of the results and allow us to identify differences across sites.

  • Strengthen the matching methodology. The use of MSIS and Medicare claims data could strengthen the estimation methodology by improving the ability to match comparison area records to treatment area records and control for additional baseline characteristics, such as the nature of medical events that led to nursing home entry.

The results from additional analysis along these lines would inform policymakers about the contribution of subsidized housing to the success of programs that aim to help people with disabilities leave institutions and live independently in the community. Although we identified positive impacts on transitions in some areas, the sample size and number of areas on which the analysis was based may be perceived as too limited for large scale policy decisions.

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