The REAC Impossible Newsletter
Volume 1, Number 7, July 2020
Head-Scratcher of the Month

Effect of Repairs on subsidized residents' health

Does making repairs to residents' apartments and buildings improve residents' overall health is a question one New York school set out to learn. This past February The New York University's Furman Center published the finding of its study in The Stoop, blog. The study concluded, that yes, modest improvements in overall health resulted from making needed repairs. Accordingly, according to the study, this finding alone is sufficient to justify billions in additional expenditures for housing renovations. 

NYU reports that, “The nation’s aging and deteriorating public housing stock is in desperate need of repair. The U.S. Department of Housing and Urban Development (HUD) estimates that the 1.1 million public housing units across the country need $50 billion to make critical improvements such as fixing broken elevators, updating old heating systems, and removing lead paint. Amidst the public housing funding crisis, there is growing concern that these poor housing conditions can compromise the health of residents.

The study (longitudinal data) was limited to six rundown New Your City Housing Authority developments containing about 800 units in 10 buildings housing about 2,000 residents. The developments were turned over to private developers for renovation along with a 50% ownership, sorta like under HUD's Renal Assistance Demonstration (RAD) program - a combination of public and private funding, with a caveat that the housing remain accessible to affordable to low-income residents.

Within units, kitchens and bathrooms were renovated and new appliances installed. Windows were replaced, air-conditioning units were also installed in every apartment at three of the developments. Common areas and building exteriors were also renovated.  “On the exterior, the developers restored building façades, replaced playground equipment, improved landscaping, and changed entrances to enhance safety. They also installed new lighting, replaced entrance doors, and introduced new security systems that included cameras, intercoms, and card readers. The renovations were largely complete by the end of 2015, though some work was still ongoing in the first half of 2016.”

NYU stipulated that there is a wealth of information about exposing residents to disease associated with exposure to for example lead, mold, pest infestation. The school stated that there have been few studies, however, that have sought to determine how repairs have improved residents' health over time.

The study published in Health Affairs , conducted by Furman Center Faculty Director Ingrid Gould Ellen, researcher Kacie L. Dragan, and NYU Wagner Dean Sherry A. Glied, attempts to fill this research gap. The study explored whether transferring ownership to private developers, and subsequent housing renovations, led to improvements in residents’ health over a three-year period.

The longitudinal study faced methodological challenges. For example, changes in housing may shape aspects of health that are not observable in the short term, and the effectiveness of any single intervention may depend on such contextual factors as climate; neighborhood conditions; social networks; and, perhaps most important, property management. Property managers have a significant impact on day-to-day conditions and quality of life in multifamily buildings. Researchers rarely have access to data on building management and typically ignore those data when studying the effects of housing on health.

Despite these challenges, a few studies have provided persuasive evidence about how housing interventions affect specific health outcomes. First, a set of studies examined the causal impact of improving insulation and heating in low-income housing. One randomized trial in New Zealand found that insulation retrofits in low-income developments reduced the odds of fair or poor self-rated health, poor mental health, and missed days of work and school. [Howden-Chapman] Another study reported that heating system upgrades reduced the number of mental disorders found among residents. [Allen T]   Finally, an evaluation of a central heating intervention in homes in Scotland found that improvements in home temperatures and dampness decreased diagnoses of hypertension. [Plat S]

A third set of studies focused on the management of vermin, since research suggests that the inhalation of allergens emitted by pests such as rodents and cockroaches can exacerbate asthma symptoms. [Krieger] A few studies indicated that integrated pest management, a method that avoids chemical use and instead removes the conditions that attract or allow for pests, resulted in decreased cockroach antigen levels, and at least one study showed reduced asthma symptoms. [Eggleston PA]

Finally, a fourth group of studies examined the effects of structural improvements to improve safety. The strongest evidence came from research that examined older adults and suggested that physical interventions such as the addition of handrails and grab bars, in combination with behavioral interventions, can reduce the risk of falling. [Cumming RG, Eriksen MD, Nikolaus T] Young children can also be vulnerable to injuries from falls. Charlotte Spiegel and Francis Lindaman showed that the installation of relatively inexpensive window bars on apartment buildings in New York City reduced fall-related deaths among children by an estimated 47 percent. [Spiegel CN]

To evaluate the repairs of residents' health NYU compared changes in diagnoses and heath care utilization for residents in the six buildings to changes in that of a sample of 1,644 residents in comparable non-renovated public housing development buildings in the same neighborhood. Results were compiled and compared in 2014, 2017 and again in 2018. New York State Medicaid medical records served as the source for comparing changes in medical conditions.

To assess the effect of the renovations on residents’ health, changes in diagnoses and health care use for residents of treatment buildings were compared to changes in the same outcomes for a matched sample of nearby Medicaid enrollees living in a set of otherwise comparable public housing buildings where renovations did not take place.  It is unclear why the study method just did not compare healthcare utilization patterns pre and post renovations in the renovated buildings rather than trying to compare to a similar set of residents’ utilization patterns in other developments’ buildings. The study points to the considerable problems with this aspect of their methodology. 

Acknowledged study limitations included inability to account for potential differences between the renovated and comparison housing developments, and inaccurate Medicaid records. Additionally, health consequences data reveal only one component of renter's overall well-being.

The study concentrated on five "housing-sensitive" conditions to analyze the effect of renovations on residents' health:

·          asthma,
·          anxiety/depression,
·          acute respiratory infections,
·          hypertension,
·          and injuries.

It also tracked overall utilization of hospital primary and emergency usage.

Self-reported measures of health and qualitative findings are also important to consider. For example, in a post-renovation survey of residents in the renovated developments and in similar nearby developments, those in the renovated developments indicated significantly higher rates of satisfaction. This finding should be expected. Liken it to eating a lowly greasy rude diner, versus a clean new at your service upscale bistro.

Because both the intervention (a combination of new ownership and renovations) and residents’ responses to it are complex, the study authors call for further study of the relationship between housing improvements and residents’ well-being. The article did not detail how these limitations impacted the published study or were overcome other than to suggest that further study was needed.

The residents in the renovated buildings presented improvements over the comparison group in four of the five housing-sensitive health conditions between during the study period. However, the researchers concede that the renovations do not significantly improve residents’ health. 

While the analysis of the building transfer and renovation in the six New York City public housing developments revealed no significant improvements in any individual health outcomes, the study found evidence of significant relative improvements in overall disease burden when measured by an index of housing-sensitive conditions - particularly among children and those who remained in the buildings for at least a year following the renovations. 

The researchers concluded, while the ownership transfer and broad-based renovation do not appear to have appreciably influenced any individual health outcome in the three years after renovation, they may have modestly moved the needle on aggregate health.

A caveat.  The study reports that, on the whole, patterns of health system use, such as the proportion of residents visiting the ED or hospital, appeared to be less sensitive to the renovations than disease outcomes were. This may indicate that people’s manner of engaging with the health care system is persistent, even when their mix of exposures, conditions, and overall well-being changes.

Their study indicated that there were no significant improvements in heath, only modest improvements. The researchers report that it is possible that a longer period with a larger sample could show a significant impact on residents’ health. The researchers point to inherent complexities preventing their proving that renovations improve health outcomes, which a larger study would overcome. It is unlikely that a larger study group can overcome the limitations. Utilizing the results of others’ studies where possible, vice more studies, may be prudent.

Further, the study group says that the results of the study demonstrates a significant need for increased investments in capital, and RAD like programs. Most experts familiar with public housing brick and mortar agree that significant expenditures are needed in NYCHA, because, simply, the housing stock is crumbling, by and large, and, of course, hazardous conditions adversely affect residents’ overall health and safety.

Hank Vanderbeek
WASHINGTON, July 14, 2020 - The Federal Housing Administration ( FHA ) today published proposed revisions to its Single Family servicing policies that are designed to remove unnecessary barriers for homeowners seeking mortgage payment relief, achieve operational consistency with industry standard best practices, and reduce burdens incurred by the industry when servicing an FHA-insured mortgage portfolio. FHA posted the proposal today on its  Single Family Housing Drafting Table . FHA will be accepting industry feedback on the proposed changes for 60 days. More

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