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.OBJECTIVE To 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 PARTICIPANTS Exploratory analysis of the Moving to Opportunity forFair 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.EXPOSURES Receipt of a traditional or low-poverty voucher vs control group. MAIN OUTCOMES AND MEASURESRates of hospitalizations and hospital days, and hospital spending. RESULTS Among 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;

Discussion | This analysis found that FES is associated with reduced criminality. The low overall prevalence of convictions in this sample was reassuring but limited detection of group differences. Nevertheless, allocation to STEP reduced subsequent and first-time convictions and was less than levels in a larger European trial. 3 Putative mechanisms include STEP's improvement of vocational functioning, 4 which is associated with reduced youth criminality, 5 and reduction of psychiatric hospitalizations, 4 which disrupt work and school functioning but may also signal reductions in episodes of behavioral dysregulation that can result in arrests. 6 However, these speculations need to be tested against more granular information about the circumstances of each arrest. Such replication with a larger sample and more comprehensive (eg, adding juvenile, jail diversion, and department of corrections data) databases is urgently needed to inform service design and policy.

Neighborhood environments are increasingly thought to affect emergency department (ED) use. However, because people decide where to live based on a range of factors, it can be challenging to identify the causal impact of living in higher-poverty neighborhoods on increased rates of ED visits. Our study leveraged the Moving to Opportunity for Fair Housing Demonstration Program, a social experiment beginning in 1994 that randomly assigned approximately 4,600 households that received federal housing assistance to different neighborhood conditions. We linked program participants in four states with an average of twelve years of administrative data on ED use (up to twenty-one years after randomization). Contrary to our expectations, we did not find a consistently significant connection between neighborhood poverty and overall ED use during this follow-up period. This result was observed for both adults and people who were children at the time of randomization, as well as for various classifications of ED visits. The findings can help direct future research that seeks to clarify the relationship between neighborhood environments and health care use.

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