Intensive New York City Housing Remediation Effort Cut Violations in Half but Did Not Yield Immediate Health Improvements

New York City’s most aggressive housing quality enforcement programs reduced hazardous housing violations in targeted buildings but did not lead to measurable changes in short-run health care utilization, according to a new study at Columbia University Mailman School of Public Health. The findings are published in the Journal of Policy Analysis and Management.

Many housing and health initiatives had focused on publicly owned housing and, until now, there was little evidence on whether housing quality interventions could alter health care use in privately owned and managed, low-quality housing buildings.

“This study centers on tenants in privately owned buildings, a large but often overlooked segment of the low-income population where landlord oversight is weaker,” said Kacie Dragan, PhD, MPH assistant professor of Health Policy and Management and principal investigator. “However despite substantial building improvements under the law we found no evidence of changes in health care spending or emergency department visits among low-income residents in the years immediately following remediation,” said Dragan.

“These results suggest that housing remediation alone may not yield immediate reductions in health care utilization, particularly when improvements cannot fully resolve longstanding hazards,” noted Dragan.

The evaluation focused on the Alternative Enforcement Program (AEP), created under the NYC Safe Housing Law of 2007 to identify and remediate the city’s 250 most distressed privately owned residential buildings each year. Landlords selected into AEP are required—within four months—to address all heat and hot water violations and at least 80 percent of “immediately hazardous” issues such as serious mold, pest infestations, rodents, peeling lead paint, broken fixtures or windows, and water leaks. These program criteria are written into the City Charter.

Reports from the NYC Department of Housing Preservation and Development show that AEP has produced significant housing quality improvements. “Compliance rates are high, despite the fact that many AEP buildings are owned by the city’s most chronically neglectful landlords,” Dragan said.

The study followed 48,151 Medicaid enrollees linked to AEP-eligible buildings from 2007–2018. In the final analysis, there were 24,294 enrollees included—14,974 residents in untreated buildings and 9,320 residents of buildings that underwent housing improvements.

Using Medicaid eligibility and claims data from 2007–2019, Dragan also measured total health care spending, the number of emergency department visits, and all health system visits tied to conditions likely linked to housing quality—injuries, respiratory conditions, and anxiety.

Despite large reductions in hazardous violations—cut by half in the treated buildings—the analysis found no evidence of meaningful short-run changes in health care utilization.

“The existing literature offers limited insight into how quickly substandard housing conditions translate into health problems, and how quickly those health problems, in turn, translate into actual utilization of the health care system,” observed Dragan.

“However, the largely null results in this study shed light on what decision makers in the health and housing sectors could realistically expect from housing quality improvement interventions,” said Dragan. 

These results have implications for policy debates. Health insurers like Medicare and Medicaid have begun piloting policies that pay for housing remediation services like pest control or ventilation, with the rationale that these services might save money by reducing health care utilization. “These findings indicate that the expectation of cost savings by insurers may not be appropriate. Still, improving the quality of low-income housing is important and worthwhile,” Dragan notes. 

Even with directed repairs and heightened oversight, it is important to emphasize that tenants in AEP buildings continue to live in some of the worst housing in New York City. Eliminating half of all open violations still leaves residents in deeply distressed conditions—underscoring how challenging it is to fully remediate decades of disinvestment and neglect.

Nationwide, 42 percent of low-income households live in homes needing at least one major repair, and as many as 20 percent of homes in low-income neighborhoods have three or more serious hazards that pose well-established risks to health. 

“These findings suggest that more comprehensive remediation efforts, paired with sustained follow-up, may be needed before measurable health improvements appear.”

The study was supported by the Agency for Healthcare Research and Quality (T32HS000055), the National Institute of Mental Health of the National Institutes of Health (T32MH019733), and the Harvard Radcliffe Institute for Advanced Study.