Medicaid Expansion Forestalls Homelessness

Under the Affordable Care Act, states can opt to expand Medicaid, extending health coverage to nearly all low-income individuals with incomes at or below 138 percent of the poverty line. Ten years later, however, 12 states still have yet to adopt the ACA’s Medicaid expansion. To characterize and contextualize the meaning of these state-specific choices on citizens’ health,  researchers from various fields have studied the impact of the Medicaid expansion on critical societal issues. Studies have identified numerous health-focused benefits of expanding Medicaid that include increased preventative health screening rates, improved management of chronic conditions, and greater access to care. 

Zewde et al. illuminate a more indirect benefit of the ACA Medicaid expansion, the prevention of home evictions. This topic is of particular significance today. The COVID-19 pandemic continues to wreak havoc on Americans’ livelihoods and health, magnifying the existing issue of stable housing. 

Evictions are unfortunately common in the United States. One in forty renter households experienced an eviction between 2000 and 2016, a particularly striking figure when compared to the much lower rates in countries such as the United Kingdom or Denmark. Affordable housing is increasingly difficult to find in the U.S., with almost half (47%) of all renter households living in unaffordable housing. Of note, individuals who live in unaffordable housing have worse health than those who do not, a fact potentially explained by difficulty affording necessary care due to housing-related financial hardship.

The authors used nearly two decades worth of eviction data in the United States to draw a compelling association between greater access to care and improved housing stability. They identified a significant decrease in evictions in states that expanded Medicaid, particularly when compared to states that did not expand. They acknowledged that the precise connection between health care coverage and evictions requires further investigation, but presented several different pathways for the relationship.

In September 2020, the Centers for Disease Control and Prevention set a moratorium on evictions until the end of the year. Without this protection, experts predict that as many as 30 million may be at risk of eviction. Individuals will face high costs of back rent when the policy expires. To avoid a layered pandemic combining both coronavirus and surging homelessness, policymakers in the remaining 12 states should consider expanding Medicaid and promoting financial security at a time when it matters most.

This Health Policy Journal Club review is written by Hannah Todd as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine where she is a medical student.

Abstract

Objectives. To evaluate the effect of the Affordable Care Act (ACA) Medicaid expansions on national rates of home eviction and eviction initiation in the United States.

Methods. Using nationally representative administrative data from The Eviction Lab at Princeton University, we estimated the effects of the ACA Medicaid expansions on county-level evictions and filings from 2000 to 2016 with a difference-in-difference regression design.

Results. We found that Medicaid expansions were associated with an annual reduction in the rate of evictions by 1.15 per 1000 renter-occupied households (P < .001), a reduction of 1.59 eviction filings per 1000 renter-occupied households (P < .001), and a reduction in the average number of evictions by 46 (P < .05). We found additional evidence that increasing rates of African American residents in a county was associated with a greater rate of evictions filed, and increased rates of poverty and rent burdens relative to income were associated with more evictions both filed and completed.

Conclusions. Evictions decreased after Medicaid expansion, demonstrating further evidence of the substantive financial protections afforded by this coverage. The reduction in the eviction filing rate suggests that Medicaid expansion could be reducing evictions by preventing the court proceeding entirely.

PMID: 31415189

Zewde N, et al. Am J Public Health. 2019;109 (10): 1379-1383.