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Eviction Moratoria Expiration and COVID-19 Infection Risk Across Strata of Health and Socioeconomic Status in the United States

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Is lifting a state-level eviction moratorium associated with the risk of individuals in that state being diagnosed with COVID-19?

Findings  In this cohort study of 509 694 individuals living in the United States, a difference-in-differences survival analysis found that residents in states that lifted eviction moratoria had an increased risk of receiving a COVID-19 diagnosis 12 weeks after the moratorium was lifted relative to residents in states where moratoria remained in place. These associations increased over time, particularly among individuals with more comorbidities and lower socioeconomic status.

Meaning  These findings suggest that eviction-led housing insecurity may have exacerbated the COVID-19 pandemic.

Abstract

Importance  Housing insecurity induced by evictions may increase the risk of contracting COVID-19.

Objective  To estimate the association of lifting state-level eviction moratoria, which increased housing insecurity during the COVID-19 pandemic, with the risk of being diagnosed with COVID-19.

Design, Setting, and Participants  This retrospective cohort study included individuals with commercial insurance or Medicare Advantage who lived in a state that issued an eviction moratorium and were diagnosed with COVID-19 as well as a control group comprising an equal number of randomly selected individuals in these states who were not diagnosed with COVID-19. Data were collected from OptumLabs Data Warehouse, a database of deidentified administrative claims. The study used a difference-in-differences analysis among states that implemented an eviction moratorium between March 13, 2020, and September 4, 2020.

Exposures  Time since state-level eviction moratoria were lifted.

Main Outcomes and Measures  The primary outcome measure was a binary variable indicating whether an individual was diagnosed with COVID-19 for the first time in a given week with International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code U07.1. The study analyzed changes in COVID-19 diagnosis before vs after a state lifted its moratorium compared with changes in states that did not lift it. For sensitivity analyses, models were reestimated on a 2% random sample of all individuals in the claims database during this period in these states.

Results  The cohort consisted of 509 694 individuals (254 847 [50.0%] diagnosed with COVID-19; mean [SD] age, 47.0 [23.6] years; 239 056 [53.3%] men). During the study period, 43 states and the District of Columbia implemented an eviction moratorium and 7 did not. Among the states that implemented a moratorium, 26 (59.1%) lifted their moratorium before the US Centers for Disease Control and Prevention issued their national moratorium, while 18 (40.1%) maintained theirs. In a Cox difference-in-differences regression model, individuals living in a state that lifted its eviction moratorium experienced higher hazards of a COVID-19 diagnosis beginning 5 weeks after the moratorium was lifted (hazard ratio [HR], 1.39; 95% CI, 1.11-1.76; P = .004), reaching an HR of 1.83 (95% CI, 1.36-2.46; P < .001) 12 weeks after. Hazards increased in magnitude among individuals with preexisting comorbidities and those living in nonaffluent and rent-burdened areas. Individuals with a Charlson Comorbidity Index score of 3 or greater had an HR of 2.37 (95% CI, 1.67-3.36; P < .001) at the end of the study period. Those living in nonaffluent areas had an HR of 2.14 (95% CI, 1.51-3.05; P < .001), while those living in areas with a high rent burden had an HR of 2.31 (95% CI, 1.64-3.26; P < .001).

Conclusions and Relevance  The findings of this difference-in-differences analysis suggest that eviction-led housing insecurity may have exacerbated the COVID-19 pandemic.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: August 9, 2021.

Published: August 30, 2021. doi:10.1001/jamanetworkopen.2021.29041

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Sandoval-Olascoaga S et al. JAMA Network Open.

Corresponding Author: Sebastian Sandoval-Olascoaga, MSc, Department of Urban Studies and Planning, Massachusetts Institute of Technology, 77 Massachusetts Ave, Bldg 9, Cambridge, MA 02139-4307 (olascoag@mit.edu).

Author Contributions: Mr Sandoval-Olascoaga had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Sandoval-Olascoaga, Arcaya.

Drafting of the manuscript: Sandoval-Olascoaga, Arcaya.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Sandoval-Olascoaga, Venkataramani.

Administrative, technical, or material support: Sandoval-Olascoaga.

Supervision: All authors.

Conflict of Interest Disclosures: Dr Venkataramani reported receiving grants from the National Institute of Health, the Center for Financial Security, the US Social Security Administration, the Robert Wood Johnson Foundation, and Independence Blue Cross outside the submitted work. Dr Arcaya reported receiving a grant from the Robert Wood Johnson Foundation outside the submitted work. No other disclosures were reported.

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