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

ImportanceHousing insecurity—that is, difficulty with housing affordability and stability—is prevalent and results in increased risk for both homelessness and poor health. However, whether interventions that prevent housing insecurity upstream of homelessness improve health remains uncertain.ObjectiveTo review evidence characterizing associations of primary prevention strategies for housing insecurity with adult physical health, mental health, health-related behaviors, health care use, and health care access.Evidence ReviewPairs of independent reviewers systematically searched PubMed, Web of Science, EconLit, and the Social Interventions Research and Evaluation Network for quantitative studies published from 2005 to 2021 that evaluated interventions intended to directly improve housing affordability and/or stability either by supporting at-risk households (targeted primary prevention) or by enhancing community-level housing supply and affordability in partnership with the health sector (structural primary prevention). Risk of bias was appraised using validated tools, and the evidence was synthesized using modified Grading of Recommendations Assessment, Development, and Evaluation criteria.FindingsA total of 26 articles describing 3 randomized trials and 20 observational studies (16 longitudinal designs and 4 cross-sectional quasi–waiting list control designs) were included. Existing interventions have focused primarily on mitigating housing insecurity for the most vulnerable individuals rather than preventing housing insecurity outright. Moderate-certainty evidence was found that eviction moratoriums were associated with reduced COVID-19 cases and deaths. Certainty of evidence was low or very low for health associations of other targeted primary prevention interventions, including emergency rent assistance, legal assistance with waiting list priority for public housing, long-term rent subsidies, and homeownership assistance. No studies evaluated health system–partnered structural primary prevention strategies.Conclusions and RelevanceThis systematic review found mixed and mostly low-certainty evidence that interventions that promote housing affordability and stability were associated with improved adult health outcomes. Existing interventions may need to be paired with other efforts to address the structural determinants of health. As health care systems and insurers respond to increasing opportunities to invest in housing as a determinant of health, further research is needed to clarify where along the housing insecurity pathway interventions should focus for the most effective and equitable health impact.

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“…One RCT 37 and 6 observational studies [38][39][40][41][42][43] assessed health associations of short-term interventions…”

Section: Targeted Primary Prevention: Short-term Strategiesmentioning

confidence: 99%

Association of Promoting Housing Affordability and Stability With Improved Health Outcomes

et al. 2022

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“…Individuals who developed cardiovascular disease or diabetes as a result of the post-acute sequelae of Covid-19 and subsequently died also may not have had their deaths assigned to Covid-19 (15,16). Finally, excess deaths not assigned to Covid-19 may also reflect deaths indirectly related to the pandemic, including deaths associated with reductions in access to health care, hospital avoidance due to fear of Covid-19 infection, increases in drug overdoses, and economic hardship leading to housing and food insecurity (17)(18)(19)(20)(21)(22)(23).…”

Section: Introductionmentioning

confidence: 99%

“…13 Finally, excess deaths not assigned to Covid-19 may also reflect deaths indirectly related to the pandemic, including deaths associated with reductions in access to health care, hospital avoidance due to fear of Covid-19 infection, increases in drug overdoses, and economic hardship leading to housing and food insecurity. 14–20…”

Section: Introductionmentioning

confidence: 99%

Monthly excess mortality across counties in the United States during the Covid-19 pandemic, March 2020 to February 2022

Paglino¹,

Lundberg²,

Cho³

et al. 2022

Preprint

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Official Covid-19 death tallies have underestimated the mortality impact of the Covid-19 pandemic in the United States. Excess mortality, which compares observed deaths to deaths expected in the absence of the pandemic, is a useful measure for assessing the total effect of the pandemic on mortality levels. In the present study, we produce county-level estimates of excess mortality for 3,127 counties between March 2020 and December 2021. We fit two hierarchical linear models to county-level death rates from January 2015 to December 2019 and predict expected deaths for each month during the pandemic. We compare these estimates with the observed numbers of deaths to obtain excess deaths for each county-month. An estimated 936,911 excess deaths occurred during 2020 and 2021, of which 171,168 were not assigned to Covid-19 on death certificates. Urban counties in the Far West, Great Lakes, Mideast, and New England experienced a substantial urban mortality disadvantage in 2020, whereas rural counties in these regions had higher mortality in 2021. In the Southeast, Southwest, Rocky Mountain, and Plains regions, there was a rural mortality disadvantage in 2020, which was exacerbated in 2021. The proportion of excess deaths assigned to Covid-19 was lower in 2020 (76.3%) than in 2021 (87.0%), suggesting fewer Covid-19 deaths went unassigned later in the pandemic. However, in rural areas and in the Southeast and Southwest a large share of excess deaths were still not assigned to Covid-19 during 2021.

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“…Regarding household crowding, rent/eviction moratoriums, mortgage relief moratoriums and extended Covid-19 unemployment benefits would prevent crowding related to economic and housing insecurity. 76,77 Second, although underlying health risks for Covid-19 resulting from weathering may not be possible to fully reverse, future harm can be prevented. Policies that would advance racial health equity, such as economic reparations, divestments from police funding and investments in community-based safety programs, and increased funding for community and social programs in underserved communities, are needed.…”

Section: Discussionmentioning

confidence: 99%

Geographic and Temporal Patterns in Covid-19 Mortality by Race and Ethnicity in the United States from March 2020 to February 2022

Lundberg

Cho

Raquib

et al. 2022

Preprint

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Prior research has established that American Indian, Alaska Native, Black, Hispanic, and Pacific Islander populations in the United States have experienced substantially higher mortality rates from Covid-19 compared to non-Hispanic white residents during the first year of the pandemic. What remains less clear is how mortality rates have changed for each of these racial/ethnic groups during 2021, given the increasing prevalence of vaccination. In particular, it is unknown how these changes in mortality have varied geographically. In this study, we used provisional data from the National Center for Health Statistics (NCHS) to produce age-standardized estimates of Covid-19 mortality by race/ethnicity in the United States from March 2020 to February 2022 in each metro-nonmetro category, Census region, and Census division. We calculated changes in mortality rates between the first and second years of the pandemic and examined mortality changes by month. We found that when Covid-19 first affected a geographic area, non-Hispanic Black and Hispanic populations experienced extremely high levels of Covid-19 mortality and racial/ethnic inequity that were not repeated at any other time during the pandemic. Between the first and second year of the pandemic, racial/ethnic inequities in Covid-19 mortality decreased—but were not eliminated—for Hispanic, non-Hispanic Black, and non-Hispanic AIAN residents. These inequities decreased due to reductions in mortality for these populations alongside increases in non-Hispanic white mortality. Though racial/ethnic inequities in Covid-19 mortality decreased, substantial inequities still existed in most geographic areas during the pandemic’s second year: Non-Hispanic Black, non-Hispanic AIAN, and Hispanic residents reported higher Covid-19 death rates in rural areas than in urban areas, indicating that these communities are facing serious public health challenges. At the same time, the non-Hispanic white mortality rate worsened in rural areas during the second year of the pandemic, suggesting there may be unique factors driving mortality in this population. Finally, vaccination rates were associated with reductions in Covid-19 mortality for Hispanic, non-Hispanic Black, and non-Hispanic white residents, and increased vaccination may have contributed to the decreases in racial/ethnic inequities in Covid-19 mortality observed during the second year of the pandemic. Despite reductions in mortality, Covid-19 mortality remained elevated in nonmetro areas and increased for some racial/ethnic groups, highlighting the need for increased vaccination delivery and equitable public health measures especially in rural communities. Taken together, these findings highlight the continued need to prioritize health equity in the pandemic response and to modify the structures and policies through which systemic racism operates and has generated racial health inequities.

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

Cited by 25 publications

References 18 publications

Association of Promoting Housing Affordability and Stability With Improved Health Outcomes

Association of Promoting Housing Affordability and Stability With Improved Health Outcomes

Monthly excess mortality across counties in the United States during the Covid-19 pandemic, March 2020 to February 2022

Geographic and Temporal Patterns in Covid-19 Mortality by Race and Ethnicity in the United States from March 2020 to February 2022

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