Association Between State-Level Medicaid Expansion and Eviction Rates

IMPORTANCE: Prior research has identified associations between housing insecurity and poor health outcomes. OBJECTIVE: To evaluate the association between US state Medicaid expansions and reductions in eviction; to examine the persistence of these associations and how they vary across US states and counties. DESIGN, SETTING, AND PARTICIPANTS: This cohort study of 25 398 county-year observations (across 40 states) used US eviction and census data for the years 2002 through 2018 (ie, 17 years). County-level associations were estimated using interactive fixed effects counterfactual estimators, and models were selected using cross validation. Across-county treatment association heterogeneities were assessed using multivariable regression methods. Analyses were performed in July of 2022. EXPOSURE: State-level Medicaid expansion under the Patient Protection and Affordable Care Act. MAIN OUTCOMES AND MEASURES: Eviction judgments; eviction judgments per 100 renter-occupied households. RESULTS: Among a total of 774 treated counties (with Medicaid expansion) and 720 control counties (untreated, without Medicaid expansion), mean (SD) eviction judgments for treated counties were 534.78 (1945.84) eviction judgments in the pre-2014 period (mean [SD] eviction rate, 2.25 [2.18] per 100 households), which decreased to 463.67 (1499.39) eviction judgments in the post-2014 period (mean [SD] eviction judgment rate, 2.02 [1.81] per 100 households). Control group mean (SD) county eviction judgments were 477.22 (1592.18) eviction judgments (mean [SD] eviction judgment rate, 1.91 per 100 households) pre-2014, and 490.22 (1575.19) eviction judgments (mean [SD] eviction judgment rate, 1.89 per 100 households) post-2014. Model estimates indicate that Medicaid expansion was associated with reductions in county eviction judgments by −66.49 (95% CI, −132.50 to −0.48; P = .047) and reductions of the eviction judgment rate by −0.25 (95% CI, −0.35 to −0.14; P < .001). Associations remained broadly consistent between 2014 and 2018, although some diminishment of associations occurred in 2018. Approximately 29% of the across-county treatment association variation was explained by across-state differences, while 9% was explained by county-level demographic and uninsurance differences. CONCLUSIONS AND RELEVANCE: In this cohort study, Medicaid expansion was associated with reductions in eviction judgments and eviction judgment rates; however, these associations were found to vary considerably both across as well as within states (across counties). These findings suggest that the channel between Medicaid expansion and evictions is sensitive to state environments as well as county specific population demographics and uninsurance levels.