Sept. 21, 2022 -- Eviction is a housing and financial crisis ― and a health crisis in the making.
Families across the country are feeling the financial squeeze. Rents are rising and inflation has increased the price of, well, everything. Meanwhile, the pandemic-related moratorium on evictions the CDC imposed was struck down in August 2021, and statewide bans on evictions have ended. As a result, the number of evictions in much of the country has hit rates not seen since before the coronavirus outbreak.
Stable housing is crucial for good health. Research shows that evictionis associated with a wide range of bad health outcomes, loss of access to medical care, and a vicious cycle of poor health. But doctors and the health care system can take steps to mitigate the harm by supporting patients facing eviction and housing insecurity.
"Housing is the bedrock that everything else rests on in terms of our health," says Kathryn Leifheit, PhD, a social epidemiologist and assistant professor of pediatrics at the UCLA David Geffen School of Medicine. "But we also know that rates of housing insecurity in the United States, and in high-income countries in general, are really high."
Eviction is also a health equity issue.
"The people who are most likely to be evicted or experience housing insecurity are single Black women with children," Leifheit says. Racial and ethnic health disparities are already a massive problem among this group of people. Rising eviction rates only threaten to widen the gap, she says.
‘Upstream and Fundamental’
Housing is one of five social determinants of health, the economic and social conditions that affect the health of individuals and populations. Among these, "housing has this special status in our minds as the most upstream and most fundamental," Leifheit says.
In recent years, scientists have started to quantify the direct effects of eviction on people's health.
"It's so complex, and I don't think the exact pathway is mapped out yet because it is so hard to do these studies," Karen Sheehan, MD, MPH, a pediatrician and professor at Northwestern University Feinberg School of Medicine in Chicago, says. "But we do see lots of associations between eviction and foreclosures and poor health in pretty much every domain."
One of the main drivers of these poor health effects is stress. "If you don't have stable housing, it contributes to stress, and that has ramifications in so many different health areas," Sheehan says.
Research has linked myriad health effects to evictions. One study found that patients who are evicted are more likely to be hospitalized in the 2 years following that eviction, says Gabriel Schwartz, PhD, a social epidemiologist and postdoctoral student with the Social Policies for Health Equity Research Program at the University of California San Francisco. A study in Sweden found that the chance of dying from any reason in the near term was higher for people who were evicted than for those who kept their homes.
Schwartz has found similarly troubling patterns in his own research. Babies born to pregnant women who experienced housing insecurity during pregnancy had higher rates of low-birth weight and/or per-term birth stays in the neonatal intensive care unit or a stepdown unit and extended hospitalizations.
Children who are evicted during childhood appear to have worse cognitive function in elementary school, a critical juncture when they are preparing for later education, Schwartz says. He found that children who had been evicted in middle childhood had scores below those of similar children who had not been evicted ― the equivalent of as much as a full year of school.
A study published this month in the journal Pediatrics found that children in families that had experienced an eviction ― formal or otherwise ― over the past 5 years were 43% more likely to be in fair or poor health and were 55% more likely to face risk to their development, according to their parents. Those effects persisted after the researchers adjusted for factors such as income and housing-related hardships.
Eviction can and often does drive people into overcrowded or unsafe housing conditions. Another study found that housing instability could increase the risk of contracting a sexually transmitted disease. And the crowded living conditions many people end up in after an eviction, either at a shelter or with family or friends, can raise the risk for infectious diseases such as COVID-19, monkeypox, and flu, Schwartz said.
Eviction has even been linked with lead poisoning, possibly because having a record of being evicted can limit families' housing options, forcing them to compromise on housing or neighborhood quality, Leifheit says.
Falling Through the Safety Net
Moving suddenly to a new area can make it harder to reach doctors or schedule appointments. "You see people falling out of these really vital safety net services at exactly the moment when they need them the most," Leifheit says.
Medicaid coverage can be imperiled by eviction. Renewing Medicaid enrollment requires families to recertify their eligibility through a form sent through the mail, Leifheit says. In New York City, Schwartz and colleagues found that eviction was associated with 63% higher odds of losing Medicaid coverage compared to demographically similar individuals who were not evicted. They also found that people who were evicted filled fewer prescriptions.
The effects of evictions on health can become cyclical. "Not only can eviction be a cause of poor health, it can also be a consequence," Schwartz says.
For example, someone who gets evicted might lose their Medicaid coverage, not be able to go to the doctor for a minor health problem, and end up having a major health crisis that lands them in the hospital. This could result in even more financial instability and increase the difficulty in finding stable housing. And so the process repeats, Schwartz says.
How to Help
Housing is a vast and thorny issue, but doctors and other health care providers can support patients facing eviction.
The first step is to be aware that patients may be in jeopardy of eviction, says Craig Evan Pollack, MD, an internal medicine doctor and professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore. Clinics should screen patients for housing insecurity and eviction. Guides exist for how to screen for social determinants of health with sensitivity, he says.
Doctors should also be aware of the housing resources and social supports in their community so they can refer patients to groups that help with housing, legal representation, and other services, says Yogesh Shah, MD, MPH, chief medical officer and vice president of medical affairs at Broadlawns Medical Center in Des Moines, IA.
For patients facing a housing crisis, Shah also recommends reviewing a patient's medication list and simplifying it as much as possible. Prioritty should be given to medications that don't have to be taken as frequently, such as only once a day, and medications that don't require special storage, such as being kept cold.
Providers can anticipate the patient's not being able to come back to the clinic soon. A more comprehensive workup may be performed while the patient is there, telemedicine may be used for follow-up appointments, rather than in-person visits, and patients should be given a hard copy of their chart, Shah said. Patients dealing with an eviction may not be able to access their information digitally or may end up in a different neighborhood or clinic and need an easy way to share their medical history.
Health care institutions can also play a role. The team approach, in which patients have access to social workers and providers other than doctors, is central to supporting patients facing or going through housing insecurity, Pollack said.
Hospitals and health care institutions should view social services as preventive medicine, Shah says. In recent years, that has been a focus at Broadlawns Medical Center, a county hospital that serves a minority patient population, he says.
"What can hospital systems do? What can we do in the area of education, area of transportation, nutrition, housing, or lack of housing? Our focus is on upstream investment; how can we as a hospital system reach out in the community to help [patients] live better quality of life?" Shah says.