Eviction And Health: A Vicious Cycle Exacerbated By A Pandemic

A large body of research demonstrates that housing is an important social determinant of health. Eviction, which is a relatively common phenomenon among renters in America, is a severe form of housing insecurity with significant health impacts. In the past several years, evidence of the detrimental effect of eviction on health has grown, with analyses demonstrating negative impacts on a variety of health metrics ranging from birth outcomes to mental health hospitalizations to all-cause mortality. As the evidence linking eviction to health has grown, clinicians, health systems, and policy makers have begun to pay increased attention to eviction and to interventions to improve housing security and health.

Recently, the economic consequences of the COVID-19 pandemic have increased the number of renters at risk for eviction. Housing instability undermines key infection prevention strategies deployed during the pandemic, compounding the detrimental consequences of eviction for health. The COVID-19 pandemic has thus brought new urgency to exploring the full scope of the eviction crisis and to understanding how eviction affects health and health equity, as well as the policy tools available to combat eviction both during the pandemic and beyond.

In this brief we highlight the prevalence of eviction, which is expected to increase dramatically as a result of the COVID-19 pandemic. We also review existing research demonstrating the many health consequences of eviction, including increased COVID-19 transmission among evicted households and their communities, and discuss how these consequences undermine health equity. We then summarize the eviction prevention policies deployed during the pandemic. We close by suggesting both additional longer-term policies to stem the tide of evictions and areas for further research.

Eviction Prevalence

In 2016, the most recent year for which national data are available, 6.1 percent of renter households were served eviction notices and 2.3 percent were evicted from their homes. Although the demographics of evicted tenants vary somewhat across the US, Black and Hispanic women and families with children are at especially high risk for eviction. Although approximately 20 percent of renters are Black, almost 33 percent of eviction filings are against Black renters. The risk for eviction is 2 percent higher for women than men, and the eviction filing rate against Black women is nearly twice the filing rate against White women (6.4 versus 3.4 percent).

More than three-quarters of evictions in 2017 were for nonpayment of rent. Rising rents in the US have far outpaced increases in renters’ wages, with median rent rising 13 percent in the past two decades and median income rising less than 0.5 percent. In 2017, more than half of poor tenants (those earning less than 80 percent of the Department of Housing and Urban Development area median family income) in the US were considered rent burdened, spending at least 30 percent of their income on housing. This means that eviction often reflects the chronic financial precarity of renters, not merely a one-time financial shock.

The adverse health effects of housing insecurity were evident before the emergence of COVID-19, but the pandemic-induced financial crisis for low- and middle-income households has increased housing precarity and related health risks. Federal, state, and local policy makers, recognizing the nascent eviction crisis and its potential to accelerate the spread of COVID-19, have implemented eviction moratoria, temporarily halting many evictions. Notably, at the federal level, it was a health agency (the Centers for Disease Control and Prevention [CDC]), rather than a housing agency, that issued an eviction moratorium, citing the detrimental health consequences of allowing evictions to continue. Although the CDC moratorium prevents landlords from removing tenants from a property, it does not prevent the filing of new eviction proceedings, which many states continue to allow. Just the filing of an eviction provokes many tenants to leave their homes, even in the absence of an eviction judgement. Furthermore, as the spread of COVID-19 and its financial sequelae continue, tenants are falling further behind on rent. In the last quarter of 2020, an estimated 12.4 million adult renters (approximately one in six renter households) in the US reported being behind on rent, indicating that in the absence of rent relief (that is, rental debt forgiveness or grants to households to pay back rent), evictions are likely to soar as the moratoria expire.

Eviction And Health

Selected research examining the link between eviction and health is summarized in supplemental exhibit 1. These studies take various forms, including qualitative, ecological, and quasi-experimental analyses. Because eviction is especially common among low-income families with children, several studies have focused on the consequences of eviction for children and their caregivers. Multiple studies have linked eviction to an increased incidence of adverse birth outcomes, including low birth weight, prematurity, and infant mortality. Prior evictions are associated with worse caregiver-reported child health and an increase in childhood hospitalizations, as well as worse self-reported health and depressive symptoms among caregivers.

Eviction is also associated with poor health among adults. Evicted adults have higher all-cause mortality than matched controls. Adults who have been evicted have worse self-reported physical health than nonevicted people, and quasi-experimental analyses indicate that eviction causes an increase in the frequency of emergency department visits. Eviction is associated with increased odds of detectable viral load among people living with HIV, and rates of illicit drug initiation and relapse both increase after evictions. Evicted adults report significantly worse mental health, have higher suicide mortality, and have higher rates of mental health hospitalizations than nonevicted adults. In surveys conducted with evicted adults, many report new depression, anxiety, and insomnia after an eviction, and counties with higher eviction rates have significantly higher rates of accidental drug- and alcohol-related deaths.

Eviction is also associated with many other social determinants of health that may compound its negative consequences. Children whose families have experienced an eviction have a higher prevalence of food insecurity and worse educational outcomes than other low-income children living in rental housing. Many evicted families report that their children had to change schools after an eviction. Evicted tenants are more likely than nonevicted tenants to move to lower-quality homes (that is, homes with broken appliances, exposed wires, or inadequate heating) and to face more subsequent moves. Quasi-experimental analyses have found that evicted adults have an increased probability of experiencing homelessness and are likely to remain in homeless shelters for a longer time than nonevicted tenants. Relative to renters who move voluntarily, evicted renters move to neighborhoods with significantly higher poverty and crime rates. Eviction can also have devastating financial consequences, with evicted people more likely than nonevicted renters to rely on social assistance programs and to experience job loss and reduced credit access.

Eviction also takes a psychological toll. In qualitative studies, tenants experiencing housing insecurity report feeling a lack of control over important aspects of their daily lives and often experience hopelessness, stigma, and uncertainty. The psychological stress of eviction also has direct physiological consequences and may further affect physical health indirectly through adoption of unhealthy behaviors such as smoking.

The findings from quasi-experimental analyses supporting a relationship between eviction and increased health care use, increased homelessness, and decreased credit access suggest that there may be a causal component of eviction’s effect on health and its determinants. The literature would be strengthened by additional studies using natural experiment study designs that simulate random assignment to eviction, as well as further qualitative research on the mechanisms linking eviction to health.

COVID-19-Specific Consequences Of Eviction

The rising eviction rates expected as a consequence of the COVID-19 pandemic will likely increase the incidence of the detrimental health consequences of eviction outlined above. Furthermore, eviction and housing displacement pose a particular health risk during a pandemic and can create a vicious cycle. Eviction often leads to tenants doubling up with friends or relatives, overcrowding, homelessness, and transiency. These unstable housing arrangements increase the likelihood of exposure to COVID-19 and make compliance with infection containment strategies such as social distancing, self-quarantining, and even hand washing challenging or impossible. Larger households that result from eviction and doubling up facilitate the spread of COVID-19, even under lockdown conditions. Infectious disease modeling has demonstrated that higher eviction rates increase infection risk for all, including nonevicted people. Policies that limit evictions significantly reduce COVID-19 infections and deaths, and quasi-experimental analyses indicate that the lifting of some eviction moratoria in late 2020 significantly increased the incidence of COVID-19 morbidity and mortality.

Although Black and Hispanic communities have long been disproportionately affected by eviction and the adverse health outcomes associated with it, the COVID-19 pandemic has acutely exacerbated racial disparities in both eviction and health. Black and Hispanic people have died of COVID-19 at higher rates than their White counterparts, and these same groups have experienced significantly more rent-related financial stress and continue to face disproportionately high eviction rates during the pandemic. Thus, the COVID-19 pandemic may further compound eviction’s contribution to health disparities.

Policy Approaches To Reducing Eviction-Related Harm

The US has the highest eviction rate among the wealthy nations in the Organization for Economic Cooperation and Development, reflecting myriad differences in housing and social policies, including less-generous investments in affordable housing in the US. As a consequence, other nations have largely avoided the eviction crisis that has exacerbated the pandemic-induced public health crisis. Policies aimed at addressing the eviction crisis in the US fall broadly into three categories: short-term eviction moratoria and emergency assistance programs (both of which have been employed during the pandemic) and longer-term strategies aimed at improving housing affordability and the financial well-being of renters.

EVICTION MORATORIA

The US has largely neglected long-term housing policies that could have attenuated the surge in housing insecurity caused by the pandemic, but various short-term eviction moratoria have been implemented at the local, state, and federal levels. Although eviction moratoria may create financial challenges for landlords, they have been effective at temporarily keeping evictions at levels well below historic averages. With the March 2020 passage of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, Congress instituted a 120-day eviction moratorium in federally subsidized affordable housing and properties with federally backed mortgages, covering an estimated 28–46 percent of rental units nationwide. Evidence suggests that the CARES Act significantly reduced evictions at covered properties. For example, in Atlanta, Georgia, evictions from federally backed properties constituted more than 30 percent of all evictions before the CARES Act went into effect but only 5 percent after. However, the extent to which rental properties fell under protection by the CARES Act varied greatly by city based on the prepandemic concentration of covered housing in different markets: Although more than 40 percent of evictions in the Atlanta area were at federally backed apartments, only approximately 10 percent of those in Milwaukee were.

The CARES Act moratorium expired on July 24, 2020, when it required landlords to provide tenants with a thirty-day notice of intent to evict, effectively delaying the initiation of eviction proceedings until August 24, 2020. On September 4, 2020, the CDC, recognizing the potential of evictions to further fuel the spread of COVID-19, issued a second federal eviction moratorium. Originally set to expire in December 2020, the CDC moratorium was first extended to January 31, 2021; then extended through March 31, 2021; and is likely to be extended further. Early evidence suggests that the ten-day gap in protection between the expiration of the CARES Act and the institution of the CDC eviction moratorium may have caused significant harm. Eviction judgments jumped significantly in August 2020 before declining again in September.

Unlike the CARES Act, the CDC moratorium is not limited to tenants residing in federally subsidized housing or properties with federally backed mortgages. The CDC order stipulates that renters make every effort to pay at least partial rent, does not include direct rent relief or financial assistance, and expects tenants to pay unpaid rent (including any late fees, penalties, or interest charged by landlords) when the moratorium expires. Although more far-reaching than the CARES act, the CDC moratorium has not stopped all evictions, and numerous cities have continued to see large numbers of eviction filings.

Many state and local governments have also issued eviction moratoria. These moratoria have varied in duration, in what types of tenants are protected, and in which stage of eviction the process was halted. In many places, state and local moratoria have halted evictions altogether. This is especially true in locales that placed moratoria on the first two stages of the eviction process: issuing notices of intention to seek eviction and initiating an eviction case in court. Because many tenants facing the threat of eviction (for example, receiving a notice) vacate their homes before their eviction case concludes, interventions at these early stages of the eviction process have proven most effective at preventing housing loss. As state and local moratoria have expired, evictions have increased, despite the ongoing federal CDC eviction moratorium.

EMERGENCY ASSISTANCE PROGRAMS

Many evictions—even during the pandemic, when renters are continuing to fall further behind on rent—are for relatively small amounts of money. For instance, among evictions filed during July 2020 in Phoenix, Arizona, almost 20 percent were for $500 or less, and in Cincinnati, Ohio, half of all eviction cases filed in that month were for $1,200 or less. Although some renters who have fallen months behind on rent payments would require significant rent relief to avoid housing loss, other evictions could be prevented with modest aid.

Many state and local governments have enacted programs to provide emergency rental assistance (that is, rent payment) for tenants, often using a portion of the funding they received through the CARES Act to support these programs. The need for emergency rental assistance has far outpaced available funds, and most rental assistance programs have stringent eligibility criteria, requiring extensive documentation to demonstrate COVID-19-related financial hardship, which is a significant barrier for already-strained households. Furthermore, rental assistance programs often require landlords to participate—for example, by voluntarily forgiving a portion of the rent—making them inaccessible to many tenants.

In addition to emergency rental assistance, wage replacement policies such as unemployment insurance and paid sick leave increase the income available to renters. Unemployment has risen sharply during the pandemic, and renters have been disproportionately affected. The CARES Act and subsequent American Rescue Plan Act have temporarily expanded the eligibility and duration of unemployment insurance and increased the amount of the benefit, buffering recipients against the financial effects of the pandemic. However, the expanded unemployment benefits are set to expire in September 2021, leaving unemployed renters again increasingly vulnerable to eviction.

LONGER-TERM STRATEGIES

The US eviction crisis and its associated health consequences preceded the COVID-19 pandemic and will remain after the acute effects of the pandemic have subsided. Long term, addressing the eviction crisis will require a multipronged policy response. Providing legal assistance to tenants, increasing investment in affordable housing and rental assistance programs, and improving the financial health of renters via increases in the minimum wage and the expansion of public benefits such as health insurance have the potential to greatly reduce the frequency of evictions.

Looking Ahead

Understanding the extent of COVID-19’s impact on eviction and the efficacy of antieviction policies, as well as further examining the downstream health consequences of eviction, remain important areas of research. In particular, the full scope of the lifetime consequences of evictions experienced during childhood and the health consequences of eviction for elderly and medically frail adults remains to be fully understood. The patchwork of eviction policies in response to the COVID-19 pandemic, which span the federal, state, and local levels, has created many natural experiments, and hence opportunities for researchers to quickly improve the knowledge base on eviction.

Swift action is required to address the predicament of poor renters facing loss of shelter while a pandemic rages. In the short term, moratoria could be extended and strengthened by blocking earlier stages in the eviction process and covering all eviction cases—not just those for nonpayment of rent. However, temporary moratoria are stopgap solutions, and rents continue to accrue. Rental assistance programs must be implemented immediately to reduce evictions and to provide tenants and landlords with funds to weather this economic and public health crisis. Over the longer term, federal, state, and local governments must implement policies to make safe and affordable housing available to lower-income Americans.