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. This cohort study estimates the association of lifting US state–level eviction moratoria with the risk of being diagnosed with COVID-19. 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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