Tenant Right-to-Counsel and Emergency Department Use in Low-Income and Uninsured Populations

Background Evictions are associated with numerous health harms, contributing to increased emergency department (ED) use. In 2017, New York City introduced the nation’s first tenant right-to-counsel program, which lowered eviction rates by providing free legal representation to low-income renters facing eviction. Health implications of this policy are uncertain. Objective To test whether right-to-counsel decreased all-cause and cause-specific ED visits by low-income and uninsured individuals. Design Retrospective cohort study of all-payer ED utilization data (1/2016–2/2020) leveraging the staggered implementation of right-to-counsel by ZIP code as a natural experiment. Subgroup analyses assessed heterogeneity by right-to-counsel implementation phase and age group. Secondary analyses examined cause-specific ED visits. Participants Medicaid-insured and uninsured individuals in New York, NY. Intervention Right-to-counsel implementation status by ZIP-month. Main Measures All-cause and cause-specific ED utilization rates per 10,000 Medicaid-insured or uninsured ZIP residents. Key Results In total, 8,206,986 ED visits (21% by residents of right-to-counsel ZIP codes) were aggregated to 8550 ZIP-months. While there was no overall association between right-to-counsel implementation and all-cause ED visits (difference-in-differences estimate −10.8 [95% CI −32.8, 11.2] visits per 10,000), we observed a significant reduction in ED visits in ZIP codes targeted for the earliest intervention phase due to their high eviction risk (−26.4 [95% CI −52.6, −0.2] visits per 10,000) and a marginally significant reduction among children (−32.4 [95% CI −67.2, 2.4] per 10,000). In cause-specific models, right to counsel was associated with increased mental-health- and substance-use-disorder-related ED visits (2.5 [0.2, 5.8] and 2.7 [0.4, 5.0] per 10,000, respectively), with no significant differences in visits for ambulatory-care-sensitive conditions. Conclusions Tenant right to counsel was associated with reduced all-cause ED visits among residents of neighborhoods included in the first of three intervention phases and possibly among children, suggesting health improvement in certain populations. Further research is needed to understand increased ED utilization for mental health and substance use following right-to-counsel. Policymakers considering similar eviction-prevention programs may want to consider potential health benefits.