Legal aid linked to fewer ED visits in New York’s highest-risk areas

A UCLA Health-led natural-experiment study found that New York City’s tenant right-to-counsel program was associated with fewer emergency department visits in neighborhoods at especially high risk of eviction, but it detected no overall reduction across all covered zip codes. The analysis included more than 8 million emergency department visits by Medicaid-insured and uninsured city residents from January 2016 through February 2020. During the program’s initial phase, researchers estimated more than 26 fewer emergency department visits per 10,000 residents in the highest-risk neighborhoods, a statistically significant reduction. The peer-reviewed study was published in the Journal of General Internal Medicine.

Researchers examined whether free legal representation for tenants facing eviction was associated with changes in emergency department use. They used the program’s staggered rollout as a natural experiment, comparing patterns among residents of zip codes where the service was introduced at different phases. The analysis was limited to Medicaid-insured and uninsured New York City residents and assessed all-cause emergency department visits, along with differences across age groups and implementation phases. Because the study relied on observational records and the phased rollout rather than random assignment, its results establish an association and do not prove that legal representation directly caused the changes in emergency department use.

Introduced in 2017, New York City’s program was the country’s first tenant right-to-counsel policy. It contracts with nonprofit law offices to provide free legal representation to low-income tenants facing eviction proceedings. The service began in 10 zip codes selected for their especially high eviction risk, homelessness rates and limited housing resources, then expanded to additional zip codes in phases. Across all covered zip codes, researchers estimated a slight drop in emergency department visits per 10,000 residents following implementation. The stronger association was concentrated in the neighborhoods targeted during the earliest phase, where the program was linked to more than 26 fewer visits per 10,000 residents. Emergency department visit rates stayed approximately the same in neighborhoods included in the second and third implementation phases.

The study also identified an unexpected increase in emergency department visits related to mental health and substance use disorders in zip codes where right-to-counsel was implemented. Study leader Katherine L. Chen, MD, assistant professor of internal medicine and population health scientist at the David Geffen School of Medicine at UCLA, said the authors considered several possible explanations in the paper. Interactions with right-to-counsel lawyers might encourage some people to seek care for undertreated conditions, while legal interactions might increase stress in the short term even if they help tenants avoid eviction in the longer term. These were proposed explanations rather than demonstrated mechanisms, and Chen said the increase warrants further research.

Chen said the association between right-to-counsel and lower emergency department visit rates among populations at elevated eviction risk underscores the importance of housing stability for overall health. She identified two priorities for follow-up research: linking eviction records with health data to determine how the program affected people who actually received an eviction filing, and soliciting patient feedback through qualitative interviews to clarify why mental-health and substance-use-related visits increased after implementation. The researchers noted that 26 other jurisdictions, including Los Angeles, have since introduced similar programs. The findings do not show that right-to-counsel uniformly reduced emergency department use or that it worsened mental-health and substance-use-related care. Instead, they identify a possible population-health benefit among residents facing the greatest eviction risk while leaving the reasons for the increase in specialized emergency department visits unresolved.

Subject of Research: Health effects of New York City’s tenant right-to-counsel program on emergency department use

Article Title: UCLA Health-led study finds NYC tenant right-to-counsel program linked to fewer ED visits in high-risk neighborhoods

Article References: UCLA Health-led study finds NYC tenant right-to-counsel program linked to fewer ED visits in high-risk neighborhoods. Original publication (Bibliographic details unavailable.)

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Keywords: Tenant right-to-counsel, Emergency department visits, Eviction prevention, Housing stability, Natural experiment, New York City, Population health, Mental health, Substance use disorders, UCLA Health, UCLA, Health-led