Housing insecurity of medicaid beneficiaries with cognitive disabilities during the COVID-19 pandemic.

BACKGROUND: While people with cognitive disabilities are more vulnerable to COVID-19, and the COVID-19 pandemic significantly increased housing insecurity in the general population, less is known about Medicaid beneficiaries with cognitive disabilities' housing insecurity during the pandemic.
OBJECTIVE: This study's aim was to explore housing insecurity of Medicaid beneficiaries with cognitive disabilities during the pandemic (April 2021-May 2022).
METHODS: We analyzed Household Pulse Survey data from 473,626 (unweighted) people; frequency-person weights were applied. Data were analyzed using descriptive statistics, chi-square, and binary and ordinal logistic regression models.
RESULTS: Findings revealed 26% of Medicaid beneficiaries with cognitive disabilities who rented or owned with a mortgage were behind on their housing payments between April 2021 and May 2022; more than half of which (52%) were very or somewhat likely to face eviction/foreclosure. Most (70%) were concerned about their ability to make their next housing payment. Medicaid beneficiaries with cognitive disabilities were more likely to experience housing insecurity than all other people with disabilities and nondisabled people. The people with Medicaid beneficiaries with cognitive disabilities more likely to experience housing insecurity included: renters; people with visual disabilities; cisgender women; transgender people; Black people; 'another' race or multiracial people; people with graduate degrees; people from lower income households; households that experienced income loss; and larger households.
CONCLUSIONS: Attention to Medicaid beneficiaries with cognitive disabilities' experiences with housing insecurity during the pandemic is critical in order to develop programs and policies to facilitate housing security.

Due to systemic inequities and discrimination, many social minority groups are disproportionately housing insecure in the United States. For example, housing insecurity is more common among Black, Indigenous, people of color (BIPOC) due to discrimination, including wealth gaps and racist housing policies.1, 2, 3, 4, 5, 6, 7, 8 Housing insecurity is also more common among renters, LGBTQ people, lower income people, those with less education, and unmarried and single people. , 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 Meanwhile, there is conflicting evidence about age (older versus younger adults), cisgender men and women, and household size (larger versus smaller households), with some evidence finding one subgroup more likely to experience housing insecurity and some finding the opposite subgroup being more likely.3, 4, 5 , , , , , , Research also indicates public assistance and insurance programs, including SSI/SSDI, Medicare, Medicaid, can play an important role in housing security.17, 18, 19, 20, 21, 22 For example, while Medicaid beneficiaries disproportionately experience housing insecurity, Medicaid programs are more frequently working to promote the housing security of Medicaid beneficiaries than previously.18, 19, 20, 21, 22

In addition, compared to people without disabilities, people with disabilities are more likely to experience housing insecurity, to live in poorer quality housing (e.g., toxins/health, space, equipment, amenities), to live in poorer quality neighborhoods (e.g., toxins/health, community resources, walkability, transportation, crime), and to be unhoused. , , 23, 24, 25 As of 2019, 13% of households with ‘worst case needs’ – very low income, severe rent burden (>50% of income on rent/utilities), do not receive housing assistance, and/or live in severely inadequate conditions – were comprised of people with disabilities younger than 62.

The COVID-19 pandemic intensified housing insecurity in the United States, with many people facing eviction, foreclosure, and becoming unhoused. The housing crisis during COVID-19 disproportionately impacted those very communities that already faced housing disparities and were more likely to contract COVID-19, including people with disabilities. , One of the most high-risk groups for contracting and dying of COVID-19 are people with cognitive disabilities, defined by the United States Census Bureau using language recommended by the United Nations, as those who have ‘a lot of difficulty’ or ‘could not at all’ remember or concentrate. People with cognitive disabilities are not only higher risk for COVID-19 but were also likely to face housing insecurity prior to the pandemic. , , 31, 32, 33 For these reasons, the aim of this study was to explore housing insecurity of people with cognitive disabilities who were Medicaid beneficiaries during the COVID-19 pandemic (April 2021–May 2022). To do so, we examined secondary United States Census Bureau COVID-19 Household Pulse Survey data from 473,626 (unweighted) people, including Medicaid beneficiaries with cognitive disabilities.

Methods

Data

Data were obtained from the United States Census Bureau (As the data are publicly available deidentified data, our IRB determined it was exempt from review). The Census Bureau administered the online COVID-19 Household Pulse Survey to randomly selected households in the United States during the COVID-19 pandemic. Between April 14, 2021 and May 9, 2022, 803,905 unduplicated people completed the survey. Given how the Census Bureau asked questions about housing insecurity, only people who rented or owned their own home with a mortgage/loan were retained (n = 476,286). We also removed people who did not complete the questions about cognitive, visual (‘a lot of difficulty’ or ‘could not at all’ see, even when wearing glasses), hearing (‘a lot of difficulty’ or ‘could not at all’ hear, even when using a hearing aid), and mobility (‘a lot of difficulty’ or ‘could not at all’ walk or climb stairs) disability status, resulting in a total sample of 473,626. The sample included 7,165 Medicaid beneficiaries with cognitive disabilities, and comparison groups of all other people with disabilities (including people with cognitive disabilities who are not Medicaid beneficiaries; n = 52,657) and nondisabled people (n = 413,804). Data were weighed using SPSS27 complex samples with the frequency person-weights provided by the Census Bureau to account for nonresponses and population demographics.

Variables

People who rented their home or owned with a mortgage/loan completed the following question: Is this household currently caught up on rent/mortgage payments (yes; no)? If not caught up on payments, they were asked a follow-up question: How likely is it that your household will have to leave this home or apartment within the next two months because of eviction/foreclosure (not at all likely; not very likely; somewhat likely; very likely)? All renters and owners with mortgages/loans were also asked: how confident are you that your household will be able to pay your next rent payment on time (highly confident; moderately confident; slightly confident; not at all confident)? The responses to these questions, along with sociodemographic questions, were used as variables in this study.

Analysis

To determine the housing insecurity of Medicaid beneficiaries with cognitive disabilities during the pandemic, we first utilized complex samples descriptive statistics. We compared the housing insecurity of Medicaid beneficiaries with cognitive disabilities with all other people with disabilities and nondisabled people using chi-square analyses (we used Bonferroni correction for post hoc analyses). Then, we explored sociodemographic (independent variables [IVs]) differences in housing insecurity among people with cognitive disabilities using a complex samples binary logistic regression model (dependent variable [DV]: differences in being caught up on rent/mortgage payments) and complex samples ordinal logistic regressions (DVs: likelihood of eviction/foreclosure, and confidence in timely future rent/mortgage payments). Confidence intervals (CI) were set at 95% for all odds ratios (ORs).

Results

Participants

Of the Medicaid beneficiaries with cognitive disabilities who rented/owned in the sample (weighted), most were cisgender women (65.1%), straight (72.3%), White (72.4%), did not have a Hispanic ethnicity (79.8%), between 18 and 44 years old (57.0%), had a high school degree or less (51.9%), and had a household income of less than $25,000 (51.1%; Table 1 ). In terms of housing, 66.6% of Medicaid beneficiaries with cognitive disabilities in the sample rented their home, while 33.4% owned their home with a mortgage/loan. See Table 1 for comparison group demographics.

Table 1

Demographics.

Characteristic	Medicaid beneficiaries with cognitive disabilities			All other people with disabilities			Nondisabled people
	Unweighted		Weighted % (SE)	Unweighted		Weighted % (SE)	Unweighted		Weighted % (SE)
	n	%		n	%		n	%
Disabilities
Cognitive disability
No	0	0.0%	0.0% (0.0%)	33,251	63.2%	61.3% (0.4%)	413,804	100.0%	100.0% (0.0%)
Yes	7165	100.0%	100.0% (0.0%)	19,333	36.8%	38.7% (0.4%)	0	0.0%	0.0% (0.0%)
Visual disability
No	5796	81.0%	80.9% (1.0%)	38,692	73.6%	71.5% (0.4%)	413,804	100.0%	100.0% (0.0%)
Yes	1357	19.0%	19.1% (1.0%)	13,901	26.4%	28.5% (0.4%)	0	0.0%	0.0% (0.0%)
Hearing disability
No	6428	90.2%	88.0% (1.0%)	43,436	82.8%	83.6% (0.3%)	413,804	100.0%	100.0% (0.0%)
Yes	696	9.8%	12.0% (1.0%)	9009	17.2%	16.4% (0.3%)	0	0.0%	0.0% (0.0%)
Mobility disability
No	5159	72.0%	73.2% (1.1%)	31,706	60.2%	61.1% (0.4%)	413,804	100.0%	100.0% (0.0%)
Yes	2004	28.0%	26.8% (1.1%)	20,926	39.8%	38.9% (0.4%)	0	0.0%	0.0% (0.0%)
Age
18 to 24	304	4.2%	9.0% (0.9%)	1768	3.4%	8.3% (0.3%)	10,436	2.5%	7.0% (0.1%)
25 to 34	1243	17.3%	24.2% (1.1%)	6185	11.7%	16.3% (0.3%)	61,431	14.8%	21.1% (0.1%)
35 to 44	1938	27.0%	23.8% (0.9%)	8347	15.9%	15.3% (0.3%)	95,081	23.0%	21.9% (0.1%)
45 to 54	1657	23.1%	19.9% (1.0%)	10,107	19.2%	17.3% (0.3%)	85,335	20.6%	18.1% (0.1%)
55 to 64	1385	19.3%	15.6% (0.7%)	11,747	22.3%	19.7% (0.3%)	78,682	19.0%	16.2% (0.1%)
65 to 74	512	7.1%	6.2% (0.6%)	9999	19.0%	16.1% (0.3%)	62,024	15.0%	12.0% (0.1%)
75+	126	1.8%	1.4% (0.3%)	4504	8.6%	6.9% (0.2%)	20,815	5.0%	3.7% (0.1%)
Gender
Cis male	1418	19.9%	28.6% (1.2%)	16,716	32.0%	38.3% (0.5%)	165,949	40.3%	48.5% (0.2%)
Cis female	5375	75.3%	65.1% (1.2%)	34,178	65.4%	57.7% (0.5%)	240,817	58.5%	50.0% (0.2%)
Transgender	141	2.0%	2.7% (0.4%)	432	0.8%	1.4% (0.1%)	1130	0.03%	0.4% (0.0%)
None of these	205	2.9%	4.1% (0.6%)	959	1.8%	2.6% (0.2%)	3607	0.9%	1.0% (0.0%)
Sexual orientation
Straight	5441	76.6%	72.3% (1.1%)	44,169	84.6%	82.3% (0.2%)	368,308	89.9%	88.7% (0.1%)
Gay or lesbian	315	4.4%	4.9% (0.5%)	2147	4.1%	4.4% (0.2%)	15,165	3.7%	3.4% (0.0%)
Bisexual	837	11.8%	14.6% (0.9%)	3344	6.4%	7.6% (0.3%)	15,928	3.9%	4.6% (0.1%)
Something else	333	4.7%	4.9% (0.6%)	1416	2.7%	3.5% (0.2%)	5755	1.4%	1.7% (0.1%)
I don't know	175	2.5%	3.2% (0.5%)	978	1.9%	2.3% (0.1%)	4646	1.1%	1.6% (0.0%)
Race
White, alone	5556	77.5%	72.4% (1.2%)	42,548	80.8%	75.9% (0.4%)	338,110	81.7%	76.5% (0.1%)
Black, alone	772	10.8%	14.9% (0.9%)	5037	9.6%	13.2% (0.3%)	34,087	8.2%	12.2% (0.1%)
Asian, alone	143	2.0%	3.2% (0.6%)	1563	3.0%	3.5% (0.2%)	22,610	5.5%	6.0% (0.1%)
Another race alone, or multiracial	694	6.7%	9.5% (0.7%)	3509	6.7%	7.3% (0.3%)	18,997	4.6%	5.3% (0.1%)
Ethnicity: Hispanic
Not Hispanic	6213	86.7%	79.8% (1.2%)	47,006	89.3%	82.5% (0.4%)	374,888	90.6%	82.9% (0.2%)
Hispanic	952	13.3%	20.2% (1.2%)	5651	10.7%	17.5% (0.4%)	38,916	9.4%	17.1% (0.2%)
Highest level of education
High school or less	2038	28.4%	51.9% (1.2%)	9391	17.8%	43.6% (0.5%)	46,848	11.3%	33.4% (0.2%)
Some college	2536	35.4%	27.6% (0.9%)	14,844	28.2%	24.3% (0.3%)	82,243	19.9%	20.7% (0.1%)
Associate's degree	975	13.6%	9.6% (0.5%)	6775	12.9%	10.5% (0.2%)	41,818	10.1%	9.9% (0.1%)
Bachelor's degree	1108	15.5%	8.0% (0.4%)	12,380	23.5%	13.0% (0.2%)	128,438	31.0%	20.1% (0.1%)
Graduate degree	508	7.1%	3.0% (0.2%)	9267	17.6%	8.6% (0.2%)	114,457	27.7%	15.9% (0.1%)
Marital status
Now married	1837	25.7%	29.1% (1.1%)	23,553	44.9%	46.2% (0.5%)	237,287	57.6%	56.7% (0.2%)
Widowed	356	5.0%	4.5% (0.5%)	3952	7.5%	6.2% (0.2%)	16,525	4.0%	3.2% (0.1%)
Divorced	2084	29.2%	20.4% (0.8%)	11,864	22.6%	16.7% (0.3%)	63,202	15.3%	11.0% (0.1%)
Separated	415	5.8%	6.3% (0.5%)	1641	3.1%	3.5% (0.2%)	7160	1.7%	2.1% (0.1%)
Never married	2445	34.2%	39.8% (1.2%)	11,417	21.8%	27.4% (0.4%)	88,104	21.4%	26.9% (0.2%)
Household income
Less than $25,000	3702	54.3%	51.1% (1.2%)	11,188	22.4%	25.9% (0.5%)	35,541	9.0%	12.7% (0.1%)
$25,000 - $34,999	1200	17.6%	19.6% (1.0%)	6407	13.4%	15.0% (0.3%)	31,571	8.0%	10.6% (0.1%)
$35,000 - $49,999	830	12.2%	11.7% (0.7%)	7005	14.0%	14.2% (0.3%)	40,169	10.2%	12.0% (0.1%)
$50,000 - $74,999	579	8.5%	9.3% (0.8%)	8979	18.0%	17.3% (0.3%)	66,331	16.9%	17.6% (0.1%)
$75,000+	502	7.4%	8.4% (0.7%)	16,042	32.1%	27.7% (0.4%)	219,959	55.9%	47.1% (0.2%)
Number of people in household (M (SE))	3.0 (0.0)		3.8 (0.1)	2.6 (0.0)		3.4 (0.0)	2.8 (0.0)		3.3 (0.0)
Medicare beneficiary
No	4815	69.3%	71.3% (1.1%)	32,270	64.2%	68.4% (0.4%)	309,872	79.1%	82.4% (0.1%)
Yes	2130	30.7%	28.7% (1.1%)	17,980	35.8%	31.6% (0.4%)	81,820	20.9%	17.6% (0.1%)
Household loss of employment income in last 4 weeks
No	2315	32.3%	65.7% (1.2%)	42,351	80.6%	75.7% (0.4%)	368,235	89.1%	84.6% (0.1%)
Yes	4842	67.7%	34.3% (1.2%)	10,186	19.4%	24.3% (0.4%)	45,102	10.9%	15.4% (0.1%)
Home status
Rent	4842	67.6%	66.6% (0.1%)	23,298	44.2%	47.2% (0.5%)	130,532	31.5%	36.9% (0.2%)
Own with mortgage/loan	2323	32.4%	33.4% (0.1%)	29,359	55.8%	52.8% (0.5%)	283,272	68.5%	63.1% (0.2%)

Housing payments

Between April 2021–May 2022, 26.3% of Medicaid beneficiaries with cognitive disabilities who rented or had a mortgage/loan were behind on their rent or mortgage payments (Table 2 ). Medicaid beneficiaries with cognitive disabilities were more likely to behind on mortgage/loan payments than all other people with disabilities (16.6%) and nondisabled people (9.1%). The following Medicaid beneficiaries with cognitive disabilities were more likely to be behind on payments: renters; people who also had visual disabilities; Black people; people who were ‘another’ race or multiracial; those with household incomes of $25,000 to $34,999; and households that lost employment income (Table 3 ).

Table 2

Housing insecurity.

Variable	Medicaid beneficiaries with cognitive disabilities (% [CI])	All other people with disabilities (% [CI])	Nondisabled people (% [CI])
Currently caught up on rent/mortgage
Yes	73.7% [71.7%, 75.7%]	83.4% [82.7%, 84.1%]∗∗∗	90.9% [90.7%, 91.2%]∗∗∗
No	26.3% [24.3%, 28.3%]	16.6% [15.9%, 17.3%]∗∗∗	9.1% [8.8%, 9.3%]∗∗∗
If not caught up on payments, likelihood eviction/foreclosure in next 2 months
Not at all likely	20.8% [17.0%, 25.2%]	24.2% [22.3%, 26.2%]	38.6% [37.4%, 39.9%]∗∗∗
Not very likely	27.1% [23.6%, 30.8%]	32.1% [29.9%, 34.4%]	31.8% [30.6%, 33.1%]
Somewhat likely	30.4% [26.4%, 34.6%]	26.8% [24.7%, 29.0%]	20.7% [19.6%, 21.7%]∗∗∗
Very likely	21.7% [18.4%, 25.4%]	17.0% [15.1%, 18.9%]	8.9% [8.1%, 9.7%]∗∗∗
Confidence in next payment on time
Highly confident	30.5% [28.3%, 32.8%]	46.6% [45.7%, 47.4%]∗∗∗	68.8% [68.5%, 69.2%]∗∗∗
Moderately confident	25.3% [23.4%, 27.2%]	24.4% [23.7%, 25.2%]	15.8% [15.5%, 16.0%]∗∗∗
Slightly confident	23.6% [21.5%, 26.0%]	16.5% [15.8%, 17.2%]∗∗∗	10.0% [9.8%, 10.2%]∗∗∗
Not at all confident	20.6% [18.9%, 22.4%]	12.6% [11.9%, 13.2%]∗∗∗	5.4% [5.2%, 5.6%]∗∗∗

Note. Differences between comparison groups and Medicaid beneficiaries with cognitive disabilities calculated using chi-square. ∗p < 0.05. ∗∗p < 0.01. ∗∗∗p < 0.001.

Table 3

Sociodemographic differences in housing security among medicaid beneficiaries with cognitive disabilities.

Variable	Behind on rent/mortgage payments (Logistic regression; OR [CI])	Likelihood of eviction/foreclosure for those not caught up on payments (Ordinal regression; OR [CI])	Confidence in paying the next rent/mortgage payment on time (Ordinal regression; OR [CI])
Renter (ref: owner with mortgage/loan)	1.49 [1.14, 1.94]∗∗	4.69 [3.03, 7.26]∗∗∗	0.69 [0.57, 0.84]∗∗∗
Additional disabilities
Visual disability (ref: no)	1.54 [1.16, 2.04]∗∗	1.09 [0.75, 1.57]	0.73 [0.57, 0.94]∗
Hearing disability (ref: no)	1.15 [0.77, 1.72]	0.87 [0.50, 1.51]	0.95 [0.70, 1.28]
Mobility disability (ref: no)	1.02 [0.79, 1.32]	1.26 [0.84, 1.88]	1.07 [0.87, 1.32]
Age (ref: 18 to 24)
25 to 34	0.82 [0.48, 1.40]	1.11 [0.51, 2.41]	0.77 [0.52, 1.14]
35 to 44	1.32 [0.78, 2.23]	1.40 [0.62, 3.15]	0.71 [0.47, 1.06]
45 to 54	1.15 [0.66, 2.03]	1.44 [0.61, 3.39]	0.54 [0.34, 0.85]∗∗
55 to 64	1.04 [0.58, 1.86]	1.20 [0.48, 2.99]	0.53 [0.33, 0.84]∗∗
65 to 74	0.59 [0.26, 1.36]	0.86 [0.23, 3.19]	0.56 [0.30, 1.02]
75+	0.77 [0.21, 2.86]	1.00 [0.21, 4.86]	0.44 [0.20, 0.98]∗
Gender (ref: cis male)
Cis female	1.03 [0.77, 1.37]	1.09 [0.70, 1.70]	0.72 [0.58, 0.90]∗∗
Transgender	1.96 [0.90, 4.25]	3.17 [1.39, 7.19]∗∗	0.59 [0.27, 1.26]
None of these	0.93 [0.43, 2.01]	0.89 [0.31, 2.52]	0.64 [0.39, 1.06]
Sexual orientation (ref: straight)
Gay or lesbian	1.32 [0.84, 2.08]	0.69 [0.41, 1.14]	0.82 [0.58, 1.16]
Bisexual	0.93 [0.63, 1.36]	0.91 [0.50, 1.65]	0.97 [0.70, 1.33]
Something else	0.62 [0.33, 1.18]	0.72 [0.40, 1.31]	1.17 [0.76, 1.79]
I don't know	1.24 [0.63, 2.43]	1.87 [0.65, 5.38]	0.86 [0.46, 1.59]
Race (ref: White alone)
Black, alone	1.49 [1.08, 2.05]∗	1.51 [0.91, 2.51]	0.64 [0.48, 0.84]∗∗
Asian, alone	0.55 [0.24, 1.30]	1.95 [0.53, 7.23]	0.64 [0.40, 1.03]
Another race alone, or multiracial	2.09 [1.44, 3.03]∗∗∗	0.86 [0.53, 1.41]	0.73 [0.55, 0.98]∗
Ethnicity: Hispanic (ref: not Hispanic)	0.86 [0.62, 1.20]	1.14 [0.74, 1.73]	0.93 [0.73, 1.19]
Highest level of education (ref: high school or less)
Some college	1.10 [0.86, 1.41]	1.05 [0.73, 1.51]	1.18 [0.97, 1.44]
Associate's degree	0.97 [0.69, 1.36]	1.10 [0.71, 1.69]	1.43 [1.10, 1.86]∗∗
Bachelor's degree	0.87 [0.61, 1.24]	1.45 [0.82, 2.56]	1.36 [1.05, 1.77]∗
Graduate degree	0.67 [0.44, 1.03]	1.98 [1.05, 3.76]∗	1.35 [0.99, 1.86]
Marital status (ref: never married)
Now married	1.20 [0.86, 1.67]	1.16 [0.77, 1.75]	1.00 [0.78, 1.28]
Widowed	1.55 [0.84, 2.88]	0.95 [0.34, 2.66]	0.99 [0.67, 1.47]
Divorced	0.87 [0.63, 1.19]	2.41 [1.48, 3.94]∗∗∗	0.97 [0.75, 1.25]
Separated	1.39 [0.89, 2.16]	1.22 [0.69, 2.15]	0.96 [0.67, 1.38]
Household income (ref: $75,000+)
Less than $25,000	1.55 [0.97, 2.47]	0.68 [0.33, 1.39]	0.52 [0.37, 0.74]∗∗∗
$25,000 - $34,999	1.85 [1.12, 3.04]∗	0.77 [0.37, 1.62]	0.47 [0.33, 0.67]∗∗∗
$35,000 - $49,999	0.88 [0.50, 1.54]	0.56 [0.25, 1.28]	0.59 [0.39, 0.88]∗
$50,000 - $74,999	0.66 [0.36, 1.18]	0.63 [0.30, 1.34]	0.90 [0.61, 1.32]
Dual eligible (ref: no)	0.92 [0.68, 1.25]	1.02 [0.69, 1.50]	1.59 [1.28, 1.97]∗∗∗
Household loss of employment income in last 4 weeks (ref: no)	2.67 [2.13, 3.36]∗∗∗	1.90 [1.35, 2.69]∗∗∗	0.36 [0.30, 0.43]∗∗∗
Number of people in household (ref: no)	1.04 [0.97, 1.11]	1.00 [0.92, 1.08]	0.93 [0.88, 0.98]∗

Note. ∗p<0.05. ∗∗p < 0.01. ∗∗∗p < 0.001. All data are weighted.

Eviction and foreclosure of people behind on payments

Of those Medicaid beneficiaries with cognitive disabilities not caught up on payments, 52.0% believed it was either ‘very likely’ (21.7%) or ‘somewhat likely’ (30.3%) they would face eviction/foreclosure within the next two months (Table 2). (This is the equivalent of 8.0% and 5.7% of the overall sample of Medicaid beneficiaries with cognitive disabilities believing they were ‘very likely’ and ‘somewhat likely’ to face eviction/foreclosure respectively.) Only 20.9% of people behind on payments said they were ‘not at all likely’ to face eviction/foreclosure. In fact, even when both groups were behind on payments, Medicaid beneficiaries with cognitive disabilities were more likely to believe they were facing eviction/foreclosure than nondisabled people. Among Medicaid beneficiaries with cognitive disabilities not caught up on payments, renters, transgender people, people with graduate degrees, divorced people, and households that lost employment income in the last month were all significantly more likely to believe they were facing eviction or foreclosure within the next two months (Table 3).

Future housing payments

In addition, 69.5% of Medicaid beneficiaries with cognitive disabilities questioned their ability to pay their next rent/mortgage payment on time – 20.6% said they were ‘not at all confident’ about their next payment, 23.7% ‘slightly confident,’ and 25.2% ‘moderately confident’ (Table 2). Only 30.5% felt ‘highly confident’ they would make their next payment on time. Compared to Medicaid beneficiaries with cognitive disabilities, all other people with disabilities and nondisabled people were more confident in their ability to make their next payment on time. Among Medicaid beneficiaries with cognitive disabilities, renters, people with visual disabilities, people aged 45–64 and 75+, cisgender women, Black people, people who were ‘another’ race or multiracial, people with household incomes of less than $50,000, households that lost employment income in the last month, and larger households were all significantly less confident about paying their next rent/mortgage payment on time (Table 3).

Discussion

Housing insecurity increases people with cognitive disabilities’ risk for institutionalization, becoming unhoused, and incarceration. , , The aim of this study was to examine the housing insecurity of Medicaid beneficiaries with cognitive disabilities during the pandemic. Between April 2021 and May 2022, 26% of Medicaid beneficiaries with cognitive disabilities who rented or owned with a mortgage/loan were behind on their housing payments; more than half of which (52%) believed they were very or somewhat likely to face eviction or foreclosure within the next two months. In addition, the overwhelming majority of Medicaid beneficiaries with cognitive disabilities (70%) were concerned about their ability to pay their next rent or mortgage payment on time. In fact, more Medicaid beneficiaries with cognitive disabilities experienced housing insecurity than all other people with disabilities and nondisabled people. For example, 14% of all Medicaid beneficiaries with cognitive disabilities said they were somewhat or very likely to face eviction/foreclosure compared to 3% of nondisabled people.

People with cognitive disabilities were more likely to be housing insecure prior to the pandemic as a result of having less money, having less education, being less likely to own their homes, and having a lack of proper support to care for themselves at home than nondisabled people and some people with other disabilities. , , , 31, 32, 33 , People with cognitive disabilities may be further disadvantaged when also Medicaid beneficiaries due to Medicaid's low income requirements, making them more likely to live in substandard housing and have a lack of affordable housing to choose from, resulting in financial incidents increasing their risk of becoming unhoused. , , , , 10, 11, 12, 13 In addition, when faced with limited financial resources, people often have to choose between spending money on health care, housing, utilities, or food; as such, housing costs not only force low income people to make more choices about how to spend their money, but also, as a result, make them more likely to face eviction.

In addition, there were a number of differences in Medicaid beneficiaries with cognitive disabilities’ housing insecurity based on sociodemographics. For example, people with cognitive disabilities who also had visual disabilities were more likely experience housing insecurity and had lower confidence in making their next payment in time. These disparities may be due to a lack of accessible information and resources for people with both cognitive and visual disabilities. People with cognitive disabilities, especially with visual disabilities, may need additional support finding accessible information about housing assistance programs and securing housing assistance.

Consistent with previous research, Medicaid beneficiaries with cognitive disabilities who were cisgender women, transgender, Black, ‘another’ race or multiracial, from lower income households, from households that lost employment income, and who lived in larger households were more likely to be housing insecure during the pandemic. These findings suggest similar patterns in housing insecurity among Medicaid beneficiaries with cognitive disabilities as in the larger population. However, some sociodemographic findings in our study conflicted with previous research. For example, although existing research indicates people with less education are more likely to be housing insecure, Medicaid beneficiaries with cognitive disabilities with graduate degrees in our study, while not more likely to be behind on payments, were more likely to believe they were facing eviction/foreclosure when behind on rent than those with high school degrees or less education. We theorize this may be due to an interaction with other variables which was not explored or could be a phenomenon specific to Medicaid beneficiaries with cognitive disabilities. Given this finding, as well as divorced people's increased likelihood of eviction/foreclosure which conflicts with previous findings about the general population, we believe examination of these subgroups would be a fruitful avenue for future study.

Given our findings and renters’ vulnerability to housing insecurity in general, more supports are needed for renters with cognitive disabilities. While eviction moratoriums can be beneficial to promote housing security, not all landlord accepted federal rental aid and some preferred to evict tenants instead. , Moreover, when moratoriums are lifted, the risk of eviction returns, especially as renters struggle to make up deferred payments. , For these reasons, it is important future relief packages/bills make efforts to reduce housing insecurity, such as through rental relief, housing vouchers, and income assistance for renters. , , These housing relief packages must be designed in ways that do not put Medicaid beneficiaries at risk of losing their benefits and services.

Those with lower household incomes and who lost household employment income experienced housing insecurity more often. To promote the housing security of Medicaid beneficiaries with cognitive disabilities, it is critical to recognize Medicaid's poverty requirements serve as a systemic barrier to housing security. While people must be low income to qualify for Medicaid, poverty reduces housing choices and often leads to people having substandard housing, segregation, institutionalization, and people becoming unhoused. , , Reforming Medicaid's asset limits and/or increasing SSI, Temporary Assistance for Needy Families (TANF) and/or unemployment benefits would help reduce disability poverty, thereby helping promote housing stability.

Limitations

A number of limitations should be noted when interpreting this study's findings. This study was a secondary data analysis; as a result, we were not able to add additional variables or ask follow-up questions. For example, there was no information about what types of cognitive disabilities people had; there may be differences in housing insecurity among people with different types of cognitive disabilities. There was not information about which types of disability-specific residential settings, such as group homes and institutions, people lived in. The dataset also did not include information about housing prior to the pandemic. The questions about housing insecurity payments were only asked of people who owned with a mortgage or rented. While the Census Bureau launched the Household Pulse Survey in April of 2020, they did not include questions about disability until April of 2021; as such, our data does not include the initial waves of the pandemic and people's housing security may differ accordingly. We did not explore interactions. Finally, it is unclear what steps the Census Bureau made to make the survey accessible to people with cognitive disabilities, which could have biased the results and/or resulted in the exclusion of people with higher support needs. We believe these limitations also represent valuable avenues for future study.

Conclusion

The need for affordable, accessible housing for people with disabilities was a crisis even before the pandemic. , , , Our findings suggest a sizable proportion of Medicaid beneficiaries with cognitive disabilities experienced housing insecurity during the pandemic, including at greater rates than nondisabled people. Attention to Medicaid beneficiaries with cognitive disabilities’ experiences with housing insecurity during the pandemic is critical in order to develop programs and policies to facilitate housing security.