Abstract
IMPORTANCE: Housing cost burden is at an all-time high in the US and may disproportionately affect health outcomes among low-income populations. Medicaid-insured individuals and those diagnosed with cardiovascular (CV) disease, such as heart failure (HF), may be especially at increased risk of adverse health outcomes associated with housing cost burden. OBJECTIVE: To assess the association between area-level housing cost burden and the probability of CV-related hospitalization or emergency department (ED) visits among Medicaid beneficiaries aged 19 to 64 years with HF. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used individual-level health care utilization data obtained from the Transformed Medicaid Statistical Information System Analytic Files (2018-2019). All zip codes in the US with resident Medicaid beneficiaries aged 19 to 64 years who had a preexisting diagnosis of HF and were continuously enrolled in 2019 were included except for those in Alabama, Rhode Island, and Utah due to data quality issues. Data were analyzed from October 2024 to October 2025. EXPOSURE: Area-level housing cost burden was defined as the zip code-level proportion of housing units occupied by individuals with an annual household income less than $35 000 who spent 30% or more of their income on housing costs. MAIN OUTCOMES AND MEASURES: The probability of a CV-related hospitalization and of a CV-related ED visit in 2019. Generalized estimating equation models were used to evaluate the association between housing cost burden and outcomes after adjusting for individual and area-level factors. RESULTS: This study included 233 195 individuals (mean [SD] age, 51.5 [9.6] years, 107 447 female [46.1%]) who were living in 19 577 zip codes. The mean (SD) zip code housing cost burden was 67.4% (16.5%). In 2019, 42 886 beneficiaries (18.4%) had at least 1 CV-related hospitalization and 75 392 (32.3%) had an ED visit. After covariate adjustment, a 10-percentage point increase in housing cost burden was associated with higher odds of CV-related hospitalizations (odds ratio [OR], 1.03; 95% CI, 1.01-1.06) and ED visits (OR, 1.03; 95% CI, 1.01-1.04). There were also higher odds of HF-related hospitalizations (OR, 1.04; 95% CI, 1.01-1.07). CONCLUSIONS AND RELEVANCE: The findings of this study suggest that area-level housing cost burden may be associated with outcomes among Medicaid beneficiaries with HF and highlights the need to investigate whether strategies that address housing affordability can play a role in improving health outcomes in this population.