How are the two related?
Homelessness is a massive problem throughout the country. People blame it on many different things…lack of affordable housing or low-paying jobs. The one issue that is the leading cause, and many people don’t think of it, is poor health. Just how does poor health impact one’s housing situation? What can be done to correct both of these?
Over half a million people experience homelessness every night. Homelessness is a persistent challenge throughout the country, with somewhere between 2–3 million people experiencing an episode of homelessness every year. Compared to other advanced economies, America’s homeless population is the largest. While most individuals are only homeless for a short time, some are chronically homeless for 30 to 40 years. It impacts men, women, and children of every race and ethnic group in big cities and small towns. The statistics show that families headed by women comprise a third of the homeless, and over 100,000 children are homeless each day, with half of them being younger than 5. While the data shows that nearly 50,000 unaccompanied youth are homeless each day, the U.S. Interagency Council on Homelessness (USICH) considers this number a significant under-count because homeless youth avoid using shelters. Domestic violence plays a significant role, with one in four women being homeless as a result. One study discovered that 92% of homeless women have experienced violence against them at some point in their lives, often before the age of 12.
Homelessness can take many forms, with people living on the streets, in encampments or shelters, in transitional housing programs, or doubled up with family and friends. It exists because people lack safe, stable, and appropriate places to live. People without a home lack personal safety. According to the National Coalition for the Homeless, over a 15 year period, 1,437 cases of violence against homeless individuals were reported, and over a quarter resulted in death.
Many people feel that homelessness is a housing problem. However, it’s so much more. It’s a housing problem, an economic problem, a quality of life problem, and a healthcare problem. Homelessness is caused by and exacerbates poverty, poor health, addiction, mental illness, and violence. When it comes to housing, the approach is known as “Housing First.” The idea is straightforward: providing housing and giving support will lead to people’s health improving. The first pilot program was started in 1988 by PATH Beyond Shelter in Los Angeles. It focused on getting people into permanent supportive housing. This means that beyond housing, the program provides individuals and families with case management services to connect them with healthcare and social services. Many similar programs have appeared across the country. The most notable is Salt Lake City, which has virtually ended chronic homelessness among veterans. The entire state of Utah has decreased chronic homelessness by 91%.
Supportive care is crucial to the programs because housing alone will not fix the problem. This is because homeless people don’t just lack housing; they’re quite often sick. This might not seem obvious at first because when homeless people are asked how they became homeless, they typically say it’s because they lost their jobs. However, what many homeless people don’t say is that they lost their job due to illness. Sickness and injuries make keeping a job difficult. Since most people get health insurance through their employer, if they don’t have a job, they don’t have insurance. The combination of unemployment and poor health usually leads to financial ruin. Per Nerdwallet’s estimate, roughly 57% of personal bankruptcies are due to medical bills. After personal safety nets are gone, very few options are available to help with healthcare or housing. So, it’s easy to see how housing and health struggles feed into one another, creating a vicious cycle.
Since homeless individuals lack access to routine outpatient healthcare, they often seek treatment in hospital emergency departments. It’s believed that close to one-third of emergency department visits are made by people struggling with chronic homelessness. This means they’re more likely to experience fragmented service and less attention to ongoing health needs, especially mental health concerns. Rates of mental illness among homeless people are twice the rate found for the general population. According to the White House Office of National Drug Control Policy, almost a third of people experiencing chronic homelessness have a serious mental illness, and two-thirds have a substance use disorder or other chronic health condition. In addition, homeless individuals have poorer physical health than the general population, including higher rates of tuberculosis, hypertension, asthma, diabetes, and HIV/AIDS. These individuals have higher rates of hospitalizations for physical illnesses, mental illness, and substance abuse than other populations. Research has found that being homeless takes 20 years off a person’s lifespan.
Most homeless people have complex behavioral and physical health needs, and being homeless compounds and exacerbates those needs. Managing chronic illnesses is challenging but sticking to treatment regimens is nearly impossible while homeless. An example of this is diabetes. To control blood sugar, medicines must be taken at certain times or with meals. Not knowing when the next meal will be makes taking medicines difficult, so people often skip doses because if they take the medication without food, it can cause dangerously low blood sugar. However, not taking the medicines will lead to elevated blood sugar, increasing the risk for heart attacks, strokes, kidney failure, and blindness. Yet, this isn’t even a factor for most people because they would need to obtain the medicines in the first place, which is hard to do if you don’t have money or insurance. Unfortunately, most adults that are homeless have more than one health issue. Furthermore, homelessness creates new health problems. Living on the street or in crowded homeless shelters is exceptionally stressful and made worse by exposure to communicable diseases, violence, malnutrition, and dangerous weather. This means that minor issues quickly develop into larger problems.
The psychological and physical impact of homelessness is a major public health concern. A fundamental aim of public health is to care for the most vulnerable members of our society. According to the Centers for Disease Control and Prevention (CDC) Foundation, “public health is the science of protecting and improving the health of people and their communities …. by promoting healthy lifestyles, researching disease and injury prevention, and detecting, preventing and responding to infectious diseases.” Public health programs often focus on the social determinants of health, including social and environmental factors, like race, income, education level, access to housing, transportation, and healthy foods. These are often factors leading to homelessness. Most local public health departments provide services, such as vaccinations, prevention screenings, treatment for communicable diseases and sexually transmitted infections, and maternal and child health services. National public health focuses on population-based interventions, like pandemic or emergency response planning, disease surveillance, food safety inspections, school and daycare inspections, and tobacco prevention. The importance of this became startlingly clear during the COVID-19 pandemic. People experiencing homelessness were identified as at the highest risk for infection, transmission, and death. Homeless people who contracted COVID-19 were 30% more likely to die than those in the general population. The pandemic highlighted the vulnerability of our public health infrastructure. The primary way to protect ourselves was to shelter in place. Homeless people lack a place to shelter, putting them at higher risk of contracting the virus and spreading it to other vulnerable community members.
A large percentage of public health funding comes from the federal government, specifically the Department of Health and Human Services (HHS). Typically, this funding goes to state health departments, which then direct it to local health agencies at the county, city, and tribal levels. Despite its importance, funding for public health is far less than it should be compared to the overall healthcare system. In 2017, public health funding represented 2.5% of the roughly $3.5 trillion spent on healthcare, only averaging $274 per person/year. Research shows that about 40% of homeless individuals are insured through Medicare and Medicaid. However, the remaining 60% have no insurance. Unfortunately, the second group is poised to grow considerably because one well-regarded study has shown that the number of elderly experiencing homelessness is expected to triple in the next ten years. Part of the issue is that our healthcare system relies on a fee-for-service (FFS) payment model. This means providers are reimbursed for each treatment they provide. That model doesn’t work for homeless people because it’s challenging to separate all the various treatments and activities that go into care coordination into billable units to be reimbursed under FFS. Also, this model provides incentives for hospitalizations, which are expensive. Instead, we should be addressing homeless individuals’ health conditions before requiring hospitalization and other costly treatments.
Several things can be done to help homeless individuals receive the care they need. The first is to bring care to them. Instead of waiting for homeless people to seek out care, we need to implement street medicine teams, mobile medical clinics, community workers, and other outreach teams to treat many of their needs without admitting them to hospitals. The other aspect of this is that these teams need to coordinate with each other and other organizations to address all the challenges homeless individuals face fully. Our health system is difficult for most of us to navigate under the best of circumstances, which means that it can’t begin to address the complexities of caring for homeless patients without some sort of change to how we do things. We also need to be creative in getting homeless people the services they need. Medicare and Medicaid often can’t address complex issues, like behavioral health services, transitional or recuperative care, but they also don’t cover eyeglasses and vision care, hearing aids, or dental care.
One option that could be a game-changer is Medicare Advantage plans because they operate under a capitated model. This means providers receive a fixed fee per member per month that’s adjusted according to the members’ expected needs, and it must be used to cover all healthcare services. So, the more complex the needs, the higher the payments. Clinicians bear the risk of treating patients because the set fees must cover costly services such as visits to emergency departments and hospitalizations. This provides the incentive to get ahead of chronic conditions that can lead to patients seeking care in those high-cost environments. This model enables plans to offer a more extensive set of programs to their members and increase care coordination activities, leading to higher quality care and reducing the overall cost of care. Given the complex care needs of the homeless population, payments would be much higher for these patients than the average patient. Clinicians would also have added flexibility to invest in the wide variety of services required to stabilize and maintain the health of their patients.
Several organizations have implemented programs in the past few decades that demonstrate that a model of care to treat homeless individuals can be done effectively and efficiently. The Safe, Healthy, Empowered (SHE) Clinic in Seattle serves women experiencing homelessness on a walk-in basis. Researchers found that women who used the clinic had fewer nonemergent ED visits in the six months after compared to the six months prior. The Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care from Indiana provides high-touch, in-home geriatric care management to low-income seniors with complex health needs. The program has a social worker and nurse practitioner conduct in-home visits and develop individualized care plans for their patients. They’re supported by a broader interdisciplinary team led by a geriatrician and include a mental health provider, pharmacist, and program coordinator. A peer-reviewed study of the program discovered that high-risk senior citizens enrolled in it had fewer hospitalizations, hospital readmissions, and emergency department visits. HUD-VASH is a collaboration between the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Housing and Urban Development (HUD). It focuses on providing homeless veterans with HUD housing vouchers and VA supportive services to help them and their families find and sustain permanent housing. The VA case managers connect them to healthcare, mental health treatment, and substance use counseling services. This, in turn, helps in the recovery process and with the ability to maintain housing. The program is largely credited with the ten-year decline in veteran homelessness. It’s clear that when you combine comprehensive health and social services with a funding model that can cover the full range of each patient’s unique needs, it makes a meaningful, long-term impact.
There’s no question that homeless people are among the most vulnerable and, somewhat, the hardest to treat. The problem is too important and too severe for us not to use all the tools, resources, and experience to find a new path forward. The first step is changing our views as a society—we must believe that homeless individuals are worth saving. We have to understand that housing and healthcare work best together and are essential to preventing and ending homelessness. Communities that invest in affordable housing incur lower public costs, achieve better health outcomes, and avoid homelessness. It’s within our grasp to end homelessness; we just have to take the necessary steps forward!