Homelessness affects people from many walks of life. A recent study found that one out of 25 Americans have been homeless sometime in their lives. Tales of how people became homeless and what their lives have been like since they have become homeless are often disheartening and complex. As illustrated in Tammy Kling’s Narrative Matters essay in the May issue of Health Affairs, “Dave Didn’t Have To Die: On Health Care For Homeless Patients,” many people who are homeless have major medical, mental health, and social needs. Dave is not an anomaly: People who are homeless die sooner than their housed counterparts, with studies showing age-adjusted mortality rates many-fold higher for people who are homeless than for those who are not.
The issue of health care for people who are homeless is complex, and in some ways even paradoxical. On the one hand, people who are homeless tend to use the health care system—and especially acute care such as that provided in the emergency department—more than average. On the other hand, people who are homeless still have higher-than-average unmet health needs. There are a multitude of different reasons for this and no simple solutions. External factors such as lack of truly accessible health care options are combined with internal factors such as mental illness and cognitive impairment, with different problems for different individuals. Many of the problems that lead people to become homeless can also be the reasons why they do not receive adequate health care. To compound this complicated picture, health care for people who are homeless varies widely across states and localities. States that have expanded Medicaid have much lower proportions of homeless individuals who are uninsured. A previous study published in Health Affairs found that the Medicaid expansion could provide health care coverage to many homeless individuals and may result in overall cost savings for states, since the Medicaid expansion is funded by federal dollars.
Certainly, improving the delivery of health care services to people who are homeless is important. Studies have shown that health care services integrated with housing and social services are the best comprehensive way to address the needs of homeless populations. Providing a “one-stop shop” enhances access to care but requires a multidisciplinary team of providers and consistent outreach efforts. Kling recommends mobile health care as one solution, which already exists in locales throughout the United States.
But simply improving health care services for people who are homeless tacks Band-Aids onto a problem rather than solving it. The single best way to improve the health of people who are homeless overall is to end homelessness. Therefore, our efforts should focus on ending homelessness. Already there are notable examples of how health care systems have worked toward solutions for homelessness. The Veterans Health Administration (VHA) is perhaps the best example. VHA clinics universally screen for homelessness and link homeless and at-risk patients with robust resources that include housing supports and other services. These efforts have contributed to reductions in veteran homelessness over the past several years. Outside the VHA system, some hospitals have funded medical respite programs that care for people who are homeless and too sick to be in shelters or on the streets, yet not sick enough to need a hospital bed; ideally such programs help people connect with supportive housing to break the cycle of homelessness. Health care systems, including Medicaid in New York, have even invested in supportive housing for high-cost patients who are homeless.
Ending homelessness may become an increasingly difficult task, as the Trump administration has proposed substantial budget cuts to several federal agencies, including the Department of Housing and Urban Development, as well as proposing to eliminate the United States Interagency Council on Homelessness. Homeless service organizations and the country at large may have to prepare for alternative solutions. As the Narrative Matters piece described, there are volunteers working in shelters, soup kitchens, homeless clinics, and other service sites throughout the country every day. We need more good Samaritans such as Kling—they can make a difference in improving the lives of individuals who are homeless—but to solve the issue of homelessness, we need more than individual volunteers.
There are corporate sponsors and philanthropic foundations dedicated to the cause of helping those who are homeless, and they should be called upon to assist. Other creative ideas should be encouraged. For example, many homeless individuals have “natural supports,” which include friends, family, neighbors, sympathetic landlords, and other people who may be enabled to provide support. This past winter, New York City’s Department of Homeless Services offered people money to house their homeless friends and family as a way to divert costs from the expensive shelter system and to encourage the use of natural supports. Although such natural supports may wear thin over time, there may be creative ways that nonprofits or government organizations could “support the supporters” to keep these ties viable as long as possible. With potential federal funding cuts, the health care system’s role in ending homelessness may also become increasingly important.
Homelessness remains a pervasive and pernicious problem that affects many Americans. The Narrative Matters piece reminds us of the humanity of those who are homeless and the people who are dedicated to helping them, but also of the necessity for broader solutions and the potential roles that the health care system could play in those efforts.