Health Care and Homelessness
Published by the National Coalition for the Homeless, July 2009
Poor health is closely associated with homelessness. For families struggling to pay the rent, a serious illness or disability can start a downward spiral into homelessness, beginning with a lost job, depletion of savings to pay for care, and eventual eviction.
The 2007 United States Census Bureau calculated that 45.7 million Americans (15.3% of the population) do not have health insurance. In 2007, 26.8 million people (18.1%) who worked part-time or full-time during the previous year were uninsured, including 21.1 million full-time workers. Whether or not Americans have health insurance is very closely tied to their incomes. Only 7.8% of people who have a yearly salary of $75,000 or higher are uninsured, compared to 24.5% of people with salaries under $25,000. In 2007, Medicaid covered 39.6 million people, which fortunately is an increase since 2006 (United States Census Bureau, 2007). However, Medicaid has numerous eligibility requirements, and many people do not qualify even if they live below the poverty line.
Of the 45.7 million uninsured Americans, 34.6 million identify as part of a family. There are 8.1 million children (11.0%) in the United States without health insurance. An estimated 10.5% of American children under the age of six do not have health insurance. This proportion is much higher for impoverished children: 17.6% of children below the poverty line lack health insurance (United States Census Bureau, 2007).
RELATIONSHIP TO HOMELESSNESS
Homelessness and health care are intimately interwoven. Poor health is both a cause and a result of homelessness. The National Health Care for the Homeless Council (2008) estimates that 70% of Health Care for the Homeless (HCH) clients do not have health insurance. Moreover, approximately 14% of people treated by homeless health care programs are children under the age of 15 (National Health Care for the Homeless Council, 2008).
Inadequate health insurance is itself a cause for homelessness. Many people without health insurance have low incomes and do not have the resources to pay for health services on their own. A serious injury or illness in the family could result in insurmountable expenses for hospitalizations, tests, and treatment. For many, this forces a choice between hospital bills or rent. According to the National Health Care for the Homeless Council (2008), half of all personal bankruptcies in the United States are caused by health problems.
Health care is even more of a problem for people who are already homeless. Homeless people are three to six times more likely to become ill than housed people (National Health Care for the Homeless Council, 2008). Homelessness precludes good nutrition, good personal hygiene, and basic first aid, adding to the complex health needs of homeless people. Additionally, conditions which require regular, uninterrupted treatment, such as tuberculosis and HIV/AIDS, are extremely difficult to treat or control among those without adequate housing.
Diseases that are common among the homeless population include heart disease, cancer, liver disease, kidney disease, skin infections, HIV/AIDS, pneumonia, and tuberculosis (O’Connell, 2005). People who live on the streets or spend most of their time outside are at high risk for frostbite, immersion foot, and hypothermia, especially during the winter or rainy periods. Although not many homeless deaths are specifically attributed to exposure-related causes such as frostbite, immersion foot, or hypothermia, the risk of death from other causes is increased eightfold in people who have experienced those conditions in the past (O’Connell, 2005).
Unfortunately, many homeless people who are ill and need treatment do not ever receive medical care. Barriers to health care include lack of knowledge about where to get treated, lack of access to transportation, and lack of identification (Whitbeck, 2009). Psychological barriers also exist, such as embarrassment, nervousness about filling out the forms and answering questions properly, and self-consciousness about appearance and hygiene when living on the streets. The most common obstacle to health care is the cost (Whitbeck, 2009). Without health care, many homeless people simply cannot pay. As a result, many homeless people utilize hospital emergency rooms as their primary source of health care. Not only is this not the most effective form of care for them, since it provides little continuity, it is also very expensive for hospitals and the government.
As a result of these factors, homeless people are three to four times more likely to die than the general population (O’Connell, 2005). This increased risk is especially significant in people between the ages of 18 and 54. Although women normally have higher life expectancies than men, even in impoverished areas, homeless men and women have similar risks of premature mortality. In fact, young homeless women are four to 31 times as likely to die early as housed young women (O’Connell, 2005). The average life expectancy in the homeless population is estimated between 42 and 52 years, compared to 78 years in the general population.
At present, there is one federally funded program, Health Care for the Homeless (HCH), that is designed specifically to provide primary health care to homeless persons. HCH projects are required to provide primary health care, substance abuse services, emergency care, outreach, and assistance in qualifying for housing. Many HCH projects also provide dental care, mental health treatment, supportive housing, and other services. In 2008, HCH programs were estimated to serve more than 740,000 homeless people per year (National Health Care for the Homeless Council). However, more health care services designed to serve the homeless are clearly needed, since HCH programs do not meet the needs of the majority of homeless Americans. In addition, lack of affordable housing complicates efforts to provide health care to homeless persons. Housing is the first form of treatment for homeless people with medical problems, protecting against illness and making it possible for those who remain ill to recover.
Universal access to affordable, high-quality and comprehensive health care is also essential in the fight to end homelessness. A health insurance system could reduce homelessness and help to prevent future episodes of homelessness, as well as ease the suffering of those on the streets. A universal health system would also reduce the fiscal impact and social cost of communicable diseases and other illnesses.
REFERENCES AND ADDITIONAL RESOURCES
- DeNavas-Walt, C., Proctor, B.D., and Smith, J. United States Census Bureau. “Income, Poverty, and Health Insurance Coverage in the United States: 2007.” Issued Aug. 2008. p. 60-233. Available at http://www.census.gov.
- National Health Care for the Homeless Council. “The Basics of Homelessness.” Feb. 2008. Available at http://www.nhchc.org.
- National Health Care for the Homeless Council. “Federal Programs to Address Homelessness in the U.S.” 2003. Available at www.nhchc.org.
- National Health Care for the Homeless Council. “Health Care for the Homeless: Comprehensive Services to Meet Complex Needs.” Dec. 2008. Available from http://www.nhchc.org.
- National Health Care for the Homeless Council. “Mainstreaming Health Care for Homeless People.” Apr. 2005. Available at http://www.nhchc.org.
- O'Connell, J., Lozier, J., and Gingles, K. Increased Demand and Decreased Capacity: Challenges to the McKinney Act's Health Care for the Homeless Program, 1997. Available from the National Health Care for the Homeless Council, P.O. Box 68019, Nashville, TN 37206 8019; 615/226-2292.
- O’Connell, J.J. “Premature Mortality in Homeless Populations: A Review of the Literature.” 19 pages. Nashville: National Health Care for the Homeless Council, Inc., 2005.
- Whitbeck, Les B. Mental health and Emerging Adulthood among Homeless Young People. 2009. Psychology Press, Taylor & Francis Group, 270 Madison Avenue, New York, NY 10016.