the Basics of Homelessness

Homelessness inevitably causes serious health problems. Illnesses that are closely associated with poverty - tuberculosis, AIDS, malnutrition, severe dental problems - devastate the homeless population. Health problems that exist quietly at other income levels - alcoholism, mental illnesses, diabetes, hypertension, physical disabilities - are prominent on the streets. Human beings without shelter fall prey to parasites, frostbite, infections and violence.

Each year, millions of people in the United States experience homelessness and are in desperate need of health care services. Most do not have health insurance of any sort, and none have cash to pay for medical care. Homeless people are concentrated in the nation's urban centers and are dispersed throughout rural America , frequently not near the health care facilities that they need. They don't have transportation or real control over their daily lives, since they depend on the routines of shelters, soup kitchens and marginal jobs to meet their most basic survival needs.

Finding health care is tough or impossible. Many people who are homeless are more concerned with meeting immediate needs for shelter, food, clothing, and safety than with seeking health care. For some, the symptoms of their illnesses or bad experiences with the health care system in their past cause them to actually avoid health care.

Unacceptable costs result from poor access to health care. Because homeless people often are uninsured and lack access to low-cost preventive health care, they go without care until relatively minor problems become urgent medical emergencies. Ultimately, most homeless people do get treated, but it is treatment of the most expensive sort, delivered in hospital emergency rooms and acute care wards. Through taxpayer support of public institutions and through the cost shifting inherent in the current health insurance system, we all pay the high costs of care deferred.

Undetected and untreated communicable diseases threaten the health of other homeless people in particular and of the public in general. These infectious and communicable diseases quickly escalate from personal trials to become costly and deadly public health emergencies. In the long run, perhaps the greatest costs are the moral and social results of neglecting the needs of dispossessed, seriously ill people in our midst.

A sensible and effective response to the health needs of homeless people has developed over the past twenty years. In locations where homeless people congregate, health and social service workers have established clinics designed to overcome the access problems they face. These sites provide comprehensive care that improves people's health and helps them to escape the trap of homelessness. These clinics are in shelters, soup kitchens, and skid-row storefronts. Medical vans visit parks, underpasses and encampments. Outreach workers aggressively seek out and patiently engage the most isolated of homeless people.

Multidisciplinary teams work to remedy the variety of problems that affect their clients' health. Going beyond traditional medical care, these effective teams work with their clients to address issues of safe shelter and permanent housing, jobs and income, family relationships and substance abuse. This comprehensive approach helps people get well and move out of homelessness.

Health Care for the Homeless (HCH) Projects are successful because they are designed and controlled by local communities to fill significant gaps in existing health care delivery systems. Each project has well-established relationships with providers of shelter, mental health, substance abuse and hospital services in its community, and has developed considerable experience in managing the care of homeless people. Careful attention is paid to delivering high quality care in a cost-effective manner.

This model of care was developed through a 19-city demonstration program established in 1985 by The Robert Wood Johnson Foundation and the Pew Memorial Trust. In 1987, the Stewart B. McKinney Homeless Assistance Act replicated the foundations' program and now 172 Health Care for the Homeless Projects are funded in part by the United States Public Health Service. HCH projects served 588,444 homeless persons in 2003; other federally-funded Health Centers served an additional 89,631 persons. The federal Health Care for the Homeless Program is widely recognized as one of the most effective McKinney Act programs, and is an indispensable, front-line component of our country's struggle with homelessness.

• Many factors put people at risk of homelessness. Systemic issues of unemployment, low wages, expensive housing, lack of health insurance and racial discrimination combine with common personal issues such as domestic violence, abuse of alcohol and other drugs, and serious mental and physical illnesses to create this persistent social problem.

• It is estimated that 2.3 to 3.5 million people are homeless at some point during an average year. 13.5 million of us have experienced "literal homelessness" at least once in our lifetimes.

• 1.2 million American families on waiting lists for subsidized housing are at particular risk of homelessness today. Any crisis could cause them to lose their precarious housing and wind up on the streets.

• Like 45 million other Americans, homeless people typically do not have health insurance; 73% of HCH clients nationally have no health care resources. The federal Medicaid program has provided coverage for many homeless women and children and some disabled men, but Medicaid policy changes are causing loss of health coverage for many people without homes.

• Homeless people are particular victims of certain diseases. Approximately one-third have mental illnesses. Perhaps one-half have a current or past drug or alcohol addiction. Communicable diseases, including HIV/AIDS and tuberculosis, ravage the homeless population. Infections of every sort are prominent among homeless people. Trauma resulting from violence and conditions caused by exposure to the elements are common among homeless people.

• Homeless people also have all the same health problems as people with homes, but at rates three to six times greater than housed people. Without a home, there is no place to recuperate from an illness or to treat an injury, and health problems tend to get far worse before they get better.

• A large segment of the homeless population is families with children, in a survey of 25 cities, accounting for 36% of the homeless population.

• Each year, more than 1.35 million children and youth experience life without a home - living in shelters, vehicles, and parks.

• One out of seven of those treated by homeless health care projects is a child under age 15.

• Two out of five Health Care for the Homeless patients are females.

• 30% of homeless persons are over the age of 45.

• Forty percent of homeless men are veterans, although veterans comprise only 34% of the adult male population.

• 64 percent of Health Care for the Homeless clients are from racial or ethnic minorities.

For more complete information on homelessness and health care, please see the fact sheets prepared by the National Coalition for the Homeless or the annotated bibliographies prepared by the Health Care for the Homeless Information Resource Center. See also papers presented at the 1998 National Symposium on Homelessness Research, sponsored by HUD and DHHS. These include Balancing Act: Clinical Practices that Respond to the Needs of Homeless People by Marsha McMurray-Avila, Lillian Gelberg and Bill Breakey.

See also the HCH 101 PowerPoint presentations here.