The burden of homelessness on the health of those afflicted continues to be a major global public health concern. Last year, the United States recorded an increase in the number of homeless for the first time since 2010. On any given night in 2017, there were 553,742 people in the U.S. experiencing homelessness.
In terms of health care, people struggling with homelessness are at an increased risk for many health problems. People who are homeless often end-up in an emergency department, and often for problems that can often be managed outside it. According to a 2008 study of high health care users in California, such visits could cost the health care system up to $44,000 per year for those who are the most frequent users.
In this Bang for the Buck article, I discuss the health care costs associated with homelessness. I’ll begin by examining the costs directly attributed to homelessness, review some programs that have been effective and may save money, and end with a recently published article whose investigation into the cost of healthcare among the homeless raises the specter of discrimination in hospitals towards the homeless.
The Health and Social Costs of Experiencing Homelessness
There are many causes of homelessness. Among them, health issues like mental illnesses play a substantial role. Left untreated, mental health problems can make coping with the challenges of life more difficult for affected individuals. In turn, a strained relationship between behavior and environment could cause many to wind up on the streets. Once homeless, mental health issues can worsen and increase treatment costs. A study in Canada between 2009 and 2011 with a sample of homeless people with mental illness found that the comprehensive cost (housing, medical care, social services, etc.) to society per year ranged from $30,000 and $56,000, depending on region. Data from Montréal indicated that this cost would increase by about $3,000 if medications were included.
Being homeless leads to an increased risk for many health problems. Because the homeless often live in environments where safe water, sanitation, protection from weather extremes, and even healthcare services may not be easily accessible, the homeless are more likely to be exposed to communicable infections such as tuberculosis. Being on the streets also increases the likelihood of injection drug use and risky sexual behaviors, leading to higher risks for HIV, HCV, and HBV. In a cohort study published nearly two decades ago, homelessness, substance abuse, and HIV were significantly correlated. In the same cohort, the hospitalization cost was $2,000 more per homeless individual compared to non-homeless individuals.
Possible Solutions to Reduce the Costs of Homelessness
It is to no surprise that this relatively small population accounts for relatively large shares of health, social, and justice service spending. Studies suggest that it would be cost-effective to invest in housing for the homeless. In a quasi-experimental study comparing 95 housed participants with 39 wait-listed controls it was shown that housing projects could lower health care, social and justice service costs by 53% for housed participants over the first 6 months. In another study, with a sample of 236 homeless adults, supportive housing decreased emergency department visits by 56%. The possible cost-effectiveness of such “housing first” projects could hold part of the answer to the rising burden on health of homelessness.
Another example is the National Health Care for the Homeless Program. Since the 1980s these clinic sites, coordinated in part by the National Health Care for the Homeless Council, have been working with the private and public sector to offer comprehensive health care for the homeless. In 2017, more than 200 Health Care for the Homeless sites were serving more than 1.4 million homeless [PDF] homeless individuals per year, and the Council now boasts a membership of more than 10,000 healthcare professionals. Among the myriad achievements of these clinics, one study that investigated the association between the utilization of the program’s services and risk of inappropriate emergency department use, found that having two or more visits to the program decreased the odds of inappropriate visits.
Though the perpetuation of such ideas rests heavily on the shoulders of policy-makers, there may be something we in the healthcare sector can do to curb the inequity in health care delivery to the homeless.
A Wrench in the Plans: Homelessness and Discrimination in Health Care
In a recently published Medical Care paper, Dr. Rishi Wadhera and colleagues evaluated patterns, causes, and outcomes of acute hospitalization among homeless persons compared to standardized non-homeless controls in Massachusetts, Florida, and California. The retrospective study compared 185,292 admissions for homeless individuals and more than 32 million admissions for controls between 2007 and 2013. One of the study’s main findings was a mean length of stay that was higher among the homeless at 6.5 days compared with 5.9 days for controls.
Interestingly, the hospitalizations for the homeless sample had lower mean costs per day at $1,535 compared with $1,834 for controls. The authors suggest that one potential explanation for the differences in spending is that healthcare professionals’ implicit biases lead to differences in the amount (or quality) of care delivered. On the other hand, the authors suggest that the longer length of stay might reflect a reticence of providers to release homeless patients without stable places to live. Though longer stays could ultimately cost more in total, less use per day may in fact point to some bias in care based on an individual’s housing situation.
Discrimination is not uncommon towards homeless people. A 2014 study by the National Coalition for the Homeless in Washington, D.C. found that nearly half (49.7%) of homeless people interviewed reported discrimination in health care settings. This was lower than discrimination reported in other settings (private businesses and from law enforcement), but higher than from interactions with social services. And a qualitative study in Toronto demonstrated that even general feelings of unwelcomeness in health care settings can lead to intense emotional responses [PDF] (e.g., feeling dehumanized) and negatively impact their willingness to seek health care in the future.
Indeed, future studies are needed to investigate how discrimination in health care uniquely affects people who experience homelessness and how this can be addressed. Could the solution simply be teaching compassion to our future physicians and health care providers. That being said, can compassion even be taught?
Red Thaddeus Miguel