The relationship between homelessness and healthcare represents one of the most significant intersections of systems affecting people experiencing housing instability. This relationship works in both directions: health problems can contribute to homelessness, while homelessness dramatically worsens health outcomes. Understanding this bidirectional relationship is essential for developing effective interventions that address both housing and health needs.
Health as a Pathway to Homelessness
Health issues can directly contribute to housing instability and homelessness:
Medical Costs and Financial Strain
- Medical debt is the leading cause of bankruptcy in the United States
- Approximately 66% of all bankruptcies are tied to medical issues—either high costs of care or time away from work
- Over 100 million Americans (41% of adults) have healthcare debt
- Even with insurance, out-of-pocket costs can deplete savings and lead to housing instability
Income Disruption Due to Illness or Injury
- Many workers, especially in low-wage jobs, lack paid sick leave
- Long-term illness or disability can lead to job loss
- The waiting period for disability benefits often creates a dangerous gap in income
- Caregiving responsibilities for ill family members can affect employment and income
Mental Health and Substance Use Challenges
- Untreated mental health conditions can affect ability to maintain employment and housing
- Substance use disorders can impact financial stability and housing relationships
- Limited access to affordable treatment creates barriers to recovery
- Stigma around these conditions can lead to discrimination in housing and employment
The American Healthcare Gap
The pathway from health crisis to homelessness is far less common in countries with universal healthcare systems, where medical care doesn't create financial catastrophe. This highlights how this pathway is largely a product of policy choices rather than an inevitable outcome of illness or injury.
How Homelessness Impacts Health
Once homelessness occurs, it creates numerous health challenges:
Exposure-Related Health Issues
- Weather exposure: Hypothermia, heat stroke, sunburn, and frostbite
- Environmental hazards: Exposure to pollution, toxins, and unsafe conditions
- Injury risk: Higher rates of trauma from accidents, assaults, and falls
- Sleep deprivation: Chronic sleep disruption affecting physical and mental health
Infectious Disease Vulnerability
- Congregate settings: Shelters and encampments can facilitate disease transmission
- Hygiene challenges: Limited access to facilities for handwashing and personal care
- Compromised immunity: Stress, malnutrition, and exposure weakening immune response
- Higher prevalence: Increased rates of tuberculosis, HIV, hepatitis C, and other infectious diseases
Chronic Disease Management Challenges
- Medication management: Difficulty storing and taking medications as prescribed
- Dietary restrictions: Limited ability to follow special diets for conditions like diabetes
- Follow-up care: Challenges attending appointments and maintaining treatment plans
- Disease progression: Conditions worsening due to inadequate management
Mental Health Impacts
- Trauma exposure: High rates of victimization while homeless
- Chronic stress: Constant survival mode affecting mental wellbeing
- Social isolation: Loss of supportive relationships
- Stigma and discrimination: Psychological impact of societal treatment
Health Disparities and Life Expectancy
The health impacts of homelessness create stark disparities in outcomes:
Mortality Rates
- People experiencing homelessness have mortality rates 3-4 times higher than the general population
- The average life expectancy for someone experiencing chronic homelessness is approximately 50 years, compared to 78 years in the general population
- Death rates from treatable conditions are significantly higher among homeless populations
- Overdose and suicide rates are elevated among people experiencing homelessness
Premature Aging
- People experiencing homelessness often exhibit health conditions typical of those 10-20 years older
- Geriatric conditions appear earlier, with "elderly" status often considered to begin at age 50
- Cognitive impairment rates are higher and occur at younger ages
- Mobility limitations and functional impairments develop prematurely
The Mortality Gap
A 25-year-old experiencing homelessness has a life expectancy similar to that of someone in the general population in the 1800s. This dramatic disparity highlights how homelessness effectively rolls back centuries of public health progress for those affected.
Barriers to Healthcare Access
People experiencing homelessness face numerous barriers to accessing healthcare:
Practical Barriers
- Transportation challenges: Difficulty reaching healthcare facilities
- Identification requirements: Lack of ID or insurance cards
- Communication limitations: No phone or address for appointments and follow-up
- Competing priorities: Basic survival needs taking precedence over healthcare
- Storage issues: Inability to safely store medications or medical supplies
Systemic Barriers
- Insurance gaps: Lack of coverage or enrollment challenges
- Provider shortages: Limited providers accepting Medicaid or serving homeless populations
- Fragmented care: Disconnected systems making coordination difficult
- Rigid appointment systems: Inflexible scheduling incompatible with homeless reality
- Geographic mismatch: Services located far from where homeless populations live
Interpersonal Barriers
- Stigma and discrimination: Negative treatment from healthcare staff
- Mistrust: Previous negative experiences creating reluctance to seek care
- Communication challenges: Medical jargon and complex instructions
- Trauma history: Past traumatic experiences affecting healthcare interactions
- Shame: Embarrassment about appearance, hygiene, or living situation
Healthcare Utilization Patterns
These barriers create distinct healthcare utilization patterns:
Emergency Department Reliance
- People experiencing homelessness use emergency departments at 5-10 times the rate of the general population
- EDs often serve as the primary source of care due to accessibility and lack of alternatives
- Conditions that could be managed in primary care settings escalate to emergencies
- ED visits frequently result in discharge back to homelessness without addressing underlying issues
Hospitalization Patterns
- Higher rates of inpatient admission compared to housed populations
- Longer average length of stay due to complex medical and social needs
- Higher rates of leaving against medical advice due to competing needs
- Frequent readmissions due to discharge to inappropriate settings
Preventive Care Gaps
- Lower rates of preventive screenings and vaccinations
- Delayed care seeking until conditions become severe
- Limited access to dental care and vision services
- Inadequate management of chronic conditions
The Cost Paradox
The healthcare system spends enormous resources treating the consequences of homelessness in emergency rooms and hospitals—often at 10 times the cost of providing housing and preventive care. This represents one of the most expensive and least effective approaches to addressing the health needs of people experiencing homelessness.
Insurance Coverage Challenges
Insurance status significantly affects healthcare access for people experiencing homelessness:
Medicaid Expansion Impact
- The Affordable Care Act's Medicaid expansion significantly increased coverage options for people experiencing homelessness
- In expansion states, the uninsured rate among homeless populations decreased substantially
- Non-expansion states continue to have large coverage gaps for this population
- Even in expansion states, enrollment and maintenance challenges persist
Enrollment and Maintenance Barriers
- Documentation requirements: Difficulty providing necessary paperwork
- Address requirements: Challenges receiving and responding to notices
- Renewal processes: Complex procedures for maintaining coverage
- Technology barriers: Online systems inaccessible to many
- Navigation complexity: Confusing systems difficult to understand
Coverage Gaps
- Categorical eligibility: Some homeless individuals don't fit eligibility categories
- Immigration status barriers: Restrictions based on documentation status
- Benefit design limitations: Inadequate coverage for needed services
- Provider network issues: Limited providers accepting available insurance
Mental Health System Failures
Mental health system inadequacies significantly impact homelessness:
Historical Context: Deinstitutionalization
- Beginning in the 1950s, large state psychiatric hospitals began closing
- Intended to shift care to community-based settings that would be more humane and effective
- Promised community mental health centers were never adequately funded or developed
- Coincided with reductions in affordable housing and social safety nets
Current System Gaps
- Insufficient community-based services: Limited outpatient treatment options
- Crisis response limitations: Inadequate alternatives to emergency departments
- Inpatient bed shortages: Long waits for psychiatric hospitalization
- Discharge planning failures: People released from psychiatric facilities without housing plans
- Fragmented funding: Multiple, uncoordinated funding streams
Treatment Access Barriers
- Provider shortages: Insufficient mental health professionals, especially in rural areas
- Insurance limitations: Inadequate coverage for mental health services despite parity laws
- High threshold requirements: Services designed for higher-functioning individuals
- Waiting lists: Long delays for treatment
- Transportation challenges: Difficulty reaching available services
Substance Use Treatment Gaps
Similar gaps exist in substance use treatment systems:
Treatment Capacity Issues
- Only about 10% of people with substance use disorders receive specialized treatment
- Detoxification services are often unavailable when needed
- Residential treatment programs have long waiting lists
- Medication-assisted treatment access is limited in many areas
- Recovery support services are insufficient to maintain long-term recovery
Housing-Related Barriers
- Housing first vs. treatment first debates: Some programs require sobriety before housing
- Recovery housing shortages: Limited options for people in early recovery
- Discharge to homelessness: Treatment programs ending without housing plans
- Environmental challenges: Returning to homeless settings with high substance availability
The Treatment-Housing Paradox
Many people experiencing homelessness face an impossible situation: they can't access housing because of their substance use, but they struggle to address substance use while homeless. This catch-22 highlights the need for integrated approaches that address both needs simultaneously.
Promising Integrated Approaches
Several models effectively address the intersection of homelessness and healthcare:
Housing as Healthcare
- Housing First: Immediate access to permanent housing without treatment preconditions
- Permanent Supportive Housing: Combining affordable housing with voluntary services
- Medical Respite: Short-term residential care for homeless individuals too ill for shelter but not sick enough for hospitalization
- Hospital to Housing Programs: Direct discharge to housing with support services
Adapted Healthcare Models
- Health Care for the Homeless Programs: Federally funded programs specifically designed for homeless populations
- Street Medicine: Mobile healthcare delivered directly to people living on the streets
- Integrated Care: Combined physical health, mental health, and substance use treatment
- Patient-Centered Medical Homes: Comprehensive primary care models with care coordination
System Integration Approaches
- Data sharing: Connected information systems across healthcare and housing
- Cross-sector partnerships: Formal collaborations between healthcare and homeless services
- Medicaid innovations: Waivers and demonstration projects targeting homeless populations
- Flexible funding models: Braided funding streams to address multiple needs
Policy Implications
Addressing the intersection of homelessness and healthcare requires policy changes:
Healthcare System Reforms
- Universal coverage: Ensuring healthcare access regardless of housing status
- Benefit design: Comprehensive benefits addressing the needs of vulnerable populations
- Provider incentives: Payment models supporting care for complex patients
- Workforce development: Training providers in homeless healthcare
Housing System Changes
- Housing as healthcare: Recognizing housing as a healthcare intervention
- Medical necessity criteria: Including housing stability in healthcare determinations
- Discharge policies: Preventing discharge from healthcare facilities to homelessness
- Accessible design: Housing that accommodates health conditions and disabilities
Cross-System Coordination
- Shared accountability: Joint responsibility for outcomes across systems
- Coordinated entry: Integrated access points for multiple services
- Unified planning: Combined strategic planning across health and housing
- Whole-person funding: Resources that follow individuals across systems
The Return on Investment
Studies consistently show that providing housing and integrated healthcare for people experiencing homelessness reduces overall public costs. A landmark study in Los Angeles found that providing permanent supportive housing reduced public spending by about 20% per person, primarily through reduced emergency healthcare and criminal justice costs.
Conclusion
The intersection of homelessness and healthcare represents both a significant challenge and an opportunity for more effective interventions. The bidirectional relationship—where health problems contribute to homelessness and homelessness worsens health—creates a cycle that requires integrated approaches addressing both housing and healthcare needs simultaneously.
The stark health disparities experienced by people without housing highlight the fundamental connection between housing and health. Housing stability is a prerequisite for good health, while healthcare access is essential for maintaining the stability needed to secure and retain housing.
By recognizing housing as a healthcare intervention and healthcare as a housing stability support, we can develop more effective approaches that break the cycle between homelessness and poor health. Promising models that integrate these systems demonstrate that solutions exist when we move beyond siloed approaches to address the whole person's needs.
Key Takeaway
Housing is healthcare, and healthcare is housing stability. Addressing homelessness effectively requires recognizing the fundamental connection between these two basic human needs and developing integrated approaches that address both simultaneously rather than treating them as separate issues.
References & Further Reading
- Fazel, S., Geddes, J.R., and Kushel, M. "The Health of Homeless People in High-Income Countries: Descriptive Epidemiology, Health Consequences, and Clinical and Policy Recommendations." The Lancet, vol. 384, no. 9953, 2014, pp. 1529-1540. https://doi.org/10.1016/S0140-6736(14)61132-6
- National Health Care for the Homeless Council. "Homelessness & Health: What's the Connection?" NHCHC, 2019. https://nhchc.org/understanding-homelessness/health/
- Baggett, T.P., et al. "Mortality Among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-Year Period." JAMA Internal Medicine, vol. 173, no. 3, 2013, pp. 189-195. https://doi.org/10.1001/jamainternmed.2013.1604
- Kushel, M.B., et al. "Emergency Department Use Among the Homeless and Marginally Housed: Results from a Community-Based Study." American Journal of Public Health, vol. 92, no. 5, 2002, pp. 778-784. https://doi.org/10.2105/AJPH.92.5.778
- Hwang, S.W. and Burns, T. "Health Interventions for People Who Are Homeless." The Lancet, vol. 384, no. 9953, 2014, pp. 1541-1547. https://doi.org/10.1016/S0140-6736(14)61133-8
- Substance Abuse and Mental Health Services Administration. "Current Statistics on the Prevalence and Characteristics of People Experiencing Homelessness in the United States." SAMHSA, 2023. https://www.samhsa.gov/homelessness-programs-resources
- Flaming, D., et al. "The Cost Study: Homelessness in Los Angeles County." Economic Roundtable, 2015. https://economicrt.org/publication/where-we-sleep/
- Health Resources and Services Administration. "Health Care for the Homeless." HRSA, 2024. https://www.hrsa.gov/grants/find-funding/HRSA-24-019
- Brown, R.T., et al. "Geriatric Conditions in a Population-Based Sample of Older Homeless Adults." The Gerontologist, vol. 57, no. 4, 2017, pp. 757-766. https://doi.org/10.1093/geront/gnw011
- Henwood, B.F., Byrne, T., and Scriber, B. "Examining Mortality Among Formerly Homeless Adults Enrolled in Housing First: An Observational Study." BMC Public Health, vol. 15, 2015, p. 1209. https://doi.org/10.1186/s12889-015-2552-1