The vulnerability and discomfort of living on the streets, in conjunction with social determinants, has made adequate health care nearly unattainable for people who are homeless. People who experience homelessness are 3-4 times more likely to die prematurely than members of the general population, with an average life expectancy of only 48 years.
While economic barriers and certain policies complicate access to healthcare for the homeless, social determinants—factors such as housing, education, quality of food, access to transportation—are a strong indicator of the type of care that someone receives, said Courtney Plasden, the medical access director at Unity Health Care. The nonprofit operates 29 sites and a mobile unit to provide primary care to homeless people in the District. “Thinking about a person and their whole health status, direct patient care is 10 percent and the other 90 percent is social determinants,” Plasden said.
The United States spends more per capita on health services than any other country in the world. Peer industrialized nations spend more on social service programs and have better health outcomes with lower spending. “We need to start working further upstream,” Plasden said.
Healthcare for homeless people is more complicated than access to a clinic or an appointment with a provider. Without a home and all of the amenities that many take for granted, basic health practices can become impossible, particularly when it comes to ostensibly simple issues such as coordination and follow-up. If you have an appointment in Ward other than where you live, how are you going to get to that appointment? If you need insulin, how will you keep it refrigerated? If you have to take daily medication for HIV and your bag with that medication is stolen at a shelter, what are you supposed to do? For many of these issues, the answer involves a more global perspective that places the patient’s medical conditions within the context of their life situation.
The Journal of the American Medical Association (JAMA) conducted a 2001 study that found 62 percent of homeless participants needed ambulatory care visits to the hospital within a single year. The study concluded that these visits were often due to the fact that many subjects didn’t have the insurance to go to the hospital in other capacities. Twenty-five percent of participants reported being unable to receive the healthcare they required.
Healthcare is complex and some policies don’t meet every individual’s needs. For instance, while people are entitled to receive care if they are injured or dying, they are not entitled to stay in hospitals or housing until they have recovered. A person could have an invasive procedure—like heart surgery or a mastectomy—and find themselves discharged from the hospital and prescribed to get “bed rest” with a quick turnaround. This is fine for someone with a safe place to recover, but being discharged onto the street can be a dangerous and painful fate.
This happened to D.C. native Ken Martin, who found himself sleeping outside of a Starbucks after having both a heart attack and heart surgery. Two days after his discharge, still outside of Starbucks, he suffered another heart attack.
Martin is now housed and has spent years working with others experiencing homelessness. According to him, for solutions to be effective, these complexities need to be considered. “Something as simple as finding a bed to rest in, for prescribed bed rest, is impossible,” Martin said in an interview. “That’s crazy.”
A relatively new initiative called Housing First—an approach to combatting homelessness that rapidly resettles people into housing without traditional upfront qualifying requirements—has been commended in terms of its economic efficiency and numeric success. However, unless Housing First initiatives have robust medical programs integrated into them, they are at risk of falling short.
A more recent 2015 study by the United States National Institute of Health (NIH) claimed that “mortality rates among Housing First participants are higher than those reported among members of the general homeless population in prior studies.” The study found that those in Housing First programs are more likely to die due to chronic illness than their counterparts in the general homeless population. This data is, in part, a result of the fact that Housing First targets those in most urgent need, which often translates to the oldest and the most ill. However, conclusions from the study are cited by the NIH as potential indications that these programs are in need of “greater integration of medical and end-of-life care.”
“I actually think Housing First programs could be a good platform from which to deliver high intensity, integrated [health] care – and I think the ACA has provisions that can make this happen,” said NIH researcher Benjamin Henwood wrote in an e-mail, “it’s just that most programs are not doing this.”
Housing First offers remedies to some select and overt symptoms of homelessness; however, many argue that it is not a sufficient cure and that viewing it as such can be detrimental to true progress. The argument is not that housing is a bad thing—housing is a necessity and a human right. In the greater conversation of medical health, it has proven to be extremely important. However, to create a healthy life, housing is simply one element in an increasingly complex equation. “It’s the mentality that is wrong: the thought that a roof over your head is the answer to all of your problems” Martin said.
While housing has repeatedly and reliably been identified as one of the key factors in good health, it is simply one social determinant, albeit a very large and influential one. For healthcare to be effective, issues that intersect with health more subtly—from diet to poverty—nmartineed to be addressed. Advocates such as Plasden and Martin are calling for a holistic approach on an individual scale to achieve the goal of a healthier community.