Health Care System Often Fails Homeless and Low Income People

by Staff of the National Coalition for the Homeless

   On Homeless Persons’ Memorial Day, when we recognize that death on the streets is all too frequently the result of homelessness, it is appropriate to consider the many ways that sickness and death intersect with homelessness.

   Poor health is always 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 today for needed health care, and eventual eviction.  Thirteen percent of homeless patients surveyed in a national study said that poor physical health was a factor in their becoming homeless.  Of those patients, half said health was a “major factor” and 15% stated that it was the “single most important” factor.

   The experience of homelessness poses very real hazards to one’s health.  With the exception of obesity, strokes, and cancer, homeless people are more likely to suffer from every category of chronic health problems.  Homeless people frequently lack access to the most basic health care services.  The vast majority of homeless people are among the 42 million people in the United States who lack health insurance of any kind-- public or private.

   Establishing health care as a right will correct a fundamental social problem that contributes to increasing homelessness.  Three important principles of health care reform still must be satisfied: universal health insurance coverage, guaranteed access to health care services, and comprehensive benefits.  Universal coverage - for all people - establishes the basic human right to health care, but does not go far enough.  The health care delivery system must be accessible for homeless people, with clinics conveniently located and no barriers of cost or provider attitudes.  Comprehensive services-including substance abuse treatment, mental health services, and dental and vision care-must be readily available for people, including those in particular need because of their homelessness.

   Bringing homeless people and poor people at risk of homelessness into the health care system will ease the pain of life on the streets, reduce the impact and cost of communicable diseases and other illnesses, and help to avoid unnecessary deaths on the streets.  For homeless people, health care is literally a matter of life and death.

   Until the health care system includes all poor and homeless people, targeted programs that respond to some of the health needs of the homeless-such as Health Care for the Homeless (HCH) and Projects for Assistance in Transition from Homelessness (PATH)- require our support.

            HCH is a McKinney Act program designed to help provide health care for homeless people who do not have access to health services.  HCH projects are successful (in some cities) because they are designed and controlled by local communities to fill significant gaps in existing health care delivery systems by providing comprehensive care in accessible clinics.  HCH services close to 450,000 homeless men, women and children each year.  However, the crumbling indigent care network, the development of managed care, stagnant federal funding, and the increase in homelessness have made it impossible for HCH programs to reach the majority of homeless people in America.  As a result, waiting lists and turn-away rates have increased.

            The PATH Program targets mental health block grant funds to the needs of homeless persons with mental illnesses.  Approximately 20-25% of the single adult homeless population suffers from some form of severe and persistent mental illness.  Homeless people with severe mental illness tend to remain homeless longer, encounter more barriers to employment and housing, and live in poorer physical health.  These individuals require ongoing access to a full range of treatment and rehabilitation services in order to stabilize both their illness and their lives.  To ensure this needed care, community-based services, such as PATH, must be expanded and increased in number.

   No federal funding stream targets the treatment needs of homeless people with substance abuse disorders.  Perhaps more than any other health condition, chemical dependencies put homeless people at risk of death on the streets.  Yet waiting lists for treatment slots are impossibly long for poor and homeless people.  On January 1, 1997, over 140,000 adults disabled by substance abuse disorders lost the SSI benefits that many had used to pay for housing and which made them eligible for Medicaid, and are now appearing on the streets, made homeless by unenlightened government policy.

   HIV/AIDS has had a devastating impact on homeless people.  At least 3 % of homeless people test positive for HIV, and 16% of single adult homeless men in New York are HIV positive.  People with HIV/AIDS often face discrimination in searching employment and housing: 36% of people with AIDS have been homeless since learning they had HIV or AIDS.  Adequate treatment of this complex illness requires stable housing, yet persons with AIDS die on the streets of our country.

   Tuberculosis, still the number one infectious disease killer of adults worldwide, is a disease of poverty to which homeless people are vulnerable because of the congregate settings in which they live and their lack of accessible health care.  Fourteen percent of those affected by TB in the United States are connected to homelessness in some form.  Much more must be done to identify and treat homeless persons infected with TB, without violating their rights or threatening their precarious sheltered arrangements. 

            Through the collaborative work of service providers, community groups, and local, state, and national organizations, these issues can be brought to the forefront, and effective models for resolution and positive change can be created and shared.  On this sad Homeless Persons’ Memorial Day, we remain committed to positive changes and to less death and suffering on the streets of our nation.