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Health Care and Homelessness
Poor health is closely 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
to pay for care, and eventual eviction.
Thirteen
percent of homeless patients surveyed in a national study published in
the 1980s stated 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
(Wright and Weber, 1987). The problem has become much worse in the last
decade, as the number of uninsured Americans continues to increase. In
1997, 43.4 million people in the United States lacked health insurance,
and nearly one-third of persons living in poverty had no health insurance
of any kind (U.S. Bureau of the Census, 1998). The coverage held by many
others would not carry them through a catastrophic illness. A recent analysis
of Health Care for the Homeless (HCH) projects found that the number of
uninsured persons seeking treatment is increasing: overall, HCH programs
report a 35% increase in the numbers of patients who are uninsured (O'Connell,
J., Lozier, J., and Gingles, K., 1997).
The
rates of both chronic and acute health problems are extremely high among
the homeless population. With the exception of obesity, strokes, and cancer,
homeless people are far more likely to suffer from every category of chronic
health problem. Conditions which require regular, uninterrupted treatment,
such as tuberculosis, HIV/AIDS, diabetes, hypertension, addictive disorders,
and mental disorders, are extremely difficult to treat or control among
those without adequate housing.
Many
homeless people have multiple health problems. For example, frostbite,
leg ulcers and upper respiratory infections are frequent, often the direct
result of homelessness. Homeless people are also at greater risk of trauma
resulting from muggings, beatings, and rape. Homelessness precludes good
nutrition, good personal hygiene, and basic first aid, adding to the complex
health needs of homeless people. In addition, some homeless people with
mental disorders may use drugs or alcohol to self-medicate, and those
with addictive disorders are also often at risk of HIV and other communicable
diseases.
Homeless
children also experience numerous health problems. A recent study of the
health status of homeless children in New York City found that 61% of
homeless children had not received their proper immunizations (compared
to 23% of all New York City two-year-olds); 38% of homeless children in
the City's shelter system have asthma (an asthma rate four times that
for all New York City children and the highest prevalence rate of any
child population in the United States); and that homeless children suffer
from middle ear infections at a rate that is 50% greater than the national
average (Redlener and Johnson, 1999). These illnesses have potentially
devastating consequences if not treated early.
PROGRAM AND POLICY ISSUES
People who are homeless are overwhelmingly uninsured and often lack access
to the most basic health care services for their complex health care needs.
At present, there is one federally funded program, Health Care for the
Homeless (HCH), that is designed specifically to provide primary health
care to homeless persons. Recent evaluations of the HCH programs have
found that HCH projects provide primary health care in a cost-effective
and efficient manner (Cousineau, 1995). HCH projects are successful because
they are designed and controlled by local communities to fill significant
gaps in existing health care delivery systems. Health and social service
workers in HCH projects provide comprehensive care through accessible
clinics and mobile and street health outreach. No other indigent care
system provides this service. In Fiscal Year 1998, the HCH program awarded
grants to 128 community-based organizations who, in turn, expanded their
service network through arrangements with over 300 service providers.
As a result, the HCH program serves more than 430,000 clients in 48 states,
the District of Columbia and Puerto Rico. For the people served by Health
Care for the Homeless programs, the restoration of physical health is
often a first step toward reentry into stable housing and mainstream society.
However,
the crumbling health care safety net, the arrival of managed care, and
growth in homelessness have resulted in increased need for homeless health
care services. Welfare reform is also having an impact: many families
leaving welfare lose health insurance, despite continued Medicaid eligibility.
A recent study found that 675,000 people lost health insurance in 1997
as a result of the federal welfare reform legislation, including 400,000
children (Families USA, 1999). These and other policy changes have made
it impossible for HCH programs to reach the majority of homeless people
in America. A 1997 study by the Bureau of Primary Health Care found that
HCH projects are experiencing a significant growth in homelessness in
their communities, and that at the same time, financial support for HCH
programs is diminishing (O'Connell, J., Lozier, J., and Gingles, K., 1997).
As a result, HCH projects have been forced to reduce program staffing,
and waiting lists and turnaway rates have increased.
Lack
of affordable housing also impacts efforts to provide health care to homeless
persons: housing is the first form of treatment for homeless people with
medical problems, preventing many illnesses and making it possible for
those who remain ill to recover.
Universal
access to affordable, high-quality and comprehensive health care is also
essential in the fight to end homelessness. A health insurance system
could reduce homelessness and, more significantly, help to prevent future
episodes of homelessness, as well as ease the pain -- and even prevent
unnecessary deaths -- of those on the streets. A universal health system
would also reduce the fiscal impact and social cost of communicable diseases
and other illnesses.
RESOURCES
Brickner, Philip et al. Under the Safety Net: The Health and Social Welfare
of the Homeless in the United States, 1991. Available as bookstore order
ISBN (paper) 0-393 30875-8 for $14.95, or (with S&H added) from W.W.
Norton and Company, 500 Fifth Ave., New York, NY 10110; 212/354-5500.
Cousineau,
Michael et al. A Study of the Health Care for the Homeless Program: Final
Report, 1995. Available, free, from the National Clearinghouse for Primary
Care Information, 2070 Chain Bridge Rd., Suite 450, Vienna, VA 22182-2536;
800/400-2742. In the Washington, DC metro area: 703/902-1248.
Families
USA. Losing Health Insurance: The Unintended Consequences of Welfare Reform,
1999. Available from Families USA, 1334 G Street, NW, Washington, DC 20005;
202/628-3030.
Gage,
Larry S. et al. America's Urban Health Safety Net, 1994. Available for
$20.00 from National Association of Public Hospitals, 1212 New York Ave.,
NW, Suite 800, Washington, DC 20005-6148; 202/408-0223.
Moran,
William and Natalie Coen. Medicaid and Homeless Individuals, 1992. Available,
free, from OEI, Office of Inspector General, U.S. Department of Health
and Human Services, Region V, 105 W. Adams St., 23rd Floor, Chicago, IL
60603; 312/353-4124.
National
Coalition for the Homeless and the National Health Care for the Homeless
Council. Life and Death on the Streets: Health Care Reform and Homelessness,
1993. Available for $5.00 from the National Coalition for the Homeless,
1012 Fourteenth Street, NW, Suite 600, Washington, DC; 202/737-6444.
National
Coalition for the Homeless. Mourning in America: Health Problems, Mortality
and Homelessness, 1991. Available for $5.00 from the National Coalition
for the Homeless, 1012 Fourteenth Street, NW, Suite 600, Washington, DC;
202/737-6444.
National
Coalition for the Homeless and the National Health Care for the Homeless
Council. 'Tis a Gift to be Simple: Homelessness, Health Care Reform, and
the Single Payer Solution, 1994. Available for $5.00 from the National
Coalition for the Homeless, 1012 Fourteenth Street, NW, Suite 600, Washington,
DC; 202/737-6444.
National
Health Care for the Homeless Council, Inc. Combatting Tuberculosis and
Homelessness: Recommendations for Policy and Practice, 1994. Available
for $5.00 from the National Health Care for the Homeless Council, P.O.
Box 60427, Nashville, TN 37206-0427; 615/226-2292.
O'Connell,
J., Lozier, J., and Gingles, K. Increased Demand and Decreased Capacity:
Challenges to the McKinney Act's Health Care for the Homeless Program,
1997. Available from the National Health Care for the Homeless Council,
P.O. Box 68019, Nashville, TN 37206 8019; 615/226-2292.
U.S.
Bureau of the Census. Health Insurance Coverage: 1997. Current Population
Reports, Series P60-202, 1998. Available, free, from U.S. Bureau of the
Census, Income Statistics Branch, Washington, DC, 20233-0001; 301/763-8576,
or at http://www.census.gov/hhes/www/hlthins.html.
Redlener,
Irwin, MD and Dennis Johnson. Still in Crisis: The Health Status of New
York's Homeless Children, 1999. Available from The Children's Health Fund,
317 East 64th Street, New York, NY 10021; 212/535-9400.
Wright,
James and Eleanor Weber. Homelessness and Health, 1987. Out of Print.
McGraw Hill, 1221 Avenue of the Americas, New York, NY 10020; 212/512-2000.
ADDITIONAL RESOURCES
HHS Homelessness Web Site Information on homelessness through the U.S.
Department of Health and Human Services, including programs, funding,
resource centers, documents and links related to homelessness in America.
***
Health Care for the Homeless Information Resource Center, c/o Policy Research
Associates, 262 Delaware Avenue, Delmar, NY 12054-1123; 888/439-3300,
ext. 246; Email: nbrady@prainc.com.
The
Health Care for the Homeless Information Resource Center publishes free
annotated bibliographies and other information on many aspects of health
care and homelessness (tuberculosis, HIV/AIDS, dental needs, child development,
etc.).
***
National Health Care for the Homeless Council, P.O. Box 68019, Nashville,
TN 37206 8019; 615/226-2292; email: nhchc@nhchc.org.
The
National Health Care for the Homeless Council advocates on federal health
care policy issues, coordinates the staffing of an HCH clinicians network,
and provides support to local projects.
***
National Resource Center on Homelessness and Mental Illness, c/o Policy
Research Associates, 262 Delaware Avenue, Delmar, NY 12054-1123; 800/444-7415,
ext. 232; Email: nrc@prainc.com.
The
National Resource Center on Homelessness and Mental Illness maintains
and updates a bibliographic database on homelessness and mental illness.
The Center publishes a series of free, annotated bibliographies and an
information packet on financing.
Last
updated - June 1999 - National Coalition on Homelessness
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