The Homelessness Connection In Health Care

While health care reform is being hotly debated across the nation, one of the groups most likely to be affected by reform has been characteristically silent: people who are homeless.

It's a common misconception that everybody living in poverty is eligible for Medicaid -- in truth, there are many poor people who are not currently eligible for Medicaid. Non-disabled, childless adults -- even those with health problems -- are often not eligible. The same applies to mothers with health conditions whose children have been placed in foster care, and young adults aging out of the foster care system.

In fact, a 1996 nationwide study of homelessness found that only 25 percent of homeless single adults were enrolled in Medicaid.

It's not always easy to see, but homelessness and health care have a clear -- and cyclical -- relationship: poor health can lead to homelessness, and homelessness can aggravate poor health. And both can be a burden on our health care system.

Many people become homeless due to a lack of health care. Untreated illnesses can lead to disability and job loss -- and unemployment remains one of the leading causes of homelessness. It's worth noting here that the leading cause of bankruptcy in the United States is medical expenses, insured or not. So people's incomes are clearly tied up with their ability to get or pay for health care; and the lower incomes lead to higher risk of homelessness.

The other side of the coin is that homelessness aggravates poor health. The lack of access to water, food, and clean, safe and stable housing only puts further pressures on a person's body.

With few resources and little access to any alternatives, homeless people will wait until the last possible moment to seek treatment, and then likely resort to costly emergency room (ER). Once they're in the hospital, then tend to stay longer. After discharge, pushed back into homelessness, their symptoms often return and worsen, until they're right back in the ER.

The cost of this inefficient, ineffective cycle is something we all pay for -- through higher medical costs, insurances rates, and local and state taxes. In fact, many cost studies of this social problem suggest that it may be more financially prudent to ensure that homeless people receive preventive and primary care before minor conditions become chronic ones.

In Seattle, the Downtown Emergency Service Center has a supportive housing project called 1811 Eastlake for chronic alcoholics who have lived for years on the streets. In evaluating the costs for 75 of the residents they found that within a year they had collectively cut days spent in jail by half. Medicaid costs dropped by over 40 percent and hospital visits had decreased by a third -- ultimately saving Seattle and the federal government millions. These findings were published in the Journal of the American Medical Association in April 2009.

A similar story comes from Chicago, called the Chicago Housing and Health Partnership. Over four years, the Partnership followed 405 chronically homeless people. Half of the 405 received immediate housing and intensive case management (similar to those services offered to the 1811 Eastlake group); the other half of the 405 were offered typical homeless services. Those receiving housing decreased the incidence of hospital admission and days spent in the hospital by a third, and decreased their emergency room visits by 25 percent. Again, cost savings are significant.

These studies suggest that addressing the health care needs of homeless people would not only benefit them, but us as well.

With worries about the cost of health care reform, the spiraling national debt, and the future of our country, it's reassuring to know that sometimes doing the right thing is actually the right thing to do.

It's little wonder that in his address to the National Conference on Ending Homelessness, Secretary Shaun Donovan of the Department of Housing and Urban Development (HUD) remarked: "Simply put, if we want to tackle health care reform -- if we want to lower costs -- we must tackle homelessness. It's that simple."

In this moment, we have a rare opportunity to both satisfy our needs for efficient, effective reform and our ethical sensibilities. In our efforts to reform health care, we must turn to hear those characteristically silent, and remember that we have a chance to provide for homeless people and lighten the load on our beleaguered health care system.

Let's take it.