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Healthcare for the Homeless - USA

Page history last edited by Robert Hackett 6 years, 7 months ago

Note: please note that this page should (a) link back to the issue overview on this topic, (b) be focused either the local, state, national, or global level, and (c) be neutrally presented, based on facts, and include footnotes for each of the items.  See the Research Guide and Information Sources to assist you. 

 

 

Scope of the Problem  factual statements on the extent of the problem in the past, current, or future


  • Homelessness implies more than just a lack of housing. The living conditions of homeless people put them under serious physical and psychological stress, which has far-reaching health consequences.[1] A combination of poor nutrition, inadequate hygiene, exposure to violence, increased contact with communicable diseases and fatigue that accompany the conditions of homelessness causes the homeless population to suffer from ill health (including physical and mental illnesses as well as substance abuse disorder) at rates that are two to six times higher than people living in stable housing. One third to one half of homeless adults have some form of physical illness and at least half homeless children have a physical illness and they are twice as likely as housed children to have such illnesses. One out of ten homeless clinic patients have been found to have poor dental health, a rate thirty-one times that found in the general population. Mortality rates among the homeless population are three to four times higher than they are in the general population.[2]
  • The health problems of the homeless people can be classified in three interrelated areas: physical illness, mental illness and substance abuse disorders. The most common physical illnesses among the homeless population are upper respiratory tract infections, trauma, female genitourinary diseases, hypertension, musculoskeletal problems, dental problems and vision problems. Many of these diseases are also common among the housed population. However, “these diseases are made worse by the stress and exposure of homelessness as well as the lack of access to ongoing treatment”.[3] In fact, about two-thirds of the problems homeless people present to primary health care sites are acute in nature (Wright). “Some of these problems, especially minor respiratory infections could easily be self treated by people in homes, with over the counter medications, appropriate nutrition, bedrest and a little bit of medical advice—all of which are inaccessible to the homeless people”.[4]
  • In regard to mental illness among the homeless population, it varies depending on the subgroups of the homeless population as well as the place, nonetheless “a broad consensus emerged that of the homeless people residing in shelters about one third had significant mental illness”.[5]
  • Regarding substance abuse, it is estimated that of people seeking primary health care from Health Care for the Homeless programs, close to 2/5 (38%) were alcohol abusers and over one out of ten (13%) abused other drugs (Wright). The drugs that represent the greatest concern for the homeless population are alcohol, heroin and cocaine. Alcohol abuse and dependence are associated with a wide range of health complications involving the liver, the nervous system and the heart. Heroin and cocaine dependence, mostly administered intravenously, increases the risks of infections such as bacterial endocarditis, hepatitis, and HIV which have a major impact on an individual’s health.[6]
  • In addition to the increased risks and prevalence of illness among the homeless population, homeless people also encounter major barriers in obtaining needed medical and psychiatric services.[7] The lack of access to medical treatment may contribute to the spread of communicable diseases leading to outbreaks that can become serious public health concerns (Badiaga et al). Additionally, the lack of access to health care implies that acute and chronic health problems among the homeless population may go untreated, “creating medical complications in multiple co-occurring conditions and ultimately impeding the individual’s ability to overcome homelessnes".[8]

 

A homeless person is a person whose primary nighttime residence is a supervised, publicly or privately-operated temporary living accommodation, including emergency shelters, transitional housing, and battered women’s shelters; or whose nighttime residence is not meant for human habitation.[9] In the United States, at least 2.3 million and probably as many as 3.5 million people experience homelessness for at least a short period of time over the course of the year.[10]

 

Homelessness implies more than just a lack of housing. Being homeless means living under conditions that can result in deterioration of health or exacerbate existing chronic and acute illnesses.[11] The failure to provide appropriate health care for the homeless population impedes the treatment of such acute and chronic illnesses, leading to medical complications which ultimately hinder the individual’s ability to overcome homelessness.[12]

A combination of poor nutrition, inadequate hygiene, exposure to violence, increases contact with communicable diseases causes the homeless population to suffer from ill health (including physical illness, mental illness, and substance abuse disorders) at rates that are two to six times higher than people living in stable housing. One-third to one-half of homeless adults have some form of physical illness and at least half of homeless children have a physical illness and they are twice as likely as housed children to have such illnesses. We note as well, mortality rates among the homeless population which are three to four times higher than they are in the general population.[13]

 

According to the 2006 study on homelessness in Minnesota, homeless people reported high needs for basic health care, dental care, prescription medicines, mental health treatment and substance abuse treatment. One program attempting to respond to such demand is the Health Care for the Homeless Project. Funded by the Robert Wood Johnson Foundation and the Pew Charitable Trusts. The program seeks to provide care for the homeless people with the least access to services.[14] After the enactment of the McKinney-Vento Homeless Assistance Act, which to date is the only major federal legislation designed to address homelessness in the US, the Health Resources and Services Administration was authorized to provide funding for health centers attending to the health care needs of homeless people.[15]

 

Being affected by complex and multiple interrelated health problems, health care services developed for the homeless population have to integrate primary care, mental health and substance abuse services. The numerous barriers faced by homeless people in accessing care call for special “adaptations to the structure of the delivery system, including extensive outreach, mobile sites and flexibility in policies and procedures".[16]

 

 

According to a study by Marsha McMurray-Avila, Lillian Gelberg and William Breakey:[17]

 

      - Rates of mortality are three to four times higher in the homeless population than they are in the general population.

      - The three most common acute illnesses that afflict homeless people are usually a direct consequence of the homeless condition: respiratory infections, trauma and minor skin ailments.

      - One chronic physical disorder considered to be a direct result of homelessness is peripheral vascular disease.

      - Contagious diseases, such as tuberculosis and HIV infection are more common among homeless people than in the general population.

      - One out of every ten homeless clinic patients have been found to have poor dental health, a rate thirty-one times that found in the general population.

      - About one-third of homeless people residing in shelters had significant mental illnesses.

      - About two-thirds of the problems homeless people present to primary health care sites are acute in nature (Wright).

      - The other third of the physical health problems of homeless people are chronic problems such as hypertension, diabetes, gastrointestinal problems, neurological disorders, chronic obstructive pulmonary disease, arthritis and other musculoskeletal problems (Wright).

      - Less than 2/5 (38%) of people seeking primary health care from health care for the homeless programs are alcohol abusers and 13% abused other drugs (Wright).

  • Minnesota

    - Over 2/5 (44%) of homeless people reported at least one chronic health problem. Asthma and high blood pressure where the two most frequently reported.

    - Over 1/3 (34%) of homeless adults consider themselves alcoholic or chemically dependent.

    - 1/3 of homeless adults reported they often felt confused, had trouble remembering things, or had problems making decisions, to the point that it interfered with daily  activities.

  • Boston, Massachusetts

According to a study on the causes of death in homeless adults in Boston, Massachusetts (1997)[18], the researchers found that:

     - Death occurred at an average age of 47 years

     - AIDS caused the most deaths in person who were 24 to 44 years of age.

     - Heart disease and cancer were the major causes of death in persons who were 45 to 64 years of age.

     - For men 25 to 44 years of age, the rate of death from heart disease was more than threefold higher than in the general population. 

 

 

 

Past Policy  key legislation and milestones including significant policy and funding shifts, major studies, etc.


  • The McKinney-Vento Homeless Assistance Act

    The Stewart B. McKinney Homeless Assistance Act (later renamed the McKinney-Vento Homeless Assistance Act) was the first major federal legislation enacted to address homelessness in the US[19]. Signed into law by President Ronald Reagan on July 22, 1987, the Homeless Assistance Act consisted of 15 programs providing a range of services to homeless people including emergency shelter, transitional housing, permanent housing, job training, primary health care and education[20].In 1985, the Robert Wood Johnson and the Pew Charitable Trusts established the Health Care for the Homeless Program. In 1987, the McKinney-Vento Homeless Assistance Act replicated the Health Care for the Homeless Program and now close to 143 Health Care for the Homeless projects are funded in part by the US Public Health Service[21]

 

Current Policy  summary of current policies in the form of legislation, programs, and funding


  • The McKinney-Vento Homeless Assistance Act

    The McKinney-Vento Homeless Assistance Act remains the only federal legislation designed to address homelessness in the US. On April 2, 2009, reauthorization bills for the Act were introduced in both the House and the Senate. In the House, Representative Gwen Moore (D-WI) introduced the Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act. In the Senate, a companion bill was introduced by Senator Jack Reed (D-WI). The HEARTH was enacted on May 20, 2009 as part of the Helping Families Save Their Homes Act[22].

 

Key Organizations/Individuals   contacts for public and private organizations and key individuals


 

Bibliography   web sites, reports, articles, and other reference material 


 

 

 

Footnotes

  1. European Federation of National Organisations working with the Homeless. "Meeting the Health Needs of Homeless People." http://www.feantsa.org/files/Health%20and%20Social%20Protection/FINAL%20meeting%20the%20health%20needs%20of%20homeless%20people.pdf
  2. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  3. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  4. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  5. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  6. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  7. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  8. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  9. Amherst H. Wilder Foundation. "Overview of Homelessness in Minnesota 2006." http://www.wilder.org/fileadmin/user_upload/research/homelessoverview2006_3-07.pdf
  10. The Urban Institute. "A New Look at Homelessness in America." http://www.urban.org/publications/9000302.html
  11. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. "Balancing Act: Clinical Practices that Respond to the Needs of Homeless People." http://aspe.hhs.gov/homeless/symposium/8-clinical.htm
  12. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  13. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  14. Neibacher, Susan. United Hospital Fund of New York. "Homeless People and Health Care: An Unrelenting Challenge." http://www.careforthehomeless.org/policy/pdfs/an_unrelenting_challenge.pdf
  15. Health Resources and Services Administration. "The Health Center Program: Special Populations." http://bphc.hrsa.gov/about/specialpopulations.htm
  16. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  17. McMurray-Avila, Marsha, Gelberg, Lillian, and Breakey William. “Balancing Act: clinical Practices that Respond to the Needs of Homeless People.” http://aspe.hhs.gov/homeless/symposium/8-Clinical.htm
  18. Hwang, Stephen, Orav, John, O'connell, James, Lebow, Joan, and Brennan Troyen. "Causes of Death in Homeless Adults in Boston." Annals of Internal Medicine 126 (April): 625-628.
  19. U.S. Department of Housing and Urban Development. "McKinney-Vento Act." http://www.hud.gov/offices/cpd/homeless/lawsandregs/mckv.cfm
  20. National Coalition for the Homeless. "HUD McKinney-Vento Reauthorization." http://www.nationalhomeless.org/factsheets/2009policy/hmv.pdf
  21. National Health Care for the Homeless Council. "The Basics of Homelessness." http://www.nhchc.org/Publications/basics_of_homelessness.html
  22. National Coalition for the Homeless. "HUD McKinney-Vento Reauthorization." http://www.nationalhomeless.org/factsheets/2009Policy/HMV.pdf

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