Being poor is bad for your health! At least that is what recent research shows. In last week’s post I noted this startling fact (quoting an article from Business Week dated January 04, 2010): “people whose household earnings are in the bottom one-third of the U.S. population, or up to twice the federal poverty level, lost 8.2 years of perfect health.” Further, it was noted that dropping out of high school, obesity, and smoking removed 5.1, 4.2, and 6.6 fewer years of perfect health respectively. In addition, according to a recent article in Bostonia (Winter-Spring 2011) if you are homeless, you are particularly endangered: “The average life expectancy of an urban homeless adult is 48 years, compared to 78 years for the rest of the population.”
To better define the problem I turn to a report on the health of New York City’s homeless population, issued in 2005 using data collected from 2001 – 2003. This report noted five main contributors to lower health standards among the city’s homeless: heart disease and cancer, poor discharge planning and outcome from hospitalization, substance abuse and mental health problems, increased rates and poor treatment of infectious diseases including HIV/AIDS, and exposure (The Health of Homeless Adults in New York City, New York City Departments of Health and Mental Hygiene and Homeless Services report (December 2005): 20-23).
Substance and alcohol use as well as mental illness accounted for 69% of hospitalizations among homeless adults, compared to 10% among non-homeless adults (p. 1). Also, “The average rates of TB and new HIV diagnoses were 11 and 16 times higher, respectively, among those who used the single adult shelter system than among the NYC adult population.” (p. 1) Homeless adults were hospitalized more often and for longer periods than non-homeless adults. Deaths of homeless individuals occurred at roughly twice the rate of non-homeless (p. 1). To add to all this, according to a brief issued by the National Coalition for the Homeless, “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.” (NCH Fact Sheet #8, National Coalition for the Homeless (June 2006): 1)
Poor health is a problem. What’s more, it’s an expensive problem. As stated by the National Health Care for Homeless Council,
Unacceptable costs result from poor access to health care. Because homeless people often are uninsured and lack access to low-cost preventive health care, they go without care until relatively minor problems become urgent medical emergencies. Ultimately, most homeless people do get treated, but it is treatment of the most expensive sort, delivered in hospital emergency rooms and acute care wards. Through taxpayer support of public institutions and through the cost-shifting inherent in the health insurance system, we all pay the high costs of care deferred. (“the Basics of Homelessness,” National Health Care for Homeless Council, http://www.nhchc.org/Publications/basics_of_homelessness.html, accessed March 26, 2011)
As stated in a previous posting, the chronically homeless usually account for 50 % of costs attributed to homelessness nationally, including hospital stays, and these costs are even higher here in Southeastern Connecticut, with a chronically homeless population roughly three to four times that of the national average.
There are many reasons for this. The National Health Care for Homeless Council notes in particular two problems for homelessness; “people who are homeless are more concerned with meeting immediate needs for shelter, food, clothing, and safety than with seeking health care.” And “for some, the symptoms of their illnesses or bad experiences with the health care system in their past cause them to actually avoid health care.” (the Basics of Homelessness) This, in turn, compounds a simple, easily solvable health concern, and leads to longer, more expensive hospital stays. In addition, homeless populations often lack adequate health care or insurance, which means that the bill falls back on the hospital and ultimately other patients and the insurance industry.
There are many causes to be sure, but a 2010 report issued by the Prevention Institute outlined several root factors contributing to health inequality among Americans, all of which boiled down to the communities which low income Americans live in; a result of “overt discriminatory actions on the part of government and the larger society, as well as to the present day practices and policies of public and private institutions that perpetuate a system of diminished opportunity for certain populations.” (“A Time of Opportunity: Local Solutions to Reduce Inequities in Health and Safety,” Prevention Institute Brief Report (April 2010): 1) This discrimination is not against any ethnic group, but against lower income populations in general, which often lack access to quality health care, employment, education, and other opportunities, some of which have been outlined in prior blog posts.
So what can we do about this health care crisis among the homeless? Well, it can be said that we have already begun to solve the problem. First off, organizations like L & M or Backus Memorial Hospitals have a system of charitable care built into their system. These are, however, limited by gifts and donations and do not completely answer the costs associated with health care among the uninsured. Connecticut has made headway in answering the lack of insurance,with programs like HUSKY insuring children and Medicaid Low Income Adult and Title 19 helping many who cannot afford insurance. Finally, community health centers all over the state are bringing routine care to low income individuals and families.
While these programs are working to make health care more available, they don’t answer the root problems. There is still an gap in health care quality, and the poorest among us, the homeless, are still bogged down with immediate concerns, and are unable or unwilling to receive help for even the smallest of problems. An important step in solving this last problem is housing: provide low income housing, along with intensive case management, to the homeless (Cf. this post for more on housing). As a study published in the Archive of General Psychiatry shows, housing the homeless significantly reduces the costs associated with homelessness, including medical costs:
Participation in Housing First was associated with substantial increases in outpatient visits and declines in use of inpatient and emergency services. Reductions in inpatient and emergency service costs partially offset the increased outpatient and housing costs. (“Effect of Full-Service Partnerships on Homelessness, Use and Costs of Mental Health Services, and Quality of Life Among Adults With Serious Mental Illness,” Archive of General Psychiatry Vol. 60, No. 6 (June 2010): 7-8.)
In addition, affecting change in the communities is important to solving these problems. As summed up in the Prevention Institute brief quoted above (p. 3-4), strengthening the communities where people work and supporting community efforts to raise the quality of healthcare are integral to solving the roots of healthcare inequality. Solving the problems associated with homelessness can be found in the community and relies on active engagement and support from the community we live in.