Homelessness is a Healthcare Problem

Homelessness and healthcare feed off each other. About 100 million Americans have some form of medical debt, with about one in five reporting such debt has forced them to change their living circumstances, including ending up homeless. According to the annual 2024 Point-In-Time Report of Homelessness, at least 770,000 people are unhoused in the U.S. It's widely agreed that this finding underestimates people experiencing homelessness who are not directly observed or have temporary shelter with friends or family.

We know that visits to the ER by those who are unhoused are much higher than for the rest of the population—and the rate increases every year. A third of ER visits are made by people experiencing chronic homelessness. While job loss also exacerbates homelessness, the underlying cause of unemployment is often illness or injury, which loops into medical debt to complete the healthcare circle of dysfunction. In Dallas and Collins Count, TX, for example, it cost nearly $200 million in 2023 for medical care, emergency shelter, and jail for the 4,410 people who were identified as homeless. This comes out to about $45,000 per person.?

While I’d like to be wrong about this, I don’t expect this complex problem to be a priority for the new administration. Instead, with their commitment to shrinking government and spending, I predict that the root causes of homelessness, including lack of healthcare, will become more acute over the next four years (I hope I’m wrong).?

Solutions will likely fall to nonprofits, states, and hospitals. Several health systems have already launched such programs. A few examples include:?

Health systems are finding it’s less costly to help unhoused patients with affordable places to live and social support. In New Jersey, St. Joseph’s Health financed the development of 56 units of affordable housing on land that the hospital owned. In New Orleans, the managed care organization Aetna invested $26.7 million in a 192-unit affordable housing complex. In Toronto, where many people are experiencing homelessness, the University Health Network partnered with the city to build 51 units of affordable housing on a parking lot it owned. And Kaiser Permanente has committed $400 million to creating or preserving 30,000 affordable housing units in parts of California, where the homeless population is the country’s highest, by 2030.

In Richmond, VA, The Society of St. Vincent de Paul (SVDP) launched a new program, Motel 2 Home, to keep at-risk families out of homelessness. My long-time mentor and collaborator, J. Stephen Lindsey, FACHE, a successful hospital CEO and healthcare entrepreneur, serves on the board of SVDP's innovative program. While he is quick to tell me that the program’s executive director, staff, and volunteers are the face of the program with the working poor, Steve focuses on one of the most challenging aspects of any charitable outreach—grant and donation fundraising. The typical profile of those they assist and guide is a family living in a short-term hotel or couch surfing with friends to keep off the streets. For families who qualify, SVDP provides a wide range of support. This includes moving costs, a security deposit, and the first month's rent for an apartment. They also repair cars vital for travel to work, clear previous eviction debt, and help with furniture. To be eligible for the program, individuals or families must have lived in a motel for more than 30 days, be employed, have reliable transportation, and not spend more than 40% of their income on housing. It costs up to $4,500 to help an at-risk family get into an apartment. SVPD also works with the family for a year as an advisor to develop skills such as household budgeting.?

Over the last five years, Republican and Democratic legislators and governors in a slew of states have looked to tinker with zoning and building codes to produce more affordable housing. Some states that have stepped up include Oregon, Florida, Montana, California, Utah, and Washington. Last year, Maryland, New York, and New Jersey passed state-level housing legislation, and Colorado may soon follow suit. However, it can be three to five years before such legislative action produces more affordable housing.?

Another harsh reality in the homeless universe is that up to 40% suffer from a mental illness, and 30% have substance abuse problems. Given that less than a quarter of people suffering from these illnesses receive treatment, healthcare leaders have their work cut out. Homelessness has been increasing since 2017, with an 18% jump from 2023 to 2024. Hospitals, federally qualified health clinics, and other providers will pay for this escalating problem one way or another. The challenge will be more difficult if federal policy becomes punitive towards this population.

John W. Mitchell, MS, blogs at https://snowpackpr.com/blog