Chronic Houselessness in the United States
Health Outcomes, Care Delivery, and the Programs that Bridge the Gap
In January 2022, around 127,768 individuals - nearly one-third of those experiencing houselessness overall - across the United States were “chronically unhoused”, an increase from 110,000 individuals in 2020. The U.S. Department of Housing and Urban Development (HUD) defines “chronically unhoused” as those who have been experiencing houselessness for at least a year while also struggling with a disabling condition, including mental illness, substance use disorders, or physical disabilities. This lack of stability in housing and subsequent lack of access to care is a known risk factor for communicable and non-communicable diseases, chronic diseases, traumatic injuries, and mental disorders. The average life expectancy of an unhoused individual is around 50 years of age, partially attributable to barriers in the accessibility and affordability of care for chronically unhoused individuals stemming from a lack of insurance, lack of transportation, and high costs.
The Impact of Chronic Houselessness on Health Outcomes and Care Delivery
The chronically unhoused population has proven more vulnerable to both chronic and acute ailments than their housed counterparts. The number of chronically unhoused individuals living with diabetes, hypertension, chronic illness, and HIV/AIDS is nearly double that of the general population. Communicable diseases such as tuberculosis, hepatitis C, and COVID-19 also have the propensity for spreading rapidly in unhoused communities and shelters due to a lack of hygiene and poor ventilation. Additionally, unhoused individuals, especially women, are at a higher risk of violent crimes such as rape, assault, and robbery, which can lead to physical and psychological injuries. There is also a higher prevalence of mental disease amongst chronically unhoused individuals - 25 percent of those who are unhoused are diagnosed with a serious mental disorder like bipolar disorder or schizophrenia, compared to only 5.6 percent in the general population.
In addition to increased susceptibility, an unhoused individual’s ability to seek and comply with treatment is greatly hindered by the circumstances surrounding houselessness. Primary care models for treating domiciled patients are difficult to apply to chronically unhoused patients as they are less likely to be able to access primary and preventive services due to a lack of transportation and insurance. As a result, unhoused individuals utilize emergency room care as their de facto source of medical treatment at a rate almost three times higher than that of the general population. However, these visits do not generally lead to appropriate follow-up or sustainable care following discharge, leading to gaps in care and the insufficient management of diseases.
Current Support Programs
The federal government established several programs that aim to support individuals experiencing houselessness and who are struggling with a mental and/or physical health condition. The Projects for Assistance in Transition from Homelessness (PATH) program, one of many Substance Abuse and Mental Health Services Administration (SAMHSA) programs, funds services for unhoused individuals with serious mental illness and connects them to providers and care. The Community Health Center (CHC) Program, managed by HHS, comprises health centers that provide primary care to individuals regardless of their ability to pay. Health Care for the Homeless Programs embedded within a number of CHCs specifically aid chronically unhoused patients by connecting their medical care with other vital social services including case management and housing assistance. In October 2022, the MOBILE Health Care Act was signed into law, providing funding to CHCs to establish mobile health clinics, an evidence-based method for increasing accessibility. These mobile clinics bring the same low-cost healthcare services to areas where transportation to a fixed-site CHC may not be feasible for many unhoused patients. Further development of resources like this with an emphasis on accessibility in the future will be necessary to provide quality and continuous care to chronically unhoused populations.