Do No Harm: Homelessness and the Resultant Barriers to Adequate Healthcare

By Jake Schwartz, AmeriCorps VISTA Program Coordinator 

    The state of the healthcare system in the United States has long been the subject of intense debate - and oftentimes heavy criticism - for the perceived shortcomings of various aspects of healthcare that fail to adequately support patients. Among the most glaring issues within U.S. healthcare are the existing financial barriers for both primary care and emergency care, the variability of treatment outcomes across different socioeconomic levels, races, and genders, and the current lack of more accessible, non-traditional methods of receiving healthcare. While each of these facets can result in hardship for people from any walk of life, these negative effects are felt at a much greater intensity for those who face homelessness. When examining U.S. healthcare from a broad point of view, it becomes clear that these aforementioned issues - cost of care, treatment outcomes, lack of accessibility - serve to further the hardships of people who face homelessness. 

    When discussing the intersection of homelessness and healthcare, a good place to focus would be our nation’s waiting rooms. Primary care exists as a proactive measure to maintain good health in a variety of ways: routine check-ups to catch potential issues before they grow into larger problems, the ability to discuss possible concerns with a trusted professional, and overall maintenance for those with chronic conditions that require close management. These are all essential to one’s health, yet it remains incredibly difficult for those facing homelessness to access this kind of care. Even for those who are able to easily access healthcare, the ways in which this system is set up often lead to confusion and headache for those who simply want to seek some form of treatment. Between understanding the types of health insurance, eligibility for health insurance, co-pays, deductibles, out-of-pocket costs, and in- and out-of-network providers, there exists far too much complicated (and potentially expensive!) red tape that often prevents homeless patients from ever receiving any level of primary medical care (Gallardo et al., 2020). 

    The issues with the primary care system also occur in both directions: they close doors for those who seek out healthcare while also actively shutting the door on current patients who are in danger of facing homelessness. Widespread reviews of nationwide hospital procedures and patient outcomes demonstrate that many hospitals/clinics fail at correctly screening their patients for high risk of future homelessness and/or fail to act on the knowledge that a patient is actively facing housing instability (Fargo et al., 2017). Further research done on the ease of access to primary healthcare depicts a similarly worrying trend of preventative medicine being limited to those who are without any form of instability in housing, employment, or nutrition (Currie et al., 2023). 

    While the conversation of primary care revolves around what isn’t happening but what should be, the dialogue around emergency care concerns what is happening but what shouldn’t be. Due to the aforementioned issues with the primary care system, we understand now that there are scores of people who are in need of healthcare but often can’t receive it. What ends up happening in these situations is that in lieu of a doctor’s appointment, those without healthcare end up relying heavily on immediate/emergency care facilities, even for issues that may or may not even fall under the severity of actual emergencies (Vohra et al., 2022). This over-reliance on emergency departments for otherwise routine care sets off a chain of events that serve to harm both the facilities and, more importantly, the patients themselves. Higher use of emergency departments leads to less available bed-space to be used, requiring medical personnel to be increasingly strict in their triage and treatment decisions. 

    Additionally, those who face homelessness are far more likely than the average patient to be prematurely discharged, which results in lower overall general health and higher rates of readmission to emergency rooms (Jenkinson et al., 2020). These disparities are further intensified when understanding that those who face homelessness are most often those who tend to over-utilize emergency rooms (known pejoratively as “frequent-flyers”). As a result of being affixed this label of being “frequent flyers”, these patients report higher instances of being denied pain medication, being denied treatment, being discharged far too early, and struggling to be taken seriously by hospital staff (Moulin et al., 2018). 

    After reviewing the state of both primary and emergency care in a traditional healthcare setting, it begs the question of, what other alternative opportunities are available? One form of healthcare that has begun to spread across the country is street/community medicine, in which small groups of nurses and/or doctors set up small booths or work out of the back of a vehicle as a mobile clinic, in order to help provide services such as check-ups or vaccinations for populations that otherwise would not be able to get medical care. The benefits of such a system are clear to see: people facing homelessness who have access to some form of healthcare - whether it be through traditional institutions or community-based services - demonstrate far less instances of sickness, have higher rates of vaccinations, have far lower instances of mental illness, and self-report far lower instances of health-related anxiety and depression than those who do not have access to healthcare (Mares & Rosenheck, 2011). Whether it be from a comprehensive overhaul of existing healthcare structures in the United States or from a wider expansion of community-based medicine, or some combination of both avenues, it remains clear that there must be more work done at the institutional and provider level to better advocate for the health and well-being of our homeless population. 


Resources 
Care For Friends Chicago | 773.932.1010 

Chicago Street Medicine | https://www.chicagostreetmedicine.org/contact.html Heartland Health Outreach | https://nhchc.org/contact/

​References 
Currie, J., Stafford, A., Hutton, J., & Wood, L. (2023). Optimising Access to Healthcare for Patients Experiencing Homelessness in Hospital Emergency Departments. International Journal of Environmental Research and Public Health, 20(3), Article 3. https://doi.org/10.3390/ijerph20032424 

Fargo, J. D., Montgomery, A. E., Byrne, T., Brignone, E., Cusack, M., & Gundlapalli, A. V. (2017). Needles in a Haystack: Screening and Healthcare System Evidence for Homelessness. In Informatics for Health: Connected Citizen-Led Wellness and Population Health (pp. 574–578). IOS Press. https://doi.org/10.3233/978-1-61499-753-5-574 

Gallardo, K. R., Santa Maria, D., Narendorf, S., Markham, C. M., Swartz, M. D., & Batiste, C. M. (2020). Access to healthcare among youth experiencing homelessness: Perspectives from healthcare and social service providers. Children and Youth Services Review, 115, 105094. https://doi.org/10.1016/j.childyouth.2020.105094 

Jenkinson, J., Wheeler, A., Wong, C., & Pires, L. M. (2020). Hospital Discharge Planning for People Experiencing Homelessness Leaving Acute Care: A Neglected Issue. Healthcare Policy, 16(1), 14–21. https://doi.org/10.12927/hcpol.2020.26294 

Mares, A. S., & Rosenheck, R. A. (2011). A Comparison of Treatment Outcomes Among Chronically Homelessness Adults Receiving Comprehensive Housing and Health Care Services Versus Usual Local Care. Administration and Policy in Mental Health and Mental Health Services Research, 38(6), 459–475. https://doi.org/10.1007/s10488-011-0333-4 

Moulin, A., Evans, E. J., Xing, G., & Melnikow, J. (2018). Substance Use, Homelessness, Mental Illness and Medicaid Coverage: A Set-up for High Emergency Department Utilization. Western Journal of Emergency Medicine, 19(6), 902–906.   https://doi.org/10.5811/westjem.2018.9.38954

Vohra, N., Paudyal, V., & Price, M. J. (2022). Homelessness and the use of Emergency Department as a source of healthcare: A systematic review. International Journal of Emergency Medicine, 15(1), 32. https://doi.org/10.1186/s12245-022-00435-3