Homelessness in the United States: History, Epidemiology, Health Issues, Women, and Public Policy

Martin Donohoe, MD, FACP

Disclosures

July 07, 2004

In This Article

Introduction

This article discusses the recent history and current etiologies of homelessness in the United States, presents information regarding homeless persons and their health problems, and describes steps healthcare providers can take to care for homeless patients and to try to overcome the social problem of homelessness. Although most issues relevant to homelessness affect both men and women, homeless women's unique circumstances and health problems will be emphasized when relevant.

The United States is a signatory to the Universal Declaration of Human Rights. Article 25(1) of this document states: "Everyone has the right to ... food, clothing, housing and medical care and necessary social services." [emphasis mine].[1] The explicit nature of the nation's societal contract to meet the housing needs of its citizens is spelled out in the Housing Act of 1949, which stipulates the "realization as soon as feasible of the goal of a decent home ... for every American family."[2] In 1968, The Fair Housing Act made discrimination on the basis of race in the housing market illegal. Regrettably, neither the Universal Declaration nor these landmark laws have solved the problem of homelessness, nor of substandard housing and racial profiling by sellers and realtors.[3]

In the United States, de-institutionalization of the mentally ill -- unaccompanied by promised outpatient psychiatric and social services -- led to a large increase in the homeless, mentally ill population in the late 1970s. The number of homeless grew in the 1980s, as housing and social service cuts increased. This was in part a consequence of the transfer of federal dollars to a huge military buildup (including the spectacularly wasteful and unsuccessful "Star Wars" strategic missile defense initiative) and consequent large budget deficits. Fortunately, public compassion soared, and in 1986, 5 million Americans joined hands across the country to raise money for homeless programs (May 25, 1986 Hands Across America). In 1987, the McKinney Act authorized millions of dollars for housing and hunger relief.

Almost 20 years later, homelessness is largely ignored by the mainstream press and the general public, and the numbers affected continue to grow. Over 7% of persons living in the United States have been homeless (defined as sleeping in shelters, the street, abandoned buildings, cars, or bus and train stations) at some point in their lives.[4] Homelessness rates have increased over each of the past 2 decades. An estimated 2.5 to 3.5 million people now experience homelessness each year.[5,6] Approximately half are families with children, the fastest-growing segment of the homeless population.[5,6] In 1 study,[7] youth had a 1-year rate of homelessness of at least 1 night of 7.6%.

Although 20% of homeless persons maintain full- or part-time jobs,[8] only 5% are privately insured, often through COBRA.[9] The majority of homeless adults are not eligible for Medicaid in most States, and are also not eligible for Medicare. Approximately 23% of homeless persons (and from 3.1 % to 4.4 % of homeless women) are veterans of the armed services, yet only 57% have received healthcare services through the VA system, where long waits for care exist.[10]

Because they usually lack health insurance, homeless persons tend not to get adequate preventive care and appropriate routine management of such chronic illnesses as hypertension, heart disease, diabetes, and emphysema. They tend to visit emergency rooms for acute illnesses.[11] Besides lack of health insurance, other barriers to care include denial of health problems; the pressure to fulfill competing nonfinancial needs, such as those for food, clothing, and temporary shelter; and misconceptions, prejudices, and frustrations on the part of health professionals.[12] When hospitalized, the average length of stay of a homeless individual, in 1 study,[13] was 4.1 days, or 36% longer than that of low-income, non-homeless individuals, even after adjustment for differences in the rates of substance abuse and mental illness and other clinical and demographic characteristics. The cost of the additional hospital days per discharge ranged from $2414 to $4094 (1992-1993 dollars).

Homeless adults have an age-adjusted mortality rate nearly 4 times that of the general population; their average life span is shorter than 45 years.[14] Homeless women 18 to 44 years of age are between 5 and 31 times more likely to die than women in the general population.[15] Homeless women older than age 44 are only 1 to 2 times as likely to die, and are healthier than their male counterparts.[15] However, homeless women in their mid-fifties are as physiologically aged as housed women in their seventies and are afflicted to a similar degree with chronic diseases, yet they do not qualify for elderly housing assistance.[8]

Homeless women are more likely than homeless men to have experienced childhood sexual abuse and/or foster care and adult partner abuse.[16] More than 50% of all homeless women and children become homeless as a direct result of fleeing domestic violence.[17] The availability of domestic violence shelter beds in the United States is poor; up to 70% to 80% of women, and 80% of children, are turned away on any given night in major cities.[17] Shelters are woefully underfunded; some do not allow children. Average length of stay at a US shelter is 14 days; most allow a 30-day maximum stay.[17] Ironically, women fleeing domestic violence are often not counted in studies of homelessness, since they are considered to have a home (albeit unlivable) or are staying temporarily in shelters.

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