The Homeless & Health Care

*I was truly impressed by the compassion demonstrated towards the homeless in excerpts of an interview with National Health Care for the Homeless Council advocates. This article offers a lot to think about; for too often people take a simplistic, stereotypical approach in assessing and addressing the homeless. Just what would Jesus do today? Step over homeless people lying in the alleyways, so He could quickly pick up a cappuccino at a nearby Starbucks? No. He would help those lying down in the alleyways and pull them up to their feet. The homeless are real people: they cry, they dream and they hurt.

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Homeless Often Overlooked In Health-care Reform Debate
from. TennesseanT.com

The debate continues in Congress and across the country over health-care reform, but one group of people who have a lot of interest in the issue but are often overlooked are the homeless.

Advocates for the homeless say these individuals face complex health problems, are generally sicker and die earlier than their housed counterparts. Advocates also say the homeless are the most frequent and expensive users of emergency room and inpatient hospital care and are much less likely than those in the general population to be insured.

"It is imperative that health reform address the complex needs and life circumstances of people experiencing homelessness," officials with the National Health Care for the Homeless Council recently said in a press statement. "Failing to do so will continue the current cycle of high-cost hospitalizations, unemployment, disability and homelessness."

Last week, the governing membership of the National Health Care for the Homeless Council met in Nashville. Tennessean editorial page editor Dwight Lewis sat down with some of them to discuss the issues.

Here are excerpts from that meeting with Marion Scott of Houston, president of the council; Barbara DiPietro of Baltimore, policy director; and Bobby Hansford of Houston, eligibility coordinator.

Who makes up the homeless?

Scott: I think the face of the homeless is reflective of society as a whole. I think that everyone now is homeless, and many of us are one paycheck away from being homeless.

I don’t think anybody is on the streets because they really want to be. ... It’s hard to find a job when you live under a bridge and there’s no clock and there’s no way to clean up in the morning or to maintain your hygiene.

DiPietro: When you look at the combining factors of increasing unemployment, loss of health insurance because of that, the foreclosure issue, you’re seeing housing, income and health care come together in a way that creates a lot of crisis for people, and this is all income levels.

One of the emerging populations we’re seeing is people who have no idea how to navigate the shelters, how to navigate social services. It’s a complex system that we’ve created that really requires high literacy, high education and a great deal of organizational skills to be able to get what you need to bring it back together. And I think that needs to be appreciated across middle-income groups, as well.

Hansford: There are several barriers that stop homeless individuals from getting back into society. For instance, we have a mobile dental unit in Houston, and one of the things they tell us is that once they receive the services it boosts their self-esteem so much to where before the service they would be embarrassed to go on job interviews or go speak to someone about a job to get back into society.

Going through programs where it will boost self-esteem, where you can get dental work done or improve your health situation, it’s a plus. It’s something I think would help homeless individuals get back into productive society.

Why should those of us who have homes or are fairly well off or are well off care about the homeless and health care?

Scott: I think it’s our obligation to assist and to help those who are, for the lack of a better word, not at an economic level where some of us are.

With the economic crisis there are a lot of people who were at that economic level we talked about earlier who are now homeless. So you never know, it may be you tomorrow.

DiPietro: In addition to it simply being the right thing to do, caring about your community, caring about your fellow neighbor ... there are cost implications as well. We’ve created a system where it is easy to fall into homelessness, and we make it difficult to get out of homelessness.

We arrest people for sleeping in a public space or loitering or all of the things that come along with that, that creates cost in our court system, it creates backlogs in our court system, it takes up time with our police when we generally rather they focus on more serious crimes.

There are cost implications with our health services, emergency departments are absolutely overcrowded, largely due to people who don’t have insurance, sometimes homeless, sometimes not. But it all comes together to create a service use that is not productive.

In fact, it’s counterproductive for the greater community and for the individual. It’s so much better to be able to focus on providing a safety net that actually is meaningful, that prevents homelessness. Homelessness, when it does occur, can be brief, so that people can get back on their feet fairly quickly. Ultimately, as a community, don’t we want people to be as productive as they can?

I was reading where the average life expectancy for a homeless person is 50 years of age, why is that and what type of health problems do we see mostly among the homeless?

Scott: The problems are reflective of society as a whole. A study of the literature will reveal that the chronic diseases may be more prevalent, diseases such as hypertension, diabetes, dermatological problems, those things may be more prevalent.

I think the thing that really impacts homeless individuals is their access to care. One thing that is very important is that the availability of health care does not mean that it is accessible. I always go back to the movie Field of Dreams, where they say, “If you build it, they will come.” Well, for the homeless, if you build it, they may not be able to get there.

DiPietro: I would emphasize, too, that behavioral health issues, like mental health issues, and serious mental illness among individuals experiencing homelessness is much higher. There’s certainly connections on why that would be. When you do have serious mental illness it is much more difficult to maintain your own independent housing. Substance abuse issues also figure highly. . . .

When you are living on the street it is difficult to maintain your health. If you are diabetic, where do you keep your insulin? If you are HIV-positive, how you do maintain a medication regime, particularly one that requires refrigeration for your medications? How is it that you maintain a diabetic diet when you’re eating out of soup kitchens, which primarily are serving very starchy casseroles and sandwiches and white processed bread and things like that?

There’s not a lot of access to clean, sterile facilities. If you’re out and you’re walking about a lot, foot issues can be worse, particularly if you’re diabetic, easily infected and once you get an infection, it all builds on itself.

And that’s where you see the in and out of the emergency rooms. We don’t have a system that is able to comprehensively care for people’s health. . . .

It is stressful trying to find out where you are going to lay your head every day, where you are going to eat. Sometimes people only get one meal a day. The fear that you have of even closing your eyes for 15 minutes. What if someone comes upon me and beats me with a bat? That’s real reality for people sleeping on the street.

And victimization is a real reality, particularly for women when they’re on the street. And so all of this stress, all of these realities and the risk that come from being exposed contribute to mental health issues, even when none existed before, contribute to a worsening of existing health conditions and it creates new health conditions that weren’t there prior to the homelessness.

Are most cities failing or doing a good job when it comes to addressing the health needs of the homeless? What needs to be done? What do you recommend?

Scott: I believe a model for the Health Care for the Homeless program, and there are 105 of them around the nation, is to actively engage and enable homeless individuals to access available services. (They) actually provide realistic approaches. For example, those providers understand that, say, when you are trying to lose weight to have surgery, you just can’t say just get on a diet and you need to have fresh vegetables and fish and chicken. They understand that these are not available, so what they do is work with individuals to come up with an appropriate plan to help them improve their health status and maintain it.

They do outreach to meet clients where they are. That means whatever their living situation is, we have to understand that level of functioning and then we start to implement treatment plans. In the traditional setting, most plans, whether they’re health care, mental health, etc., build upon the premise that food, clothing and shelter are available. The medication needs to be refrigerated. We have clocks to take our medicine but homeless providers actually understand that’s not the case and understand that plans to improve access to available services have to be realistic and start where homeless people are.

DiPietro: The number one thing that we can do in this country and in every community is to support comprehensive health-care reform at the national level. That is the key. Seventy percent of our clients are uninsured. And it is a myth, and people believe it, unfortunately that just because you are poor you qualify for Medicaid. That is simply not the fact.

The Medicaid expansions that are proposed in the three bills in Congress right now, that is the number one piece that is really going to get the access points. Right now our clinics work on grants from government for the most part and they rely on private fundraising. That’s not sustainable and it’s not really a good way of financing health care. Getting access to Medicaid and comprehensive services that come along with that, not only gives the financing mechanism to the clinics so they can actually bill for their services, but at the same time give clients access to the care that they need.

There’s 10 million people who would be newly eligible for Medicaid should that expansion go forward. That’s 10 million people who would have access to health care that currently don’t. It would encompass more than just the homeless. This is all low-income people, below about $14,000 a year for an individual. That is critical.

What if nothing passes when it comes to health-care reform? What happens to the homeless?

DiPietro: It will definitely get worse. It gets worse for everyone. It’s not about isolating the homeless from greater mainstream, because that’s disingenuous as well. This is about everybody. This is about all of our health. The United States is the wealthiest country in the world and yet we rank number 37th in the World Health Organization on our health system. That’s embarrassing, frankly.

And we pay more. We pay 40 percent more for our health care per capita than the next-most-expensive health-care system. That’s ludicrous. We are paying for universal health care but we are not getting universal health care. And everyone should be angry about that. Angry about where that money goes.

It is stressful trying to find out where you are going to lay your head every day, where you are going to eat. Sometimes people only get one meal a day. The fear that you have of even closing your eyes for 15 minutes. What if someone comes upon me and beats me with a bat? That’s real reality for people sleeping on the street.

And victimization is a real reality, particularly for women when they’re on the street. And so all of this stress, all of these realities and the risk that come from being exposed contribute to mental health issues, even when none existed before, contribute to a worsening of existing health conditions and it creates new health conditions that weren’t there prior to the homelessness.

Are most cities failing or doing a good job when it comes to addressing the health needs of the homeless? What needs to be done? What do you recommend?

Scott: I believe a model for the Health Care for the Homeless program, and there are 105 of them around the nation, is to actively engage and enable homeless individuals to access available services. (They) actually provide realistic approaches. For example, those providers understand that, say, when you are trying to lose weight to have surgery, you just can’t say just get on a diet and you need to have fresh vegetables and fish and chicken. They understand that these are not available, so what they do is work with individuals to come up with an appropriate plan to help them improve their health status and maintain it.

They do outreach to meet clients where they are. That means whatever their living situation is, we have to understand that level of functioning and then we start to implement treatment plans. In the traditional setting, most plans, whether they’re health care, mental health, etc., build upon the premise that food, clothing and shelter are available. The medication needs to be refrigerated. We have clocks to take our medicine but homeless providers actually understand that’s not the case and understand that plans to improve access to available services have to be realistic and start where homeless people are.

DiPietro: The number one thing that we can do in this country and in every community is to support comprehensive health-care reform at the national level. That is the key. Seventy percent of our clients are uninsured. And it is a myth, and people believe it, unfortunately that just because you are poor you qualify for Medicaid. That is simply not the fact.

The Medicaid expansions that are proposed in the three bills in Congress right now, that is the number one piece that is really going to get the access points. Right now our clinics work on grants from government for the most part and they rely on private fundraising. That’s not sustainable and it’s not really a good way of financing health care. Getting access to Medicaid and comprehensive services that come along with that, not only gives the financing mechanism to the clinics so they can actually bill for their services, but at the same time give clients access to the care that they need.

There’s 10 million people who would be newly eligible for Medicaid should that expansion go forward. That’s 10 million people who would have access to health care that currently don’t. It would encompass more than just the homeless. This is all low-income people, below about $14,000 a year for an individual. That is critical.


What if nothing passes when it comes to health-care reform? What happens to the homeless?

DiPietro: It will definitely get worse. It gets worse for everyone. It’s not about isolating the homeless from greater mainstream, because that’s disingenuous as well. This is about everybody. This is about all of our health. The United States is the wealthiest country in the world and yet we rank number 37th in the World Health Organization on our health system. That’s embarrassing, frankly.

And we pay more. We pay 40 percent more for our health care per capita than the next-most-expensive health-care system. That’s ludicrous. We are paying for universal health care but we are not getting universal health care. And everyone should be angry about that. Angry about where that money goes.