A recent University of California study titled Health Conditions Among Unsheltered Adults in the U.S. brings into focus public policy blind spots that make progress challenging for clinicians and other professionals working to end homelessness. Personally, the study’s findings evoke a question that preoccupied me during my tenure as director of a 10-agency health care network treating over 21,000 unduplicated homeless individuals per year: Why do policy debates about homelessness pay such scant attention to significant health needs that both precipitate the loss of housing and create daunting obstacles to regaining stability after an individual or family has become homeless?
I felt moved to reflect more deeply on many of our homeless patients’ stories after reading both the study and articles about the Trump administration’s anticipated plans to push local and state governments to limit services that the administration views as “accommodating” or “enabling” and instead sweep people sleeping outside into remote, mass shelters. More specifically, I felt inspired to explore the profound dissonance between these stories and the solutions to homelessness proposed by both the Trump administration and within the State Senate in my home state of Washington. In this blogpost I apply a Public Health lens to uncovering some of the reasons for this dissonance and pointing to policy approaches that my experience tells me will work much better.
I’ll start with the University of California study’s findings. The highlights include:
- Health and behavioral healthcare needs are significant contributing factors in loss of housing
- Significant numbers of both unsheltered and sheltered people reported that abuse and trauma led to a loss of housing—46% and 34% respectively (Those numbers are even more pronounced among women)
- 50% of unsheltered people reported that they suffer from a combination of a physical health condition, a mental health issue, and a substance use condition
- Whether unsheltered or sheltered, people report worsening health conditions the longer they are homeless.
These findings clearly align with dozens of patient stories I can recall, and also with the results a 2018 survey of over 1,000 people living homeless—both sheltered and unsheltered– in Seattle and King County. The survey found that
- Over half (53%) identified at least one health condition that “prevented them from holding employment, living in stable housing, or taking care of themselves” and 33% of this subset indicated living with multiple disabling conditions
- 44% reported psychiatric or emotional conditions
- 37% reported posttraumatic stress disorder (PTSD)
- 26% reported a physical disability.
Interestingly, and contrary to popular theories that people living homeless migrate to service-rich communities and don’t want to work, the survey also found that 83% were living in King County when they lost housing, 53% had either grown up in King County or had moved from elsewhere more than 10 years before they were surveyed, and 50% had received payment for work during the past year.
The Seattle-King County survey result that stood out most starkly to me, though, was that only 19% of respondents were currently accessing health services. Given the prevalence of self-reported serious health conditions, the fact that so many people experiencing homelessness fall through gaps in Seattle’s robust community health care safety net is sobering.
The national literature around the health needs of the homeless population demonstrates that the Seattle area is not an outlier in this regard, however, and that healthcare access barriers are in fact systemic. Some examples:
- The homeless population has been shown to have an overall mortality rate significantly higher than the general population and the life expectancy of people living homeless is approximately 30 years less than the general population.
- High rates of many common chronic health conditions and communicable diseases contribute to early mortality rates and frequently undermine hospital-based and shelter-based interventions.
- Chronic diseases particularly impact the chronically homeless population, which exhibits high rates of co-morbidity, i.e., two or more chronic conditions.
- Local Public Health and other government agencies often struggle to contain clusters of HIV and outbreaks of Hepatitis that disproportionately impact the unsheltered population.
- The homeless population is aging rapidly, and, as it does, many shelters and housing providers struggle to meet elder residents’ health needs such as memory loss and complications from advanced chronic disease.
- African Americans, Native Americans, and other People of Color disproportionately experience homelessness, poor health outcomes, and higher mortality from various chronic diseases.
Considered collectively, the data cited in the literature provide some helpful context for the 2013 statement by the Obama Administration that homelessness should be understood as a Public Health crisis. That statement in turn mirrors at least six official policy statements on homelessness by the American Public Health Association (APHA) since the 1980s.
Mountains of empirical evidence undergird such statements, yet analyses of homelessness frequently address this evidence only tangentially.
The Trump Administration’s root cause analysis, presented in a September 2019 Council of Economic Advisors report titled The State of Homelessness in America, provides a good example of this kind of shortcoming. In fairness, within its complicated exposition on policies and other factors that increase or decrease homelessness, the report does note that “research has shown that individuals with severe mental illness [and] substance abuse problems [along with] a history of incarceration, low incomes, and weak social ties are more likely to become homeless.” It also makes brief, oblique references to the administration’s “increased emphasis on serious mental health” as well as its “policies that have contributed to the first reduction in total drug overdose deaths in decades.” Yet, had the report’s authors focused directly on Public Health, it would have been impossible to have avoided at least some discussion of the broad spectrum of chronic diseases and physical disabilities, not solely the substance use and mental health conditions, that play an important role in the loss of housing. The report would also have addressed the many ways in which such conditions hamper the efforts of local governments, hospitals, community health care providers, and homeless services agencies to help people exit homelessness. Finally, it would likely have also addressed dramatic racial disparities in rates of homelessness, rates of mortality, and poor outcomes from common chronic diseases.
Unfortunately, after releasing its State of Homelessness report, the Trump Administration signaled upcoming initiatives that that may actually increase the difficulty of caring for homeless individuals with chronic medical and behavioral health conditions. The administration appears to be leaning on a prominent role for law enforcement, with a focus on shelters that sequester homeless people away from downtown in large, centralized facilities. Such an approach would closely mirror the past policy advocacy of Executive Director of the U.S. Interagency Council on Homelessness (USICH) Robert Marbut, the Trump Administration’s newly appointed point person on the issue. According to a 2015 Huffington Post article focusing on his consulting work, Dr. Marbut testified before the Daytona Beach, Florida City Commission that the city had been too accommodating to people living homeless. He suggested that the city “should discourage ‘goodies’ in the form of handouts from citizens and social services…and it should join forces with other nearby municipalities to change their habits of ‘enabling’ the poor.” Based on the model that he established for a shelter in San Antonio, eschewing “goodies” that “enable” people living homeless means denying critical services to people who, for example, cannot pass a substance use test.
A vision for how to end homelessness that a group Washington State Senate Republicans recently put forward aligns with the Marbut consultancy approach. As reported in Seattle’s Real Change newspaper, the Senators used this vision to introduce a series of bills, including one that “would make high-barrier shelter a requirement.” These shelters “would not have to involve buildings, would have to involve police security and some kinds of counseling, and would not allow people to use drugs or alcohol on site.” Another bill, dubbed the Blue Flag Law, “would put an involuntary hold on a person who ‘manifests self-neglect’ by failing to provide for food or hygiene, resulting in an ‘unpleasant aroma’ or other factors.” State Republican Senator Steve O’Ban, who introduced a bill that would allow a court-appointed resource executor (CARE) coordinator to make medical and personal decisions for a homeless person, defended the loss of personal autonomy that would result, saying:
“It’s time to think of these individuals as if they were our own children…If you had an adult child who was wandering the street and living exposed in an encampment, you would want someone to grab that child — who may be resisting help — to get them the treatment they need, that they must have, if they are going to live a healthy, long life.”
This policy vision treats “tough-love” shelters; stricter police enforcement of “relative homeless crimes,” as one Washington State Republican Senator calls them; and forced behavioral health treatment as the critical missing puzzle pieces for communities struggling with the growth of unsheltered populations.
Proposed models such as these that would effectively increase barriers to shelter and other services employ analyses of homelessness that ultimately rely on reductive “either-or” propositions that lack supporting empirical evidence. Examples of such propositions that I have heard during my career include:
- Either a person accepts a prescribed set of services offered at a certain site or they are “service-resistant” and should be denied help elsewhere
- Either a person will completely abstain from drugs or alcohol or they can’t (or don’t deserve to) exit homelessness
- Either a person finds housing or they should be warehoused inremotely locatedmass shelter.
These kinds of analyses ignore the insidious and pernicious impact of the state of homelessness, in and of itself, on the capacity of the people with the greatest vulnerabilities to gain traction within mainstream healthcare and social services programs. The story of one patient served by the Seattle-King County Health Care for the Homeless Network (HCHN) graphically illustrates this phenomenon:
“James” was a 50-year-old with a severely infected foot and lived in a tent in a suburb south of Seattle when he first visited a HCHN Mobile Medical Program van. He worked for a roofing contractor, had stepped on a nail at work, and had initially delayed going to the ER after his injury. The foot became infected, and he went to the ER and then to other clinics before visiting the van. Despite this care, however, the wound was not healing. The HCHN team postulated that a chronic substance use disorder, a mental health condition, and cognitive impairment, likely related to a previous traumatic brain injury, were all potentially interfering with his ability to take his antibiotics as prescribed. Moreover, his living situation made it extremely difficult to keep off his injured foot and keep it elevated as instructed. It also made it very difficult to maintain his wound dressings properly and keep the wound clean.
The HCHN physician referred James back to the ER, where he was told that the infection had reached the bone and that his foot would need to be amputated. Although he immediately left the hospital against medical advice, he continued working with his HCHN behavioral health case manager, who provided intensive support as well as a connection to outpatient wound care several times a week. Eventually this case manager helped James file for disability and secure a subsidized studio apartment not far from the hospital. Once housed and able to regularly access wound care, James’ condition began to stabilize. He avoided amputation and moved his focus to getting and staying sober.
This story, like others that I would share if space allowed, bolsters the argument made by Housing First advocates that a safe, decent home of one’s own provides the critical foundation for personal stability, improved health, and recovery. I would guess that most of us would find coping with a debilitating medical condition or staying engaged in substance use treatment while living homeless an overwhelming proposition. As the personal histories of our patients graphically illustrate, none of the needs of the people we pass sleeping on the sidewalk exists in a vacuum, just as the needs of people with stable housing don’t. In fact, the most common thread running through the homeless patient stories that I heard over the past 20 years is the knock-on effect wherein the loss of housing, chronic and/or acute health conditions, financial collapses related to job loss or a disability, and domestic issues related to family or relationship problems create a downward spiral into a day-to-day existence dominated by crisis management. Another common thread involves the challenge of fighting off the hopelessness one feels when caught in such a spiral.
A spot on the floor of a high-barrier shelter, especially a remotely located one, will not magically enable someone to pull themselves up by their bootstraps when they’re trying to manage multiple crises, particularly when some of these involve unmet significant health needs. Consider, for example, the need for transportation among people suffering from debilitating illnesses requiring regular trips to a hospital or specialist. If a community pushes a homeless cancer patient requiring chemotherapy to sleep at a mass shelter located nowhere near a hospital, how likely will it be that this patient will receive these critical medical services? The same problem holds for people living homeless with diabetes, schizophrenia, dementia, hepatitis, or HIV who receive care at centrally located specialist offices far from remotely located shelters.
Rather than focusing so intently on enforcement, a Public Health-oriented policy vision would directly address the challenges of maintaining a solid connection to much-needed outpatient healthcare, acknowledging that these challenges are part and parcel of living homeless, whether sheltered or not. In helping people whose complex chronic conditions put them at high risk for chronic homelessness and living unsheltered, the first step entails providing a safe, decent housing unit with supports specifically tailored and scaled to reduce barriers to accessing treatment. A critical companion step involves beefing up the capacity of community health care providers to bring services to the homeless and formerly homeless people who are the least able to consistently access office-based and appointment-based care, e.g., people with cognitive impairments, serious mental illness, or other debilitating conditions. Policy change is desperately needed in this area. For example, in almost all states Medicaid rules and reimbursement rates discourage community health care organizations from investing in place-based care at supportive housing buildings or other more accessible facilities. Rather than the “either-or” logic of enforcement-oriented models, we need a national policy paradigm that uses a “both-and” analytical framework, one of the hallmarks of good Public Health practice.
Unfortunately, the Trump Administration’s proposed FY 2021 budget strongly suggests that it intends to push in the opposite direction. For example, as the National Low Income Housing Alliance points out, the administration would drastically cut housing benefits that help millions of low-income seniors, people with disabilities, families with children, and other individuals afford their homes. By focusing primarily on real estate development regulations and their impact on the insufficient stock of affordable housing, the Trump administration’s State of Homelessness in America report provides a theory about homelessness that it can argue is consistent with such draconian cuts. Yet its analysis provides no path forward for communities struggling with the increasingly severe and complex health conditions for which shelters, encampment operators, and even some Housing First supportive housing agencies feel woefully ill equipped to address. The administration’s analysis, like the one informing the Washington State Senate proposals outlined above, simply chooses to skirt the question of how to help these service providers grapple with the constellations of chronic diseases and disabilities impacting many of their homeless and formerly homeless clients. Further, it ignores the ways that one health condition often conspires with another to increase the risk of complications and further debilitation, thus decreasing the client’s capacity to stay in shelters and engage with high-barrier services.
In addressing homelessness for Public Health Seattle-King County from 2008 to 2019, a period in which our region saw the number of people living outside skyrocket at an even faster pace that the number of people living homeless overall, I witnessed more progress in increasing shelter bed counts than progress in recognizing and acting on the severity of health and social needs. The intensive, nearly daily health care case management support that helped HCHN patient James over a six-month period represents the exception that proves the rule. If in doubt, ask the hundreds of HCHN physicians, behavioral health professionals, nurses, and other health care providers who struggle mightily to keep up with demand when they visit shelters, encampments, and supportive housing buildings.
A much more effective alternative to the Trump Administration’s expected push for communities to warehouse unsheltered people away from downtown areas entails scaling up successful models for providing highly integrated housing, health care, and social services. In fact, such models are at Dr. Marbut’s fingertips within the federal government’s own library of best practices. In particular, the lessons that partnerships in Portland, Denver, and Los Angeles have learned about developing and refining these models could provide other communities, as well as the federal government and state legislatures, with much needed guidance and inspiration.
My colleagues in these cities would acknowledge that, of course, not all people experiencing homelessness require intensive health care and health-related services in order to stabilize their lives. Yet, they would also point out that helping people who face the greatest barriers to entering and succeeding in housing–the group about which our communities should worry most—necessitates solutions that directly address serious health conditions and an elevated risk for contracting communicable diseases. It’s time for greater investment at the local, state, and federal level in visions for ending homeless that consider the whole person and integrate services accordingly. In his way we’ll be much more likely to solve what started as a housing crisis and has evolved into a Public Health crisis as well.