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Health care for the homeless

Homeless populations suffer from chronic illness, mental illness, and substance abuse in addition to the daily difficulties finding food and shelter. Outreach is needed to ensure this population receives adequate health care.

The chronically homeless most often suffer from chronic illness and tend to have increased use of the emergency department (ED) in order to address their medical needs.  Homeless populations tend to utilize outpatient ambulatory care services far less than non-homeless groups typically due to competing demands that include securing food and safety.  This population often seeks medical attention during the peak of an episode of illness. Sometimes utilizing the emergency department for routine medical care,  the homeless visit the ED in greater proportions than the general public.  Homeless populations also tend to have a higher incidence of multiple chronic illnesses coupled with co-existing psychiatric illness and substance abuse issues that increase their risk for hospitalization and prolonged hospital stays.

This study made use of a cross-sectional design that sought to determine access of medical care for the mentally ill among the chronically homeless population and to determine the impact on medical outcomes.  Data came from the Collaborative Initiative to Help End Chronic Homelessness. A total of 870 participants were consented for the study and provided information regarding their sociodemographic characteristics, health, and insurance status.  Participants identified their usual source of care as either the ED or a primary care physician, with 27.5 percent reported using the ED as their regular source of care.

Of those who utilized the emergency department for care, a larger percentage were male, homeless longer (p=0.07), homeless at a younger age (p=0.01), and had a higher rate of drug abuse (p=0.03) compared to peers. Psychiatric illness was high among participants, but showed no statistical difference in the usage of the ED versus primary care physicians.   Those who received care from a primary care physician had a higher number of medical problems (4.5 versus 3.6; p=0.001).  The percentage of those with insurance was highest among participants that utilized a primary care physician (65.5 percent versus 31.9 percent; p=0.001). Those with a primary care provider were less likely to report difficulty with paying for health care (26.3 percent versus 47.5 percent; p=0.001).  The majority of insurance coverage was provided through state assistance programs.  The inability to afford health care and meet the needs of everyday life served as the major barriers to accessing health care.


The information provided from this study proves to be critical in identifying factors that could potentially impact physical and mental health outcomes. It suggests health insurance would improve medical access for the chronically homeless population. Previous studies have shown that improved access to care reduces mortality and morbidity. As this study shows, health insurance, by way of reducing the cost of care, could improve the health of the chronically homeless.  Access to insurance could potentially reduce unnecessary ED visits and contribute to driving down health care costs in that domain.

A useful extension of this study would seek to identify overall health outcomes of the chronically homeless population.  Pre-existing disease burden may have served as a driving factor for those that sought care from a primary care provider or obtained medical insurance.  By controlling for disease chronicity and adjusting for health status, a follow up study might avoid this flaw.  Despite this possible bias, it would seem that greater outreach to the homeless population is in order to ensure that eligible individuals receive the health care they deserve.

Chwastiak, L., et al. “Impact of health insurance status and a diagnosis of serious mental illness on whether chronically homeless individuals engage in primary care.” AJPH. 2012; 102: e83-e89.


Ellana Stinson, MD

Ellana Stinson, MD, MPH
About Ellana Stinson, MD, MPH

Ellana Stinson, MD is an emergency medicine physician practicing in Boston, MA. She began contributing to Policy Prescriptions® in 2012. Contact: Facebook | Twitter | More Posts

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