During the pandemic, social distancing and sheltering in place has been especially challenging for people experiencing homelessness. Even before COVID-19, marginalized homeless populations disproportionately suffered deficiencies in the specific social determinants of health (SDoH), particularly with housing stress, and typically rotated between the streets, jails, shelters, and hospitals.
As the COVID-19 pandemic continues to claim lives and dramatically affect livelihoods, the virus is proving to have a disproportionate impact on people experiencing homelessness, who are often less able to shelter in place, maintain social distancing, or protect themselves. As the economy continues to suffer the effects of pandemic, many more people are at risk of becoming homeless due to the impending eviction crisis. At this critical moment, it is important to fully understand the implications of increased rates of homelessness on effective healthcare delivery and explore how the worst outcomes can be avoided.
ER Visits, Admissions, and Overall Costs Decline When Homeless
Even outside of pandemic conditions, people with no place to live often rely on hospital emergency departments (ED)—the most expensive point of entry into the healthcare system—for their primary care. Generally, they also have trouble controlling chronic diseases such as diabetes and hypertension, resulting in increased hospital admissions. This reality is a long-standing challenge. A 2015 study published in the journal Health Affairs (HA) found that just 3% of “super users” in New York City generated 30 percent of adult charges. A 2019 study (also published in HA) correlated homeless shelter use with an increase in hospital service use, with spikes in ED and hospitalization in the days immediately before and after shelter stays.
Hospitals and social service providers are working to achieve more cost-effective healthcare delivery and outcomes to help underserved, homeless populations. The University of Illinois calculated that it costs 70 times more to take care of a homeless patient than other patients.
The system’s hospitals find that, overall, it is cheaper to pay rent (with aid from federal funding) for homeless patients than allow them to be evicted in the first place, where it can cost up to $3,000 a night in the hospital for a critical patient, compared to $1,000 a month in rental subsidy. The homeless cannot pay $3,000 a night for a hospital stay so it ends up falling on the federal government to take care of it.
Such housing support can be combined with other social services, including mental health and jobs/life skill coaching. Step-up, a nonprofit in Los Angeles, operates 421 units in “community-based permanent supportive housing.” A crucial part of the Step-up program is that the client plays an essential role in determining what services they need on their journey to self-sufficiency and achieving permanent stability.
The Pandemic Homeless Challenge
COVID-19 and its impact on the social fabric and economy is exacerbating the tension between homelessness and health care. The poor have been hit especially hard during the pandemic, including many working households. A 2019 Federal Reserve survey found that 40% of Americans could not come up with an extra $400 to cover an economic emergency, much less stave off eviction if they lose their income to unemployment. And as eviction bans expire, it is expected that there may be a massive influx of individuals experiencing homelessness.
“There’s a confluence of issues that would keep individuals who are on the lower end of the income scale, or are unemployed and underinsured, from being able to stem the tide” of the virus spreading, says Mavis Nimoh, the executive director of the Center for Prisoner Health and Human Rights, a partnership between Rhode Island’s Miriam Hospital and Brown University’s medical school.
Additionally, there is growing concern that the virus is poised to spread among enlarged homeless camps in urban centers. Shelters are scrambling to enact social distancing standards, such as increasing distance between beds and spreading shelter residents among additional facilities. In Denver, for example, officials are clearing out long-standing homeless encampments and dispersing the population to “safe outdoor spaces” with handwashing facilities. The city, which deals with a continuing influx of homeless transients, is moving some clients to apartments and hotels and reuniting others with family. City social agencies are also doing their best to expand homeless services to a growing number of people impacted by loss of income and eviction.
“People tend to think that homelessness is a finite number, and it’s not,” said Tracy Brooks, senior director of emergency services for the Denver Rescue Mission. “It’s not like we have 100 homeless people today, and if we get all them housed, then we are done having homelessness.”
Strategies to Address Homelessness and Health in the Pandemic
In a March white paper, HA lays out several actions to protect “vulnerable populations” during the pandemic:
1: Place a moratorium on evictions. State legislative bodies can enact measures to stymie evictions. Similarly, governors, mayors, and other leaders can freeze the execution of evictions and provide rental assistance.
2: Protect people who are homeless and increase affordable housing. More than 560,000 individuals were homeless in the US on a given night in 2019. People without consistent housing have a high rate of untreated infectious and chronic disease and disabilities. At the same time, half of the adult homeless population is over fifty years old, increasing the risk of health complications. For many people who experience homelessness, COVID-19 could be significantly more life-threatening and difficult to contain.
3: Place a moratorium on utility shut-off. The COVID-19 pandemic and social distancing requirements create a situation in which utility shut-off results in a life-threatening emergency for most Americans. Clean water, electric, gas, and steam utilities are essential to heat a home, cook, preserve perishable foods and medication, and use medical equipment—all necessary to shelter in place, especially for extended periods.
“Social distancing puts the onus on public leaders and health officials to create the conditions required for individual efforts to be successful,” concluded the authors. “State and local leaders can and should act now to protect workers, freeze evictions and utility shut-offs, and prioritize programs that secure safe and healthy housing conditions and nutritional supports.”
COVID-19 has created a magnifying glass on the homeless community which has amplified the concern of homeless people’s health. In addition to the health concern for homeless people, there is the fear of massive spread amongst homeless people, which could then spread to whole cities. As a community there needs to be a call to action to place a moratorium on evictions, protect people who are homeless and increase the amount of affordable housing available, and/or place a moratorium on utilities being shut off. Adopting these strategies could save lives and limit the spread of the virus, as well as ultimately prove to be a better use of resources than the potential overcrowding of hospitals and emergency services during the pandemic. Care coordination/data sharing products like ClientTrack can facilitate COVID-19 testing and non-congregant sheltering for homeless populations.