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Homelessness is one of America's most vexing social problems (Baxter & Hopper, 1982; Rossi, 1989). Although precise quantification of the problem is impossible, it is obvious to even the most casual observer that the past 15 years have seen an explosion in the number of persons living on the streets, in their cars, under bridges, and in emergency shelters. Women and children are the fastest growing segment of the homeless population, and members of racial minorities make up a large majority of these dispossessed people, belying the old stereotype of a Skid Row populated by older White male alcoholics. Credible estimates of their numbers reach into the millions. Unseen millions more find precarious refuge in the homes of friends and family members.
Because of the role of health problems as both a cause and a consequence of homelessness, homeless people have an enormous stake in the efforts to solve the American health care crisis. However, compared to other groups who are better organized, homeless people risk being overlooked in efforts to reform the financing and delivery of health services in the United States. Obviously, the provision of health insurance for all people should be seen as one strategy to prevent homelessness. But this article assumes that mass homelessness will not be solved in the near future. Rather, health care reform strategies must take into account the unique challenges in bringing health care services to people who are impoverished and homeless. Our article centers around three points:
1. Homeless people have special needs and use the health care system differently from those who have stable housing. Improving their health status will require a unique, comprehensive and multidisciplinary response that includes a wide range of services.
2. Given these special needs, unregulated managed health care plans will not be able to deliver health care in a way that promote access to a wide range of services for homeless people.
3. The transition to a national or statewide health program should maintain and in some places expand the role of traditional safety net providers, public health departments, and outreach programs that provide health care for the homeless.
HEALTH AND HOMELESSNESS
Health care concerns figure prominently in the etiology of homelessness. Consider the case of a minimum wage earner who is uninsured and becomes sick or injured. Without health insurance, the individual will likely delay seeking care until the problem worsens. The health problem may lead to the loss of employment, and then the family must struggle to obtain health care from an overcrowded and underfunded public health system, hospital emergency rooms, or clinics. Diverting family resources from food, other necessities, and, finally, rent in order to pay for physician visits, medication, or lab tests places the family at risk for eviction and homelessness. This scenario is very typical and underscores the role of health care reform in preventing people from becoming homeless in America.
But whereas health problems cause homelessness among some, the social conditions of life on the street cause disease and death among those already homeless. Homeless people live in crowded shelters, in run-down hotels, or on the street where they have little access to bathrooms, regular meals, and privacy. These conditions expose homeless people to communicable disease and put them at risk for injuries caused by accidents and acts of violence. Several studies document that homeless people suffer from many of the same health problems as people who are not homeless, although disease rates are higher than expected (Institute of Medicine, 1988). Common problems include upper respiratory infections, trauma, dermatitis, hypertension, gastrointestinal disorders, and peripheral vascular disease (Brickner, 1990; Wright & Weber, 1987). The recent surge in the rate of tuberculosis in American cities can be traced, in part, to the rise in homelessness (Centers for Disease Control, 1991; McAdam & Brickner, 1990). Chronic mental health and substance abuse problems also disproportionately affect homeless people (Fisher & Breakey, 1986; Koegel, Burnam, & Farr, 1988; Leshner, 1992). Homeless children, sensitive to the stress of constant moves, sleep deprivation, and inadequate nutrition, are twice as likely to suffer from acute and chronic illnesses and depression. Many are developmentally delayed and at increased risk for child abuse and neglect. Depression is also common among the many young women who head homeless families; yet they seldom have adequate access to mental health services and social support (Bassuk & Rosenberg, 1988; Wood, Valdez, Hayashi, & Shen, 1990).
Although they experience higher morbidity and mortality rates, homeless people often lack the most basic elements of access to health care: knowledge of the health care system, health insurance, transportation, and even a …