Homelessness, Health, and At-Risk Populations During COVID-19

July 30, 2020 - (6 min read)

The post is a part of the Housing is Health series which aims to foster dialogue that considers health across housing-related policy areas, centered around health equity, and highlights best practices and lessons learned by cities and for cities.


The link between homelessness and health is not always addressed intentionally. We know that the lack of good health can often lead to homelessness. As individuals struggle with health-related issues, it can impact their ability to do well at work, resulting in loss of employment and inability to pay health care costs. Many workers are in jobs without health insurance and even people who are employed may be one illness away from losing their homes. In their February 2019 Fact Sheet, The National Health Care for the Homeless Council found that people who are homeless have higher rates of illness and die on average 12 years sooner than the general U.S. population.

What is also well known is the impact of homelessness on health. In their paper on Homelessness, Health and Human Needs, The National Center for Biotechnology Information (NCBI), writes about homelessness as a complicating factor in health care, saying “homelessness increases the risk of developing health problems such as diseases of the extremities and skin disorders; it increases the possibility of trauma, especially as a result of physical assault or rape. It can also turn a relatively minor health problem into a serious illness.”

A study published in the American Journal of Public Health Association (AJPH), found that homeless individuals used the emergency room almost four times more than other low-income residents of Boston. Emergency care for approximately 6,500 homeless individuals totals $16 million a year in emergency-room care for the state’s health care system or almost $2,500 per person. The connection between homelessness and health is clear. And for the most at-risk homeless populations – the landscape is even more daunting.

Special Health Needs of At-Risk Populations

‘The homeless’ can often be thought of in a limited way — people who are living unsheltered on the streets and visibly struggling to get by. But for individuals who are experiencing homelessness and have co-occurring disorders and/or challenges, their unmet health and social needs can create far greater consequences.

Consider women fleeing domestic violence who have experienced trauma; children fleeing abusive family situations who have high adverse childhood experiences scores; individuals with mental health and/or substance use disorders who may be perceived as violent or dangerous, among others. In the case of individuals who are homeless and experiencing mental health challenges, we know that jails have now replaced institutions as the primary system of care. The financial and social costs are high for individuals and municipalities, and outcomes are poor for individuals trapped in the cycle of emergency rooms and jails.

Compounding these co-occurring disorders and/or challenges are structural and institutional racism. Black and Latinx individuals account for 40 percent and 20 percent of people experiencing homelessness, respectively. People of color make up more than half of the uninsured population. People of color are also disproportionately involved with the criminal justice system, and homeless youth care more likely to be female (38 percent), transgender or non-gender binary (3 percent), or African American (36 percent).

The Health System Role in Addressing Homelessness

The costs of poor health among people experiencing homelessness are often seen by the health system. This has brought greater recognition among health stakeholders and policymakers to look at these issues in new ways. Led by Dr. Jeffrey Brenner and his work in Camden, New Jersey through the Camden Coalition, doctors have worked to better diagnose and address the complex needs of the most vulnerable individuals. By focusing on individuals who frequently visit emergency rooms, doctors aim to address the basic needs of the most vulnerable individuals, such as assisting people with staying on their medication and addressing social and environmental factors including access to food and housing.

Now with United Healthcare, as the Senior Vice President of Integrated Health and Social Services, Dr. Brenner demonstrates the growing recognition among health insurers of the link between health, social needs, and services, including housing. United Healthcare has invested more than $400 million in affordable housing and joins insurers such as Kaiser Permanente in investing in housing.

At the federal level, the Centers for Medicare and Medicaid Innovation (CMMI) have also spurred efforts to better address the health and social needs of the most at-risk individuals. Through Accountable Health Communities, based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs, CMMI is working to support efforts in 29 communities.

City Approaches to Address Homelessness and Improve Health Outcomes

Since the most significant drivers of health fall outside of the health system, the engagement of the health care sector to address complex social needs including housing is timely and significant. No one entity or sector can address these complex challenges on their own. Mayors and city leaders have the convening power and authority to advance more holistic and comprehensive approaches to address homelessness. And with the stronger engagement of health care stakeholders in communities around the country, the issue of homelessness demands the willingness of stakeholders to share power and resources. It also requires stakeholders to recognize the imbalance that our nation’s investment in health care is far greater than the factors (e.g., housing) that can support good health or drive poor health outcomes.

In Greensboro, NC, the Greensboro Housing Coalition, along with city leaders, the CONE Health System and UNC Greensboro, have come together to better address housing and to better meet social needs. Through a robust collaboration, these partners are working together to improve housing conditions, expand access to affordable housing, provide eviction prevention support, and connecting those who are housing insecure to helpful supports and services, including eviction prevention efforts.

Albuquerque, NM is taking important steps to better address the needs related to homelessness, mental health, and substance use issues. As part of their police reform efforts, they are reimaging supports and services by incorporating a community safety division that will be staffed by behavioral health specialists, social workers, and other civilians to better meet the needs of their most vulnerable populations. This effort further expands on the number of cities moving away from punitive actions to public health approaches to homelessness, including Huntington, WV, Indianapolis, IN, and San Antonio, TX. These approaches have strong partnerships with health systems to better connect at-risk populations to appropriate treatment and care and ultimately improve outcomes.

Cities and health stakeholders can further align their shared values and interests and work to address housing insecurity and homelessness, specifically targeting Black, Indigenous and People of Color, through expanding access to affordable housing including permanent supportive housing, and an emphasis on needed wrap-around services such as food support and job training among others. Together, partnerships can promote transformational, holistic approaches that improve community health and well-being for all residents.

About the Authors

Sue Pechilio Polis is the Director of Health & Wellness in the National League of Cities Institute for Youth, Education, and Families.



Lauren_Lowery_smallLauren Lowery is the program director for housing & community development at the National League of Cities.