Health Advocacy for People Experiencing Homelessness
The National Health Care for the Homeless Council’s (NHCHC’s) training, research, and advocacy support clinicians and the 1 million patients1 served annually in 300 Health Care for the Homeless federally qualified health centers (FQHCs) and 100 medical respite programs. The NHCHC’s work is fundamentally ethical in nature. The NHCHC community is galvanized to serve a population that is often shunned by society and large segments of the health care system: people experiencing homelessness. Its mission statement is expressed in moral terms: “Grounded in human rights and social justice, the National Health Care for the Homeless Council’s mission is to build an equitable, high-quality health care system through training, research, and advocacy in the movement to end homelessness.”2 Rights, justice, and equity are fundamentally ethical concepts.
In the introduction to this theme issue, I offer 3 reasons why we, as members of society and clinicians, are ethically obligated to offer homeless health care in the United States and to work to end homelessness: (1) homelessness harms people’s health and well-being; (2) homelessness harms the health system and health professionals; and, finally, (3) homelessness is a result of inequitable policies, practices, and choices our society has made.
Homelessness as a Health Hazard
The health effects of homelessness are grave, with higher incidence and severity of illness and injury among people experiencing homelessness.3 Chronic conditions, such as diabetes, hypertension, and heart attack are almost twice as prevalent among people experiencing homelessness than in the general population4; substance use disorders are 3 times as prevalent; and depression and hepatitis C are more than 6 times as prevalent.4 Homelessness also has serious developmental effects on children, and children experiencing homelessness have higher rates of mental distress, physical illness, and dental problems.5 Lacking stable housing makes treating every condition more difficult and further damages health. People who die on the streets on average live roughly 30 fewer years than the US life expectancy, and the age-adjusted death rate of the homeless population is at least twice that of the general population.6,7,8,9
Homelessness Is Harmful to Our Health System and Health Professionals
People experiencing homelessness access primary care less frequently because they are often uninsured and have experienced marginalization and stigma by health care organizations, resulting in their more frequent emergency department use and presentation with comorbid conditions that are more acute because they have been untreated.10 People experiencing homelessness are hospitalized at up to 4 times the rate of the general population and have longer inpatient hospital stays.10,11 Because these patients’ conditions are exacerbated by lack of care and unstable housing, costly intensive care is devoted to addressing needs of persons with conditions that could have been—and should have been—treated earlier in primary care settings.
Moral injury and moral distress occur among health care professionals placed in situations in which they feel they cannot provide high-quality care and healing or in situations in which they feel constrained from doing what they believe to be right for a patient.12 Moral injury and moral distress are the reality every day for many clinicians who are trying to treat people experiencing homelessness. Clinicians experience distress when treating persons whose conditions have their roots in nonmedical causes that are socially determined. Following protocols that do not promote patients’ best interests or that result in patients’ discharge to unsafe conditions can generate feelings of frustration, burnout, and moral injury among well-intentioned professionals.
Homelessness Is a Result of Society’s Choices That Promote Inequity
Ethics involves evaluating choices in light of their effects or their alignment with principles, such as justice and fairness. I want to be clear: the scale of homelessness in the most powerful and wealthy country on earth demonstrates that mass homelessness is a social problem resulting from many choices society has made over time. The US Department of Housing and Urban Development estimates that well over 500 000 people experience homelessness on any given night in the United States.13 More than a third of these vulnerable human beings are “unsheltered,” exposed to the elements in parks, on subways, on the streets, and in the woods. In any given year, the US Department of Education states that approximately 1.5 million of our nation’s children (eg, the population of the state of Maine14) experience homelessness.15
The high numbers of racial minorities experiencing homelessness are a direct result of inequitable federal laws, policies, practices, and broken treaties with Indigenous nations that resulted in transgenerational trauma, forced migration, segregation, and denial of educational and employment opportunities and basic human rights. African Americans represent 13% of the general population but constitute more than 40% of people experiencing homelessness16; Native Americans/Alaskan Natives make up 1.7% of the general population but constitute almost double their share of the homeless population.13,17 The largest cause of mass homelessness was a roughly 75% reduction between 1979 and 1982 in federal funding to make housing affordable for poor people,18 and this housing shortage extends to the present day. Funding has remained intractably low since 1982 and is only available to 1 of 4 households that qualify for federal rental assistance.19 Compare that to tax subsidies promoting home ownership—almost all of which go to wealthy Americans, are available to everyone who qualifies, and exceed $200 billion per year20—to see a clear example of inequitable policy and practice.
Delivering high-quality health care to people experiencing homelessness while working to end homelessness puts moral motivation and good intentions into action. Given systemic causes of homelessness, which have excluded some groups from opportunities while unfairly conferring advantage to others, homeless health care is about more than expressing compassion. As admirable and ethical as compassion is, responding robustly to remedy structural causes of homelessness is a matter of justice. We can largely end homelessness on a massive scale. To continue to choose not to do so is unjust and immoral.
This theme issue of the AMA Journal of Ethics addresses ethical implications of this struggle to deliver high-quality homeless health care while working to end homelessness and considers clinicians’ and organizations’ roles and obligations to deliver equitable care and promote justice.
National Health Care for the Homeless Council. The Health Care for the Homeless Program. April 2021. Accessed September 16, 2021. https://nhchc.org/wp-content/uploads/2021/04/HCH-Fact-Sheet_2021.pdf
Statement of principles and mission. National Health Care for the Homeless Council. Accessed September 16, 2021. https://nhchc.org/who-we-are/get-involved/statement-of-principles/
National Health Care for the Homeless Council. Homelessness and health: what’s the connection? February 2019. Accessed January 13, 2021. https://nhchc.org/wp-content/uploads/2019/08/homelessness-and-health.pdf
National Health Care for the Homeless Council. Advance care planning for individuals experiencing homelessness. In Focus. 2016;4(2). Accessed June 25, 2021. https://nhchc.org/wp-content/uploads/2019/08/in-focus-advance-care-planning-final-for-posting-1.pdf
Head Start Early Childhood Learning and Knowledge Center. Caring for the health and wellness of children experiencing homelessness. US Department of Health and Human Services. Updated March 2020. Accessed January 13, 2021. https://eclkc.ohs.acf.hhs.gov/publication/caring-health-wellness-children-experiencing-homelessness
National Health Care for the Homeless Council. Homeless Mortality Data Toolkit: understanding and tracking deaths of people experiencing homelessness. January 2021. Accessed September 16, 2021. https://nhchc.org/wp-content/uploads/2020/12/Homeless-Mortality-Toolkit-FULL-FINAL.pdf
- Roncarati JS, Baggett TP, O’Connell JJ, et al. Mortality among unsheltered homeless adults in Boston, Massachusetts, 2000-2009. JAMA Intern Med. 2018;178(9):1242-1248.
O’Connell JJ. Premature mortality in homeless populations: a review of the literature. National Health Care for the Homeless Council; December 2005. Accessed September 16, 2021. http://sbdww.org/wp-content/uploads/2011/04/PrematureMortalityFinal.pdf
Remembering those lost to homelessness. National Coalition for the Homeless. December 21, 2018. Accessed June 25, 2021. https://nationalhomeless.org/category/mortality/
- Lin WC, Bharel M, Zhang J, O’Connell E, Clark RE. Frequent emergency department visits and hospitalizations among homeless people with Medicaid: implications for Medicaid expansion. Am J Public Health. 2015;105(suppl 5):S716-S722.
- Hwang SW, Weaver J, Aubry T, Hoch JS. Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services. Med Care. 2011;49(4):350-354.
- Borges LM, Barnes SM, Farnsworth JK, Bahraini NH, Brenner LA. A commentary on moral injury among health care providers during the COVID-19 pandemic. Psychol Trauma. 2020;12(suppl 1):S138-S140.
US Department of Housing and Urban Development. HUD 2019 Continuum of Care Homeless Assistance Programs homeless populations and subpopulations. September 20, 2019. Accessed September 16, 2021. https://files.hudexchange.info/reports/published/CoC_PopSub_NatlTerrDC_2019.pdf
QuickFacts: Maine. US Census Bureau. Updated July 1, 2019. Accessed July 28, 2021. https://www.census.gov/quickfacts/ME
National Center for Homeless Education. Federal data summary: school years 2015-16 through 2017-18. January 30, 2020. Accessed July 29, 2021. https://nche.ed.gov/wp-content/uploads/2020/01/Federal-Data-Summary-SY-15.16-to-17.18-Published-1.30.2020.pdf
Racial disparities in homelessness in the United States. National Alliance to End Homelessness. June 6, 2018. Accessed June 11, 2021. https://endhomelessness.org/resource/racial-disparities-homelessness-united-states/
Office of Minority Health. Profile: American Indian/Alaska Native. US Department of Health and Human Services. Accessed December 19, 2020. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=62
Fact of the week: federal budget authority for housing assistance has declined by more than $75 billion in real dollars since 1978-79. National Low Income Housing Coalition. December 3, 2018. Accessed December 19, 2020. https://nlihc.org/resource/fact-week-federal-budget-authority-housing-assistance-has-declined-more-75-billion-real
3 in 4 low-income renters needing rental assistance do not receive it. Center on Budget and Policy Priorities. Updated July 2021. Accessed September 16, 2021. https://www.cbpp.org/three-out-of-four-low-income-at-risk-renters-do-not-receive-federal-rental-assistance#:~:text=Federal%20Rental%20Assistance-,Three%20Out%20of%20Four%20Low%2DIncome%20At%2DRisk%20Renters%20Do,Not%20Receive%20Federal%20Rental%20Assistance&text=With%20limited%20funds%2C%20federal%20rental,risk%20renters%20afford%20modest%20housing
Cortwright J. The mortgage interest deduction: smaller, but even more unfair. City Observatory. April 24, 2018. https://cityobservatory.org/the-mortgage-interest-deduction-smaller-but-even-more-unfair/