Correspondence
Hospitalizations and the Homeless
N Engl J Med 1998; 339:1166-1167October 15, 1998
- Article
To the Editor:
Salit et al. (June 11 issue)1 report that homeless people in New York City are hospitalized, on average, for longer periods than other low-income people and at a cost often greater than that of providing supportive housing for an entire year. In the accompanying astute editorial,2 Starr reviews some causes of homelessness, including increased housing costs coupled with decreased real wages for the least skilled workers and lack of community mental health care.
Both articles highlight the need for a substantial increase in affordable housing, a critical component of a solution to homelessness that my colleagues and I have been advocating for more than 10 years. But the lack of affordable housing is not, as Starr suggests, a result of overly restrictive building and safety codes. Rather, the federal government has dramatically decreased its investment in affordable housing for the poor. In 1977, federal funds subsidized more than 375,000 additional households as compared with the preceding year; in 1997, the number of new households added dropped to just over 50,000. At the same time, much affordable housing in the private housing market has been lost to gentrification and commercial development. Decreased real wages and lack of health care exacerbate the effects of these losses.
New policies are needed to reverse these trends. For fiscal year 1999, the Clinton administration has asked for $545 million to fund subsidies for 103,000 currently unsubsidized households, a step in the right direction. But to date, the House and Senate have approved only $100 million and $40 million, respectively. In contrast, Congress and the President recently approved legislation to spend more than $200 billion on the nation's roads and highways.
2 ReferencesMaria Foscarinis, M.A., J.D.
National Law Center on Homelessness and Poverty, Washington, DC 20004-14061
Salit SA ,Kuhn EM ,Hartz AJ ,Vu JM ,Mosso AL . Hospitalization costs associated with homelessness in New York City. N Engl J Med 1998;338:1734-1740
Full Text | Web of Science | Medline2
Starr P . The homeless and the public household. N Engl J Med 1998;338:1761-1762
Full Text | Web of Science | Medline
To the Editor:
The Department of Veterans Affairs is the nation's largest direct provider of services to homeless persons, providing health care services to over 65,000 homeless veterans each year. A recent national survey of Veterans Affairs medical centers showed that homeless veterans were almost seven times as likely to be hospitalized as other, similarly eligible disabled or low-income veterans.1 Of those hospitalized, 82 percent had been given primary mental health diagnoses (50 percent had psychiatric disorders and 31 percent had substance-abuse disorders). Homeless veterans with mental illness were almost twice as likely to be readmitted within 30 days after discharge and used significantly more outpatient services, incurring $3,196 more in annual health care costs than similar patients who were not homeless. Although 20 percent of our inpatients with mental health diagnoses were homeless at the time of admission (i.e., staying in temporary shelters or on the streets), an additional 15 percent had no stable residence but were temporarily living doubled up with family or friends.2 In 1995, homeless veterans accounted for 26 percent of all Veterans Affairs inpatient expenditures for mental health ($404 million).
Could Salit et al. provide comparable data from their sample? Such data, combined with the excess cost per hospital admission, would provide a more complete estimate of the substantial social costs of homelessness, or at least the health care costs.
In addition to acute medical and psychiatric treatment, the provision of comprehensive health care for homeless people requires specialized outreach efforts, intensive case management, and residential services — services that the Department of Veterans Affairs provides through more than 300 programs nationwide. The responsibility for providing these services to homeless persons falls almost exclusively on safety-net health care systems such as urban public hospitals and Veterans Affairs facilities.3 These systems perform a unique and very costly service that benefits society in general and other health care providers in particular.
3 ReferencesRobert Rosenheck, M.D.
Veterans Affairs Northeast Program Evaluation Center, West Haven, CT 06516Kenneth W. Kizer, M.D., M.P.H.
Department of Veterans Affairs, Washington, DC 200201
Rosenheck RA, Leda C, Sieffert D, Burnette C. Fiscal year 1995 end of year survey of homeless veterans in VA inpatient and domiciliary care programs. West Haven, Conn.: Northeast Program Evaluation Center, 1996.
2
Rosenheck R ,Seibyl CL . Homelessness: health service use and related costs. Med Care 1998;36:1256-1264
CrossRef | Web of Science | Medline3
Wilson NJ ,Kizer KW . The VA healthcare system: an unrecognized national safety net. Health Aff (Millwood) 1997;16:200-204
CrossRef | Web of Science | Medline
To the Editor:
In his editorial, Starr highlights the implications of the failure to deal with social problems “upstream” (lack of housing, education, health insurance, and substance-abuse prevention). Starr accurately predicts that the “time limits on welfare benefits . . . may contribute to future increases in homelessness.” This is already happening, and attention is being drawn to the unforeseen consequences of changes in the welfare system.1 The financing formula for reimbursing homeless shelters is being affected by the changes and by the sharp decline in the number of welfare recipients. The reimbursement of shelters is still intricately tied to the number of people deemed eligible for welfare benefits. This policy is forcing shelter operators to turn homeless people away, reduce the number of days they operate, or simply go out of business.
The greatest challenge for New York State as it implements mandatory Medicaid managed care is to muster the political will to include the homeless as a special-needs population, as has been done for people with human immunodeficiency virus infection or AIDS and mental health problems. Managed-care organizations should be made to address the issue of access to and coordination of care for the homeless in order to prevent costly health care delivery, as shown by Salit and her colleagues. To succeed, New York State must develop a comprehensive risk-adjusted rate for this special population. Furthermore, a partnership between managed-care organizations and community-based organizations — in this case, shelter operators — must be forged. The shelter operators have already demonstrated cultural competency in the delivery of service to this special population.
1 ReferencesJackson A. Omene, M.D.
Woodhull Medical Center, Brooklyn, NY 11206Author/Editor Response
The authors reply:
To the Editor: We agree with Foscarinis that federal cutbacks in housing subsidies for the poor have been a major contributor to homelessness. Since welfare rents do not generate enough income to cover housing operating costs, it is unlikely that New York City's shortage of low-income housing will be resolved without increased subsidies.
Rosenheck and Kizer ask whether our sample could be used to provide a more complete estimate of the health care costs of homelessness. We estimated the citywide impact of our findings several months ago during a state legislative debate over extension of a housing program for homeless mentally ill persons. Our estimate first assumed that there are about 23,000 general-hospital discharges of homeless people in New York City annually. This assumption was based on comparisons of our sample with one-day head counts of hospitalized homeless patients that are conducted periodically by the public hospitals and on the impression of public and private hospital staff that the public hospitals treat about two thirds of all hospitalized homeless persons in the city. We found that 20 percent of hospitalizations of homeless people were for potentially preventable disorders, that the average cost of such hospitalizations was $12,000, and that the additional cost per discharge for hospitalizations associated with homelessness for the remaining 80 percent was $2,400. On the basis of this information, we estimated that the citywide costs for excess hospitalizations associated with homelessness are $100 million annually. Since homeless people receive services from many other health care providers in the city (the Veterans Affairs facilities, state psychiatric hospitals, community clinics, and shelter and prison clinics), the full impact of homelessness is actually far greater.
Instead of spending this money on hospitalization, it may be possible, as Starr advised, to target services “upstream” to those likely to have high costs “downstream.” A high-priority upstream target would be the 10 percent of chronically homeless single adults in the city (85 percent of whom have serious psychiatric or medical problems) who use the majority of shelter days.1 The cost of housing this core group may be substantially offset by the savings in hospital costs.
As was true for the Department of Veterans Affairs, we also found that homeless patients accounted for 26 percent of public-hospital spending for psychiatric and substance-abuse treatment, although they represented just 10 percent of discharges.
We agree with Omene that homeless people need more coordinated health care, but unless we first provide housing, it will be extremely difficult to engage this transient population in Medicaid managed-care provider networks.
1 ReferencesSharon A. Salit, M.A.
Arthur J. Hartz, M.D., Ph.D.
United Hospital Fund, New York, NY 10118-2399- Citing Articles (3)
Citing Articles
1
Brie A. Williams, James McGuire, Rebecca G. Lindsay, Jacques Baillargeon, Irena Stijacic Cenzer, Sei J. Lee, Margot Kushel. (2010) Coming Home: Health Status and Homelessness Risk of Older Pre-release Prisoners. Journal of General Internal Medicine 25:10, 1038-1044
CrossRef2
Kenneth W. Kizer, R. Adams Dudley. (2009) Extreme Makeover: Transformation of the Veterans Health Care System. Annual Review of Public Health 30:1, 313-339
CrossRef3
David Buchanan, Louis Rohr, Laura Kehoe, Susan B. Glick, Sharad Jain. (2004) Changing Attitudes Toward Homeless People. A Curriculum Evaluation. Journal of General Internal Medicine 19:5p2, 566-568
CrossRef
