Technically Accessible, Practically Ineligible: The Effects of Medicaid Expansion Implementation on Chronic Homelessness

Mortal Systemic Exclusion Yielded Steep Mortality-Rate Increases In People Experiencing Homelessness, 2011-20

The number and percentage of people in the US dying while homeless has increased in recent years. However, information about the causes of death most prevalent among this population, and about how cause-specific mortality rates may be shifting over time, has been limited to locally specific data. Using a unique data set of 22,143 homeless decedents in twenty-two localities across ten states and Washington, D.C., from the period 2011-20, we found large increases in all-cause and cause-specific homeless mortality rates. The largest increases in cause-specific homeless mortality rates in the ten-year period were for deaths related to drug and alcohol overdose, diabetes, infection, cancer, homicide, and traffic injury. We discuss implications of these results and posit that people experiencing homelessness are systematically excluded from the life-affirming institutions of housing and health care, in an example of mortal systemic exclusion. The findings have important implications for existing local and federal policy approaches to homelessness.

Persistent Disparities: Trends in Rates of Sheltered Homelessness Across Demographic Subgroups in the USA

CONTEXT

Homelessness is a public health crisis affecting millions of Americans every year, with severe consequences for health ranging from infectious diseases to adverse behavioral health outcomes to significantly higher all-cause mortality. A primary constraint of addressing homelessness is a lack of effective and comprehensive data on rates of homelessness and who experiences homelessness. While other types of health services research and policy are based around comprehensive health datasets to successfully evaluate outcomes and link individuals with services and policies, there are few such datasets that report homelessness.

METHODS

Gathering archived data from the US Department of Housing and Urban Development, we created a unique dataset of annual rates of homelessness, nationally, as measured by persons accessing homeless shelter systems, for 11 years (2007-2017, including the Great Recession and prior to the start of the 2020 pandemic). Responding to the need to measure and address racial and ethnic disparities in homelessness, the dataset reports annual rates of homelessness across HUD selected, Census-based racial and ethnic categories.

FINDINGS

Between 2007 and 2017, across all types of sheltered homelessness, whether individual, family, or total, Black, American Indian or Alaska Native, and Native Hawaiian and Pacific Islander individuals and families were far more likely to experience homelessness than non-Hispanic White individuals and families. Particularly concerning about the rates of homelessness among these populations is the persistent and increasing nature of these disparities across the entire study period.

CONCLUSIONS

While homelessness is a public health problem, the hazard of experiencing homelessness is not uniformly distributed across different populations. Because homelessness is such a strong social determinant of health and risk factor across multiple health domains, it deserves the same careful annual tracking and evaluation by public health stakeholders as other areas of health and health care.

Addressing Housing-Related Social Needs Through Medicaid: Lessons From North Carolina's Healthy Opportunities Pilots Program

North Carolina Medicaid's Healthy Opportunities Pilots program is the country's first comprehensive program to evaluate the impact of paying community-based organizations to provide eligible Medicaid enrollees with an array of evidence-based services to address four domains of health-related social needs, one of which is housing. Using a mixed-methods approach, we mapped the distribution of severe housing problems and then examined the design and implementation of Healthy Opportunities Pilots housing services in the three program regions. Four cross-cutting implementation and policy themes emerged: accounting for variation in housing resources and needs to address housing insecurity, defining and pricing housing services in Medicaid, engaging diverse stakeholders across sectors to facilitate successful implementation, and developing sustainable financial models for delivery. The lessons learned and actionable insights can help inform the efforts of stakeholders elsewhere, particularly other state Medicaid programs, to design and implement cross-sectoral programs that address housing-related social needs by leveraging multiple policy-based resources. These lessons can also be useful for federal policy makers developing guidance on addressing housing-related needs in Medicaid.

Health services and the Project RoomKey COVID-19 initiative for the unhoused: A university and community partnership

A hotel-based clinic to serve Project RoomKey residents is a model for meeting the health care needs of an unhoused population. The purpose of this paper is to describe the health services provided by students and licensed clinicians at a hotel that was designed to allow unhoused community residents to shelter in place during the early stages of the Covid pandemic (May 1–June 30, 2020). Documents developed for the project may be useful to others who are setting up similar services for unhoused residents in their own communities.