Homelessness

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Basics

Description

Defined as the condition in which (i) an individual lacks a fixed, regular, and adequate nighttime residence; or (ii) an individual who has a primary nighttime residence that is (a) a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill); (b) an institution that provides a temporary residence for individuals intended to be institutionalized; and (c) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings

Epidemiology

Prevalence

As of January 2017, there are 553,742 homeless individuals in the United States on any given night: 33% are homeless families, 7.2% were veterans, 7.4% were unaccompanied children and young adults (1).

  • From 2016 to 2017, homelessness increased for the first time in 7 years, reflective of a 9% increase in number of people experiencing homelessness in unsheltered locations and specific changes happening within cities. Risk for becoming homeless remains high in certain populations (see “Risk Factors”) (1).
  • Although many people experiencing homelessness reside in temporary housing or shelters, 35% live unsheltered (1).
  • There was a 12% increase in individuals with chronic patterns of homelessness in 2017 when compared to 2016, both in sheltered and unsheltered populations. However, the number of individuals experiencing chronic homelessness has declined by 18% between 2010 and 2017 (1,2).

Risk Factors

  • Economic factors
    • Poverty
      • 2018 federal poverty definition: $25,100 annual income for four-person household in the lower 48 states and District of Columbia, slightly higher in Alaska and Hawaii (3)
      • In 2016, 12.7% of the U.S. population fell below federal poverty definition (U.S. Census Bureau).
    • Unemployment: U.S. rate 4.4% in June 2017 (U.S. Bureau of Labor Statistics)
    • Lack of affordable health care: In 2016, 8.8% of people in the United States were uninsured for the entire calendar year, a 0.3% decrease since 2015 (4).
      • Young adults (ages 19 to 34 years) are disproportionately uninsured (12.1%) compared with the average for all ages (9.1%); the uninsured rate for ages 19 to 25 years decreased by 12% between 2009 and 2016, following Affordable Care Act provision allowing individuals in this age group to stay on parental insurance plans (4).
      • The number of uninsured nonelderly Americans has dropped 43% since October 2013 (4).
    • Lack of affordable housing: Housing is considered affordable if ≤30% of household income is devoted to housing costs.
      • An estimated 12 million households are “severely housing cost burdened” (≥50% of income is spent on housing).
  • Additional at-risk populations: intimate partner violence (IPV), victims of violence; youth (particularly those aging out of foster care); veterans; rural; addiction; psychiatric illness; disabled due to chronic medical disease, psychiatric illness, or substance use disorder; reentry after incarceration/prison
    • IPV: 12% of overall homeless population, and as many as 1 in 5 families, will have reported experiencing IPV; IPV leads directly to homelessness in many cases (2).
    • Youth: In 2017, Department of Housing and Urban Development (HUD) estimates 40,799 unaccompanied individual homeless youths (up to age 24 years) and another 9,800 persons in families where the parent is a youth (1). Approximately 550,000 youths in a year will experience homelessness lasting longer than a week (2).
    • Veterans: 7.4% of homeless adults; homelessness rate decreased by about half between 2010 and 2017 (1).
    • Transgender individuals: In 2017, fewer than 1% of all persons experiencing homelessness were either transgender or did not identify as male, female, or transgender, but there was an increase in this group from 2016.
    • Addiction disorders: 46% of homeless individuals report alcohol and/or drug use as a major factor contributing to homelessness (2).
    • Psychiatric illness: 45% of homeless report indicators of a mental health issue in the past year; 25% of homeless adults suffer from chronic mental illness (2).
    • Reentry after incarceration: Up to 50,000 people each year enter homeless shelters from jails or prisons (2).
  • Fundamental issues in homelessness and health care that require ongoing consideration:
    • Unstable housing, limited access to nutritious food and water, lack of transportation
    • Higher risk for abuse and violence
    • Physical/cognitive impairments, behavioral health problems
    • Developmental discrepancies for children: speech delay, chronic ear infection, insufficient opportunity to practice gross and fine motor skills
    • Higher risk for communicable disease
    • Lack of health insurance/resources, discontinuous/inaccessible health care, lack of a medical home, barriers to disability assistance
    • Cultural/linguistic barriers: racial and ethnic groups overrepresented in homeless population
    • Limited education/literacy
    • Lack of social supports: Alienation from family and friends precipitate homelessness.
    • Criminalization of homelessness: frequent arrests for loitering, sleeping in public places

General Prevention

  • Policy and funding for community programs to provide emergency/rapid housing, housing stabilization, and case management services
  • Increased Medicaid eligibility for homeless and expanded home and community-based services and case management to the homeless population (5)
  • HUD: increasing permanent supportive housing units, increasing services for veterans and those with disabilities (5)
  • Social justice policy recommendations: permanent affordable housing, foreclosure and homelessness prevention, increased funds for HUD McKinney-Vento programs (emergency, transitional, and permanent housing) and National Housing Trust Fund, rural homeless assistance, universal health care, universal livable income, employment/workforce services, prevention of hate crimes against the homeless, decriminalization of homelessness

Commonly Associated Conditions

  • Hunger
  • Worsening of chronic medical conditions: lack of healthy food, places to store medications, or medical equipment; lack of restful sleep; decreased health literacy; limited transportation to appointments
    • Infectious diseases
      • Tuberculosis (TB), HIV/AIDS, STI
      • Skin/nail infections and infestation (lice, bedbugs, and scabies)
      • Liver disease (e.g., hepatitis B or C, or alcohol related)
    • Cognitive impairment: traumatic brain injury (TBI), cerebrovascular accident (CVA), substance use
    • Dental problems
    • Exposure-related conditions (frostbite, heatstroke)
    • Psychiatric illness
    • Trauma: increased risk of assault, victims of hate crimes

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