Description

• Lacking a fixed, regular, and adequate nighttime residence
• Chronic homelessness: lacking fixed, regular housing for at least 1 year or at least four episodes of being unhoused in the past 3 years for a combined length of at least 1 year
• People struggling with homelessness often have complex and chronic medical illnesses such as mental illness, substance use disorders, and physical disabilities (1).

Epidemiology

Incidence

• Increasing since 2016 nationwide
• The COVID-19 pandemic disrupted accounting of unsheltered people, but conditions during the pandemic may have increased the incidence (1).

Prevalence
In 2019, 0.17% of the U.S. population (approximately 580,466 individuals) experienced homelessness on any given night: 61% in sheltered locations, 39% in unsheltered locations (1).

• 6% are veterans, 30% are families with children, 6% are unaccompanied youth (age <25 years), and 19% are chronically homeless individuals.
• 48% of the homeless population is white.

Risk Factors

• Poverty
  • 2022 federal poverty level: $27,750 annual income for four-person household in the lower 48 states and District of Columbia, slightly higher in Alaska and Hawaii (2)
  • In 2020, 11.4% of U.S. population below federal poverty line (1% increase from 2019)
• Unemployment: U.S. rate 3.7% in August 2022 (U.S. Bureau of Labor Statistics)
• Lack of affordable health care: In 2022, 8.6% of U.S. population (280 million) were uninsured for the entire calendar year (3).
• Lack of affordable housing: <30% of gross income for housing costs, including utilities; roughly 37.8 million U.S. households spend >30% on housing costs; 18.2 million households spend ≥50% of income on housing.
• Intimate partner violence (IPV): 12% of overall persons experiencing homelessness and about 20% of families experiencing homelessness report IPV; IPV often involves exertion of psychological and financial control that leaves survivors with poor credit, limited support, and few resources.
• Veterans: decreasing due to policy changes; decreased by 10% from 2020 to 2021 (2)
• Transgender individuals: 0.4% identify as transgender and 0.2% as gender nonconforming (2)
• Addiction disorders: 46% report substance use as a major factor contributing to homelessness (1).
• Psychiatric illness: 25% of adults experiencing homelessness (1)
• Post-incarceration: 50,000 people each year enter homeless shelters from jails/prisons (1).

General Prevention

• Policy and funding for community programs to provide emergency/rapid housing, housing stabilization, and case management services. The CARES Act of 2020 and the American Rescue Plan Act of 2021 provide funding for permanent housing. Over the past 5 years, the fastest growing forms of assistance include rapid rehousing and “other permanent housing.”
• Increased Medicaid eligibility, expanded home- and community-based services, and case management for people experiencing homelessness
• HUD: increasing permanent supportive housing units, increasing services for veterans, families with children, and those with disabilities
• 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 basic income, employment/workforce services, prevention of hate crimes against the homeless, decriminalization of homelessness

Commonly Associated Conditions

• Hunger and malnutrition
• Exposure-related conditions (frostbite, heatstroke)
• Substance use disorders and their associated conditions
  • Liver disease (alcohol, hepatitis B and C)
  • Abscesses (intravenous drug use)
  • Overdose
• Dental problems
• Psychiatric illness
• Trauma (increased risk of assault, victims of hate crime)
• Infectious diseases
  • Skin/nail infection and infestation (lice, bedbugs, and scabies)
  • Tuberculosis, HIV/AIDS, STI
• 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