Homelessness

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Basics

Description

Defined as the condition in which (i) an individual or family lacks a fixed, regular, and adequate nighttime residence; or (ii) an individual or family who has a primary nighttime residence that is (a) a public or private place not meant for human habitation; (b) in a publicly or privately operated shelter designated to provide temporary living arrangements; (c) an institution where they have resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution (1)

Epidemiology

Prevalence

As of January 2018, there are roughly 553,000 homeless individuals in the United States on any given night: 65% are staying in sheltered locations such as emergency shelters or transitional housing and 35% are staying in unsheltered locations such as on the street, in abandoned buildings, or any place unfit for human habitation (2).

  • From 2017 to 2018, homelessness increased for the second year in a row by 0.3%, reflective of a 3% increase in the number of people experiencing homelessness in unsheltered locations (2).
  • From 2017 to 2018 the number of homeless families with children decreased by 2% and the number of homeless veterans decreased by 5% (2).
  • Roughly 36,000 unaccompanied youth, under age 25, experienced homelessness in 2018 (2).
  • There was a 2% increase in individuals with chronic patterns of homelessness in 2018 when compared to 2017, driven by a 16% increase in sheltered populations with a 4% decrease in unsheltered populations. However, the number of individuals experiencing chronic homelessness has declined by 26% between 2007 and 2018 (2).

Risk Factors

  • Economic factors
    • Poverty
      • 2019 federal poverty definition: $25,750 annual income for four-person household in the lower 48 states and District of Columbia, slightly higher in Alaska and Hawaii (3)
      • In 2017, 12.3% of the U.S. population fell below federal poverty definition
    • Lack of affordable health care: In 2016, 8.8% of people in the United States were uninsured for the entire calendar year. In 2017, the percentage of uninsured did not statistically differ from 2016 (4).
      • Working age adults (ages 19 to 64 years) had a lower rate of health insurance in 2017 when compared to children and older adults. Those aged 26 to 34 were least likely to be insured. 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 uninsured rate for people under age 19 and between ages 50 and 59 increased from 2016 to 2017 (4).
    • Lack of affordable housing. Housing is considered affordable if ≤30% of household income is devoted to housing cost. An estimated 37.8 million U.S. households face cost burdens in housing (>30% of income is spent on housing) and 18.2 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 (5).
    • Youth: On a single night in 2018, 36,000 unaccompanied youth under age 25 experienced homelessness. 89% were ages 18 to 24. 51% of homeless unaccompanied youth were unsheltered (2).
    • Veterans: the number of homeless veterans decreased by 5% from 2017 to 2018 and by 48% since 2009 (2).
    • Transgender individuals: In 2018, 0.5% of all persons experiencing homelessness identified as transgender and 0.2% identified as gender nonconforming (2).
    • Addiction disorders: 46% of homeless individuals report alcohol and/or drug use as a major factor contributing to homelessness (5).
    • 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 (5).
    • Reentry after incarceration: Up to 50,000 people each year enter homeless shelters from jails or prisons (5).
  • 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 (6)
  • Department of Housing and Urban Development (HUD): increasing permanent supportive housing units, increasing services for veterans and those with disabilities (6)
  • 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, sexually transmitted infection (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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Basics

Description

Defined as the condition in which (i) an individual or family lacks a fixed, regular, and adequate nighttime residence; or (ii) an individual or family who has a primary nighttime residence that is (a) a public or private place not meant for human habitation; (b) in a publicly or privately operated shelter designated to provide temporary living arrangements; (c) an institution where they have resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution (1)

Epidemiology

Prevalence

As of January 2018, there are roughly 553,000 homeless individuals in the United States on any given night: 65% are staying in sheltered locations such as emergency shelters or transitional housing and 35% are staying in unsheltered locations such as on the street, in abandoned buildings, or any place unfit for human habitation (2).

  • From 2017 to 2018, homelessness increased for the second year in a row by 0.3%, reflective of a 3% increase in the number of people experiencing homelessness in unsheltered locations (2).
  • From 2017 to 2018 the number of homeless families with children decreased by 2% and the number of homeless veterans decreased by 5% (2).
  • Roughly 36,000 unaccompanied youth, under age 25, experienced homelessness in 2018 (2).
  • There was a 2% increase in individuals with chronic patterns of homelessness in 2018 when compared to 2017, driven by a 16% increase in sheltered populations with a 4% decrease in unsheltered populations. However, the number of individuals experiencing chronic homelessness has declined by 26% between 2007 and 2018 (2).

Risk Factors

  • Economic factors
    • Poverty
      • 2019 federal poverty definition: $25,750 annual income for four-person household in the lower 48 states and District of Columbia, slightly higher in Alaska and Hawaii (3)
      • In 2017, 12.3% of the U.S. population fell below federal poverty definition
    • Lack of affordable health care: In 2016, 8.8% of people in the United States were uninsured for the entire calendar year. In 2017, the percentage of uninsured did not statistically differ from 2016 (4).
      • Working age adults (ages 19 to 64 years) had a lower rate of health insurance in 2017 when compared to children and older adults. Those aged 26 to 34 were least likely to be insured. 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 uninsured rate for people under age 19 and between ages 50 and 59 increased from 2016 to 2017 (4).
    • Lack of affordable housing. Housing is considered affordable if ≤30% of household income is devoted to housing cost. An estimated 37.8 million U.S. households face cost burdens in housing (>30% of income is spent on housing) and 18.2 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 (5).
    • Youth: On a single night in 2018, 36,000 unaccompanied youth under age 25 experienced homelessness. 89% were ages 18 to 24. 51% of homeless unaccompanied youth were unsheltered (2).
    • Veterans: the number of homeless veterans decreased by 5% from 2017 to 2018 and by 48% since 2009 (2).
    • Transgender individuals: In 2018, 0.5% of all persons experiencing homelessness identified as transgender and 0.2% identified as gender nonconforming (2).
    • Addiction disorders: 46% of homeless individuals report alcohol and/or drug use as a major factor contributing to homelessness (5).
    • 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 (5).
    • Reentry after incarceration: Up to 50,000 people each year enter homeless shelters from jails or prisons (5).
  • 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 (6)
  • Department of Housing and Urban Development (HUD): increasing permanent supportive housing units, increasing services for veterans and those with disabilities (6)
  • 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, sexually transmitted infection (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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