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OCR for page 76
Access to Health Care
Services for
Homeless People
INTRODUCTION
In a nation abundantly endowed with hospitals, physicians, and ad-
vanced health care technology, millions of Americans have difficulty
obtaining health care. Problems of access to care especially affect the
poor, members of minority groups, and residents of most inner cities and
many rural areas. Homeless people often face additional obstacles to
receiving health care services.
This chapter reviews factors that directly determine how homeless
people do or do not obtain physical and mental health services, first, as
a part of the larger population of the poor and then, more specifically,
as homeless people. It begins by discussing the following questions:
· Why do poor people use health care services to a lesser extent than
non-poor people?
· What are the barriers to health care specifically faced by homeless
people?
· What is the role of public and private health insurance and the impact
of Medicaid in providing financial access?
The chapter then discusses the role of the traditional system of health
care for the indigent (including the National Health Service Corps) and
examines its role in filling the gaps resulting from the failure of Medicaid
to provide access. The chapter then reviews two specialized health care
systems: one to treat mental illness and the other to provide services to
veterans.
76
OCR for page 77
ACCESS TO HEALTH CARE SERVICES 77
HEALTH CARE OF THE INDIGENT
A right to health care has never been established in the United States
either by statute or case law, but a broad base of public opinion generally
appears to support the notion that people should be able to get medical
attention when they need it, regardless of economic or social circum-
stances (New York Times, December 1, 19874. To quote from the 1983
report of the President's Commission for the Study of Ethical Problems
in Medicine and Biomedical and Behavioral Research:
The Commission concludes that society has an ethical obligation to ensure
equitable access to health care for all. This obligation rests on the special
importance of health care: its role in relieving suffering, preventing premature
death, restoring functioning, increasing opportunity, providing information about
an individual's condition, and giving evidence of mutual empathy and compassion.
Furthermore, although life-style and the environment can affect health status,
differences in the need for health care are for the most part undeserved and not
within the individual's control.
The President's commission also stated that "equitable access to health
care requires that all citizens be able to secure an adequate level of care
without excessive burdens" and that "efforts to contain rising health
costs are important but should not focus on limiting the attainment of
equitable access for the least well served portion of the public" (Presi-
dent's Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research, 19831.
Reality, however, has not matched that aspiration. For example, in
1986, the Robert Wood Johnson Foundation funded a study of a random
sample of the general public to determine to what extent people have
access to health care in the United States (Robert Wood Johnson
Foundation, 19871. Along the lines of a previous study conducted in 1982
(Aday et al., 1984), the surveyors interviewed 10,130 people (adults and
adults responding on behalf of their minor children), primarily by telephone
contact. A separate sample of 300 households without telephones was
interviewed to increase the representative nature of the sample. Eighteen
percent of Americans surveyed were unable to identify a usual source of
medical care a question that health services researchers consider a
benchmark for access to care. It should be noted that 18 percent of the
population is equal to 40 million people. The proportion of the population
without a usual source of care had increased two-thirds since the survey
conducted in 1982.
A somewhat similar survey, the National Health Interview Survey
(NHIS), is conducted on a continuous basis by personnel of the U.S.
Bureau of the Census. Reports of data drawn from this survey are
published at various times by the National Center for Health Statistics,
OCR for page 78
78 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
a division of the Public Health Service of the U.S. Department of Health
and Human Services. The method used in this survey personal inter-
views based on a random sample of households is generally considered
by statisticians to be more reliable than telephone interviews, especially
in obtaining a valid sample of the general population.
Comparisons with the data obtained in the Robert Wood Johnson
Foundation survey (1987) must be limited because the NHIS survey does
not estimate how many people lack a "usual source of health care."
However, both surveys asked the respondents if they had seen a physician
at any point in the year prior to the interview. The Johnson survey
reported that 33 percent of the respondents answered in the negative (up
from 19 percent in the 1982 survey). NHIS reported that 24 percent of
the respondents answered in the negative in their survey; this was the
same percentage as that in each of the previous 5 years (Kovar, 19871.
There are many reasons why people might not use medical care; the
most obvious is that some do not need it. In the aggregate, Americans
were probably healthier in 1986 than they were in 1982, and young adults
continue to use medical care less frequently than do older people. There
are, however, certain circumstances under which the need for medical
service is broadly supported both by professional consensus and popular
opinion, and in those circumstances the Johnson survey found some
disheartening results. Seventeen percent of persons with identified chronic
illnesses (e.g., diabetes or heart disease) that require regular medical
supervision did not see a physician in the previous year; 20 percent of
persons with hypertension had not had their blood pressure checked in
a year; and 15 percent of pregnant women did not receive prenatal care
during their first trimester.
People in fair or poor health with incomes below 150 percent of the
poverty level visited physicians 27 percent less often than did non-poor
people in poor or fair health; blacks in fair or poor health had one-third
fewer physician visits than did non-Hispanic whites. Poor children saw
physicians in 1986 as often as non-poor children did, but poor children
were three times as likely to be reported as being in poor or fair health.
Poor people were somewhat more likely to be hospitalized in 1986 than
non-poor people, but they were substantially more likely to have serious
health problems of the sort that ordinarily lead to hospitalization.
Controlling for degree of illness, the poor received substantially less
hospital care, physicians' services, and dental care than the non-poor
(Robert Wood Johnson Foundation, 1987~.
Data from NHIS are not adjusted by severity of illness. Even so, NHIS
found that poor children (under age 17) had fewer physician visits than
non-poor children. Poor adults (between ages 17 and 64) and the poor
elderly (over age 64) had a higher average number of such visits per year
OCR for page 79
ACCESS TO HEALTH CARE SERVICES 79
than the non-poor in the same age ranges; however, it has long been
established that the poor have a significantly higher burden of illness
than the non-poor (National Center for Health Statistics, 19884.
Ethnicity, location, education, and social circumstances contribute to
difficulties in obtaining needed medical care, but the primary reason for
access problems among the poor and near-poor is financial. Obviously,
the inability to pay for care is a condition that also applies to the homeless
poor (Robertson and Cousineau, 19861. Nine percent of low-income
people reported to the Johnson surveyors instances in which they had
been deterred from seeking medical care for financial reasons or had
sought care and had been turned away (Freeman et al., 19871. Predictably,
the greatest difficulties in obtaining medical care are experienced by low-
income people without health insurance, either public or private. As
shown in Figure 4-1, the proportion of those deterred from care by
financial considerations is twice as great (13 percent) among the uninsured
as that among the population as a whole (6 percent).
The most likely explanation for the Johnson survey's finding of reduced
access to health care compared with that 5 years ago, especially for low-
income Americans, is the substantial increase in the number of people
without health insurance. Although the numbers are subject to interpre-
tation and are not derived from entirely consistent data sources, the
number of Americans without health insurance at any given time has
increased from roughly 25 million in 1977 to perhaps as many as 37
million or 38 million today. Slightly more than half of the uninsured live
in households with incomes that are less than 150 percent of the poverty
level. More than half of the uninsured live in households that have at
least one employed person (Sulvetta and Swartz, 19861. In addition, as
Table 4-1 indicates, those people without health insurance coverage are
concentrated primarily in the younger segment of the U.S. population
ILL
O I
ct 1 0-
I
Z (9
LL] LiJ
~ O . ,
Do:
Total Low-lr~come Black Hispanic Uninsured
FIGURE 4-1 Percentage of Americans not receiving health care for economic
reasons in 1986. SOURCE: Kovar (19871.
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80 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
TABLE 4-1 Health Insurance Coverage, Fourth Quarter, 1985
(numbers in thousands)
Age and Race
Percent
Percentage No. not Percentage Distribution
Covered by Covered by not Covered of Uncovered
Population Insurance Insurance by Insurance Population
Insurance
Total 235,520 86.7 31,285 13.3 100.0
Age
< 16 55,612 84.5 8,616 15.5 27.5
16-24 34,596 78.6 7,389 21.4 23.6
25-34 41,363 83.6 6,786 16.4 21.7
35-44 32,133 89.1 3,514 10.9 11.2
45-54 22,459 90.0 2,273 10.1 7.3
55-64 22,135 88.5 2,553 11.5 8.2
Total under 65 208,298 85.1 31,131 14.9 99.5
Total 65 and over 27,222 99.4 154 0.6 0.5
Race
White 200,083 87.6 24,840 12.4 79.4
Black 28,496 80.7 5,501 19.3 17.6
Spanish origina 14,175 73.0 3,822 27.0 12.2
NOTE: Numbers do not add due to rounding.
aPeople of Spanish origin may be of either race.
SOURCE: U.S. Bureau of the Census (1985).
and among minorities, two subpopulations that are disproportionately
represented among the homeless.
Here, the NHIS data tend to support the Johnson survey, at least
concerning the extent of the problem of a lack of health insurance among
the poor. NHIS reported that 28 percent of families with an annual
income below $10,000 lacked any form of health insurance, even Medicaid.
Because NHIS found that virtually all respondents in their survey who
were over age 65 had some coverage (usually Medicare, frequently with
some supplemental coverage), the more accurate figure for those with
incomes below $10,000 per year is that for the poor population under age
65. When the elderly are removed from the calculation, the proportion
of the poor without anv coverage rises to 32 percent for those with
, - 7 — ~ ~
incomes under $5,000 per year and to 37 percent for those with incomes
between $5,000 and $9,999 per year. According to NHIS, among those
under age 65, the groups most likely to lack coverage (irrespective of
income) are those who are unemployed (38 percent), the poor (35 percent),
those with less than 12 years of education (26 percent), those between
OCR for page 81
ACCESS TO HEALTH CARE SERVICES 81
the ages of 18 and 24 (25 percent), and blacks and others (20 percent
each). As to why people lack coverage, 63 percent of the respondents to
the NHIS survey who did not have coverage identified the inability to
afford such insurance as their primary reason (U.S. Department of Health
and Human Services, 1987J.
For the proportion of uninsured people to be so great and to be
increasing appears to be unprecedented in recent history. Although the
number of uninsured people increased with the growth of unemployment
during the recession of 1981-1982 (as was the case in earlier recessions),
it has continued to increase during the period of economic growth that
has largely prevailed since then. Beginning in the 1930s, economic growth
in the United States has invariably been accompanied by expanded and
improved health insurance coverage (along with other employment-based
fringe benefits), but that pattern no longer holds. As Table 4-2 indicates,
the percentage of uninsured has steadily increased since 1980 (there was
a slight decrease of 0.2 percent in 1986~.
Over the past several decades, health insurance has been tied primarily
to employment for most nonelderly Americans or to income support
programs through Medicaid for those outside the labor market. The
growth in the number of uninsured people during the past decade has
occurred largely among the employed, and may be attributable to changes
in the labor market. Employment in manufacturing industries, which
have traditionally provided the most generous insurance benefits, has
fallen, and the most dramatic employment increases have occurred in
service industries in which employee benefits have historically been and
continue to be less generous. In addition, although the unemployment
TABLE 4-2 Nonelderly Population Without Health
Insurance, 1980-1986
No. of
Nonelderly Nonelderly
Population Uninsured Percentage
Year (in millions) (in millions) Uninsured
1980 199.0 29.6 14.9
1981 200.6 NAa NA
1982 202.1 30.7 15.2
1983 203.9 32.7 16.0
1984 205.6 35.0 17.0
1985 207.2 36.8 17.8
1986 209.4 36.9 17.6
aNA = Not available.
SOURCE: U.S. Congress, House, Committee on Ways and
Means (1987).
OCR for page 82
82 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
rate has fallen in the past several years, the labor force has expanded
dramatically, so that the number of unemployed people remains quite
sizable.
Among low-income people, access to health care is often difficult, even
for those who have Medicaid coverage or private insurance. Access to
health care is still more difficult for people without any form of health
insurance. Extending health insurance to those not presently covered is
a critical issue in terms of preventing homelessness, especially as it may
result from the financial consequences of illness or injury. As indicated
earlier, one principal barrier to care is financial, but other barriers include
an undersupply of services in many poor communities, provider hostility
or resistance, cultural differences, and transportation.
This last barrier transportation is especially crucial for the rural
poor. Transportation to and from health care facilities in rural areas may
be largely unavailable, and clinics may be located many miles away.
During the site visits to rural areas in Alabama, Minnesota, Mississippi,
and North Dakota, members of the committee heard references to poor
people in need of health care paying a friend or neighbor to transport
them to a health care program, with no guarantee of a return trip home.
Health care could literally be out of reach for the rural poor and the rural
homeless.
Both the health care system for the indigent and the Medicaid system
impose considerable noneconomic costs on their users as a result of
resource scarcity, governmental suspicion of the beneficiaries of public
programs, or both. Waiting times are often long at hospital clinics or
income maintenance eligibility centers; physical amenities are generally
few; and the hours of operation often appear to have been established to
suit the convenience of the facilities' employees rather than that of its
clients. These problems are encountered by many low-income people,
but they have especially severe consequences for the homeless.
MEDICAID
In the United States, the major program for the provision of health
insurance for low-income people now covers a smaller fraction of the
poor than it did at any time in the past decade. Aggregate Medicaid
enrollment has not grown, but the number of poor people has increased
by roughly 40 percent (U.S. Department of Health and Human Services,
19851. To understand the importance and limitations of Medicaid as a
vehicle for providing access to health care for low-income people,
including the homeless, it is necessary to penetrate a thicket of Medicaid
practices, beginning with two of Medicaid's fundamental precepts: eli-
gibility and benefits.
OCR for page 83
ACCESS TO HEALTH CARE SERVICES 83
Eligibility
Medicaid was erected on the structures of the preexisting income
maintenance programs provided under the Social Security Act, specifi-
cally, Aid to Families with Dependent Children (AFDC) and Aid to the
Blind, the Disabled, and the Old-Aged, all of which (except AFDC) were
federalized and subsumed under Supplemental Security Income (SSI) in
1972 (Stevens and Stevens, 1974~. Eligibility for either AFDC or SSI
automatically confers Medicaid eligibility on the recipient, except in a
few complicated instances in certain states. In addition, states may
provide Medicaid for "categorically related people," those in households
that would be eligible for AFDC or SSI except that their incomes exceed
eligibility standards by no more than one-third. Categorically related
people may also be covered, at state option, if they are "medically
needy," meaning that their total income minus their medical expenses is
less than a set level determined by the state. That level ranges from the
maximum standard of income eligibility up to 133/ percent of that
standard.
As with income maintenance programs, Medicaid is a federal-state
program financed in part (about 54 percent) by the federal government,
but administered by the states under federal rules and supervision. The
latitude for state discretion is extremely wide and the result is extraor-
dinary diversity. It is often suggested that Medicaid is best understood
as 54 separate programs (the 50 states plus the District of Columbia,
Puerto Rico, the Virgin Islands, and Guam), rather than a single, unitary
program. Thus, individuals with incomes as high as $414 a month, before
medical expenses, are eligible for Medicaid in Wisconsin, although an
income in excess of $117 a month would render individuals ineligible in
Tennessee. For a family of four in Alabama, $147 a month is the cutoff
point for eligibility, but a family of four in California is "medically needy"
at an income level of $801 per month (U.S. Department of Health and
Human Services, 19851. Table 4-3 illustrates the wide diversity from state
to state of the threshold of eligibility based on annual income (and
percentage of the official poverty level) for the three major programs
(AFDC, medically needy, and SSI) that enable a family or individual to
be eligible for Medicaid. Interstate variation extends to eligibility cate-
gories as well as income levels. A particularly dramatic example is the
contrast between the 27 states that provide AFDC (and thus, automati-
cally, Medicaid) to two-parent households with children in which the
principal wage earner is unemployed and the 23 states in which such
households are ineligible for Medicaid (U.S. Congress, House, Committee
on Ways and Means, 19871.
Perhaps of still greater concern, in terms of the problems of homeless
OCR for page 84
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OCR for page 92
92 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
Commission to Prevent Infant Mortality cites the increase in the number
of "boarder babies" many of whom are infants with AIDS for whom
there are no homes (their own or foster homes), who, as a consequence,
spend weeks or months in hospitals as a factor in increased costs to
such facilities (Medicine and Health, 19874.
Whatever the sources or magnitude of financing for uncompensated
care, they have not grown over the last decade nearly as fast as the
number of uninsured people has. It appears that the provision of
uncompensated care by hospitals is more sensitive to the supply of the
subsidy than to the demand for services. As a result, the amount of
uncompensated care provided by hospitals, although it has increased
substantially in the past several years, has not increased as fast as the
number of uninsured people (Feder et al., 19841. Therefore, uninsured
homeless individuals are, in a sense, competing with the growing numbers
of other uninsured domiciled people for the relatively scarce resource of
subsidized hospital services, especially because the homeless population
is concentrated in those areas where the demands on hospitals are
greatest.
Clinics
The other principal pillar of the indigent care system has been the free-
standing clinics supported by public or philanthropic funds. These sprang
up in many cities contemporaneously with the founding of modern
hospitals around the turn of the century and retained a special focus on
service to the poor.
The expansion of free-standing clinic services for low-income com-
munities was encouraged by the war on poverty in the 1960s, which
supported the development of about 125 neighborhood health centers
serving approximately 1.5 million people. In 1976 federal support for
such centers was merged with various other forms of categorical support
for clinic activities under Section 330 of the Public Health Service Act
(Davis and Schoen, 19781. Under the Omnibus Budget Reconciliation
Act of 1981 (P.L. 97-35), federal financial support both for community-
based health centers and specialized maternal and child health care
centers was substantially reduced. A number of localities closed or
consolidated facilities. Many health centers, public and private, were
forced to reduce their budgets and services. Nonetheless, several hundred
such centers survive, in both urban and rural areas, supported by federal
and local—and in some instances, state appropriations, as well as
Medicaid and Medicare revenues. The performances of such centers are
as diverse and variable as all their other characteristics, but most
evaluations have been relatively positive. In most instances they do not
OCR for page 93
ACCESS TO HEALTH CARE SE
RVICES 93
appear to have supplanted hospital emergency rooms or clinics as
providers of care to the poor, but rather to have reached previously
unserved populations, and they remain important to the care of indigents
in many communities. Few such centers reached out to the homeless
before the initiation of the Robert Wood Johnson Foundation-Pew
Memorial Trust Health Care for the Homeless program. However, many
now constitute important components of health care services for homeless
individuals.
The National Health Service Corps
Over the past decade, many of the facilities and programs that conduct
health care for the medically indigent have relied on the National Health
Service Corps (NHSC) for the recruitment of professional personnel.
The NHSC was established in 1974 both as a response to the problems
of inadequate physician supply in underserved areas and a perceived
need to subsidize professional education for students who might be
attracted to serve in those areas. It is now being phased out in the face
of budgetary pressures and a perceived physician surplus. The NHSC
has placed physicians, nurse practitioners, dentists, and other health care
personnel in neighborhood health centers, free-standing clinics, outpatient
departments, and other providers of service to medically underserved
communities. In several of the sites visited by the committee where
health care services were being provided to homeless people, NHSC
practitioners played a central role. The overall performance and cost-
effectiveness of the NHSC are matters of some dispute, but the committee
is pleased to note that the Stewart B. McKinney Homeless Assistance
Act of 1987 (P.L. 100-77) contains specific provisions authorizing NHSC
placements in sites providing health care to homeless people.
Categorical Programs
Contributing further to the organizational complexities of providing
care to low-income persons are hundreds of specialty outpatient programs
that offer such services as family planning, alcohol and drug treatment,
mental health care, disease-specific services, or services to specific
populations, such as migrant workers or native Americans. While some
of these programs were not designed specifically to serve the poor, they
do, in effect, provide service to low-income people who are members of
those groups to whom the programs are targeted. Many of these programs
rely heavily on federal funding. In many instances this source of funding
has been cut back in the last decade, with some substitution of state or
local funding. The availability of any such services and their relevance
OCR for page 94
94 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
to the needs of homeless people vary considerably from community to
community, and an accurate generalization is impossible. Such service
programs are, however, an important part of the indigent care system in
some areas and should not be overlooked in any overview of that system.
ADDITIONAL BARRIERS TO ACCESS FOR
HOMELESS PEOPLE
In their evaluation of the benefit status of homeless people seen in 16
of the Robert Wood Johnson Foundation-Pew Memorial Trust Health
Care for the Homeless (HCH) projects, Wright and Weber (1987) noted
that a determination of benefit status could not be made for 24 percent
of the people seen by workers in these projects. Of the 76 percent for
whom benefit status was known, about half were receiving some form of
financial benefit and about half were not. They concluded that almost all
clients of the HCH projects who were eligible for any benefits from public
entitlement programs were already enrolled in them and that those who
were not enrolled were not simply because they were not eligible. After
examining several possible factors that conceivably could affect whether
a homeless person receives any existing form of financial assistance
(including Medicaid), they concluded that by far the most significant
factor was the leniency of eligibility requirements for each program as
determined by each state:
The "entitlement problem" for the homeless is not that they do not participate
in programs for which they are eligible, but that in many states they are not
eligible for programs of assistance regardless of their rather obvious needs.
(Wright and Weber, 1987)
Wright and Weber noted that among the 16 projects included in their
study, the proportion of homeless clients receiving any benefits ranged
from 22 to 82 percent; the basis for this variation was primarily the
eligibility standards of the respective states. However, they also noted
that "the benefit levels typical of most social welfare programs are so
low as to make only a marginal contribution" to the ultimate goal of
"getting the client off the streets or out of the shelters and into some
reasonably stable housing and social situation."
Ineligibility is only one barrier to access for the homeless; there are
others. The extreme case of such barriers to the homeless has been the
requirement that individuals have a permanent address for Medicaid
eligibility or for receipt of services from certain providers with defined
areas of geographic responsibility. Even with the recent passage of federal
legislation prohibiting the requirement of a fixed address as a basis for
eligibility for entitlement programs, homeless people are still in no position
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ACCESS TO HEALTH CARE SERVICES 95
to receive mail notices of clinic appointments, laboratory or x-ray results,
or required reappearances for recertification of Medicaid eligibility or
appeals of disability determinations. Absence of an address is not the
only documentation problem encountered by homeless people. In the
shelters and on the streets, where homeless people spend much of their
time, personal identification papers are a valuable commodity sought by
thieves and entrepreneurs. The exigencies of a homeless existence rarely
afford a means of protecting personal documents from theft, loss, or
damage from the elements.
Particular problems that bureaucratic obstacles can create for homeless
people were frequently reported to the committee during its site visits.
One important example is the scheduling of clinic appointments and
ancillary services at times that conflict with the availablity of the only
daytime meals homeless people can get or with the time they must begin
lining up for shelters to ensure that they have a place to sleep that night.
The problems of access put a premium on the ability of homeless people
to cope with and manage complicated bureaucratic systems and routines.
Those abilities are often limited among homeless people in general and
not only among those whose capacity is impaired by mental disorders or
substance abuse. For example, the lack of a watch can make the keeping
of appointments quite difficult. The use of public transportation, a frequent
source of frustration even for the average urban commuter, presents a
greater impediment to a person who has money for only one fare and
cannot afford to make mistakes in matters oftransfers orroutes. Moreover,
providers experienced in working with homeless people report that they
avoid institutions and bureaucratic procedures, often because of prior
negative experiences (Brickner et al., 1985~. In addition, in many instances
service providers are not interested in efforts to reduce these barriers.
Homeless people can appear as extremely unattractive potential clients
that institutions or professionals may try to avoid. At the most basic
level, homeless people often are physically unattractive, unwashed, and
lack clean clothes. They may not be compliant, in part because of the
exigencies of a homeless existence. Providers often feel that they will
not or cannot follow through with therapeutic or self-care regimens
(Brickner et al., 19851.
Many homeless people, with or without identifiable mental illness, are
passively resistant to service provision, including health services (Vicic
and Doherty, 1987~. Successfully engaging such persons for purposes of
diagnosis and treatment involves extra efforts on the part of health care
providers. Many providers may not be sufficiently motivated or knowl-
edgeable to undertake such efforts. The health care system in general,
and providers of service to poor people in particular, are most responsive
to those patients who are most motivated, demanding, or both. Providers
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96 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
of services tend to react negatively to those who appear to be uncoop-
erative or uncompliant.
MENTAL HEALTH CARE
Approximately one-third of all homeless people show symptoms of
mental illness. The barriers to access discussed above generally apply
also to this group of homeless people. In most respects, especially with
regard to the reluctance of health care institutions and providers to treat
the homeless, the barriers are even greater.
There are, however, two major exceptions to this observation. The
mentally ill among the homeless are theoretically more likely than those
without such a disability to be eligible for SSI benefits (and, therefore,
Medicaid). The SSI program specifically provides for benefits to the
mentally disabled. This greater access to SSI eligibility is, however,
somewhat illusory because the standards by which disability is determined
are open to a wide range of interpretations. The extent to which such
interpretations can determine eligibility was clearly seen during 1981-
1984 when, in response to what was intended to be simply a clarification
of such standards, thousands of mentally disabled people were dropped
from the SSI rolls. Later restoration of most of them did not completely
allay misgivings about the operation.
The potential of the mentally ill for SSI eligibility may be helpful, but
the health care benefits received to support treatment for mental illness
are generally inadequate, if not inappropriate. In those states in which
Medicaid programs fund mental health care (not all do), it is usually only
for inpatient care, and then it is only for a very limited period of time
(usually 30 days). The prospective patient, therefore, is in a situation of
being declared eligible for benefits based on a disability for which treatment
is either poorly funded or not funded at all. The concept that such
treatment might ultimately enable the individual to move on to productive
employment appears to have been sacrificed to cost-containment mea-
sures.
Government, especially at the state level, has long accepted a primary
responsibility for the provision of mental health services. The creation
of large state-operated mental health facilities goes back to the middle
1800s, and many states mandate such a responsibility in their state
constitutions. A role for the federal government is more recent, having
largely begun with the report of the Joint Commission on Mental Illness
and Health, Action for Mental Health, in 1961 and the various pieces of
legislation that sought to implement the most significant recommendations
of that commission. The general intent of that legislation was to transfer
mental health care from the large state-operated hospitals to small
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ACCESS TO HEALTH CARE SERVICES 97
community-based mental health centers. This, as much as the discovery
and widespread use of psychotropic drugs, was a key element in what is
now called deinstitutionalization.
At the time of passage of the Mental Retardation Facilities and Com-
munity Mental Health Centers Construction Act of 1963 (P.L. 88-184),
it was anticipated that 2,500 community mental health centers would be
constructed throughout the United States. At best, only about 700 of
these centers ever opened (President's Commission on Mental Health,
19781. Unlike the general health care system, which has a seemingly
adequate supply of hospitals, the mental health care system severely
lacks the most basic units for treatment posing the ultimate barrier to
access.
Despite substantial increases in state spending on mental health, little
has been done to increase the supply of community-based mental health
care centers. Of the approximately $6 billion spent annually on state-
operated mental health care, more than $4 billion, or approximately 70
percent, is spent on state institutions (Rubenstein, 19861. Although to
some extent this allocation of expenditures is the result of the effort to
upgrade the quality of care in state institutions that accompanied the
effort to transfer care to community-based facilities, the net effect on the
mentally ill person in the community remains the same: there is no place
to go. In the competition for such a scarce resource as community-based
treatment, the homeless person is in a particularly uncompetitive position.
There have been some recent developments toward increasing access
to mental health care services for the homeless. One of the most notable
programs is the Community Support Program (CSP), which is directed
by the National Institute of Mental Health. CSP was developed to provide
time-limited demonstration grants in support of efforts to find new
approaches for providing services to the homeless mentally ill. The
Stewart B. McKinney Homeless Assistance Act of 1987 (P.L. 100-77)
authorized an additional $10 million for this program for fiscal year 1987
as well as $30 million for a new block grant program for services to
homeless people who are chronically mentally ill.
The mentally ill among the homeless are quite noticeable, and this has
raised anew old issues regarding a civil commitment to treatment facilities.
The current basis of commitment in most states can be described as a
clear and present danger to him- or herself or others. Even in those states
that have a broader basis for commitment (e.g., an inability to perform
life-sustaining activities), such factors as budget constraints, fear of legal
reaction, or a desire to provide treatment in the least restrictive environ-
ment have left the clear and present danger criterion as the basis for
commitment. As a consequence, a new approach, outpatient commitment,
has been proposed (American Psychiatric Association, 19871. Outpatient
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98 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
commitment refers to the procedure by which a court orders treatment
in the community for a person who does not meet the standard for civil
commitment to an institution (Kanter, 1987~. Such an approach is based
on an assumption that there are programs in existence that are not only
prepared to treat people so committed but that have the facilities and
space to do so. That is not the case in most jurisdictions. Especially
troublesome are reports of attempts to commit mentally ill people to
outpatient services and then require that they pay for those services
(Stefan, 19861. The penalties that would be imposed on someone who is
committed by the courts to outpatient services and who then refused to
pay for such services have not yet been identified.
VETERANS
As many as 40 percent of the homeless adult men in some communities
are veterans, and many of those are Vietnam-era veterans. Some may
be eligible for services from the largest public health care system in the
United States: the Veterans Administration (VA).
The VA health care system includes 172 hospitals, 229 outpatient
clinics, 117 nursing homes, 16 domiciliary facilities, and a range of
contracted services, directly employing more than 200,000 people at an
annual expense of almost $10 billion. In fiscal year 1986, this system
provided almost 1.5 million inpatient stays and more than 20 million
outpatient visits. It has particularly extensive services for alcoholism and
drug dependence, operating 103 specialized alcoholism programs and 51
specialty drug dependence programs (Veterans Administration, 1987~.
Veterans with an unblemished discharge status are automatically eligible
for free VA services for the treatment of service-connected illnesses or
disabilities; free or subsidized services are also available to low-income
and elderly veterans. Although they are more stringent than they have
been in the past, the income eligibility criteria for VA medical services
remain substantially more generous than those of other publicly supported
benefits.
Yet, it is widely believed that relatively few homeless people take
advantage of the VA health care services to which they are at least
theoretically entitled. In part as a response to this perception, the VA
has undertaken a number of initiatives to expand services to homeless
veterans. Five million dollars has been appropriated for 43 demonstration
projects for the community-based treatment of the chronically mentally
ill, with particular emphasis on outreach to homeless veterans. Additional
funds were appropriated in mid-1987 for the development of new and
expanded domiciliary services for homeless veterans, and a number of
VA facilities and programs have begun to undertake more aggressive
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ACCESS TO HEALTH CARE SERVICES 99
outreach programs to homeless veterans, as mandated by the Omnibus
Budget Reconciliation Act of 1986 (P.L. 99-509~.
The interim report of that effort, released in October 1987 and covering
the first 4 months of the Homeless Chronically Mentally Ill (HCMI)
outreach project, partially confirmed the belief that homeless veterans
do not for various reasons—avail themselves of VA medical services
(Rosenheck et al., 19871. Although 97 percent of the 6,342 individuals
contacted during the first 4 months appeared to be eligible veterans (i.e.,
veterans who had been honorably discharged), of those for whom intake
assessments were completed (N = 4,010), only 18 percent were receiving
any financial support from the VA. With regard to access to VA health
and mental health care, a sample of 727 veterans contacted through the
HCMI program showed that 75 percent of the sample had three or fewer
contacts with VA mental health outpatient services during the 6 months
immediately prior to contact with the outreach program; 42 percent had
no contact with any medical or psychiatric outpatient providers, but 38
percent did have at least one admission to some form of inpatient care.
VA health care facilities are often located at some distance from where
homeless people congregate. This presents a serious issue of access,
especially if there is no specific outreach program to homeless veterans.
This situation is further exacerbated by the VA's system of priority
eligibility; who actually receives care is based on the level of disability,
whether it is service connected, and the capacity of the specific VA
facility in question (U.S. Department of Health and Human Services,
19871. The recent initiatives of the VA are particularly encouraging, but
the gap between current and potential services to homeless veterans
remains considerable. In addition, the extent of the disability by which
one qualifies for full benefits has been raised, making it more difficult for
some veterans to qualify. Unless such veterans live in a state where their
disability qualifies them for Medicaid, they may be without health care
benefits. One especially troublesome issue was reported to the corr~mittee
during its site visits: Veterans whose disabilities are such that they receive
no or only partial VA benefits may be denied non-VA benefits (Medicaid,
SSI, or general assistance), on the erroneous assumption, by those
responsible for determining eligibility for non-VA programs, that the
financial relief for such individuals should come from the VA. The VA
HCMI project found that more than half (54.8 percent) of the veterans
seen in the sample of intake assessments were receiving no benefits from
any source.
One final and substantial barrier to access to care for veterans comes
in the nature of their discharge from military service. If their military
discharge was anything other than honorable (i.e., less than honorable
or dishonorable), they are effectively barred from receiving VA benefits.
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100 HOMELESSNESS, HEALTH, AND HUMAN NEEDS
The VA has a system by which the nature of a discharge can be reviewed
and possibly upgraded, but it is cumbersome and requires extensive
documentation. It is also not well publicized among veterans, especially
disaffiliated homeless veterans. Each of these are specific and serious
obstacles to the receipt of health care services by homeless veterans.
Outreach and educational programs, such as those that are now being
initiated by the VA, as well as counseling programs, which have been
conducted for many years by such organizations as Vietnam Veterans of
America and Swords to Plowshares, could be highly effective in resolving
veterans' access to health care. Ultimately, the success of such efforts
depends on the criteria—and the interpretation of those criteria—by
which requisites for upgrading of discharge status will be evaluated.
SUMMARY
Homeless people, who are predominantly low-income, uninsured res-
idents of mostly low-income communities, share with other low-income
residents of such communities a range of difficulties in getting health care
when they need it. The most significant barriers to access are financial.
At the same time, the homeless encounter a range of additional barriers
to health care.
In order to develop service programs to meet the health care needs of
homeless people, it is necessary to address both the general issues of
access to care and the special problems encountered by homeless people
in obtaining access. Financing mechanisms are obviously the first pre-
condition, whether they are through improving eligibility for Medicaid or
other benefit programs or through procurement of direct subsidies.
Financing, however, while a necessary condition, is not sufficient.
Problems of scheduling, transportation, and negotiating systems must
also be solved. The practices and attitudes of providers, along with the
special problems posed by the passivity, isolation, and resistance of
homeless people, many of whom have had negative experiences with
health care institutions, must also be taken into consideration. How some
of these problems have been met in a number of specific programs is the
primary content of the next chapter.
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Representative terms from entire chapter:
care services
