Homeless Demonstration program was 33 (Knight and Lam, 1986). A 1984 study of Baltimore's homeless found that only 2 percent were age 65 or older, compared with 18.1 percent of the general population (O'Connell et al., 1990).

It is always difficult to disentangle the effects of access to health care, or, conversely, lack of access, on health status; for the homeless, the difficulties in doing so increase exponentially. Indeed, poor health and the resulting inability to work, often byproducts of homelessness, may also result in homelessness. Although homeless people may have the same array of acute and chronic problems as one finds in the general population, the rates are clearly higher, and the numbers of comorbidities, including alcohol/substance abuse and mental illness, are far in excess of these rates for the general population. Many of these conditions and morbidities are amenable to medical intervention; routine health care should prevent some diseases altogether and minimize exacerbations and complications of chronic diseases. Yet the personal health care services needed by the homeless may require a different organizational configuration, a different array of services, and a different mix of providers than those required for the domiciled population. These suppositions, as well as the inability of traditional clinics and hospitals to care for the homeless adequately, gave rise to the Health Care for the Homeless Demonstration Projects and the subsequent U.S. Public Health Service's McKinney Health Care for the Homeless Program. These demonstrations rely on community-based programs that are often colocated in places in which the homeless may be found in large numbers, such as congruent feeding programs and shelters.

Although the evidence that the homeless lack access to health services, except through targeted programs, is anecdotal and inferential, it is quite convincing. In the 1988 Institute of Medicine report Homelessness, Health, and Human Needs the chapter on access reviews the limitations in systems of care for the poor and medically indigent (e.g., in public general hospitals and not-for-profit hospitals serving the poor, clinics, the National Health Service Corps, categorical programs, mental health and Veterans Administration systems, and Medicaid programs) and suggests that, in general, the homeless compete with the poor for these services. In addition to general underfinancing of health care services for the poor, the report identified additional barriers to access facing the homeless: bureaucratic and scheduling issues, lack of transportation, negative perceptions on the part of providers and institutions, and the avoidance of institutions by the homeless themselves because of prior experience (Institute of Medicine, 1988). Despite the lack of quantifiable data, no one has disputed the statements made on the original brochure for the Health Care for the Homeless Demonstration Projects: "Most homeless people do not now receive needed health services. Many are afraid of large institutions, most are uninsured, and



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