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Insured homeless people report less difficulty accessing health care, according to UCSF researchers

University of California - San Francisco

Insured homeless people report fewer barriers to accessing outpatient care and better adherence to prescription regimens than their counterparts without insurance. The study, published in JAMA, is among the first to analyze barriers to health care use in a national sample of urban, suburban and rural homeless people. Results add weight to previous research, which has focused only on the urban homeless in specific cities, according to Margot B. Kushel, MD, UCSF fellow in general internal medicine at San Francisco General Hospital Medical Center and Jennifer Haas, MD, UCSF assistant professor of medicine.

For homeless people, health care competes with more immediate needs, such as obtaining food and shelter. However, prior research shows that given the opportunity, homeless people are willing to obtain care for chronic problems. It is an absence of insurance that appears to be an important barrier to accessing care, according to Kushel.

Haas explained that having insurance may enable easier access to outpatient services, in particular, thereby preventing late stage illness. "Homeless persons too often reach a point at which they have little choice but to seek emergency room care. They seek emergency room care whether or not they have insurance," she said.

In the sample of 2974 homeless persons, the researchers identified 663 veterans. Veterans were analyzed to determine whether they were receiving insurance benefits to which they were entitled. Most veterans in the study reported receiving an honorable discharge (90 percent), making them eligible for these benefits. Despite this, almost half of the homeless veterans (48.4 percent) were uninsured. Only 26.8 percent had VA insurance.

"These data suggest that improving insurance rates among homeless veterans will require not only expansion of eligibility, but also improvements in identifying and enrolling those who qualify," said Kushel.

Subjects were asked if they needed care from a physician or nurse in the past year, but were unable to obtain it. If they responded affirmatively, they were classified as being unable to receive needed care in the past year. They were also asked whether they were supposed to be talking prescription medication and if they had been able to take the medication as prescribed. If the response was negative, they were classified as having been unable to comply. More than half (55.6 percent) of respondents reported being uninsured, and over one quarter of respondents in the study (26.7 percent) reported no contact with a medical provider in the past year. Those with insurance were more likely than their uninsured counterparts to seek a site of care that was not an emergency room. Women were more likely than men to use ambulatory care, as are the marginally homeless, compared to the literally homeless, said the researchers.

The investigators analyzed data from the National Survey of Homeless Assistance Providers and Clients (NSHAPC). The survey, performed by the Census bureau, was designed to enroll people who used a variety of homeless service agencies in urban, suburban, and rural areas. The largest metropolitan areas were chosen to represent urban areas. Other areas were randomly sampled from the remaining small and large sized areas to represent suburban and fringe areas. Groups of rural counties were also selected at random.

Factors associated with the use of ambulatory care, emergency departments, and acute care hospital services, and perceived barriers to health care were analyzed in five domains: sociodemographic characteristics, physical health, mental health and substance abuse, and history of homelessness. Respondents were categorized as literally homeless if they had spent the majority their time on the street or in a shelter and marginally housed if they had spent the majority of their time staying in transitional housing, a hotel, or a friend's or relative's home.

Census bureau results enabled researchers to qualify the national homeless population. The current homeless population is predominately young (75 percent between 25-44, median age 37) and male. Yet, their rates of hospitalization are similar to the frail elderly. "Homelessness really takes on toll on health," said Haas.

  • More than 90 percent are single, but nearly 43 percent of respondents had been married previously.
  • Just over 40 percent of women and 3.4 percent of men were living with a child at the time of the survey.
  • More than two-thirds of the respondents are located in urban areas. Overall, 22.4 percent of respondents are veterans (32.6 percent of the men and one percent of the women).
  • Fewer than one quarter of respondents noted income greater than $600 per month.
  • Nearly 45 percent of the respondents spent the majority of their time homeless living on the street or in shelters (literally homeless) and the remainder spent the majority of their time staying with friends or family, or in hotels or transitional housing (marginally housed).
  • The median duration of homelessness for the sample was one year. Just over 15 percent were homeless for more than five years.
  • Almost three-quarters had a problem with mental health or drug or alcohol abuse. Many reported having more than one problem.


Because the subjects were sampled from those using homeless assistance services, the respondents do not represent homeless persons who did not or could not use these services. Eric Vittinghoff, PhD, MPH, UCSF assistant professor of epidemiology and biostatistics was a co-investigator on the study. The study was supported by a faculty development grant in general internal medicine from the Department of Health and Human Services.

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