Health Care and Policy Interventions to Improve the Health of Patients Experiencing Homelessness

Abstract

Housing instability and homelessness are associated with significant health burdens, including high rates of chronic and infectious disease, disproportionate vulnerability to violence and injury, and increased risk of premature death and disability. In addition, between 28-57% of nonelderly homeless adults lack health insurance coverage. Consequently, homelessness is associated with reduced access to outpatient primary care services and increased rates of emergency department (ED) visits, which are costly and inefficient for both health systems and patients. In the context of mounting emphasis on value-based reimbursement structures, health systems and policymakers have a vested interest in reducing high-cost utilization and addressing social determinants of health, including housing. Therefore, in this dissertation, I address three research questions at the intersection of housing needs and the United States health care delivery system. The first study is a systematic review of the peer-reviewed literature evaluating interventions to reduce ED utilization among adults who experience homelessness. The second study uses state-level panel data to examine the impact of Medicaid expansion on rates of adult homelessness by comparing states that opted to expand their Medicaid eligibility requirements under the Affordable Care Act (ACA) with states that did not. Finally, the third study uses multiple years of national data to assess clinical quality performance among a subset of federally qualified health centers that received Health Care for the Homeless (HCH) funding from 2014-2017 to provide homeless-tailored primary care services. Key findings include the need for larger, more generalizable studies with rigorous designs to assess the effectiveness of strategies to reduce ED use among homeless patients; expanding Medicaid eligibility may mitigate the impact of large or unexpected medical expenses among families with children who are at risk of homelessness; and finally, HCH-funded health centers have demonstrated improvements on several clinical quality indicators over time and have distinct organizational characteristics that are associated with performance on these indicators. Collectively, these studies sought to answer timely health policy and management questions about individuals who experience housing needs, a group that comprises one of the most under-resourced and socially disadvantaged patient populations in the United States.