On a recent night this winter, I stood under Chicago’s Dan Ryan Expressway and watched my co-worker examine a golf ball-sized abscess on his foot. The patient winced in pain. “I kept ignoring him for weeks because I thought he would go away,” he said. We were a team of medical students and doctors providing basic health care to homeless people. But because we rely on volunteers and limited supplies, our visits are few and our medical care is basic.
The results of the 2022 national point-in-time count will soon be released, revealing the state of homelessness in the United States two years into the COVID-19 pandemic. We need our legislators and hospitals to take action regardless of these findings. We can no longer wait for the number of homeless people to skyrocket before funding for homeless health care is increased – homeless Americans already cost our health care system millions each year.
The US homeless population increased for the fourth year in a row in 2020. Due to COVID-19 concerns, the 2021 US homeless count results were incomplete and unmatched. People’s housing must remain the top priority for policymakers, but this will take time. In the meantime, we must address the health and healthcare costs of more than 580,000 homeless Americans. We must expand the scope of cost-effective homeless health care to reduce system-wide spending on this population.
One solution: Require hospitals to spend a portion of their mandatory community benefit funds to bring health care to the streets, where people live.
Street medicine can help reduce the cost of caring for the homeless by reducing emergency room visits and hospitalizations. Many homeless Americans do not have a primary care physician or use community health centers. Often this is because they don’t want to leave their belongings unattended, they don’t have access to transportation, or they have lost faith in the health care system. As a result, their poorly managed illnesses lead to hospital visits with huge bills. The average homeless person visits the emergency room five times a year, at an annual cost of $18,500. When patients are uninsured or unable to pay, hospitals often foot the bill.
Existing street medicine programs have been shown to reduce hospital spending. Between 2015 and 2017, Lehigh Valley Health Network in Pennsylvania saved $3.7 million in reduced emergency department visits and hospitalizations after instituting a street medicine team.
Not-for-profit hospitals in the US are already required to spend a portion of their surplus earnings on “community benefits” to qualify for federal income tax exemption. Most hospitals meet this obligation by covering the costs of hospital visits for low-income patients. However, given the high rates of homelessness in US cities, lawmakers could tighten the requirements that hospitals must dedicate a specific portion of their community benefits to street medicine. If hospitals don’t comply, they would risk losing their coveted tax-exempt status.
Mount Carmel Health System in Columbus, Ohio, has already pioneered this use of community benefits to fund a mobile van that visits local homeless encampments to provide basic care and connect patients with social services in the community. Similarly, Mission Health System in western North Carolina directs community benefits to fund a homeless outreach team.
Time and time again, homeless people have sought care and left feeling humiliated and angry. One man I spoke with compared being in the hospital to cruelty to animals: he felt like “a pig in a barn” because he was homeless. Bringing health workers out into the streets can rebuild some of the lost trust felt by some outside the traditional health care setting.
Certainly, there are limits to providing health care outside of the hospital. Street medicine teams struggle to get a large amount of medical supplies into the field. Furthermore, redirecting benefits from the hospital community to street care inevitably takes money away from other community improvements. However, street medicine is one of our only tools to combat the bottom line on costly hospital visits.
After careful examination with a cell phone flashlight under the freeway, the volunteer doctor determined that the patient with the swollen foot should go to the hospital. His abscess needed to be drained in a sterile environment to prevent infection and we did not have a proper medical van. They took him to the hospital, where he spent a long and expensive night in the emergency room.
As we move into the next phase of the COVID-19 pandemic, it is more important than ever to fund health care for the homeless. More than half a million Americans remain homeless each night. Hospitals have closed due to the financial burdens of unpaid medical bills. We must do more to reduce health care spending by requiring our legislators, policymakers and hospitals to invest in more street medicine.
Anna Thorndike is a medical student at the University of Chicago and a volunteer with Chicago Street Medicine.
The opinions expressed in this article are those of the author.