Vulnerable Populations II

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Vulnerable Populations-Part II Sandra Ashburn HCS/531 July 25, 2011 Dr. T. Lane

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Vulnerability makes people sicker and shortens their lives, and is related to the lack of adequate income, housing, education, food, and social inclusion. The specific circumstances that increase vulnerability are job displacement by mechanization and automation; social exclusion (African Americans, Native Americans, women, immigrants, sexual orientation); chronic malnourishment; homelessness; chronic illness and disability; living with HIV/AIDS; alcohol and drug abuse; chemical exposures; mental illness; foster children aging out of the system; prisoners released from incarceration, and veterans suffering from post-traumatic stress disorder. Martens (2009) states, “In modern Western societies, several categories of patients experience lower quality of health care in terms of accessibility of care, satisfaction with care and adequate receipt of care, such as the homeless (Kim, 2007), nonelderly women with disabilities (Shin & Moon, 2008); mentally disordered (McCabe & Leas, 2008) and ethnic minority (Edelman, 2008). In this paper the subject to discuss is the homeless as a vulnerable population, the financial impact on the homeless, the funding used to assist the homeless, health, and illness trends, and evaluation of the risk to the health care system if the homeless rate continues to increase as the Patient Protection and Affordable Care Act of 2010 is enacted. In July 1987, the Congress passed the Stewart B. McKinney Homeless Assistance Act, because of concerns that the needs of the homeless were not met. Before this legislation had responded to the homeless needs for food and shelter, but the McKinney Act was the first law designed to address the diverse needs of homeless people (GAO, 1999). The McKinney Act includes emergency food and shelter, longer-term housing and supportive services, provided physical and mental health care, education, and job training (Akins, & National Coalition for the Homeless, W. C., 1988). This Act was responsible for meeting the survival needs of homeless persons. Some of these agencies are part of this Act are the Federal Emergency Management Agency (FEMA) emergency food and shelter funds; the Department of Housing and Urban Development (HUD) housing funds, and the Department of Health and Human Services (HHS) primary and mental health care program funds. The Omnibus McKinney Homeless

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Assistance Act of 1988 renewed the McKinney Act (National Coalition for the Homeless, W. C., 1989). The homeless experience financial stresses just the same as a low-income family would. There is increased stress because of no money to pay rent, lack health care due to inability to afford health care. Shi and Singh (2008) talks of health care centers with walk in appointments, which can provide health care and medications free, which can reduce the health care barrier as well as reduce the stress that the homeless feel. The Mental Health Services for the Homeless Block Grant program sets aside funds for states to implement services for the homeless with mental illness. The homeless veterans have services through the Veterans Administration and the Salvation Army also provides support services for the homeless (p. 455-456). Homeless is expensive. The cost of an emergency shelter bed funded by HUD's Emergency Shelter Grants program is approximately $8,067 more than the annual cost of a federal housing such as Section Eight Housing (Rosenheck, Bassuk, & Salomon, 1998). Looking at hospitalization, medical treatment, incarceration, police intervention, and emergency shelter expenses can add up quickly, making homelessness expensive for cities and taxpayers. The homelessness access the most costly health care services when they come to the hospital (National Alliance to End Homelessness, 2011). According to National Alliance to End Homelessness a report referenced in the New England Journal of Medicine, showed the homeless spent an average of four days longer per hospital visit than the nonhomeless. This extra cost, approximately $2,414 per hospitalization, is attributable to homelessness A study of hospital admissions of homelessness in Hawaii revealed that 1,751 adults were responsible for 564 hospitalizations and $4 million in admission cost. The cost for treating these homeless individuals was $3.5 million or about $2,000 per person (Martell J.V, 1992). National Alliance to End Homelessness states, homelessness cause serious health care issues such as psychological disorders, addiction, alcoholism, and HIV/AIDS; inability to treat medical problems can aggravate medical problems, placing their health in danger along with increasing the cost. According to the United States Government Accountability Office website (1999) there are 50 federal programs run by eight agencies that provide services to the homeless. Twenty-six programs run by

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six agencies offer food and nutrition services, including food stamps, school lunch subsidies, and supplements for food banks. In fiscal year 1997, more than $1.2 billion in obligations was reported for programs targeted to the homeless. Federal efforts to help the homeless are being coordinated in several ways, and many agencies have established performance measures for their efforts, as required by the Government Performance and Results Act. The White House: Office of Management and Budget (2010) website speaks of the President’s 2012 budget progressing toward the goals of the Federal Strategic Plan to End Homelessness. The health reform includes all homeless individuals and families who will be eligible for Medicaid insurance. Beginning in 2014, health, and homeless service providers will not be dependent on proving a person’s disability status to obtain reimbursement for most health services but states would have to participate. In an average night in the 23 cities surveyed, 94% of people living on the streets were single adults, four percent were part of families and two percent were unaccompanied minors. Seventy percent of those in emergency shelters were single adults, 29% were part of families, and one percentunaccompanied minors (U.S. Conference of Mayors, 2008). The homeless population is estimated to be 42% African American, 39% white, 13% Hispanic, four percent Native American and two percent Asian, although it varies widely, depending part of the country they are living. An average of 26% of homeless people are considered mentally ill, but 13% of homeless individuals were physically disabled (U.S. Conference of Mayors, 2008). A study done in Philadelphia comparing the mortality rate for homeless population with the rate in the general population of Philadelphia; it was found that the homeless adults have an age-adjusted mortality rate nearly four times that of the general population; their average life span is shorter than 45 years (Hibbs, 1994). The majority of homeless adults are not eligible for Medicaid or Medicare in most States Approximately 23% of the homeless are veterans of the armed services, but only 57% receive health care through the VA system, where long waits for care exist. The homeless lack health insurance, which causes them not to receive adequate preventive care and routine management of chronic illnesses such as

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hypertension, heart disease, diabetes, and emphysema and t hey visit emergency rooms for acute illnesses (Kushel & Bangsberg, 2002). The homeless do not have transportation; they depend on the routines of shelters, and soup kitchens to meet their most basic survival needs. The homeless are more concerned with meeting immediate needs for shelter, food, clothing, and safety than with seeking health care, some just avoid going. They go without care until minor problems become an urgent medical emergency. Barriers to health care include lack of knowledge about where to get treated, lack of access to transportation, and lack of identification (Whitbeck, 2009). As a result of these factors, homeless people are three to four times more likely to die than the general population (O’Connell, 2005). This increased risk is especially significant in people between the ages of 18 and 54. In conclusion our government has created various programs and funding to help those in need. It is unfortunate fact that many have taken the aid they receive for granted, and instead of improving their state of being, they continue to live their lives as homeless. There has to be a limit or a timeline set to the aid that homeless receive, and instead more educational and motivational programs have to be implemented. It is a cycle that will not end until different approach is taken into consideration. Prevention has to be the main concentration not only for the government but also for the community as well. Only by getting to the root of the problem this cycle can be ended. There should be more drug/alcohol awareness, job motivation, and most important education. Education is the key to one's success, and with right education no individual will find himself or herself homeless.

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Akins, J., & National Coalition for the Homeless, W. C. (1988) Necessary Relief: The Stewart B. McKinney Homeless Assistance Act Retrieved from EBSCOhost. GAO: U.S General Accounting Office (1999) Homelessness: Coordination and evaluation of programs are essential. Retrieved from http://www.gao.gov/archive/1999/rc99049.pdf Hibbs, J. R. (1994) Mortality in a cohort of homeless adults in Philadelphia U.S National Library of Medicine Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8022442 Kushel, M., & Bangsberg, D. (2002) Emergency department user among the homeless and marginally housed: Results from a community based study American Journal of Public Health, 92, 778-784. Martell, J., Seitz, R., & Harada, J. (1992) Hospitalization in an urban homeless population: the Honolulu Urban Homeless Project Annals of Internal Medicine, (116), 299-303 National Alliance to End Homelessness (2011) Cost of Homelessness Retrieved from http://www.endhomelessness.org/section/about_homelessness/cost_of_homelessness National Coalition for the Homeless, W. C. (1989) The Stewart B. McKinney Homeless Assistance Act Revised Summary Retrieved from EBSCOhost National Coalition for the Homeless (2009) Health Care and Homelessness Retrieved from http://www.nationalhomeless.org/factsheets/health.html National Health Care for the Homeless Council. (2010) The Basics of homelessness Retrieved from http://www.nhchc.org/Publications/basics_of_homelessness.html National Health Care for the Homeless Council (2010). Mainstreaming health care for homeless people. Retrieved from: http://www.nhchc.org/Publications/Mainstreaming.pdf. O’Connell, J. (1997). Increased Demand and Decreased Capacity: Challenges to the McKinney Act's Health Care for the Homeless Program. National Health Care for the Homeless Council. Retrieved from http://www.nhchc.org/Publications/basics_of_homelessness.html Rosenheck M.D, R. (1998) Special populations of homeless Americans The 1998 National Symposium on Homelessness Research Retrieved from http://aspe.hhs.gov/progsys/homeless/symposium/2Spclpop.htm Salit, S. A., Kuhn, E. M., & Vu, J. M. (1998) Hospitalization costs associated with homelessness in New York City New England Journal of Medicine, (338), 1734-1740 The White House: Office of Management and Budget. (2010) Winning the future for cities and metropolitan areas Retrieved from http://www.whitehouse.gov/omb/factsheet/cities-andmetropolitan-areas Whitbeck, Les B. (2009) Mental health and Emerging Adulthood among Homeless Young People Psychology Press, Taylor & Francis Group, 270 Madison Avenue, New York, NY 10016.