Homelessness, Health, and Human Needs (1988) / Chapter Skim
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4. Access to Health Care Services for Homelessness People
4. Access to Health Care Services for Homelessness People
Pages 76-102
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From page 76... ...
It begins by discussing the following questions: · Why do poor people use health care services to a lesser extent than non-poor people? · What are the barriers to health care specifically faced by homeless people?
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From page 77... ...
This obligation rests on the special importance of health care: its role in relieving suffering, preventing premature death, restoring functioning, increasing opportunity, providing information about an individual's condition, and giving evidence of mutual empathy and compassion. Furthermore, although life-style and the environment can affect health status, differences in the need for health care are for the most part undeserved and not within the individual's control.
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From page 78... ...
that require regular medical supervision did not see a physician in the previous year; 20 percent of persons with hypertension had not had their blood pressure checked in a year; and 15 percent of pregnant women did not receive prenatal care during their first trimester. People in fair or poor health with incomes below 150 percent of the poverty level visited physicians 27 percent less often than did non-poor people in poor or fair health; blacks in fair or poor health had one-third fewer physician visits than did non-Hispanic whites.
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From page 79... ...
More than half of the uninsured live in households that have at least one employed person (Sulvetta and Swartz, 19861. In addition, as Table 4-1 indicates, those people without health insurance coverage are concentrated primarily in the younger segment of the U.S.
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From page 80... ...
not Percentage Distribution Covered by Covered by not Covered of Uncovered Population Insurance Insurance by Insurance Population Insurance Total 235,520 86.7 31,285 13.3 100.0 Age < 16 55,612 84.5 8,616 15.5 27.5 16-24 34,596 78.6 7,389 21.4 23.6 25-34 41,363 83.6 6,786 16.4 21.7 35-44 32,133 89.1 3,514 10.9 11.2 45-54 22,459 90.0 2,273 10.1 7.3 55-64 22,135 88.5 2,553 11.5 8.2 Total under 65 208,298 85.1 31,131 14.9 99.5 Total 65 and over 27,222 99.4 154 0.6 0.5 Race White 200,083 87.6 24,840 12.4 79.4 Black 28,496 80.7 5,501 19.3 17.6 Spanish origina 14,175 73.0 3,822 27.0 12.2 NOTE: Numbers do not add due to rounding. aPeople of Spanish origin may be of either race.
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From page 81... ...
Beginning in the 1930s, economic growth in the United States has invariably been accompanied by expanded and improved health insurance coverage (along with other employment-based fringe benefits) , but that pattern no longer holds.
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From page 82... ...
MEDICAID In the United States, the major program for the provision of health insurance for low-income people now covers a smaller fraction of the poor than it did at any time in the past decade. Aggregate Medicaid enrollment has not grown, but the number of poor people has increased by roughly 40 percent (U.S.
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From page 83... ...
Eligibility for either AFDC or SSI automatically confers Medicaid eligibility on the recipient, except in a few complicated instances in certain states. In addition, states may provide Medicaid for "categorically related people," those in households that would be eligible for AFDC or SSI except that their incomes exceed eligibility standards by no more than one-third.
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From page 84... ...
84 Cat a_ V)
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From page 87... ...
The net result of Medicaid eligibility practices is that only slightly over half of all people with incomes below 150 percent of the poverty level are covered by Medicaid at any one time. Among the clients of the Johnson-Pew Health Care for the Homeless (HCH)
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From page 88... ...
Under federal law, every state that participates in the Medicaid program must cover inpatient hospital care, hospital outpatient services, physician services, rural health clinic services, other laboratory and x-ray services, skilled nursing facilities for adults, family planning, home health care services, and nurse-midwife services, although states may impose a number of restrictions or limitations on the use of these services. Almost all participating states also provide at least some coverage for other items, such as prescription drugs, although here the patchwork of limitations and restrictions becomes more formidable (U.S.
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From page 89... ...
As for other poor people, Medicaid coverage can be a major benefit to the homeless in removing a primary barrier to receiving health care, but it rarely solves all access problems. Many providers of health care services, especially institutions such as hospitals and free-standing health centers, certainly are more willing to serve the poor with Medicaid coverage than those without any financial resources.
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From page 90... ...
The role of hospitals in caring for poor people is indeed highly variable, but it is not inconsistent with the data to characterize 400 to 500 urban hospitals, and a similar number of rural hospitals, as the backbone of the health care system for the indigent (Feder et al., 1984~. Altogether, the nation's hospitals provide something over $6 billion a year in bad debt and charity care, primarily to low-income people, in addition to roughly $16 billion in services to Medicaid recipients (American Hospital Association, 19861.
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From page 91... ...
Relatively little uncompensated care takes the form of elective surgery. For example, uninsured people who are seriously injured in automobile accidents or who have gone into labor are more likely to get inpatient hospital care than those with cataracts or chronic hernias.
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From page 92... ...
As a result, the amount of uncompensated care provided by hospitals, although it has increased substantially in the past several years, has not increased as fast as the number of uninsured people (Feder et al., 19841. Therefore, uninsured homeless individuals are, in a sense, competing with the growing numbers of other uninsured domiciled people for the relatively scarce resource of subsidized hospital services, especially because the homeless population is concentrated in those areas where the demands on hospitals are greatest.
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From page 93... ...
However, many now constitute important components of health care services for homeless individuals. The National Health Service Corps Over the past decade, many of the facilities and programs that conduct health care for the medically indigent have relied on the National Health Service Corps (NHSC)
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From page 94... ...
ADDITIONAL BARRIERS TO ACCESS FOR HOMELESS PEOPLE In their evaluation of the benefit status of homeless people seen in 16 of the Robert Wood Johnson Foundation-Pew Memorial Trust Health Care for the Homeless (HCH) projects, Wright and Weber (1987)
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From page 95... ...
Many homeless people, with or without identifiable mental illness, are passively resistant to service provision, including health services (Vicic and Doherty, 1987~. Successfully engaging such persons for purposes of diagnosis and treatment involves extra efforts on the part of health care providers.
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From page 96... ...
Later restoration of most of them did not completely allay misgivings about the operation. The potential of the mentally ill for SSI eligibility may be helpful, but the health care benefits received to support treatment for mental illness are generally inadequate, if not inappropriate.
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From page 97... ...
Although to some extent this allocation of expenditures is the result of the effort to upgrade the quality of care in state institutions that accompanied the effort to transfer care to community-based facilities, the net effect on the mentally ill person in the community remains the same: there is no place to go. In the competition for such a scarce resource as community-based treatment, the homeless person is in a particularly uncompetitive position.
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From page 98... ...
Five million dollars has been appropriated for 43 demonstration projects for the community-based treatment of the chronically mentally ill, with particular emphasis on outreach to homeless veterans. Additional funds were appropriated in mid-1987 for the development of new and expanded domiciliary services for homeless veterans, and a number of VA facilities and programs have begun to undertake more aggressive
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From page 99... ...
With regard to access to VA health and mental health care, a sample of 727 veterans contacted through the HCMI program showed that 75 percent of the sample had three or fewer contacts with VA mental health outpatient services during the 6 months immediately prior to contact with the outreach program; 42 percent had no contact with any medical or psychiatric outpatient providers, but 38 percent did have at least one admission to some form of inpatient care. VA health care facilities are often located at some distance from where homeless people congregate.
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From page 100... ...
Each of these are specific and serious obstacles to the receipt of health care services by homeless veterans. Outreach and educational programs, such as those that are now being initiated by the VA, as well as counseling programs, which have been conducted for many years by such organizations as Vietnam Veterans of America and Swords to Plowshares, could be highly effective in resolving veterans' access to health care.
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From page 101... ...
1987. Progress Report on the Yeterans Administration Program for Homeless Chronically Mentally Ill Veterans.
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From page 102... ...
1985. Disability, Functional Limitation, and Health Insurance Coverage: 1984/85.
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