Barbara DiPietro is the Senior Director of Policy at the National Health Care for the Homeless Council. She joins us this week to talk about what homelessness looks like in the United States, the wildly disporportionate incidence of COVID-19 in people currently experiencing homelessness, and how the dual crises of rising unemployment and insurance loss are making people more at-risk for becoming homeless. She explains why Medicare for All and the fight to make housing a right are interrelated struggles.
In the United States, both our healthcare and our housing systems have failed to protect us during COVID-19, and the two systems can interact in dangerous ways. To talk specifically about this intersection, we welcome Barbara DiPietro to the program, from the National Healthcare for the Homeless Council.
Stephanie starts by asking what homelessness really looks like, and to address any myths people might have. Barbara says that most Americans when they picture homelessness will conjure to mind a street-homeless man who is a chronic alcoholic, but that description represents only about 10% of the homeless population. In fact, the homeless population is primarily low-income, working families and adults, and 1/3rd to 1/2 of shelter stays are children. Even families that work full-time, earning above minimum wage, often do not earn enough to afford rent in addition to meeting their food needs and other basic expenses.
On any given night in America, there are about 1/2 a million people who we can count as homeless (many more are not counted). Over the course of a year, at least 1.5 million people use the shelter system, and possibly 2 million more are experiencing housing instability or doubling up.
Barbara mentions that health issues and healthcare costs are actually one of the leading causes of homelessness in America. Medical debt and hospital bills can quickly overwhelm income, and leave people without cash to pay rent. However, other important issues can also lead to homelessness: domestic violence, fires, losing your job, etc, can all lead to losing your housing. Right now during COVID-19 we have millions of people losing their jobs, and unemployment benefits running out, along with a very vague national eviction order.
What about the common notion that Medicaid is likely to cover everyone who becomes homeless, or that you can seek care in an emergency room? As Barbara mentions, your ability to access Medicaid depends entirely on the state you’re in, as 15 states still have not expanded Medicaid to cover low-income people without meeting other requirements. Even in states that have expanded Medicaid, many people are churned in and out of the program.
While it’s technically true you can receive life-saving care at an emergency room, it doesn’t mean you won’t be billed for that care, or that you’ll be treated with dignity. That care also won’t be coordinated, and the emergency room is not the right place for providing primary and behavioral health in the community. Barbara would like to see more hospitals advocating for Medicare for All, since it would move these patients out of the ER and into appropriate primary care settings, which could really help with ER volume and capacity for all who need it.
What would a public option do for healthcare access for homeless populations? Barbara says: well, it’s better than nothing. We have to be honest though: the public option is primarily about incrementally increasing health insurance coverage. As Stephanie mentions, if an ACA marketplace plan (bronze, silver, or gold) is unaffordable to you, a public option plan will likely be as well.
Why is housing so important for the fight for Medicare for All? Barbara reminds us that a Medicare for All system creates an incentive to do better preventive work in the community, to keep people from getting sick in the first place. People who are homeless often experience tremendous amounts of healthcare conditions, so our housing crisis is fueling increases in disabilities, untreated chronic health conditions, and overuse of ERs and inpatient care. Housing is a key “social determinant of health,” so guaranteeing secure housing can create tremendous savings to the healthcare system.
What about access to long-term care for homeless populations? It is really not good, reports Barbara. Nursing homes and other long-term care institutions do not want homeless patients and will turn them away, unless they have a “discharge option” – a home to be discharged to after a short stay. Facilities don’t believe they can make money off of homeless clients, and buy into the stigma that homeless clients will be too much trouble to care for.
How is the COVID-19 pandemic impacting homelessness, with millions of Americans losing their jobs? Barbara tells us the CARES Act has been helpful by preventing states from cutting their Medicaid rolls during the crisis, but of course many states have extremely limited Medicaid eligibility to begin with, and if you lose your job in one of those states you will have nowhere to turn for healthcare.
What about the international experience with housing policy as well as healthcare policy? NHCHC just published a paper comparing countries with single-payer healthcare and how that has helped responding to COVID-19. Countries with single-payer healthcare systems also generally invest more in housing stability and income stability for their populations, and invest more in public health. The U.S. doesn’t even have a national testing plan for COVID-19, and we have been disinvesting in public health – some counties don’t even have a public health department anymore.
How are homeless populations being directly impacted by COVID-19? Here in Boston, over 1/3rd of people staying at one large shelter tested positive for coronavirus. Shelter testing has been all over the map, including some shelters with very low rates, but one shelter in San Francisco had positive rates over 66%. When you think through the public health advice we’ve all been given to stay safe from COVID-19 – social distancing, wash your hands, stay away from people, wear a mask, wash your hands, other hygiene steps – if you’re homeless, you may not have access to a bathroom, or have any control over the area you live in. You may live with 150 other people in one room. Maintaining 6′ distance is just not possible. Many homeless people also have a range of health issues that make them more vulnerable to the disease. All of this created a pressure cooker, particularly in the shelter system. Many people have been shifted to hotel or motel rooms, which has the side-effect of disconnecting them from much of their access to healthcare. Barbara feels we have not yet appreciated the scope of the healthcare crisis taking place among homeless populations likely taking place during this crisis.
What should we people be advocating for during the next CARES Act, if one is passed? NHCHC has prioritized rental assistance (which is included in the House version of the bill), a restoration of the $600 supplement to unemployment, as well as aid to states and local governments. Medicaid takes up 1/3rd to 1/2 of many states’ budgets, and without federal assistance, many states may cut their Medicaid programs to balance their budgets, and Medicaid is the single most important healthcare program for homeless populations.
NHCHC has published an issue brief specifically on the impact Medicare for All for all could have on people experiencing homelessness during coronavirus.
NHCHC is also hosting a webinar called “COVID-19 Coffee Chat: How to Be a Single-Payer Advocate During a Pandemic,” coming up on Friday, September 25 from 1-2 EST. You can register here.
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