In 2014, an estimated 1.49 million people used a shelter program at some point during the year and on a given night 30 percent of homeless people were without shelter.  During the same year, 1.15 million homeless people were seen at Federally Qualified Health Centers (Health Centers) for medical care, dental care, and other health care, including 813,331 at Health Care for the Homeless Program Grantee (HCH) Health Centers.

Health Centers serve a critical role in providing health care for homeless individuals and other low-income individuals.  Nationwide, half or nearly half of homeless patients seen at Federally Qualified Health Centers and HCH Health Centers did not have health insurance in 2014.  In states that had not expanded Medicaid at the beginning of 2014, the percent of
homeless patients seen at Health Care for the Homeless Program Grantee Health Centers without insurance was an astounding 82%.

Health Centers must provide certain basic health services, including health services related to family medicine, internal medicine, and pediatrics, diagnostic laboratory and radiologic services, preventive health services such as prenatal services, appropriate cancer screening, well-child services, immunizations, screenings for communicable diseases and cholesterol, pediatric eye, ear, and dental screenings, preventive dental services, and emergency medical services.

These services are important for homeless patients because many of them have chronic conditions and other life-threatening or serious conditions that require prompt and consistent care and, in some cases, are disproportionately at risk of contracting severe and deadly diseases and illnesses.

Because of the life-endangering nature of so many illnesses and health conditions, it is crucial to assess whether homeless patients are receiving prompt and life-saving diagnosis and treatment.  Our new report discusses twelve of these chronic and other life-threatening or serious conditions based on the current known state of diagnosis and treatment of homeless patients.  To accurately assess the diagnosis and treatment rates for homeless individuals, included in the report are analyses of data at twenty-nine health centers where 100% of the patients were homeless.  Nineteen of these health centers are located in Medicaid-expansion states and ten of the health centers are located in states that had not expanded Medicaid at the beginning of 2014.  The report supports the finding that although many homeless patients are diagnosed and able to receive treatment for these chronic conditions and other life-threatening or serious conditions, many homeless patients are not being diagnosed or receiving adequate treatment for these conditions.

For example, homeless women appear not to be receiving cervical cancer screening at recommended levels or even at similar levels as Health Center patients in general.  At the Health Centers where 100% of the patients were homeless, an average of only 41.7% of women between the ages of 24 and 65 had Pap Test screening with the range at the health centers between 13% and 69%.  The screening level was below the recommended level of 93.0% at all twenty-nine of these Health Centers and was below the average level for Health Center patients in general of 56.3% at twenty-four of the twenty-nine Health Centers.  Eight of the Health Centers where cervical cancer screening was less than the average and recommended levels were in Florida, Maine, New Mexico, Texas, Utah, and Wyoming, which had not expanded Medicaid at the beginning of 2014.

Likewise, homeless individuals appear not to be receiving colorectal cancer screening at recommended levels or even at similar levels as Health Center patients in general.  At Health Centers where 100% of patients were homeless, the colorectal cancer screening level for adults age 50 to 75 averaged only 22.8% and ranged at the health centers from 0.4% to 56%.  The screening level was below the recommended level of 70.5% at all
twenty-eight reporting Health Centers and was below the average level for Health Center patients in general of 34.5% at twenty-two of the twenty-eight Health Centers.  Nine of the Health Centers where colorectal cancer screening was less than the average and recommended levels were in Florida, Maine, New Mexico, Tennessee, Texas, Utah, and Wyoming, which had not expanded Medicaid at the beginning of 2014.

Some homeless individuals with HIV or AIDS are not receiving prompt access to care upon diagnosis compared to the recommended or average levels.  HIV Linkage to Care, which measures such access to care, occurs when a patient has a medical visit for HIV care within ninety days of their first-ever HIV diagnosis, including a medical visit with a health center
provider who initiates treatment for HIV or a visit with (not referral to) a referral resource who initiates treatment for HIV.  This early access to care is important because if patients are seen for follow-up care within ninety days of initial HIV diagnosis, then the probability of HIV-related complications and transmission of disease are reduced.

The average HIV Linkage to Care was 88.3% at nineteen of the twenty-nine Health Centers reporting this information with a range at the health centers from 22% to 100%.  The HIV Linkage to Care was less than 100% and the recommended level of 85% at seven of the nineteen Health Centers where 100% of the patients were homeless.  Two of these Health Centers are located in Florida and Utah, which had not expanded Medicaid at the
beginning of 2014.  The HIV Linkage to Care was lower for homeless patients in states that had not expanded Medicaid (75.6%) compared to homeless patients in states that had expanded Medicaid (92.8%).

Homeless patients have not received blood pressure control, heart attack/stroke treatment, and cholesterol treatment at as high a level as the recommended and/or average level of Health Center patients in general.  For example, the percent of hypertensive homeless patients between the ages of 18 and 85 at the Health Centers where 100% of the patients were homeless with successful blood pressure control averaged 55.2% with a median of 55.6%, meaning the percent at half of the health centers is less than this amount, and a range from 24% to 82%.  The percent of patients with blood pressure control was less than the overall Health Center average level of 63.7% and the recommended level of 61% at twenty-three of the twenty-nine Health Centers.  Eight of the Health Centers where blood pressure control was less than the average and recommended levels were in Maine, New Mexico, Tennessee, Texas, Utah, and Wyoming, which had not expanded Medicaid at the beginning of 2014.

Homeless patients appear not to have diabetes control at recommended levels or even at similar levels as Health Center patients in general.   Having controlled diabetes is critical because there will be fewer long-term complications, such as organ failure, amputations, and blindness.  The percent of homeless patients at the Health Centers where 100% of the
patients were homeless with successful diabetes control averaged 65.9% with a median of 65.7%, meaning the percent at half of the health centers is less than this amount, and a range from 33% to 90%.  The diabetes control level was below the recommended level of 84% at twenty-five of the twenty-nine Health Centers and was below the average level for Health Center patients in general of 68.4% at sixteen of the twenty-nine Health Centers.  Five of the health centers where diabetes control was less than the average level are located in New Mexico, Texas, and Utah, which had not expanded Medicaid at the beginning of 2014.

Homeless patients at some Health Centers appear not to have asthma treatment at similar levels as Health Center patients in general.  The percent of homeless patients with asthma at the Health Centers where 100% of the patients were homeless with an asthma treatment plan averaged 83.8% with a median of 87.5%, meaning the percent at half of the health centers is less than this amount, and a range from 49% to 100%.  The screening level was below the overall Health Center average level for Health Center patients in general of 80.8% at ten of the twenty-nine Health Centers.  Three of the Health Centers where asthma treatment was less than the average level were located in Florida, Texas, and Utah, which had not expanded Medicaid at the beginning of 2014. Receiving asthma pharmacologic therapy is important because if patients with persistent asthma are provided with appropriate pharmacological therapy, then they will be less likely to have asthma attacks and less likely to develop asthma-related complications including death.

Homeless patients are not being diagnosed or receiving life-saving treatment for grave medical conditions.  With limited funding for Health Centers, access to health insurance may be impacting the ability of homeless persons to access screening for cancer and other diseases and care for HIV/AIDS and other chronic and life-threatening conditions. Expanding health insurance coverage and Health Center funding can allow all homeless patients to receive needed care.