On a recent night this winter, I stood under Chicago’s Dan Ryan Expressway and watched my coworker examine a foot abscess the size of a golf ball. The patient shivered in pain. “I just kept ignoring it for weeks ’cause I thought it’d go away,” he said. We were a team of medical students and doctors providing basic health care to people living on the street. But since we rely on volunteers and limited supplies, our visits are few and our medical care is elementary.
Results from the nationwide 2022 Point-in-Time count will soon be released and reveal 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 cannot keep waiting for homeless numbers to skyrocket before we increase funding for homeless health care—homeless Americans already cost our health care system millions each year.
The U.S. homeless population increased for the fourth consecutive year in 2020. Due to COVID-19 concerns, the results of the 2021 U.S. homeless count were incomplete and incomparable. Housing people should remain the top priority for policymakers, but this will take time. In the interim, we need to address the health and health care costs of over 580,000 Americans without housing. We must expand the reach of cost-effective homeless health care to reduce system-wide spending on this population.
One solution: require hospitals to spend a portion of their mandated community benefits funds on bringing health care to the streets, where people are living.
Street medicine can help cut the cost of caring for people experiencing homelessness by reducing E.R. visits and hospitalizations. Many unhoused Americans do not have a primary care doctor or utilize community health centers. Often, this is because they do not want to leave their belongings unattended, they do not have access to transportation, or they have lost faith in the health care system. As a result, their mismanaged diseases lead to hospital visits with enormous bills. The average person experiencing homelessness visits the E.R. five times per year, costing an annual $18,500. When patients are uninsured or unable to pay, hospitals typically pick up the tab.
Existing street medicine programs have proven to lower 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.
Nonprofit hospitals in the U.S. are already required to spend a portion of their surplus profit on “community benefits” in order to qualify for exemption from federal income taxes. Most hospitals fulfill this obligation by covering the costs of hospital visits for low-income patients. However, given the high rates of homelessness across U.S. cities, legislators could tighten requirements so that hospitals must devote a specified portion of their community benefits toward street-based medicine. If hospitals fail to 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 to social services in the community. Similarly, Mission Health System in western North Carolina directs community benefits to fund a homeless outreach team.
Time and again, people experiencing homelessness have sought care and left feeling humiliated and angry. One man I spoke with equated being in the hospital to animal cruelty—he felt like “a pig in a stall” because he was homeless. Bringing health care workers out on the street can rebuild some of the lost trust felt by some outside of a traditional health care environment.
There are certainly limits to delivering health care outside of the hospital. Street medicine teams struggle to bring extensive medical supplies into the field. Additionally, redirecting hospital community benefits toward street care unavoidably takes money away from other community improvements. However, street medicine is one of our only tools to combat back-end spending on expensive hospital visits.
After a careful examination by cell phone flashlight under the expressway, the volunteer physician 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. He was brought to the hospital, where he was in for a long and expensive night in the E.R.
As we move into the next phase of the COVID-19 pandemic, it is more important than ever to fund homeless health care. Over half a million Americans remain homeless each night. Hospitals have closed due to the financial burdens of unpaid medical bills. We must try harder to reduce health care spending by demanding our legislators, policymakers and hospitals invest in more street medicine.
Anna Thorndike is a medical student at the University of Chicago and volunteer for Chicago Street Medicine.
The views expressed in this article are the writer’s own.