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'Care In Your Heart': Homeless Health Care Costs Prompt Experiments On The Margins


Home For Health

BOSTON -- The first time Ron died, he had already been in the emergency room dozens of times.

He was 62 when he suffered that first heart attack in 2010 and momentarily flatlined. It happened again two months later, the result of years of drugs and alcohol abuse that left him homeless, uninsured and forced to rely on the ER for nearly every medical need he had collected during some 30 years of living on the street.

Ron, who agreed to speak with The Huffington Post on the condition that his last name be withheld, is an extreme case. A bipolar alcoholic and crack addict, he is wiry and worn at 64. Extreme or not, cases like Ron's place a significant burden on local health care systems. And for countless men, women and children themselves, homelessness is an insurmountable sentence to a lifetime of poor health and inadequate care -- both of which can feed on one another in an unforgiving cycle.

"Being homeless is not a nice life to be living," Ron says. "I'm constantly fighting with the devil."

Radical poverty puts enormous stress on the U.S. health care system, which often struggles to address poor patients' most basic needs. People who live in what the Centers for Disease Control and Prevention calls "low socioeconomic circumstances" are far more likely to engage in unhealthy behaviors, have limited access to health care, get poorer quality of care and, not least, simply wither and die.

For overworked emergency rooms and underfunded safety-net hospitals, chronic conditions are particularly hard to treat. In many cases, preventative care is all but a fantasy. As a result, low-income Americans are much more prone to preventable hospitalizations, to the tune of $6.7 billion and 1 million hospital visits per year, according to the federal Agency for Healthcare Research and Quality.

Once extreme poverty leads to homelessness, things get even worse. Homeless patients are less likely to seek out or have access to follow-up care or fill critical prescriptions, resulting in numerous return visits for the same problems. Research in the New England Journal of Medicine suggests that homeless hospital patients generally stay at least four days longer per visit, which can mean thousands a pop to a safety-net hospital teetering on the edge of bankruptcy.

"It's a horrible mess," says John Lozier, executive director of the National Health Care for the Homeless Council, "and it all becomes more pronounced with the longevity of homelessness."

Though precise data on the U.S. homeless population is fuzzy, the Department of Housing and Urban Development states that of the 636,000 Americans it estimates spent a night homeless last January, roughly 1 in 6 were chronically homeless, beginning another cycle from the street to a shelter, an emergency room or jail.

Within that group, many battle a complex "trimorbidity" of health problems, including substance abuse, mental health issues and chronic conditions like diabetes and heart disease exacerbated by years on the street. According to the not-for-profit housing-placement group Pathways to Housing, chronic homelessness cuts average lifespan by about 25 years.

Policy prescriptions for long-term homelessness have languished for decades. In the past two years, however, a radical pilot program launched by Boston Medical Center has helped top ER users like Ron more proactively, betting their health will improve with a permanent roof over their heads.

In addition to housing, the pilot program -- known as High Utilizers of Emergency Services to Home, or HUES to Home -- seeks to provide the most frequent homeless visitors to Boston Medical, a 508-bed, private, nonprofit safety-net hospital in the city's South End, with intensive case management, helping them get sober or get treatment for mental illness.

"You and I, and most of us who have a place to go to if we're sick, you know, have to deal with the disease," says Andy Ulrich, Boston Medical Center's executive vice chair of emergency medicine. "When you take that same medical condition, or that same psychiatric condition or that same level of substance abuse and you add to it that they're living under a bridge somewhere or they're living in the shelters, it adds to the complexity and difficulty."

Added complexity also means added costs. From October 2009 to June 2010, Medicaid reimbursed Boston Medical for more than $3.6 million in costs, excluding costs from other ERs and respite centers, as well as claims not yet paid. At that rate, a year's care would cost those 35 patients a combined $5.4 million, an average of roughly $155,000 each.

"You're talking about the most addicted, the most mentally affected people," says Boston city councilor Mike Ross who, in 2009, convened a city council meeting championing permanent supportive housing, and who, along with city mayor Thomas M. Menino, supported the HUES to Home program.

"These aren't choirboys," Ross admits. "Some of these people have done bad things."

Two years in, the program is still relatively unproven. Internal data suggests that participants have seen substantial drops in key measures like ER usage and calls to EMS. Yet the actual cost savings of those changes remains undetermined, and participants continue to battle serious, even life-threatening, addiction and other health issues. Meanwhile, more traditional homeless advocates argue that such funding is better spent on more broad-based shelters.

Still, even in these incipient stages, the program's directors and participants say even the smallest signs of success are promising, given the scope of the challenges the chronically homeless face.

"In all of the shelters, in the street life, in the places I've been, there's a lot of people out there that need help, believe me," Ron says. "We really, seriously need some help."