Journal of General Internal Medicine

, Volume 24, Issue 7, pp 841–847 | Cite as

Rising Inability to Obtain Needed Health Care Among Homeless Persons in Birmingham, Alabama (1995–2005)

  • Stefan G. Kertesz
  • Stephen W. Hwang
  • Jay Irwin
  • Ferris J. Ritchey
  • Mark E. LaGory
Populations at Risk

Abstract

Background

Homeless persons depend disproportionately on the health-care safety net for medical services. National reports identify financial strains to this safety net. Whether this has affected homeless persons is unknown.

Objectives

We quantified changes in the proportion of homeless persons reporting unmet need for health care in Birmingham, Alabama, comparing two periods, 1995 and 2005. We assessed whether a period effect was independent of characteristics of persons surveyed.

Design

Analysis of two surveys conducted with identical methods among representative samples of homeless persons in 1995 (n = 161) and 2005 (n = 161).

Measurements

Report of unmet need (inability to obtain care when needed) was the dependent variable. Two survey periods (1995 and 2005) were compared, with multivariable adjustment for sociodemographic and health characteristics. Reasons for unmet need were determined among the subset of persons reporting unmet need.

Results

Unmet need for health care was more common in 2005 (54%) than in 1995 (32%) (p < 0.0001), especially for non-Blacks (64%) and females (65%). Adjusting for individual characteristics, a survey year of 2005 independently predicted unmet need (odds ratio 2.68, 95% CI 1.49–4.83). Among persons reporting unmet need (87 of 161 in 2005; 52 of 161 in 1995), financial barriers were more commonly cited in 2005 (67% of 87) than in 1995 (42% of 52) (p = 0.01).

Conclusion

A rise in unmet health-care needs was reported among Birmingham’s homeless from 1995 to 2005. This period effect was independent of population characteristics and may implicate a local safety net inadequacy. Additional data are needed to determine if this represents a national trend.

Key words

homeless persons access to care safety net survey 

Notes

Acknowledgements

The authors wish to express their appreciation to Mina Madani and Sheila Samples for their help in reconciling databases, and to Young-il Kim for statistical programming.

Support

The original data collection was funded by grants from the Office of Development, City of Birmingham, AL, and the Office of Planning and Community Development of Jefferson County, AL. Dr Kertesz’s effort was supported by a Research Career Development Award from the National Institute on Drug Abuse (K23-DA-015487).

Conflict of Interest

The lead author has, or has had in the last 5 years, formal associations including employment or membership on the staff at four nonprofit safety net providers referenced in the manuscript, including a county hospital, a Veterans Administration hospital, and a federally qualified community health center, and an academic teaching hospital. The lead author has provided informal advice to one other referenced safety net provider, a faith-based volunteer clinic. No other author of the manuscript has a potential conflict of interest.

References

  1. 1.
    Committee on the Health Care of Homeless People. Homelessness, Health, and Human Needs. Washington, D.C.: Institute of Medicine; 1988.Google Scholar
  2. 2.
    Brickner PW, Scharer LK, Conanan BA, Savarese M, Scanlan BC. Under the safety net: The Health and Social Welfare of the Homeless in the United States. New York, NY: W.W. Norton & Co.; 1990.Google Scholar
  3. 3.
    Kushel MB, Vittingoff E, Haas JS. Factors associated with the health care utilization of homeless persons. JAMA. 2001;285:200–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health. 1997;87:217–20.PubMedCrossRefGoogle Scholar
  5. 5.
    Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. JAMA. 2000;283:2152–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Hwang SW, Orav EJ, O’Connell JJ, Lebow JM, Brennan TA. Causes of death in homeless adults in Boston. Ann Intern Med. 1997;126:625–8.PubMedGoogle Scholar
  7. 7.
    Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated with homelessness in New York City. N Engl J Med. 1998;338:1734–40.PubMedCrossRefGoogle Scholar
  8. 8.
    Strunk BS, Cunningham PJ. Trends in Americans’ Access to Needed Medical Care, 2001–2003. Washington, DC: Center for Studying Health System Change; 2004. http://www.hschange.org/CONTENT/701/. Accessed 3/29/09.Google Scholar
  9. 9.
    Institute of Medicine. America’s Health Care Safety Net: Intact but Endangered. Washington, DC: National Academies Press; 2000.Google Scholar
  10. 10.
    Hoffman C, Sered SS. Threadbare: Holes in America’s Health Care Safety Net. Menlo Park: The Henry A. Kaiser Family Foundation; 2005. http://www.kff.org/uninsured/upload/Threadbare-Holes-in-America-s-Health-Care-Safety-Net-report.pdf. Accessed 3/29/09.Google Scholar
  11. 11.
    Hadley J, Cravens M, Coughlin T, Holahan J. Federal Spending on the Health Care Safety Net from 2001–2004: Has Spending Kept Pace with the Growth in the Uninsured? Washington, DC: Kaiser Family Foundation; 2005. Available at: http://www.kff.org/uninsured/7425.cfm. Accessed 3/29/09.Google Scholar
  12. 12.
    Fishman LE, Bentley JD. The evolution of support for safety-net hospitals. Health Aff (Millwood). 1997;16:30–47.CrossRefGoogle Scholar
  13. 13.
    Holahan J, Cook A. The U.S. economy and changes in health insurance coverage, 2000–2006. Health Aff (Millwood). 2008;27:w135–44.CrossRefGoogle Scholar
  14. 14.
    Coughlin TA, Zuckerman S, McFeeters J. Restoring fiscal integrity to Medicaid financing? Health Aff (Millwood). 2007;26:1469–80.CrossRefGoogle Scholar
  15. 15.
    United States Congress. Deficit Reduction Act of 2005. Available at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_bills&docid = f:s1932enr.txt.pdf. Accessed 3/29/09
  16. 16.
    Kaiser Commission on Medicaid and the Uninsured. Deficit Reduction Act of 2005: Implications for Medicaid. Washington, DC: Kaiser Family Foundation; 2005. Available at: http://www.kff.org/medicaid/7465.cfm. Accessed 3/29/09.Google Scholar
  17. 17.
    Duke EM. Remarks to the 33rd Annual Convention of the National Association of Community Health Centers. Washington, DC: United States Department of Health and Human Services Health Resources and Services Administration; September 17, 2002. Available at: http://archive.hrsa.gov/newsroom/releases/2002speeches/nachc-sept.htm. Accessed 3/29/09.
  18. 18.
    Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9:208–20.PubMedGoogle Scholar
  19. 19.
    Wenzel SL, Bakhtiar L, Caskey NH, et al. Homeless veterans’ utilization of medical, psychiatric, and substance abuse services. Med Care. 1995;33:1132–44.PubMedCrossRefGoogle Scholar
  20. 20.
    Koegel P, Sullivan G, Burnam A, Morton SC, Wenzel S. Utilization of mental health and substance abuse services among homeless adults in Los Angeles. Med Care. 1999;37:306–17.PubMedCrossRefGoogle Scholar
  21. 21.
    Desai MM, Rosenheck RA, Kasprow WJ. Determinants of receipt of ambulatory medical care in a national sample of mentally ill homeless veterans. Med Care. 2003;41:275–87.PubMedCrossRefGoogle Scholar
  22. 22.
    Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: application to medical care use and outcomes for homeless people. Health Serv Res. 2000;34:1273–302.PubMedGoogle Scholar
  23. 23.
    LaGory M, Ritchey FJ, Gerald L. Homelessness in Birmingham and Jefferson County: A Needs Assessment. Birmingham, AL: Office of Community Development of the City of Birmingham, and the Office of Planning and Community Development of Jefferson County; 1995.Google Scholar
  24. 24.
    Ritchey FJ, Lagory ME, Fitzpatrick KM, Hale T, Irwin J. Report of Results of the Birmingham, Alabama Metropolitan Area Survey of Homeless Persons, January 27–28, 2005. Birmingham: University of Alabama at Birmingham; 2005.Google Scholar
  25. 25.
    Rossi PH, Wright JD, Fisher GA, Willis G. The urban homeless: estimating composition and size. Science. 1987;235:1336–41.PubMedCrossRefGoogle Scholar
  26. 26.
    United States Congress. McKinney Homeless Assistance Act. Pub L No. 100–77; 1987.Google Scholar
  27. 27.
    LaGory M, Ritchey FJ, Fitzpatrick K, Irwin J. A Needs Assessment of the Homeless of Birmingham and Jefferson County. Birmingham: University of Alabama at Birmingham; 2005.Google Scholar
  28. 28.
    Berk ML, Schur CL, Cantor JC. Ability to obtain health care: recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey. Health Aff (Millwood). 1995;14:139–46.CrossRefGoogle Scholar
  29. 29.
    Burt MR, Aron LY, Douglas T, Valente J, Lee E, Iwen B. Homelessness: Programs and the People They Serve. Technical Report of Findings of the National Survey of Homeless Assistance Providers and Clients. Washington, DC: Urban Institute; 1999. Available at: http://www.huduser.org/publications/homeless/homeless_tech.html. Accessed 3/29/09.Google Scholar
  30. 30.
    Cunningham PJ, Hadley J. Differences between symptom-specific and general survey questions of unmet need in measuring insurance and racial/ethnic disparities in access to care. Med Care. 2007;45:842–50.PubMedCrossRefGoogle Scholar
  31. 31.
    Long SK, King J, Coughlin TA. The implications of unmet need for future health care use: findings for a sample of disabled Medicaid beneficiaries in New York. Inquiry. 2005;42:413–20.PubMedGoogle Scholar
  32. 32.
    Robertson MJ, Cousineau MR. Health status and access to health services among the urban homeless. Am J Public Health. 1986;76:561–3.PubMedCrossRefGoogle Scholar
  33. 33.
    Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92:778–84.PubMedCrossRefGoogle Scholar
  34. 34.
    Kim TW, Kertesz SG, Horton NJ, Tibbetts N, Samet JH. Episodic homelessness and health care utilization in a prospective cohort of HIV-infected persons with alcohol problems. BMC Health Serv Res. 2006;6:19.PubMedCrossRefGoogle Scholar
  35. 35.
    Kertesz SG, Larson MJ, Cheng DM, et al. Need and non-need factors associated with addiction treatment utilization in a cohort of homeless and housed urban poor. Med Care. 2006;44:225–33.PubMedCrossRefGoogle Scholar
  36. 36.
    Desai MM, Rosenheck RA, Kasprow WJ. Determinants of receipt of ambulatory medical care in a national sample of mentally Ill homeless veterans. Med Care. 2003;41:275–87.PubMedCrossRefGoogle Scholar
  37. 37.
    Bird CE, Jinnett KJ, Burnam MA, et al. Predictors of contact with public service sectors among homeless adults with and without alcohol and other drug disorders. J Stud Alcohol. 2002;63:716–25.PubMedGoogle Scholar
  38. 38.
    Wenzel SL, Audrey Burnam M, Koegel P, et al. Access to inpatient or residential substance abuse treatment among homeless adults with alcohol or other drug use disorders. Med Care. 2001;39:1158–69.PubMedCrossRefGoogle Scholar
  39. 39.
    LaGory M, Ritchey F, Fitzpatrick K. Homelessness and affiliation. Sociol Q. 1991;32:201–18.CrossRefGoogle Scholar
  40. 40.
    National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide. Rockville, MD: National Institutes of Health; 2005. Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf. Accessed 3/29/09.Google Scholar
  41. 41.
    Kertesz SG, Pletcher MJ, Safford M, et al. Illicit drug use in young adults and subsequent decline in general health: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Drug Alcohol Depend. 2007;88:224–33.PubMedCrossRefGoogle Scholar
  42. 42.
    Kim TW, Alford DP, Malabanan A, Holick MF, Samet JH. Low bone density in patients receiving methadone maintenance treatment. Drug Alcohol Depend. 2006;85:258–62.PubMedCrossRefGoogle Scholar
  43. 43.
    Gelberg L, Linn LS. Social and physical health of homeless adults previously treated for mental health problems. Hospital & Community Psychiatry. 1988;39:510–6.Google Scholar
  44. 44.
    O’Connell JJ. Dying in the shadows: the challenge of providing health care for homeless people. Can Med Assoc J. 2004;170:1251–2.CrossRefGoogle Scholar
  45. 45.
    Hibbs JR, Benner L, Klugman L, et al. Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med. 1994;331:304–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Cheung AM, Hwang SW. Risk of death among homeless women: a cohort study and review of the literature. Can Med Assoc J. 2004;170:1243–7.CrossRefGoogle Scholar
  47. 47.
    Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA. 1995;274:305–11.PubMedCrossRefGoogle Scholar
  48. 48.
    Petersen LA, Burstin HR, O’Neil AC, Orav EJ, Brennan TA. Nonurgent emergency department visits: the effect of having a regular doctor. Med Care. 1998;36:1249–55.PubMedCrossRefGoogle Scholar
  49. 49.
    Han B, Wells BL. Inappropriate emergency department visits and use of the Health Care for the Homeless Program services by Homeless adults in the northeastern United States. J Public Health Manag Pract. 2003;9:530–7.PubMedGoogle Scholar
  50. 50.
    Bazzoli GJ, Kang R, Hasnain-Wynia R, Lindrooth RC. An update on safety-net hospitals: coping with the late 1990s and early 2000s. Health Aff (Millwood). 2005;24:1047–56.CrossRefGoogle Scholar
  51. 51.
    Lipson DJ, Naierman N. Effects of health system changes on safety-net providers. Health Aff (Millwood). 1996;15:33–48.CrossRefGoogle Scholar
  52. 52.
    Desai MM, Rosenheck RA. Unmet need for medical care among homeless adults with serious mental illness. Gen Hosp Psych. 2005;27:418–25.CrossRefGoogle Scholar
  53. 53.
    Padgett D, Struening EL, Andrews H. Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults. Med Care. 1990;28:805–21.PubMedCrossRefGoogle Scholar
  54. 54.
    Cunningham PJ, Bazzoli GJ, Katz A. Caught in the competitive crossfire: safety-net providers balance margin and mission in a profit-driven health care market. Health Aff (Millwood). 2008;27:w374–82.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Stefan G. Kertesz
    • 1
  • Stephen W. Hwang
    • 2
    • 3
  • Jay Irwin
    • 4
  • Ferris J. Ritchey
    • 4
  • Mark E. LaGory
    • 4
  1. 1.Division of Preventive Medicine, University of Alabama at Birmingham School of Medicine, BirminghamAL and Birmingham VA Medical CenterBirminghamUSA
  2. 2.Centre for Research on Inner City HealthThe Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s HospitalTorontoCanada
  3. 3.Division of General Internal Medicine, Department of MedicineUniversity of TorontoTorontoCanada
  4. 4.Department of SociologyUniversity of Alabama at BirminghamBirminghamUSA

Personalised recommendations