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



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.


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.


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


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.


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).


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 



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.


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.


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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

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