In a series of studies analyzing homeless people covered by government-funded health insurance in Canada, researchers have found that homeless men, women and children have higher hospitalization rates and more doctors' appointments, compared with the general population.

The researchers, led by Dr. Stephen Hwang from St. Michael's Hospital in Toronto, say their findings could have policy implications for health services, particularly in light of recent changes in legislature that expand Medicaid coverage to low-income Americans.

They published the results of their three studies in the American Journal of Public Health.

Although homeless people are known to have higher rates of both chronic and acute health conditions than the general population, Dr. Hwang says that until now, there has not been a comprehensive assessment of their health care use.

Because there is difficulty acquiring this information in the US - since over half of homeless adults lack health insurance - Dr. Hwang and his team carried out their studies in Toronto, where everyone has universal health coverage and databases record all doctor, emergency department (ED) and hospital visits.

High intensity use by small group of homeless people

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For 4 years, the researchers followed 1,165 homeless people who were recruited from shelters and meal programs, and compared them with people in the general population considered low-income, who were the same age and gender.

Dr. Hwang and colleagues found that homeless single women visit the ED more than twice a year on average, which is 13 times more often than women in the general population. Single homeless men also visit the ED an average of two times a year, which is nine times more than men in the general population.

Other findings revealed that 95.5% of homeless people used health services during the 4-year period, compared with 84.2% of people in the general low-income population.

Additionally, the top 10% of homeless people who accessed health care had an average of 39 visits per person each year.

"This very high intensity use by a relatively small number of homeless people can have a substantial impact on the health care system," says Dr. Hwang.

Though not having health insurance in the US has been perceived as a major barrier to obtaining ambulatory care, producing unnecessary visits to the ED and hospitalizations, Dr. Hwang says homeless people on universal health care continue to have higher rates of ED care:

"The provision of universal health insurance, while important, doesn't fully address the barriers to appropriate health care for this vulnerable population."

High costs could be averted

The researchers were also able to estimate health care spending for the homeless individuals in the study, based on the data they used from the Institute for Clinical Evaluative Sciences, where Dr. Hwang is an adjunct scientist.

Per year, the cost of health care for the individuals was $6.7 million USD, which breaks down to $5,725 per person.

The researchers note that this is likely a conservative figure, however, because homeless individuals usually have longer inpatient stays and higher hospital costs.

Although it is generally hypothesized that homeless people visit the ED because they do not have sufficient access to primary care, Dr. Hwang says that the majority of homeless people who landed in the ED had previously visited a doctor's office.

Dr. Hwang adds:

"For the first time, we have data showing the exact extent to which people who are homeless use health services and how much more they use these services compared with the general population."

He also notes that the study reveals "a subset of people who are high users," and he says if interventions are developed for that top 10%, certain health care use may be averted.