Is Caring for the Homeless and Uninsured Really Someone Else’s Problem?

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Clinical Scenario

They’re discussing the treatment of a young homeless man who was assaulted in an alley. He sustained a broken nose, soft tissue trauma, and lacerations to the face and ears, along with several broken teeth. The gist of the conversation centers on what needs to be done in the emergency department.  

The resident physician suggests calling an otolaryngologist to evaluate the patient and perform repairs on his face and ears. The attending, however, strongly believes that “no otolaryngologist will see and operate on this homeless guy with no insurance. It’s better to glue his lacerations, bandage his ears, and forget the broken nose. Let’s patch him up quickly and get him out; we can’t afford the expense of his care. If he isn’t an addict now, he will be in the future. Let him be someone else’s problem down the line.” The resident reluctantly agrees. You consider stepping toward them and saying, “I’m an otolaryngologist. Do you mind if I see the patient?”

Discussion

Caring for the homeless and uninsured in America can be a challenge. It has been estimated that nearly 600,000 people in the United States are homeless, a number that may well be underestimated. Because of the “fluidity” of homeless persons’ dwellings, it’s very difficult to capture the true prevalence of homelessness. Some persons may live in a shelter for a while, and then move back to the streets and parks for longer periods. 

Most homeless people are also uninsured, although most uninsured are not necessarily homeless. Current statistics on the prevalence of the uninsured (or underinsured) indicate that over 27 million people (3 million of them children) are living in the United States with limited access to, and availability for, continuity of care.

Perhaps the most challenging groups of people to deal with when it comes to offering proper healthcare are the economically disadvantaged, the uninsured, low-income children, racial and ethnic minorities, the elderly, and those with chronic physical and mental conditions. 

In particular, the homeless are vulnerable to physical assaults due to weakness, malnutrition, substance abuse, and lack of safe shelter. Lack of education and communication skills may prevent them from understanding the nuances involved in accessing the U.S. healthcare system and obtaining forms of personal identification to better receive treatment for injuries and illnesses.  

Two other special groups that may be marginalized with respect to lack of care are veterans with mental health illnesses and undocumented migrants. Veterans who choose to be homeless often experience significant post-traumatic stress disorder, and, while eligible for healthcare from the Department of Veterans Affairs, choose not to seek that care. Undocumented migrants are rapidly becoming a substantial group in need of healthcare, with few or no options in a community where they fear being reported and deported. While they may not become homeless, many are uninsured and may turn to unlicensed practitioners for health issues.