Homeless and other uninsured people often have significant mental health disorders, which can limit their decision-making capacity and their attention to the daily skills of life. Limited access to safe shelter, food, clean water for drinking and bathing, and clean clothes all predispose the homeless to infections and gastrointestinal disorders. Substance use—alcohol, drugs, and tobacco—can further aggravate pre-existing medical conditions or lead to new ones. As homeless encampments arise in areas where they weren’t previously seen, societal support for healthcare for this population may deteriorate, and they may increasingly be seen as social pariahs, further reducing concern for their plight.
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November 2023Limited Healthcare Delivery Options
Public or social healthcare in the United States is insufficient to provide the infrastructure for these groups. Our healthcare delivery system is primarily built on the foundation of federal, state, and third-party insurance coverage. While some care is available through community health plans, free clinics, and federally qualified health centers, they currently serve a small proportion of the homeless and uninsured populations.
Additionally, some homeless people don’t trust public health entities to have their best interests at heart in the limited care that’s provided. This isn’t an indictment of local health centers, which typically provide the best care they can under their constraints, but rather a recognition that, in general, the United States has failed to transition to a healthcare system that provides the greatest good for the greatest number.
The emergency and acute care departments at hospitals typically provide the bulk of the significant care for the homeless, particularly those with serious illnesses and untreated chronic conditions. Understandably, the attitude of providers at some emergency departments may tend toward a cynical approach when it comes to caring for the homeless, particularly in light of limited resources and budget constraints.
Many hospitals do provide “charitable care” for low-income persons, including the homeless and uninsured/underinsured, with federal government reimbursement in the form of Medicare Disproportionate Share Hospital payments. Medicaid and the Children’s Health Insurance Program can be helpful in supporting care for the homeless and uninsured, but the level of support varies among states.
It’s a difficult navigation for an individual otolaryngologist to locate and obtain the resources to care for a homeless person who requires medical help—in particular, surgical procedures. Often, the otolaryngologist will have to present the patient’s needs to hospital administration, secure a willing anesthesiologist to become a pro bono member of the surgical team, and provide their surgical services and postoperative care without compensation. The engagement of social workers in the otolaryngologist’s healthcare system is valuable in obtaining financial support where feasible. Depending on the hospital and the patient’s surgical recovery, it can be quite daunting.