Health systems joining efforts to reduce homelessness

From developing housing to deploying mobile medical units, most of the nation's large health systems are investing in efforts to alleviate homelessness - and in turn reduce emergency care costs, new Cornell research finds.

More than half of the 200 largest U.S. health systems report having at least one homeless mitigation program, with the majority focused on housing, according to the research - the first to investigate the scope and drivers of such programs nationally. Programs serving the unhoused are more likely to be found in states that expanded Medicaid coverage under the Affordable Care Act and have more robust shelter capacity, the researchers found.

With significant cuts planned to Medicaid and federal homeless and housing assistance programs, health systems could become bigger players in responding to homelessness - or scale back their involvement, said Charley Willison, assistant professor in the Department of Public and Ecosystem Health in the College of Veterinary Medicine, and core faculty fellow at the Cornell Health Policy Center in the Cornell Brooks School of Public Policy.

"Health systems can potentially play a crucial role filling gaps in responses to homelessness, but their ability to do so appears to be conditional on their state's existing infrastructure," Willison said. "If retrenchment in federal safety net spending leads health systems to limit their investments, particularly in states lacking shelter beds, inequality could be exacerbated."

Willison is the senior author of "Health System Responses to Homelessness in the United States: Prevalence and Predictors," published July 22 in Health Affairs Scholar. Co-authors include first author Dr. Alisa Dewald, an emergency room physician, and Naquia Unwala, a medical student, both research associates in Willison's Public Health Governance Lab; Timothy Creedon, assistant professor of health economics at the Centre for Health Policy and Management at Trinity College Dublin's School of Medicine; and Phillip Singer, associate professor of political science and adjunct associate professor in population health sciences at the University of Utah.

In 2024, the federal government's annual estimate of the number of people experiencing homelessness on a single night was the highest on record - 771,480 people, or about 23 of every 10,000 people in the U.S. The unhoused are referred to as "frequent utilizers" of emergency rooms, comprising 1-5% of the total patient population but 12-18% of emergency room visits, costing nearly four times more than other Medicaid recipients, according to the research. That reality has prompted increased scrutiny about how health systems are responding to the issue beyond simply providing primary care and sometimes shelter.

Policymakers and researchers also have increasingly sought to address structural risk factors - known as social determinants of health - before patients must resort to emergency care. One relatively new policy reflecting that approach enables health systems to tap Medicaid to pay some short-term housing costs for unhoused patients, who have a mortality rate up to 10 times the general population's.

Building on findings reported in 2024, the new research scoured health systems' websites for data on mitigation programs. They identified programs spanning five categories: housing, community outreach, shelter medicine, medical respite and behavioral health. Examples included a $31 million investment into new housing units in Santa Cruz County, California; a mobile medical unit in Huntsville, Alabama; and street-based psychiatric assessments in Gainesville, Florida.

Surprisingly, Willison said, considering its cost and longer-term commitment, housing was the most common type of mitigation program by more than 20 percentage points. Most sought to build affordable or permanent supportive housing.

Analyzing possible drivers of those strategies, the researchers found several interesting but not statistically significant associations. For example, mitigation programs were more likely in health systems with teaching hospitals or a higher ratio of primary care doctors, less likely among systems that spent more on low-income patients.

The primary drivers were states' Medicaid expansion status and shelter capacity. Willison said both factors suggested health systems exploited cost-effective opportunities to build upon existing infrastructure. But with 5-10 million people projected to lose Medicaid, the researchers said, it remains to be seen if health systems' homeless mitigation programs take on bigger roles - or never get off the ground.

"We might only see homeless mitigation programs in states that can continue to support shelter capacity themselves," Willison said. "Low-income and rural states may be harder hit, with those health systems less likely to establish or sustain these programs."