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Improving Care for Older Adults
The homeless population in the United States is getting older. In 1990, single adults over 50 years old made up about 11% of the group. A study from Rebecca T. Brown, an LDI Senior Fellow and Assistant Professor of Medicine in the Division of Geriatric Medicine at the Perelman School of Medicine, and several coauthors from the University of California San Francisco (UCSF) found that recently, this proportion has climbed to over one-third.
Homelessness takes a huge toll on the health of older people. Over an average of 55 months, unhoused people 50 years and older in Oakland, California died at a rate 3.5 times greater than their housed counterparts in the city, according to the JAMA study titled “Factors Associated With Mortality Among Homeless Older Adults in California: The HOPE HOME Study.” “The mortality rate is astounding,” said Brown, who noted that the findings are consistent with previous studies in other parts of the country.
Most of these older, unhoused people age quickly and, according to other research by Brown, show signs of geriatric conditions like impaired vision and urinary incontinence at rates higher than the housed population 20 years older.
For many homeless, “50 is the new 75,” noted senior author Margot B. Kushel, Division Chief at the Division of Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center. Unfortunately, housing interventions are often aimed at seniors or people who are the most dysfunctional—and not at this growing population. Overall, the average life expectancy of homeless people is 42 to 52 years old. If assistance isn’t available until someone reaches 65 years old, then he or she may be dead by then.
People who lose housing for the first time after 50 years old—a category that described 45% of the interviewees—are at particular risk of dying early. The newly homeless are largely working poor people who experienced some trauma, such as a rent increase, job loss, family breakup, or sickness, that made housing unaffordable. They are not especially likely to suffer from mental illness or substance abuse. In the U.S., renters over 50 years old are at the highest risk of becoming homeless. They have less ability than others to increase their income if rents rise or medical costs increase and are highly susceptible to economic blips.
The newly homeless tend not to have the resilience that protects some long-termers from the harmful effects of their life situations. “Becoming homeless in later life is a health shock,” noted Brown. “If you’re concentrating on staying warm and safe, you can’t follow doctors’ orders. Your medication might have been lost or stolen. You have a million competing demands that keep you from focusing on self-care.” In other words, if you become homeless late in life, you are going to do terribly.
The Brown-written report draws on work by Dennis P. Culhane, LDI Senior Fellow and the Dana and Andrew Stone Chair in Social Policy at the University of Pennsylvania’s School of Social Policy & Practice, about the effect of growing up in the second half of the baby boom. Economic conditions have put Americans born between 1955 and 1964 at special risk for homelessness throughout their lives. “At all income levels, people in the second half of the baby boom are worse off than the baby boomers who came earlier,” said Culhane. “The earlier baby boomers (1946 to 1954), born after a steep, 15-year drop in U.S. births, became adults in a society where housing was plentiful and workers of all skill levels were in great demand,” Culhane said.
Homelessness first became an issue in the U.S. during the 1980s, when many of the opportunities available to early baby boomers dried up for those born after 1954. “Late boomers entered the housing market at a time in which there was a retrenchment of affordable housing support.”
The 1983 recession, which took place when the younger cohort was between 19 and 28 years old, was “very deep and profound,” Culhane said. “We know that if you don’t get into the job market by your mid-20s, your probability of having stable employment throughout your life is low. There are life-long implications to early unemployment.”
African-Americans have had a particularly precarious relationship with housing. In the Oakland survey, 80% of adults 50 years and older who were homeless were Black in a city that is about 23% African-American, noted Brown. Throughout the country, Black people have a three-to four-fold higher risk of becoming homeless. Because of redlining and other discriminatory practices, Black people are much less likely to own their homes than White people (43% to 74%), and thus have been unable to build up the equity that might protect against financial setbacks. In addition, Black people were strongly affected by the 1983 recession: A quarter of Black people with less than a high school education were unemployed, noted Culhane.
“The enormous numbers of unemployed [people] drove a huge amount of the urban underground economy, including cocaine trafficking,” said Culhane. This, in turn, led to the era of mass incarceration, in which six times as many Black people have been imprisoned on drug charges as White people. Ex-offenders have a difficult time finding employment and may end up homeless.
Housing First programs, which offer homes without preconditions, such as being drug-free, have been effective at keeping people off the streets or in shelters. The most striking success comes from the U.S. Department of Veterans Affairs (VA). In 2009, President Obama made a commitment to end homelessness for 100% of veterans. In programs designed by Culhane, the VA created 80,000 permanent housing slots and (in 2011) provided $1.6 billion worth of housing vouchers and supportive services. “We were ramped up to scale,” explained Culhane. As a result, homelessness among veterans has dropped 50%. However, noted Culhane, these types of housing programs don’t keep people from losing their living quarters in the first place. “Prevention is much more difficult,” he said. “It is particularly important for the 55- to 65-year-old group, which has a high risk of dying early.”
Outside of the VA, most of the social service programs that could prevent homelessness are focused on people who are either elderly, severely mentally ill, or substance abusers.
While the Oakland study authors feel that it is totally appropriate to emphasize care for the sickest people, they emphasized that older middle-aged people who look a lot healthier should not be ignored—because they’re dying, too. More resources, they feel, need to be expended on helping the working poor remain housed. “It is just so devastating when people lose housing. Everything falls apart,” said Brown.
“One of the best ways to prevent homelessness among adults over 50 years old would be the expansion of Supplemental Security Income (SSI),” said Culhane. SSI gives out cash payments to low-income, disabled, and blind individuals over 65 years old. “Given the accelerated aging of people who experience homelessness, many will be eligible for SSI due to increased morbidity and disability, and eventually due to age,” he explained. “Unfortunately, even the boldest version of Build Back Better did not include SSI reforms. Access needs to be streamlined, and payment levels need to reflect housing cost changes. In some places, rental supplements will be needed. There is talk of a bill that could be advanced in the next Congress.”
One promising direction comes from Medicaid. “Recovery Act funding allows states to fund significant expansions in the use of Medicaid for finding housing, moving in, and setting up an apartment,” Culhane said. Home and Community Based Services has garnered much interest among some in the health care area.
Help could not come sooner. Brown, who sees unhoused patients in her clinical practice, has witnessed the devastating effects up close. “Homeless people are often really depressed,“ she said. Homelessness is an “existential crisis.”
The study, “Factors Associated with Mortality Among Homeless Older Adults in California: The HOPE HOME Study, was published on August 29, 2022 in JAMA Internal Medicine. Authors include Rebecca Brown, Jennifer Evans, Karen Valle, David Guzman, Yea-Hung Chen, and Margot Kushel.
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