Homelessness and Health – Part II
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[Samantha Williams] I’m Dr. Samantha Williams, a research psychologist at the CDC. Today I’m speaking with John Lozier, the Executive Director for the National Healthcare for the Homeless Council, a Nashville-based, national membership organization that works in the area of homelessness and health care.
John, what can public health practitioners and clinicians do to improve the health of the homeless population?
[John Lozier] Well, we have to be serious about being sure that health care and housing are extended to everybody, in the first place. The health care reforms have reached—looks like when they’re completed, 95 percent of the population, but that leaves five percent out—excluded. Some of those are people who are undocumented and that’s a huge political problem, but also a huge public health problem. We have to draw everyone into care if the society as a whole is going to become and remain healthy. Paying attention to housing status in every clinical encounter is important. If you don’t know that somebody is homeless when you’re providing treatment for a wound, and you say go home, elevate this lacerated foot for three days, rest in bed, keep it clean, change the bandages. There’s no real option. Simply being aware is the first step. And on top of that awareness, being kind and gentle. It’s basic human stuff, but it is so easy for people to—even practitioners—to judge folks based on their socioeconomic status, on presumptions about what’s homeless, you know, why people are homeless, to impute moral failure to what is really victimization by a larger economic system. That’s the big challenge for practitioners. There’s a lot else that obviously needs to be done in terms of systems adjustments, data collection, fine-tuning clinical practices, but the baseline is to be aware of the impact of homelessness on a person’s ability to adhere to a treatment plan and to be sensitive to the needs of the human being in front of you.
[Samantha Williams] Are there programs that you are involved in that focus on improving the sexual health of the homeless?
[John Lozier] Yes. The National Healthcare for the Homeless Council and our Healthcare for the Homeless Clinicians Network have published adapted clinical guidelines on a number of topics, including sexual and reproductive health. Sexually transmitted diseases are very, very common among homeless people. One would think the lack of privacy that’s so common for homeless people inhibits dangerous behaviors but it does not. Clinicians in health care for the homeless programs have had to learn to be very careful in addressing sexual behaviors, in part because so many of the homeless women have experienced sexual abuse in their lifetimes. Either as children, sexual abuse can be so traumatic that it can be part of the etiology of homelessness, or as homeless adults or homeless youths who have perhaps been engaged in sexual trade or have simply been so exposed and vulnerable that they’ve been victimized by others. So in approaching homeless patients, one has to learn to be very, very careful, extraordinarily so, about touching, about how you ask questions, about when you perform certain exams. It’s an area that we are very sensitive to and part of a broader focus on trauma that has informed much of health care for homeless as we have evolved.
[Samantha Williams] What impact do you think that the Affordable Care Act will have on homelessness and health?
[John Lozier] The health care reform that’s been enacted should be a very, very important tool for breaking the tragic and deadly link between poor health and homelessness. In 2014, everybody who’s under 133 percent of poverty will be eligible for Medicaid. They have not been heretofore, unless they were a mom with small children and poor or disabled and poor. We’ve eliminated that categorical eligibility and invited all people into a mainstream system of care. The financial barrier, theoretically, will be gone. There’s much fine tuning to be done as that expansion of Medicaid takes place, but by and large, the financial reasons for homelessness, the going bankrupt because of medical care, should taper off. The lack of access to health care when you are homeless should begin to taper off. I think the biggest challenge and implementation of health reform may be the supply of providers of public health planning sort of issues. All of a sudden, three years from now, there will be millions of new paying patients to see what is still a very limited supply of particularly primary care providers. The other big piece about health care reform is that the community health center program is going to expand, double, or better; that includes health care for the homeless. So the access problems that relate to geography should be ameliorated pretty soon.
[Samantha Williams] John, thank you for being with us during our inaugural Public Health and Homelessness Symposium at CDC. If listeners would like more information about the National Healthcare for the Homeless Council or about John Lozier, please visit www.endhomelessness.org.
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