Health Care Access and Use Among Adults Experiencing Homelessness

Demographic and policy changes have occurred since the last large, representative study of homeless adults in the 1990s, which may affect health care access and use.

To describe the prevalence of poor health care access and short-term health care and use the Gelberg-Andersen Behavioral Model for Vulnerable Populations to assess the association between changes in homelessness with health care access and short-term care use.

This representative survey of adults experiencing homelessness in California from October 2021 to November 2022 used multistage, venue-based, and respondent-driven sampling. Data were analyzed from May 2023 to December 2024.

Shelter status (predisposing vulnerable), insurance (enabling), impairment with activities of daily living (ADL; need), and illicit substance use during the previous 6 months (need).

The study assessed self-reported no prior-year ambulatory care use and prior 6-month unmet health care need, unmet medication need, emergency department (ED) use, and hospitalization. Population prevalence estimates with Wald 95% CIs and multivariable Poisson regressions were calculated to compute prevalence ratios (PRs).

Thirty-two hundred adults completed the survey (mean age, 46.1 [95% CI, 45.3-46.9] years; 1965 cisgender men [67.2%], 1148 cisgender women [31.2%], and 57 transgender and gender queer individuals [1.6%]), of whom 2016 (77.6%) were unsheltered, 2609 (82.6%) were insured, 1056 (34.4%) had an ADL impairment, and 911 (37.1%) reported illicit substance use 3 or more times a week. A total of 1121 (39.1%) reported no ambulatory care use; 765 (24.3%) reported an unmet health care need and 714 (23.3%) an unmet medication need; 1252 (38.9%) used the ED; and 668 (22.0%) were hospitalized. Lack of ambulatory care use (PR, 1.71; 95% CI, 1.51-1.94) and unmet health care needs (PR, 1.19; 95% CI, 1.02-1.40) were more prevalent for those who were unsheltered. Lack of ambulatory care use (PR, 0.63; 95% CI, 0.57-0.70) and unmet health care needs (PR, 0.80; 95% CI, 0.67-0.95) were less prevalent for those with insurance. Unmet health care needs (PR, 2.13; 95% CI, 1.79-2.55), ED use (PR, 1.15; 95% CI, 1.02-1.30), and hospitalization (PR, 1.74; 95% CI, 1.40-2.17) were more prevalent for those with an ADL impairment. Lack of ambulatory care use (PR, 1.46; 95% CI, 1.19-1.79) and unmet health care needs (PR, 1.30; 95% CI, 1.08-1.55) were more prevalent for those who used illicit substances 3 or more times a week.

This cross-sectional study found that adults experiencing homelessness reported poor access to ambulatory care and a high prevalence of short-term care use, despite high rates of insurance. Changes in homelessness during the past 30 years were associated with worsened health care access and use.