Emergency room.

Worsening Health Inequity During Pandemic for People Experiencing Homelessness

This piece was adapted from a post that originally ran at On the Flying Bridge on March 28, 2021.

By Michael Greeley

With great fanfare last week, DoorDash announced an initiative to provide same-day home delivery of approved COVID-19 test collection kits.

Much of the business model innovation in health care today is to move as much care as is feasible to the home. But what does that mean for the homeless?

Habitat for Humanity estimates that over 100 million people are homeless globally and that 1.6 billion lack “adequate shelter.”

In the United States, the Annual Homeless Assessment Report in 2019 counted 553,000 homeless people. This figure was thought to be closer to 580,000 at the start of the pandemic in early 2020. Undoubtedly, that number spiked over the course of 2020 with the pandemic’s devastating economic dislocations. Nearly 65% of the homeless are either Black or Latino. Many are older, and at significant risk of severe COVID-19 infection.

The risk of infection among people experiencing homelessness or housing instability is compounded by the fact that  they may have no choice but to shelter in congregate settings and/or they may work essential, in-person jobs. And for children sheltered in inadequate, unsafe housing, lead poisoning also poses a risk. With a nearly 50% reduction in regular lead testing due to COVID-19, experts fear that up to 10,000 additional children now have elevated blood levels of lead.


Many point to the significant HUD budget cuts of the early 1980s as to when structural homelessness became a chronic condition. Today it is estimated that in two of the largest states (New York and California) the level of homelessness is 0.47% and 0.38%, respectively.

Home ownership has a number of implications, most profoundly with wealth creation.

The homeownership level at the end of 2020 was more than 65.5%, marking a recovery from the lows reached in the middle of the last decade after a pronounced decline caused by the Great Recession.

Last year was a scorching hot year for home sales, in large measure due to 30-year fixed mortgage rates below 3.0% and the mass pandemic migration out of cities. According to the S&P Case-Schiller National Home Price Index, home prices increased by 10.4% in 2020, with December 2020 showing the greatest monthly increase in the last seven years, often pricing the less fortunate out of the market.

The Urban Institute (UI) has documented racial inequities in homeownership, finding in 2020 that Black homeownership was 44.1%, while Latino and white ownership levels were 49.1% and 74.5%, respectively. The UI projects that for the first time ever by 2040 the level of ownership for each generation will be lower than the preceding generation at that same age.

Meanwhile, the National Association of Realtors (NAR) identified 1.07 million homes for sale at the end of 2020 (and likely below 1.0 million at the end of 1Q21), a 23% decline from the end of 2019, which is likely to drive up the price of available homes and put home ownership even further out of reach for many.

The Bureau of Labor Statistics projects that by 2026, approximately 30% of the labor force will be between 65-74 years of age; Harvard University research suggests that 2.4 million of those senior citizens will not be able to afford adequate housing. The aging of America will quite literally add to the homeless population, further pressuring the resiliency of the $93 billion spent on public health infrastructure.


Government relief could come in a number of ways.

The recently passed COVID-19 relief bill calls for $21.6 billion in emergency rental assistance, $5.0 billion in housing vouchers, and $850 million for tribal and rural housing support, although some legislators believe between $70 – $100 billion in housing aid is required. An analysis by the Center on Budget Policies and Priorities estimates that approximately 20% of renters are now behind on their rent payments.

And, importantly, at the pandemic’s onset, a number of states severely limited the potential to be evicted or have necessary utilities cut off.

Of course, government relief programs have limitations. First and foremost, no single federal or state agency “owns” this issue, severely limiting accountability and creating inefficiencies. For instance, the $22 billion Section 8 housing voucher program managed by the Department of Housing and Urban Development (HUD) has led to both abuse and discrimination. This month a massive lawsuit was filed against 88 brokerage firms and landlords in New York City, alleging systemic bias against those with housing vouchers; there are 125,000 households in NYC that rely on such vouchers.

Mortgage forbearance programs tend to last up to twelve months, and are now starting to wind down. According to Black Knight Inc., a mortgage data analytics firm, more than 50% of the 2.7 million forbearance cases will end in 2Q21, likely causing a spike in the number of homeless people.

And as eviction moratoriums expire, the consequences can be life-threatening.

A recent study by scholars at the University of California, Los Angeles, Johns Hopkins University, the University of California, San Francisco, Boston University, and Wake Forest University found that the 27 states that lifted eviction moratoriums (of the 44 that had initially implemented them), the incidence of COVID-19 infection was a staggering 1.6 times that of those remaining 17 states that left the moratoriums in place (this increased to 2.1 times higher after sixteen weeks). Mortality rates were also 1.6 times higher, but increased to 5.4 times higher than states that still had moratoriums in place after sixteen weeks. Just between March and September 2020, it is estimated that there were 11,000 deaths tied to the lifting of state eviction moratoriums.

Studies of the homeless population during the pandemic have found similar trends. Currently, the general population is showing ~4.5% positivity rate for COVID-19, markedly down from ~12.5% during the winter peak, according to Johns Hopkins data. The National Health Care for the Homeless Council estimates that positivity rates for the homeless population are now between 9% – 12%, further compounded by their lack of access to quality healthcare. At the outset of the pandemic, positivity rates at community health centers with Section 330(h) grant funding were 15%, only to settle around 10% after each spike.

Setting aside the pandemic, life expectancy for the homeless is significantly lower. The homeless charity Crisis in the United Kingdom found in research conducted in 2011 that life expectancy rates were as much as 30 years below that of the general population. Twenty years ago, one of the most comprehensive studies of this issue was conducted at the Columbia University Center for Homeless Prevention Studies, which found that across the U.S., mortality rates for people experiencing homelessness were approximately four times that of the general population.

These data highlight the stark, pre-existing inequities that the COVID-19 pandemic has further exacerbated. Policy must go further to address homelessness and housing insecurity. Innovation may help to mitigate disparities.

Tech-enabled initiatives to bring health care home are motivated by the aim of “meeting people where they are.” For no population is this goal more crucial than for those without permanent or stable housing. As we work to address the homelessness crisis in the U.S., we should work in tandem to bring health care directly to those who are most vulnerable.

The Petrie-Flom Center Staff

The Petrie-Flom Center staff often posts updates, announcements, and guests posts on behalf of others.

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