Why Supportive Housing Just Isn’t Enough (by Lee Hill)

The Public Writing

LeePicFor the past 9 weeks I have been volunteering for a Portland based non-profit organization called The Giving Tree (http://thegivingtreenw.org). The Giving Tree aims to provide professional resident services to people living in affordable housing, and aims to support Portland’s 10 year plan to end homelessness. The services provided include: advocating on the client’s behalf, connecting them to resources, and helping them build support networks. The goal is to empower each individual to reach and achieve their own goals which often include gaining employment and improving both their physical and mental health.

While the efforts made by the city of Portland to end homelessness are commendable; supportive housing alone is not enough to meet all the needs of the residents. Many of the residents have chronic health problems as a result of being homeless, and do not have access to the proper health care they so desperately need. Unmanaged and untreated health conditions often worsen to such a degree that emergency rooms are becoming the resident’s only form of primary care, which not only costs the state, but leaves the follow up care fragmented or non-existent.

This lack of follow up care further compounds health problems which often result in return visits to the emergency room for more costly health services. In one study alone at a hospital in New England, it was estimated that treating the homeless and formerly homeless cost the state over $3.2 million per year. This is just one hospital—the city of Portland has 3 major hospitals— I wonder how much it costs the state of Oregon to treat preventable diseases in the homeless population?

Supportive housing is an important first step, but it needs to be integrated with health care. After all, when the residents become sick, their untreated health conditions often worsen, and impede their ability to find employment; further creating a dependence on the state. If health care is made accessible to the residents by meeting them where they are at, diseases can be treated preemptively; making expensive trips to the emergency room only necessary when it is an actual emergency.

While there are numerous health clinics in and around the Portland area that provide support for the homeless, many of the residents simply will not seek treatment; primarily because other needs such as food take precedence, and as a result sacrifice medical care until health issues become critical. If an outreach program existed, whereby trained medical professionals visit residents on site— either on a monthly or bi-weekly basis— to provide basic medical support, many diseases could be caught before they become debilitating, and require urgent, and costly care.

There needs to be an extended effort to fully integrate health care initiatives with supportive housing. Once the needs of shelter, health care, and food have been met, the residents will be free and able to pursue employment opportunities. The result of which will help them move out of supportive housing freeing up more space for the homeless still on the streets. What is clear, is that while supportive housing takes people experiencing homelessness off the street; alone it is not enough to help the same people move forward in their lives.

The Research Question

Why is mental illness so prevalent among the homeless population; how does being homeless effect personal health, and in what ways does homelessness effect the economy?

I chose my research question based on my experience volunteering with The Giving Tree. I was surprised to see such a prevalence of mental illness among the residents that I have been working with; all of which were formally homeless, and all have some form of chronic health problems as a result. Very few have the means to obtain the treatment they so desperately need. As a business Major I am interested to see how homelessness effects our economy, and what the true cost of Homelessness is.

Research Resources:

  • Cost of Homelessness.”National Alliance to End Homelessness:p., n.d. Web.

18 Nov. 2014.

This article talks about the cost that homelessness has on our economy. What I liked about this, is that it expands beyond health care costs; covering the costs incurred to the American tax payer that emergency shelters, prisons, and jails have. This eye opening article is short but to the point. Like the other articles it contains some great statistics which I think will add weight to my writing.


The author points out that people experiencing homelessness are more likely to need the most costly health services. This is partly due to the homeless lifestyle that often exposes them to serious health issues such as HIV/AIDS, as well as addiction and host of other ailments. It’s estimated that on average homeless people spend four days longer per hospital visit than non-homeless people, costing approximately $2,414 per hospitalization. In addition, psychiatric hospitalizations are on average 100 times higher than their non-homeless cohorts averaging a cost of $2000 dollars per person. The total health care cost for the state to treat the homeless was an estimated 3.5 million per year. Furthermore, many of the health issues that people experiencing homelessness are suffering from require consistent care, care which is inhibited by homelessness since housing instability often detracts from regular medical treatment. This in turn compounds existing health problems that then require even more care, which then costs even more money for successful treatment.

The cost to the economy however is not just through medical expenditure, but also there is a significant cost incurred through incarceration. People experiencing homelessness are more likely to spend more time in jail; usually as a result of laws that specifically target the homeless population such regulations against loitering and begging. Typical costs to incarcerate a person is over $20,000 per year. According to a two year study cited in the article each homeless person incarcerated costs the taxpayers over $14,000 per year, and that is primarily for overnight jail.

In addition to expensive health care treatment, and unnecessary incarceration, emergency shelters that are designed to provide short term housing are often used to provide long term housing instead. The cost of which is approximately $8,000 more per person then it costs to house someone via section 8 housing. Interestingly enough, studies in LA—which is home to roughly 10% of the nation’s homeless population— found that housing just four chronically homeless people in permanent accommodation actually saved the state $80,000 per year.

  • “United States Interagency Council on Homelessness.”Economic Value of Ending

Homelessness. N.p., n.d. Web. 20 Nov. 2014.

While this article is only two paragraphs long, it contains a nice graph which illustrates how supportive housing impacts the economy. I choose this article since I have been working directly with homeless people that are now living in supportive housing.


The graph illustrates the difference between the use of major services before and after entry into supportive housing programs. In the state of Oregon the graph shows a drop of over 50% in cost to the state. My only criticism of this information is that it does not define what the major services are, nor does it define if the cost relates to one homeless person or many homeless people. What it does do is illustrate the benefit that supportive housing has in reducing the cost to the state, this further supports the claims from the previous article.

  • Zlotnick, Cheryl, Suzanne Zerger, and Phyllis B. Wolfe. “Health Care for the Homeless: What We Have Learned in the Past 30 Years and What’s      ” American Journal of Public Health 103.S2 (2013): S199-205. Academic       Search Premier. Web. 16 Nov. 2014.

I choose this peer reviewed article as I felt it directly answered the first part of my research question as to why mental illness is so prevalent within the homeless population. Upon reading the article it helped me develop the second part of my question which is about how being homeless effects there physical health.


In the 1980’s state mental hospitals were deinstitutionalized, and with the combined effect of an economic recession, the number of people suffering from homelessness drastically increased, and transformed their demographic from one which was mainly a population of men with alcohol problems, to a more diverse population that included a large number of people who also suffered from mental illness. In addition to deinstitutionalization, and economic recession, cuts to social services, and the gentrification of areas that traditionally offered low cost housing forced many people into homelessness.

People suffering from homelessness have an increased likelihood of contracting HIV, as well as developing chronic health conditions such as hypertension, and tuberculosis. Furthermore, people suffering from homelessness have a greater chance of exposure to communicable diseases and parasites that are easily transferred in crowded environments such as shelters. Lack of permanent housing acts as a barrier to health care leaving no place to store much needed medications, and basic survival needs for food and shelter take precedence over self-care practices that could prevent further illnesses.

  • Bharel, Monica, Wen-Chieh Lin, Jianying Zhang, Elizabeth O’Connell, Robert Taube, And Robin E. Clark. “Health Care Utilization Patterns of Homeless        Individuals in Boston: Preparing for Medicaid Expansion Under the Affordable      Care Act.” American Journal of Public Health S2 (2013): S311 –        317. Academic Search Premier. Web. 16 Nov. 2014.

I choose this article as it takes a look into a health care program that has already been successfully established in Boston, to see how health care treatment has an impact on the lives of homeless people. Due to its comprehensive study I felt the results could be applied nationwide and not just restricted to Boston.


This is an article that highlights the Boston Health Care for the homeless program (BHCHP) and in an attempt to understand the disease burden and utilization of health care of homeless people that have access to health insurance. It concludes that health care coverage alone is not always enough and that adequate health care has to be integrated with other resources to tackle complex issues such as housing, hunger and unsafe environments.

People suffering from homelessness have to give precedence to shelter, safety and food; therefore often sacrificing medical care until health problems become urgent. Unmanaged and untreated health conditions often worsen and can prolong the duration of homelessness by impeding the ability to find employment. In addition primary care often ends up falling into the hands of the emergency room, which often leaves follow up care fragmented or nonexistent.



One comment

  1. Madeleine

    Hey Lee! This is a very compelling and thought-provoking piece of writing! I haven’t though too much about the persisting health effects the homeless experience. Your research collection went really well; your sources had both great content and were authoritative!

    It would have been nice to have a few areas mentioned where we could jump into helping these people, so that us readers could get involved right away.

    Overall, very well written and thoughtful piece! Good work!

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