Overview 

During the COVID-19 pandemic, the realities of healthcare inequity in the United States reached a crescendo. The power of structural racism and socioeconomic status to penetrate every aspect of life became undeniable as people of color experienced rates of COVID-related illness and death 2 to 3 times higher than the white population, and adults of low socioeconomic status had a death rate 5 times greater than the high-income population. For people experiencing homelessness, factors like higher disease burden and pre-existing chronic respiratory conditions resulted in higher levels of severe COVID-19 infections and long-term morbidity. However, American healthcare disparities have long preceded the pandemic and continue to this day. At Housing Up, we understand the importance of bringing the issue of healthcare inequity to the forefront of the affordable housing conversation and recognize the fundamental role that safe and affordable housing plays in health and well-being.

Social Determinants of Health 

The Western medical approach teaches us that our health is the product of biological processes, genetics, and personal life choices. What is often left out is how our backgrounds, life experiences, and systemic inequality contribute to different health outcomes. The picture is incomplete without considering the social determinants of health defined as the nonmedical factors, including the environments in which we live, work, play, worship, and age, that shape health and well-being. When discussing the intersections between homelessness and health, it is critical to expand the conversation beyond the purely medical and examine the environmental and social conditions that influence poorer health outcomes and lower quality of life.

Environmentally, people experiencing homelessness face a unique set of challenges that impact health. Living without sufficient or stable shelter leaves individuals especially vulnerable to the elements, as extreme heat or cold can lead to heatstroke, dehydration, frostbite, and hypothermia. While the weather and environment can cause these more acute ailments, they can also exacerbate pre-existing conditions and contribute to the emergence of new health issues. On the other hand, residing in shelters comes with different health risks. Living in close quarters has long been a primary promoter of the spread of infectious diseases. Shelters are no exception, as people experiencing homelessness have a much higher likelihood of contracting communicable diseases like Tuberculosis and COVID-19 in shelters. 

Compounding these risk factors are barriers and stigma within the healthcare system. Despite the existence of federal programs like Health Care for the Homeless, the majority of unhoused people do not have health insurance. Lack of health insurance can result in delays in treatment, leading to worse health outcomes and higher rates of disability. Outside of the logistical and economic barriers to healthcare is the social stigma that unhoused people experience. A recent study revealed that unhoused individuals with chronic health conditions who had experienced or perceived stigma from healthcare providers were much less likely to seek care in the future. Of those interviewed, they often felt they were stereotyped as “drug addicts or criminals” and were “treated as less than human” by providers.

Race is a socially constructed category that has very real effects on one’s healthcare experience. In the media, we often see misleading headlines connecting race and biology. The reality is there is no biological basis for race and that the different health outcomes that we see are not a result of genetics but rather the history and perseverance of racism in the United States. An abundance of data shows that healthcare providers’ racial biases, both conscious and unconscious, largely contribute to the racial disparities in healthcare. The intersections of being homeless and being a person of color create an even more complex picture involving the social and economic barriers associated with homelessness and the systemic oppression of racism. In the US, it is impossible to discuss health inequity without acknowledging the central role that racism plays in creating discriminatory and unjust healthcare practices and systems.

Health and Homelessness in DC

In DC, health is a major concern for people experiencing homelessness. According to the 2024 Point in Time Survey, it is estimated that 22.1% of unhoused individuals in DC live with a chronic health condition, while 19.6% of people are physically disabled. Individuals can experience homelessness for the first time because their disability or chronic health condition prevents them from working and paying their bills. On the other hand, for those already experiencing homelessness, chronic conditions may go untreated and worsen, posing significant barriers to exiting homelessness. In addition to physical conditions, people experiencing homelessness are more likely to live with a serious mental illness. The stress of living without housing can exacerbate mental health conditions and present challenges in accessing necessary medication and mental health services and securing stable employment. In DC, it is estimated that 34.1% of individual adults and 9.5% of adults in families experiencing homelessness have a history of mental illness. While these statistics show only a snapshot of the health challenges unhoused people in DC face, the need for change is clear. How do we then, as a community, move forward and enact the changes we want to see? 

Solutions: Housing First and Support Services   

Since the early 1990s, research has demonstrated the effectiveness of the Housing First model in reducing homelessness. In contrast to the Treatment First model, which requires individuals to be sober or in treatment programs as a condition for receiving housing, the Housing First approach maintains that once the basic need of safe and affordable housing is met, people can transform their lives. With this perspective, the benefits of the Housing First model extend far beyond shelter and security. Housing First programs have been shown to reduce substance use and hospital visits while increasing preventative care visits. While providing safe and affordable housing is an excellent first step, offering support services is instrumental to continued success. Providing case management and mental health services ensures long-term well-being essential to creating opportunities.

At Housing Up, we understand the vital role that health plays in serving our families. We offer a range of services, including affordable housing and comprehensive support services like mental health support, youth programs, and case management. The majority of the more than 900 families Housing Up serves are families of color, and many of them participate in our permanent supportive housing program due to mental and physical health challenges. Acknowledging the intersections of health, housing, and social inequity is essential to understanding how to best serve our clients. Supporting Housing Up not only supports the right to affordable housing but also the health of the DC as a whole.