Rachel Solotaroff has treated homeless patients at her Portland, Oregon health clinic for nearly a decade. But only recently has she noticed an unsettling trend in the type of people seeking care.
Last month, she met a man who had been sleeping on cement for so long that his metal hip replacement had begun to wear through the skin. Before that, she treated a struggling diabetic woman who had stopped taking her medicine because she had had no fridge to store it in. From dementia, to chronic heart disease, to arthritis, Solotaraff has become a first-hand witness to the dramatic aging of America’s homeless population.
“It’s incredible to me,” Solotaroff, the director of the homelessness-focused nonprofit Central City Concern, said. “This is the last age group that should be living on the street. I’m at the point where I will sign any piece of paper in order to get them indoors.”
This spike in elderly homeless patients isn’t confined to Portland. Thanks to a devastating housing crisis hitting just as the first Baby Boomers reached retirement, nearly half of the country’s homeless are now over the age of 50. And the number will only rise as the generation continues to age. According to U.S. Department of Housing and Urban Development (HUD), the number of homeless seniors will double between 2010 and 2050 — leaving an estimated 95,000 elderly citizens without shelter.
This increase means health providers are seeing a new, challenging array of chronic diseases — like cancer or Alzheimer’s — that don’t fall into the traditional bucket of homeless health issues — like drug addiction or mental illness. Social aid organizations and clinics admit they’re years behind when it comes to shifting their services toward this older clientele. Their work with the homeless is merely a Band-Aid that isn’t addressing the deeper root of this new health care need.
Policy experts agree on the permanent solution here, even though it may not seem like it’s immediately related to health care. It’s not an expansion of clinics or a network of doctors. It’s not even an insurance plan. It’s housing.
The healing power of housing
“None of this is fixable without housing,” said Margot Kushel, professor of medicine at University of California, San Francisco. “Once someone is housed, depression often lifts, stress fades away, infections heal. It’s instant.”
Kushel’s been leading a study on the effects homelessness has on older people’s health since July 2013, using Oakland, California as an example for many mid-sized cities across the country. With her team of researchers, she’s kept tabs on 350 homeless people over the age of 50 over the past 18 months to understand their path to homelessness and track their changes in health. She’s found that most end up on the streets after a series of events — job loss, illness, family crisis — all leaving them without the means to pay for housing.
The biggest surprise isn’t in the type of illnesses they face, she said, but in the fact that 43 percent of her participants are very new to being homeless.
“A lot of these people have been healthy their whole lives,” she said. “But it doesn’t take long for their health to plummet once they’re homeless.”
Angie Whitehurst, a formerly-homeless vendor for Washington D.C.’s street newspaper, said the job market is a major reason people her age are stuck on the streets. After having a stroke, the 62-year-old woman found herself physically unable to work in common job settings, making each rent check a struggle. There’s simply not a lot of work for people over 50, especially for women, especially in entry-level jobs — and especially if they don’t have a home.
“It’s all working against you. It costs money to interview for a job. You have to wear something nice, find a way to get there on time, clean up. And if you don’t get it, which is usually the case, finding health insurance when you’re under 65 is nearly impossible,” she said. “Who has time for that when you’re already dancing on air?”
Whitehurst said many of the older people she knows on the street try to stay out of the public eye, either because they feel like a nuisance or are simply embarrassed of their condition.
The shame of homelessness leaves many unable to ask for help from their families or from social services, Kushel’s observed. And the services that do exist aren’t equipped for the population. Bunk beds at a homeless shelter, for example, just don’t work for people in their 60s. Kushel said that working to provide care to an aging person can sometimes feel ridiculous when they’re living without a home.
“What are you going to do?” she said. “You can’t add bright lights or install a handrail for someone living under a bridge. It doesn’t make economic sense — and it really doesn’t make moral sense.”
At least 15 of her study’s participants have died on the streets so far, mostly from things like cancer and stroke — ailments that generally kill the general population about a decade later. One was hit by a car.
Kushel hopes her study can help influence housing policy and strengthen eviction defense programs, since the elderly homeless population is only growing.
“I’m worried we’re just seeing the tip of the iceberg,” she said. “And I’m worried our service systems aren’t prepared.”
Fighting for independence
In the nation’s capital, the social safety net for aging homeless people is not prepared. There are only a few social programs geared directly toward the elderly.
The nonprofit So Others Might Eat (SOME) provides one of the only temporary housing options for low-income seniors in D.C., offering space for up to 42 people. But for those without an income, who qualify as “abused, neglected, exploited, or displaced,” SOME only has six available housing slots. According to Julie Maggioncalda, director of senior services at SOME, the waiting list is so long they had to stop adding people.
“It’s atrocious, it’s impossible to reach everyone who needs our help,” she said.
Like Kushel, Maggioncalda said she’s struck by how many people contact her who have only recently became homeless and have nowhere else to turn. She’s met people forced to leave a subsidized apartment without an elevator because they could no longer maneuver the stairs. Others were evicted after losing the little bit of income they had coming in. For this group of people, SOME’s mission is to give them a place to stabilize — get a week of good sleep, food, hygiene — before determining their real health needs.
“We have to look at other side of the wave to adequately assess someone whose been living on the streets for a while,” Maggioncalda said. “And by that point, many are able to take care of themselves.”
Her main goal is to help steer people into independent, permanent living situations. Too often, doctors who see elderly homeless people coming into their ER on a regular basis eventually send them to a Medicaid-funded nursing home where they can get constant care. But many of these patients could probably live on their own, if they just had the right tools to recover.
“Imagine going straight from living independently on the streets, to living in a highly-structured environment with round-the-clock attention. It’s frightening,” she said. “We want our clients to be able to be independent and housed. It’s a real option.”
Keeping people whole
A growing number of organizations are using a similar model to addressing post-hospital care. At least 70 cities have some kind of “medical respite program” for homeless people, usually elderly folks, who have recently been released from the hospital.
Often, after a homeless patient is released — with the recommendation from their doctor to rest up — they return to an environment where rest is hard to come by. So these respite programs give people a place to recuperate before heading back to the streets. It’s a clear example of essential housing is for improving health, according to John Lozier, director of the National Health Care for the Homeless Council (NHCHC).
But advocates working on this issue don’t want to stop there. “Permanent housing is the goal,” Lozier said.
Moving past temporary housing to secure long-term solutions requires more federal investment. NHCHC has been working with other housing organizations to return funding to the National Housing Trust Fund (NHTF), a sum of money collected from Fannie Mae and Freddie Mac to support low-income renters. The fund, which was ironically suspended in 2008 because of the housing crisis’ impact on funds, was finally funded for the first time in 2015. But it has a ways to go until it can effectively impact the rapidly aging homeless population.
“Beyond that, we have to look at broader, affordable housing efforts across the country,” Lozier said. “We don’t have time to just wait.”
Some homeless people may already be eligible for housing options, but simply don’t know how to access them — or that they even exist. Central City Concern’s Solotaroff said that connecting these people with a social worker can, at times, be life-saving. Especially if a person is dealing with severe mental health issues.
But sometimes, the most important person for an ailing, aging person is someone they know. Solotaroff spoke of a former patient who was kicked out of his apartment for accidentally starting a fire while smoking with his oxygen tank. His wife was in a nearby assisted living apartment, but he wasn’t able to join her because of his track record. He decided to live in the park across the street from her facility, to be close. A social aid group finally found him a place to live, but it was on the other side of town from his wife, too far for him to travel. He died shortly after moving in.
“As people age, people want comfort. You want to be around people you love. We sometimes have to ask people to choose between those people and a roof over their head — it’s not right,” she said.
“The end goal is finding places that keep people sheltered, but also keep people whole.”