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Running head: MEDICAL CARE FOR HOMELESS 1

House of Representatives Bill 29: Providing Mobile Medical Care for the Homeless

Mary Hefferan

Ferris State University

MEDICAL CARE FOR HOMELESS 2

Abstract

On July 3, 1944, President Roosevelt signed into law the Public Health Service Act (PHSA) to

help strengthen the nation’s health by improving and streamlining the distribution of public

health services. The PHSA offers grants for disease research and increases aid for individual

state budgets for public health services (Public Health Reports, 1994). Since its enactment,

amendments have been made that improve and add to the PHSA to expand health care coverage

for vulnerable populations. Currently, a bill has been proposed to the House of Representatives

(HR) that amends the PHSA and attempts to reach the vulnerable, growing population of

homeless in the nation. This bill is known as HR 29: Medical Mobilization of Homeless Health

Improvement Act of 2013. It intends to amend the PHSA to improve the access to health care

for the homeless by providing funding for mobile medical units that provide primary health

services, substance abuse assistance, and counseling for those suffering from mental health

disorders (HR 29, 2013). In this paper, analysis of HR 29 is conducted by examining the health

care issue of homelessness and discussing the potential impact HR 29 could have on the nursing

profession and the public. Strategies are explored that either support or thwart its enactment,

important stakeholders related to HR 29 are identified, and important institutions related to this

health care issue are contacted for their input.


House of Representatives Bill 29: Providing Mobile Medical Care for the Homeless

In a struggling economy with rising health care costs and high unemployment rates, the

population facing homelessness has grown nationwide. From 2009 to 2010, the number of

people facing homelessness on a single night increased from 643,067 to 649,917, or 1.1 percent

(HR 29, 2013). It is also estimated that “2.3 to 3.5 million Americans experience homelessness

each year” (Baggett, O’Connell, Singer, & Rigotti, 2010, pg. 1326). As the number of homeless

grows, the nation faces a population whose medical needs are not being met and are

consequently becoming a financial drain on health care funds. Homeless individuals often lack

health insurance, therefore lack access to adequate primary care. This leads to increase use of

the emergency room (ER) for routine medical care or for conditions that could have been

prevented with regular primary care visits (Ku, Scott, Kertesz, & Pitts, 2010). As a result, ERs

are becoming overcrowded and more health care dollars are spent due to frequent visits. The

homeless also face more acute and chronic medical conditions, higher incidences of mental

illness, and substance abuse compared to the general population (Baggett et al., 2010).

In an effort to address lack of access to medical care for the homeless, HR 29 was

introduced on January 3, 2013, sponsored by Congresswoman Nydia Velàzquez of New York. It

will add an amendment to the PHSA that “award[s] grants, contracts, or cooperative agreements

to eligible entities…to enable such entities to improve access of homeless individuals to mobile

medical health care services” (HR 29, 2013, para. 10). There are no cosponsors of this bill and it

was referred to the House of Energy and Commerce. The intention of this paper is to discuss

homelessness as a health care issue, how HR 29 will impact this issue by providing medical care

for the homeless, nursing and public implications if enacted, and key stakeholders involved.

Also included are possible political strategies to support HR 29, defining strategies that could


thwart it, and speaking to important organizations that could be influential in its enactment for

their input.

The Health Care Issue of Homelessness

As the number of homeless individuals grows, their health care needs and impact on the

nation becomes a pressing issue that requires attention. Facing the challenges and dangers of

being homeless, many suffer more serious health problems as a result and have no access to

adequate health care. “Homeless people are three to six times more likely to become ill than

housed people” (National Coalition for the Homeless [NCH], 2009, para. 6). Their increased

risk of suffering from health issues is mainly due to the nature of living in the streets. Many

homeless live in unhygienic conditions, are exposed to respiratory diseases such as tuberculosis

and influenza, engage in risky behavior, and are at risk for sexual and physical abuse (Hudson et

al., 2010).

As well as facing constant exposure to harmful environments, the diseases homeless

individuals often suffer from are those that require consistent treatment, such as severe mental

illness. “20 to 25% of homeless population in the United States suffers from some form of

severe mental illness” (NCH, 2009, para. 1). Treatment of and recovery from a mental illness

requires a multidisciplinary approach including pharmacotherapy, counseling and social support

(Mayo Clinic, 2012). Even if homeless individuals have been diagnosed with a mental illness

and given a treatment plan, it is unlikely that they have the health insurance to keep up with

treatment. In 41 states, homeless adults are ineligible for Medicaid, even if their income is zero

(National Public Radio, 2009). Even those who are former veterans eligible for VA insurance

are lacking insurance. In a study conducted by Kushel, Vittinghoff and Haas (2001) surveying


homeless individuals, almost half of the homeless veterans eligible for VA benefits remained

uninsured. Higher rates of untreated, worsening mental and physical health for the homeless

could continue if their ability to access health care is not improved.

Unfortunately, many barriers exist to the homeless when attempting to obtain health care

and medical treatment. Many simply do not know how to access programs that offer free health

care to individuals, or do not know how to enroll in programs that could benefit them.

Paperwork for accessing health care programs may be complicated or lengthy, language barriers

may exist that inhibit full understanding of these programs, and programs may have extensive

wait times for access to physicians and health care professionals (Hoshide, Manog, Noh, &

Omori, 2011). Even if homeless individuals were able to navigate through these barriers,

transportation to these services is not guaranteed and often left up to the individual to find their

own way or finance public transportation.

In addition to lack of insurance and access to health care as a barrier for homeless

individuals, many do not receive medical care for reasons related to fear and mistrust of the

system. Individuals facing legal troubles may resist identifying themselves to obtain access to

health care, have negative attitudes toward the health care system, or are ashamed of their status

and feel they would be discriminated against (Hoshide et al., 2011; Hudson et al., 2010).

Unfortunately, their feelings and perceptions of discrimination are not unwarranted. A study

performed by Wen, Hudak and Hwang (2007) showed that the homeless participants felt “they

were being ignored, rushed, brushed aside or treated rudely” (pg. 1012) during encounters with

health care professionals. These feelings of discrimination and rejection from health care

society, lead to avoidance of all health care institutions as a result (Wen et al., 2007).


Identification and Intent of Legislation Policy

As the evidence shows, the homeless are an underserved, vulnerable population when

referring to health care access and utilization. The enactment of HR 29 could break down many

barriers the homeless have when attempting to receive health care. If passed, HR 29 would

provide funding to hospitals for partnerships with local primary care clinics in an attempt to

reduce the amount of costly ER visits from homeless individuals by providing mobile medical

care units that reach the homeless in their own environment (HR 29, 2013). These mobile health

care units would provide “primary care, screenings, dental care, medications, behavioral health

care, immunizations, lab tests, case management, benefits assistance, and assessments and

triage” (Kim, 2013, para. 6).

Funding for the potential grants awarded by HR 29 would be distributed by the Secretary

of Health and Human Services. Grants provided would only be allowed for use in activities to

“increase access of homeless individuals to mobile medical services” (HR 29, 2013, para. 16).

Areas with high concentrations of homeless would be given priority for grant, such as Florida,

California and New York, where 40 percent of the homeless population is located. The bill also

specifies limitations to grants of funds. It limits hospitals or health care facilities to one

partnership grant, restricting them from creating other partnerships and receiving more grants

(HR 29, 2013).

The proposed bill also refers to the definition of a “homeless individual” as outlined by

the PHSA and specifies how long they are eligible for services provided. Homeless individuals

are previously defined by the PHSA as “an individual who lacks housing…including an

individual whose primary residence during the night is a supervised public or private facility”


(National Health Care for the Homeless Council, 2013, para. 2). These individuals would be

able to access these services for 12 months after they have found housing (HR 29, 2013).

Although the potential cost of providing grants for mobile medical care under HR 29 may

be daunting, the estimated savings on ER visits from homeless individuals leads the author to

support the enactment of this legislation. HR 29 (2013) discloses that the savings of visiting an

ER versus a mobile medical unit would be more than $800 per visit. If homeless individuals had

access to mobile medical units, it could in turn reduce the amount of overcrowding of ERs with

non-life-threatening issues that distract the staff’s focus from critically ill patients. Initial start-

up costs may be high for this program, but the long term savings could be substantial based on

these statistics. HR 29 should be enacted and supported to reach the vulnerable population of

homeless individuals in an accessible environment, in addition to potentially reducing excessive

health care spending from ER visits.

Analysis

Implications for the Nursing Profession

HR 29 could have many potential positive impacts for the nursing profession. Nurses

could play a key role in implementation of mobile medical units. Specifically, nurse

practitioners (NPs) could manage these units, based on the laws of practice in the state, and act

as a less expensive type of primary care practitioner. In addition to being less expensive than

traditional primary care physicians, NPs provide a more holistic approach to care. NPs “play a

leading role by providing care management, health promotion, and instruction in patient self-care

while physicians focus more on medication management and treatment of acute complications”

(Bodenheimer & Grumbach, 2012, pg. 79). Their training and expertise place NPs in a very


significant position if HR 29 is enacted since the homeless have needs beyond the treatment of

acute problems alone.

Another potential positive from the enactment of HR 29, could be an expansion in

nursing education. Under supervision, nursing students could participate in medical mobile

outreach programs as part of their community health education. They could provide blood

pressure screening, basic self-care instructions, and preventive care measures. Students could

help screen for more serious health issues and refer them to the licensed practitioner on site.

This could expand clinical site availability and expose future nurses to the needs of this

vulnerable population, potentially creating more advocates in the production of services to the

homeless. Currently, the University of California, San Francisco (UCSF) uses medical and

nursing students, medical residents and physicians in clinics to provide homeless individuals

with various medical and counseling services including urgent care, health education, and

support groups (UCSF, 2013). UCSF could provide a valuable framework for how the medical

mobile units could be operated by students.

As with any program development that requires more medical professionals, the concern

is whether or not there will be enough to staff the programs. In addition to a primary physician

shortage, America is facing a growing nursing shortage. Kovner and Knickman (2011) state that

“reports of nursing shortages…have arisen periodically over the past 60 years” (pg. 322). In

2010, the Institute of Medicine called for an increase in baccalaureate-prepared nurses by 80%

and doubling the amount of nurses holding doctorate degrees (American Association of Colleges

of Nursing [AACN], 2012). The current statistics show the U.S. falling short with only 50% of

registered nurses having baccalaureate or graduate degrees (AACN, 2012). Unfortunately,

nursing schools are not able to expand their programs to train the amount of nurses needed. The


AACN (2012) reports an “insufficient number of faculty, clinical sites, classroom space, clinical

preceptors, and budget constraints (para. 19). The nursing shortage that the U.S. faces may

prove to be prohibitive when attempting to enact HR 29 if more nurses are needed to operate

mobile medical units.

Implications for the Public

Although they lack housing, the homeless are members of the public. As members of the

public, the homeless would unmistakably be the most impacted by HR 29. HR 29 would reach

those who do not have access to health care clinics and lack a stable form of any primary care.

By extending services to the streets where the homeless are located, the mobile medical units

could eliminate the problem of transportation and provide medical care in a more trusting,

familiar environment.

Although the cost of mobile medical units may make the public fearful, similar methods

for mobilization of health care for homeless individuals have been developed, trialed and proven

successful in the past. In 2000, several Phoenix area hospitals and clinic collaborated efforts to

produce a free-standing clinic and mobile medical unit to provide comprehensive and preventive

care to homeless and at-risk youth populations (U.S. Department of Health & Human Services

[USDHHS], 2009). They also provided referrals for follow up services that were needed, how to

access these services, and helped them make appointments. Data collected after implementation

of this program show a decrease in ER use by 27% by users and an increase in follow up

appointments of 19% (USDHHS, 2009). Also, patients reported feeling safer and more

comfortable accessing this type of care and would return to seek further medical care.


However, when the government is already facing challenging budget issues and deficits,

the public and congressional leaders may not be in support of funding a program that requires

further spending with a potential unknown rate of success. In the Phoenix program described

previously, the operating budget was just over $1 million in 2010 to “cover staff salaries and

benefits, supplies, licensing fees, medicine, equipment, fuel, van repairs and maintenance, and

outside services for radiology, vision, and hearing” (USDHHS, 2009). It may also be difficult to

measure the success of such programs if initiated. HR 29 outlines the savings compared to an

ER visit, but it may be difficult to quantify the health care dollars saved from providing more,

but less expensive medical care to the homeless.

Another potential negative may be shown through the workers who are serving the

homeless population. A program was piloted in Boston called the High Utilizers of Emergency

Services to Home which provided the most frequent users of ERs (most homeless) a non-profit

safety net hospital for case management and treatment services (Pearson, 2012). Although there

was an overall reduction of ER visits in the population followed, many of the health care

professionals found it defeating when they encountered those that continue to participate in the

same risky behaviors that caused the initial health problem (Pearson, 2012). The public may

choose to view only those who are not helped by HR 29, and wonder how effectively their tax

dollars are being spent.

Key Stakeholders in HR 29

There are many influential stakeholders identified that play key roles in whether or not

HR 29 is enacted. First, Nadia Velàzquez of New York’s 7th Congressional district is the sponsor

of this bill. As a long-time resident and representative for New York, Velàzquez has fought for


the rights of the underrepresented and poor. Representing New York, previously described as

having a large population of homeless, provides her with a distinct interest in creating programs

to help them. Also influential would be the members of the committee and subcommittee HR 29

was referred to: House Committee on Energy and Commerce (HCEC), and Health Subcommittee

(HS). Fred Upton, a republican representative for Michigan’s 6th district, is the chairmen of the

HCEC and would be important in passage or rejection of this bill. His position on HR 29 is not

given, but he has flatly opposed the Patient Protection and Affordable Care Act (PPACA), and

may not be in support of adding more money to and already costly health care system. The vice

chairman of HCEC is Marsha Blackburn (R-TN) and although she opposes PPACA, she supports

expanding access to care at a lower cost.

Furthermore, the HS consists of many members that could have vested interest in HR 29.

The chairman of the HS is Joe Pitts (R-PA), joined by ranking member Frank Pallone Jr. (D-NJ).

While both support the notion that Americans need more affordable options for health care, their

views differ largely in regards to the PPACA. Although the HR 29 is separate from the PPACA,

it may draw the same republican opposition as the PPACA, since it will require more

government spending. The common views of the Republican Party focus on spending cuts and

reduction of federal control in states (Political Party Platforms, 2012).

Strategies to Support Passage of HR 29

In order to gain support for HR 29 a few simple, economical strategies could be applied

to spread the knowledge of how it would impact the lives of the homeless living in the

community. The internet presents an easy opportunity to reach many at little to no cost. Social

media websites, like Facebook, could be used to incite interest in the bill. HR 29 already has a


Facebook page dedicated to its support. Facebook users can “like” the page and will then be

updated via their newsfeed on current news of the bill.

To further utilize Facebook, supporters of HR 29 could pay a fee to have their message

appear on the side margins of the social website. These messages could consist of information

about HR 29, or request volunteers for events and rallies to support its enactment. In addition to

gaining support from volunteers, their use presents another political strategy to help support HR

29. The volunteers could spread the word of the benefits of HR 29 through the community by

door to door campaigns, rallies, or posting literature at local community centers. Although this

strategy works on a very local level, as knowledge of HR 29 grows, political leaders of

communities could become involved and bring the message to Congress.

An additional strategy that could be employed to reach a broader audience would be to

access local television or newspapers and present a compelling case for HR 29. A possible

impactful human interest story might highlight the excessive costs of the homeless’ E.R. visits

and how HR 29 would attempt to reduce them. University of Southern California (USC)

reported a story of a homeless man who, in three years, accumulated nearly $1 million in medical

charges from E.R. visits, all paid for by taxpayers (Arnquist, n.d.). Since this man had no form

of health insurance, hospitals are not reimbursed fully or if at all, and must shift the cost to other

patients who have health insurance (Arnquist, n.d.). The public may not be aware that these

costly visits are costing them money as well.

Strategies to Prevent Passage of HR 29

The subject of cost is equally persuasive if attempting to prevent the passage of HR 29.

Those who oppose HR 29 could highlight the overwhelming costs of health care and question the


proposal to spend more with programs created as a result of the bill. Television or other media

ads could run with the shocking numbers of health care expenditures. Kovner and Knickman

(2011) found that in “2008, total U.S. health care costs were $2.3 trillion-$7,681 per person” (pg.

17). And with more health care spending, Americans who have private insurance may be finding

their premiums rise as a result. “U.S. households spent almost 6% of their income on health care

in 2008” (Kovner & Knickman, 2011, pg. 17). These types of advertisements are considered

negative campaigning and are shown to be effective if shown in moderation (Pederson, 2012).

It may be controversial to campaign against a program that provides services to the

homeless, but strategies could be developed to promote strengthening of existing programs,

rather than enacting a bill that would create new ones. Those who oppose HR 29 could attend

homeless awareness meetings to promote strengthening programs that find housing first rather

than treating homeless on the streets. Campaign messages could consist of statements such as

rather than offering medical treatment, “offering the provision of housing to the homeless

community decreases the number of visits they make to emergency departments by 61%” (Green

Doors, n.d., para. 3). Finding housing first for homeless individuals promotes better health

outcomes and could be the primary message behind an opposing view of HR 29 (NCH, 2009).

The “housing initiative” encourages finding housing first for the homeless individual, then

providing the services needed (Housing First, n.d.). This initiative could be promoted by

working with local public health committees as an alternative to HR 29.

Meeting with Key Organizations

In order to gain support for HR 29, it is beneficial to speak to organizations that may be

influential in its enactment. The support of local homeless outreach programs could be powerful


and represent community support to the Congress members when voting on HR 29. The North

End Community Ministry of Grand Rapids, Michigan is an example of a local program that

reaches out to the homeless and those in need. Linda Richardson, a food pantry organizer, was

contacted to gain a clearer perspective of the needs of the homeless population. She finds that as

more struggle in a bad economy, the needs of the public are becoming overwhelming for her

ministry. Many have lost their jobs and subsequently their health care, but do not meet the

requirements for Medicaid. Her program offers food to individuals and families in need and

offers diet counseling for those who suffer from diabetes or cardiovascular disease. Linda states

that these programs have been successful, and participants are open to learning and feel

empowered with knowledge after they leave. Success of programs like these, could build a

foundation for the promotion of HR 29.

During analysis of HR 29, Kate Barsten of Hope Academy was contacted. Hope

Academy in Indianapolis, Indiana, treats students who struggle with substance abuse and/or

mental illnesses while they attend high school classes for credit. Since homeless individuals are

more likely to have substance abuse problems and mental illness, she and Hope Academy’s input

on the needs of this population could help guide programs that offer counseling services. Kate,

an educational counselor, found that many of her adult students had trouble once they left Hope

Academy finding programs to continue their counseling that were easily accessible and

affordable to them. Some are displaced from their homes and are temporarily staying with

friends. This offers them little stability and puts them at risk for relapse, much like

homelessness. More consistent, easily accessible care, like mobile medical units, could help

reduce their risk for relapse.


Conclusion

Lack of access to health care for the homeless is an undeniable concern facing America.

There are many who face homelessness every day and the numbers continue to grow. Health

problems associated with homelessness are severe and many remain who are not able to obtain

consistent preventative counseling or disease management services. HR 29 would provide an

incentive to hospitals and organizations to improve the provisions of medical care to the

homeless. If the PHSA is amended and HR 29 is added, overall health care costs associated with

ER visits are projected to decrease by increasing the use of less expensive mobile medical

services. The author of this paper has chosen to support the enactment of this bill due to its

potential reduction in health care costs and its focus on reaching the vulnerable population of the

homeless and providing them with accessible health care. Nursing and public implications have

been explored and several strategies have been presented to aid in promotion or prevention of

HR 29 that could be inexpensive and reach a large population.


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