Are Canadians who are experiencing homelessness getting the health care that they need? The average person might assume that the answer to this question must be “yes,” because Canada has a system of universal health insurance. In fact, almost all previous studies of unmet needs for health care among homeless people have been done in the US, where more than half of people who are homeless do not have any health insurance. These studies have (not surprisingly) found that lack of health insurance greatly increases the risk of unmet needs for care. Amazingly, almost no studies have looked at this issue in countries that ensure that its citizens and residents have universal health insurance.
We recently published a study in the American Journal of Public Health that looked at unmet needs for health care among homeless people in Toronto, Canada. We surveyed a representative sample of 1169 homeless individuals at shelters and meal programs and asked them if within the last year they had needed health care but been unable to get it. Fully 17% of homeless individuals -- about one in six – reported unmet needs for care. Mothers with children who were living in family shelters were more than twice as likely to have unmet needs for care than the average mother with children living in Toronto. Among the homeless people that we interviewed, those who were younger and those who had been a victim of physical assault in the past year were more likely to have unmet needs.
These findings show us that homeless people still have substantial unmet health care needs within Canada’s system of universal health insurance. However, it’s important to realize two things. First, this finding should not be misinterpreted to mean that our system of universal health insurance is “broken” or “doesn’t work.” In fact, another recent study asked almost the same question that we did of homeless people across the US and found that 32% had been unable to obtain needed medical or surgical care in the past year. So, the rate of unmet needs among homeless people in the Canadian system is about half that of homeless people in the US. Universal health insurance works!
Second, our study underscores the importance of understanding the difference between a health insurance system and a health care delivery system. When people are disadvantaged and marginalized, it’s not enough to say that that their health care will be paid for, so there’s nothing to worry about. We need to realize that there can be many other barriers to obtaining needed care, such as not having a family physician, not having transportation to the clinic or doctor’s office, not understanding when it’s important to seek health care, or being reluctant to seek care because of previous bad experiences with health care providers. All of these factors, and more, come into play when a person is homeless.
We need to continue to design health care delivery systems that meet the needs of people who are homeless. Some of the most promising strategies include having teams of health care providers work in outreach settings such as shelters, drop-in centres, and mobile health units; enhancing the capacity of our many outstanding community health centres to provide comprehensive care for homeless patients; integrating the delivery of care for physical health, mental health, and addictions; and educating and empowering individuals who are homeless to help improve their own health.
Stephen Hwang's primary appointment is in the Department of Medicine at the University of Toronto, with cross-appointments in the Departments of Public Health Sciences and Health Policy, Management and Evaluation. His research focuses on deepening our understanding of the relationship between homelessness, housing, and health through epidemiologic studies, health services research, and longitudinal cohort studies. His current research projects include a study of predictors of health care utilization in a representative sample of 1,200 homeless men, women, and families in Toronto, a study of the barriers to the management of chronic pain among homeless people, and an evaluation of the effects of a supportive housing program on health and health care utilization among homeless and hard-to-house individuals.