“Homelessness is a state, not a trait,” said Margot Kushel, M.D., of the University of California, San Francisco at the recent American Association for the Advancement of Science conference in Seattle. Older adults increasingly experience that state, with 33% of participants in her Oakland, California, study becoming homeless for the first time when they were 50 to 59 years old. Fifty-six percent of participants rated their health as fair or poor, a similar percentage to housed frail people over age 85, Kushel explained in a recent webinar, declaring, “When we talk about the homeless, 50 is the new 75.”
These health issues are exacerbated in people living with HIV, many of whom already experience aging-related illnesses earlier in life than the general population. In San Francisco, 67% of people living with HIV are more than 50 years old, the San Francisco AIDS Foundation reported. Early in the epidemic, many thought they would never reach old age and therefore didn’t plan for that stage of their lives. “Dead people don’t need retirement accounts,” activist Tez Anderson quipped at last year’s Association of Nurses in AIDS Care conference. He and many other long-term survivors dropped out of higher education or the workforce to deal with their health. Now they find it difficult to return to work, in part because they rely on public health insurance to pay for the medications that keep them alive. That insurance is in jeopardy if one earns money above a relatively low threshold, he explained.
Insurance is not the only reason people may find it difficult to return to work after dealing with a health issue. “People who have something go wrong with their health are much more likely to leave the labor force and to end up retired earlier than they would like. … The longer someone is out of the labor force, the lower their chance of returning to work,” Beth C. Truesdale, Ph.D., of Harvard University wrote in an email. Work is a neglected social determinant of health, she noted at the AAAS conference.
One way to get people back to work is paid family and medical leave, she wrote: “Paid leave for workers facing health problems (or caring for family members facing health problems) would help workers return to work after an illness or injury, either their own or a family member’s.” Current U.S. law provides only for unpaid leave to deal with serious health issues.
Without a solid work history in the runup to retirement, social security benefits are limited. Older people currently receive an average of $18,036 a year in such benefits, the American Association of Retired Persons reports. Extremely low-income (ELI) households are defined as those with incomes below 30% of the median family income. In California, that threshold is $20,150.70, based on U.S. Census Bureau figures. Affordable housing is defined as costing no more than 30% of household income. Across the U.S., 35 affordable housing units are available for every 100 ELI households. In California, that ratio is 22 units for every 100 needed, Kushel noted.
Redlining practices, deeds to houses that exclude certain populations, socioeconomic disparities, and other issues make these few units even less available to people of color. Priority systems for public housing often only consider individual vulnerabilities, exacerbating racial disparities based on systemic issues, Kushel said. Furthermore, mental health diagnoses are based on white ideas of what is “normal,” Marisa Zapata, Ph.D., of Portland State University added.
One way to provide culturally appropriate supportive housing is to build it. In the Seattle area, for example, Native Americans are 10 times more likely to be homeless than white people, Colleen Echohawk of Chief Seattle Club explained at AAAS: “Our housing policies are inherently racist.” Her organization partnered with local public authorities to build modular housing for her community. Supportive services are based on Native American cultural practices. Their approach tells people, “You will be accepted in this space,” she explained. Substance use and other health issues are addressed after people move in, rather than making sobriety a condition for being housed.
However, just having a roof over one’s head may not be enough, if the location lacks access to important things such as public transit. “There may be cheaper housing, but that’s not housing people should be in,” Zapata noted. Transportation is a special issue for the elderly and people living with chronic health conditions such as HIV, who need to regularly access specialized medical care. One solution may be an on-call shuttle service, she suggested.
Homelessness includes not just people living on the street, in encampments, or in shelters. That is the population included in the biannual “point in time” count. While not unsheltered, people living in shacks, their cars, or doubled up with other families beyond the permitted occupancy rate for the apartment are also homeless. The only figures for this unhoused population come from local departments of education that report the number of students classified as homeless, Zapata explained. Her research includes these figures, but it still under-represents people without school-age children who are unhoused but not unsheltered.
Scientific results can be helpful to move policy, but such an impact may be difficult “at this point in time in our country that is so profoundly anti-science,” Kushel said.
However, there is hope, she concluded. “Policies are human-made, and they can be unmade,” she said.